acute and emergency Flashcards

Question

what are the types of shock

Answer 1

-Hypovolemic shock -Cardiogenic Shock -Distributive Shock -Obstructive Shock

Answer 2

- anaphylactic shock -neutrogenic shock - septic shock

Answer 3

- ABCDE response - fluid resus -vasopressors -O2 managment - underlying causes

Answer 4

Neuropathic pain may be defined as pain which arises following damage or disruption of the nervous system. It is often difficult to treat and responds poorly to standard analgesi

Answer 5

- diabetic neuropathy - post-herpetic neuralgia -trigeminal neuralgia -prolapsed intervertebral disc

Answer 6

first-line treatment*: amitriptyline, duloxetine, gabapentin or pregabalin

Answer 7

Try the other three drugs - amitriptyline, duloxetine, gabapentin or pregabline Drugs should be switched, not added

Answer 8

Localised neuropathic pain (e.g post-herpes)

Answer 9

Opioids include substances like endorphins, semi-synthetic, and synthetic compounds that act on opioid receptors

Answer 10

These receptors, present in the CNS, mediate the actions of opioids.

Answer 11

* Brain, brainstem, and spinal cord. * **µ1-receptors**: Involved in **pain transmission; activation leads to analgesia** * **µ2- and µ3-receptors**: Found in the brainstem; their **activation causes** * respiratory depression * reduced gastrointestinal motility, * vasodilation * pupillary constriction in overdose.

Answer 12

Spread throughout the brain, brainstem, and spinal cord. Associated with cognitive effects, dysphoria, hallucinations, and depressed consciousness.

Answer 13

Almost exclusively in the brain and brainstem. Potentiate µ-receptors, enhancing analgesia, respiratory depression, and dependence.

Answer 14

Include endorphins, dynorphins, and enkephalins, produced mainly in the brain and brainstem. β-Endorphin: Targets µ-receptors, influences appetite, sexual behaviour, and pain control during exercise. Met-enkephalin: Acts on Î´-receptors, modulating the flight-or-fight response. Dynorphin: Involved in appetite, mood, and stress regulation.

Answer 15

cytochrome P450 (CYP450

Answer 16

* ***oxidation, reduction, and hydrolysis*** Cytochrome P450 enzymes ***CYP3A4 and CYP2D6*** —> modifying opioids to form more water-soluble metabolites. Example: **Codeine —>CYP2D6 —>morphine** (more active)

Answer 17

Involves conjugation reactions like glucuronidation. Morphine is glucuronidated to morphine-3-glucuronide (inactive) and morphine-6-glucuronide (active and potent).

Answer 18

Genetic polymorphisms in CYP450 enzymes, especially CYP2D6, can significantly affect the metabolism of certain opioids (like codeine and tramadol), leading to variability in clinical response.

Answer 19

Some opioids have active metabolites that contribute to their analgesic effect or side effects. For example, the metabolites of morphine include both analgesic and neuroexcitatory compounds.

Answer 20

Most opioid metabolites are excreted by the kidneys. Renal impairment can lead to the accumulation of these metabolites, increasing the risk of toxicity, especially in opioids with active metabolites.

Answer 21

offer patients with advanced and progressive disease regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain No co-morbidities, use 20-30mg of MR with 5mg morphine for breakthrough pain I.e 15mg modified-release morphine tablets twice a day with 5mg of oral morphine solution as required

Answer 22

-constipation (laxatives) - nausea and vomiting (antiemetic) - respiratory depression - drowsiness (adjust prescription if an issue) Oral morphine is preferred to transdermal morphine prescription

Answer 23

- Breakthrough dose morphine is 1/6 of daily dose - all patients who receive opioid should be given a laxative - care should be taken with patients with chronic kidney disease

Answer 24

oxycodone is preferred to morphine in palliative patients with mild-moderate renal impairment if renal impairment is more severe, alfentanil, buprenorphine and fentanyl are preferred

Answer 25

may respond to strong opioids, bisphosphonates or radiotherapy. Studies do not support use of NSAIDS Strong opioids have the lowest number needed to treat for relieving the pain and can provide quick relief, in contrast to radiotherapy and bisphosphonates*. All patients, however, should be considered for referral to a clinical oncologist for consideration of further treatments such as radiotherapy

Answer 26

Dose should be increased by 30-50% Add bisphosphonates, radiotherapy and denosumab to treat metastatic bone pain.

Answer 27

Nausea Drowsiness

Answer 28

Constipation

Answer 29

* Oral codeine to oral morphine- divide by 10 * Oral tramadol to oral morphine - divide by 10

Answer 30

Divide by 1.5 or 2

Answer 31

Divide by 2

Answer 32

Divide by 3

Answer 33

Divide by 1.5

Answer 34

Rise in creatinine of 26µmol/L or more in 48 hours OR >= 50% rise in creatinine over 7 days OR Fall in urine output to < 0.5ml/kg/hour for more than 6 hours in adults (8 hours in children) OR >= 25% fall in eGFR in children / young adults in 7 days.

Answer 35

Increase in creatinine to 1.5-1.9 times baseline, or Increase in creatinine by ≥26.5 µmol/L, or Reduction in urine output to <0.5 mL/kg/hour for ≥ 6 hours

Answer 36

Increase in creatinine to 2.0 to 2.9 times baseline, or Reduction in urine output to <0.5 mL/kg/hour for ≥12 hours

Answer 37

* Increase in creatinine to ≥ 3.0 times baseline, or * Increase in creatinine to ≥353.6 µmol/L or * Reduction in urine output to <0.3 mL/kg/hour for ≥24 hours, or * The initiation of kidney replacement therapy, or, * In patients <18 years, decrease in eGFR to <35 mL/min/1.73 m2

Answer 38

Renal tranplant ITU patient with unknown cause of AKI Vasculitis/ glomerulonephritis/ tubulointerstitial nephritis/ myeloma AKI with no known cause Inadequate response to treatment Complications of AKI Stage 3 AKI (see guideline for details) CKD stage 4 or 5 Qualify for renal replacement hyperkalaemia / metabolic acidosis/ complications of uraemia/ fluid overload (pulmonary oedema)

Answer 39

Emergency surgery, ie, risk of sepsis or hypovolaemia Intraperitoneal surgery CKD, ie if eGFR < 60 Diabetes Heart failure Age >65 years Liver disease Use of nephrotoxic drugs NSAIDs aminoglycosides ACE inhibitors/angiotensin II receptor antagonists diuretics

Answer 40

Accounts to 25% of drug-induced AKis

Answer 41

drugs: the most common cause, particularly antibiotics penicillin rifampicin NSAIDs allopurinol furosemide systemic disease: SLE, sarcoidosis, and Sjogren’s syndrome infection: Hanta virus , staphylococci

Answer 42

histology: marked interstitial oedema and interstitial infiltrate in the connective tissue between renal tubules

Answer 43

fever, rash, arthralgia eosinophilia mild renal impairment hypertension

Answer 44

sterile pyuria white cell casts

Answer 45

Antepartum haemorrhage is defined as bleeding from the genital tract after 24 weeks pregnancy, prior to delivery of the fetus

Answer 46

shock out of keeping with visible loss pain constant tender, tense uterus* normal lie and presentation fetal heart: absent/distressed coagulation problems beware pre-eclampsia, DIC, anuria

Answer 47

shock in proportion to visible loss no pain uterus not tender lie and presentation may be abnormal fetal heart usually normal coagulation problems rare small bleeds before large vaginal examination should not be performed in primary care for suspected antepartum haemorrhage - women with placenta praevia may haemorrhage

Answer 48

painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks the bleeding is often less than menstruation cervical os is closed complicates up to 25% of all pregnancies

Answer 49

a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature cervical os is closed when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a 'blighted ovum' or 'anembryonic pregnancy'

Answer 50

- heavy bleeding with clots and pain Cervical os is open

Answer 51

not all products of conception have been expelled pain and vaginal bleeding cervical os is open

Answer 52

Waiting for a spontaneous miscarriage' First-line and involves waiting for 7-14 days for the miscarriage to complete spontaneously If expectant management is unsuccessful then medical or surgical management may be offered

Answer 53

increased risk of haemorrhage she is in the late first trimester if she has coagulopathies or is unable to have a blood transfusion previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage) evidence of infection

Answer 54

oral mifepristone. 48 hours later, misoprostol If bleeding has not started within 48 hours after misoprostol treatment, they should contact their healthcare professional

Answer 55

a single dose of misoprostol (vaginal, oral or sublingual)

Answer 56

women should be offered antiemetics and pain relief a pregnancy test should be performed at 3 weeks

Answer 57

Undergoing a surgical procedure under local or general anaesthetic' The two main options are vacuum aspiration (suction curettage) or surgical management in theatre Vacuum aspiration is done under local anaesthetic as an outpatient

Answer 58

antiphospholipid syndrome endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome uterine abnormality: e.g. uterine septum parental chromosomal abnormalities smoking

Answer 59

airway, breathing, circulation burns caused by heat: remove the person from the source. Within 20 minutes of the injury irrigate the burn with cool (not iced) water for between 10 and 30 minutes. Cover the burn using cling film, layered, rather than wrapped around a limb electrical burns: switch off power supply, remove the person from the source chemical burns: brush any powder off then irrigate with water. Attempts to neutralise the chemical are not recommended

Answer 60

head + neck = 9%, each arm = 9%, each anterior part of leg = 9%, each posterior part of leg = 9%, anterior chest = 9%, posterior chest = 9%, Anterior abdomen = 9%, posterior abdomen = 9% The palmar surface is approximately 1%

Answer 61

First degree Red and painful, no dry blisters

Answer 62

Second degree burn Pale piping, painful, blistered and reduced cap refill time

Answer 63

Second degree Typically white, but may have non-blanching erythema Reduced sensation Painful to deep pressure

Answer 64

- third degree burn - white (waxy) - brown (leathery) Black in colour with no blisters or pain

Answer 65

ventricular septal defects (VSD) - most common, accounts for 30% atrial septal defect (ASD) patent ductus arteriosus (PDA) coarctation of the aorta aortic valve stenosis

Answer 66

tetralogy of Fallot transposition of the great arteries (TGA) tricuspid atresia

Answer 67

very common in the first 24 hours of life and may occur when the child is crying or unwell from any cause

Answer 68

Central cyanosis can be recognised clinically when the concentration of reduced haemoglobin in the blood exceeds 5g/dl

Answer 69

nitrogen washout test (also known as the hyperoxia test) may be used to differentiate cardiac from non-cardiac causes. The infant is given 100% oxygen for ten minutes after which arterial blood gases are taken. A pO2 of less than 15 kPa indicates cyanotic congenital heart disease

Answer 70

supportive care prostaglandin E1 e.g. alprostadil used to maintain a patent ductus arteriosus in ductal-dependent congenital heart defect this can act as a holding measure until a definite diagnosis is made and surgical correction performed

Answer 71

refers to cyanosis around the mouth and the extremities such as the hands and feet occurs immediately after birth in healthy infants. It is a common finding and may persist for 24 to 48 hours.

Answer 72

Most common cause of congenital heart disease Presents around 1-2 months but may not be picked up until the baby is 6 months old

Answer 73

ventricular septal defect (VSD) right ventricular hypertrophy right ventricular outflow tract obstruction, pulmonary stenosis overriding aorta severity of the right ventricular outflow tract obstruction determines the degree of cyanosis and clinical severity

Answer 74

cyanosis unrepaired TOF infants may develop episodic hypercyanotic 'tet' spells due to near occlusion of the right ventricular outflow tract features of tet spells include tachypnoea and severe cyanosis that may occasionally result in loss of consciousness they typically occur when an infant is upset, is in pain or has a fever causes a right-to-left shunt ejection systolic murmur due to pulmonary stenosis (the VSD doesn't usually cause a murmur) a right-sided aortic arch is seen in 25% of patients chest x-ray shows a 'boot-shaped' heart, ECG shows right ventricular hypertrophy

Answer 75

surgical repair is often undertaken in two parts cyanotic episodes may be helped by beta-blockers to reduce infundibular spasm

Answer 76

Transposition of the great arteries (TGA) is a form of cyanotic congenital heart disease. It is caused by the failure of the aorticopulmonary septum to spiral during septation. Children of diabetic mothers are at an increased risk of TGA.

Answer 77

aorta leaves the right ventricle pulmonary trunk leaves the left ventricle

Answer 78

cyanosis tachypnoea loud single S2 prominent right ventricular impulse 'egg-on-side' appearance on chest x-ray

Answer 79

maintenance of the ductus arteriosus with prostaglandins surgical correction is the definite treatment.

Answer 80

collection of blood that is between the skull and the dura. It is almost always caused by trauma and most typically by ˜low-impact' trauma (e.g. a blow to the head or a fall). Collection is typically in the temporal region (MIDDLE MENINGEAL ARTERY)

Answer 81

Extradural haematoma Ludic period

Answer 82

biconvex (or lentiform), hyperdense collection around the surface of the brain. They are limited by the suture lines of the skull.

Answer 83

treatment is craniotomy and evacuation of the haematoma.

Answer 84

insulinoma - increased ratio of proinsulin to insulin self-administration of insulin/sulphonylureas liver failure Addison's disease alcohol causes exaggerated insulin secretion mechanism is thought to be due to the effect of alcohol on the pancreatic microcirculation → redistribution of pancreatic blood flow from the exocrine into the endocrine parts → increased insulin secretion nesidioblastosis - beta cell hyperplasia

Answer 85

blood glucose levels and the severity of symptoms are not always correlated, especially in patients with diabetes. blood glucose concentrations <3.3 mmol/L cause autonomic symptoms due to the release of glucagon and adrenaline (average frequency in brackets): Sweating Shaking Hunger Anxiety Nausea blood glucose concentrations below <2.8 mmol/L cause neuroglycopenic symptoms due to inadequate glucose supply to the brain: Weakness Vision changes Confusion Dizziness Severe and uncommon features of hypoglycaemia include: Convulsion Coma

Answer 86

If the patient is alert, a quick-acting carbohydrate may be given (as above) If the patient is unconscious or unable to swallow, subcutaneous or intramuscular injection glucagon may be given. Alternatively, intravenous 20% glucose solution may be given through a large vein

Answer 87

in the community (for example, diabetes mellitus patients who inject insulin): Initially, oral glucose 10-20g should be given in liquid, gel or tablet form Alternatively, a propriety quick-acting carbohydrate may be given: GlucoGel or Dextrogel. A 'HypoKit' may be prescribed which contains a syringe and vial of glucagon for IM or SC injection at home

Answer 88

intracranial haemorrhage that is defined as the presence of blood within the subarachnoid space, i.e. deep to the subarachnoid layer of the meninges.

Answer 89

intracranial aneurysm (saccular ˜berry' aneurysms) accounts for around 85% of cases conditions associated with berry aneurysms include hypertension,adult polycystic kidney disease, Ehlers-Danlos syndrome and coarctation of the aorta arteriovenous malformation pituitary apoplexy mycotic (infective) aneurysms

Answer 90

- Headache (sudden onset, thunderclap) - severe (worst in my life) - occipital typically peaking in intensity within 1 to 5 minutes there may be a history of a less-severe 'sentinel' headache in the weeks prior to presentation nausea and vomiting meningism (photophobia, neck stiffness) coma seizures ECG changes including ST elevation may be seen this may be secondary to either autonomic neural stimulation from the hypothalamus or elevated levels of circulating catecholamines

Answer 91

Non-contrast CT (acute blood, hypodense, bright on CT) If CT done within 6 hours of symptoms, may appear to be normal LP after 12 hours of symptoms shows Xathochromia CSF will also show normal or raised opening pressure

Answer 92

supportive bed rest analgesia venous thromboembolism prophylaxis discontinuation of antithrombotics (reversal of anticoagulation if present) vasospasm is prevented using a course of oral nimodipine intracranial aneurysms are at risk of rebleeding and therefore require prompt intervention, preferably within 24 hours most intracranial aneurysms are now treated with a coil by interventional neuroradiologists, but a minority require a craniotomy and clipping by a neurosurgeon

Answer 93

re-bleeding happens in around 10% of cases and most common in the first 12 hours if rebleeding is suspected (e.g. sudden worsening of neurological symptoms) then a repeat CT should be arranged associated with a high mortality (up to 70%) hydrocephalus hydrocephalus is temporarily treated with an external ventricular drain (CSF diverted into a bag at the bedside) or, if required, a long-term ventriculoperitoneal shunt vasospasm (also termed delayed cerebral ischaemia), typically 7-14 days after onset ensure euvolaemia (normal blood volume) consider treatment with a vasopressor if symptoms persist hyponatraemia (most typically due to syndrome inappropriate anti-diuretic hormone (SIADH)) seizures

Answer 94

conscious level on admission age amount of blood visible on CT head

Answer 95

subdural haematoma is a collection of blood deep to the dural layer of the meninges. The blood is not within the substance of the brain and is therefore called an ˜extra-axial' or ˜extrinsic' lesion. They can be unilateral or bilateral.

Answer 96

Acute: Symptoms usually develop within 48 hours of injury, characterised by rapid neurological deterioration Subacute: Symptoms manifest within days to weeks post-injury, with a more gradual progression. Chronic: Common in the elderly, developing over weeks to months. Patients may not recall a specific head injury.

Answer 97

Altered Mental Status: Ranging from mild confusion to deep coma. Fluctuations in the level of consciousness are common. Focal Neurological Deficits: Weakness on one side of the body, aphasia, or visual field defects, depending on the haematoma's location. Headache: Often localised to one side, worsening over time. Seizures: May occur, particularly in acute or expanding hematomas.

Answer 98

Papilloedema: Indicates raised intracranial pressure. Pupil Changes: Unilateral dilated pupil, especially on the side of the haematoma, indicating compression of the third cranial nerve. Gait Abnormalities: Including ataxia or weakness in one leg. Hemiparesis or Hemiplegia: Reflecting the mass effect and midline shift.

Answer 99

Memory loss- especially in chronic SDH Personality Changes: Irritability, apathy, or depression. Cognitive Impairment: Difficulty with attention, problem-solving, and other executive functions.

Answer 100

Nausea and Vomiting: Secondary to increased intracranial pressure. Drowsiness: Progressing to stupor and coma in severe cases. Signs of Increased Intracranial Pressure: Such as bradycardia, hypertension, and respiratory irregularities (Cushing's triad).

Answer 101

Motor, verbal and eye features (M6, V5, E4)

Answer 102

6. Infant moves spontaneously or purposefully 5. Infant withdraws from touch 4. Infant withdraws from pain 3. Abnormal flexion to pain for an infant (decorticate response) 2. Extension to pain (decerebrate response) 1. No motor response

Answer 103

5. Orientated 4. Confused 3. Words 2. Sounds 1. None

Answer 104

4. Spontaneous 3. To speech 2. To pain 1. None

Answer 105

25-30 ml/kg/ day 1 mol/kg/day of K+, Na+ and CL- Approximately 50-100g per day of glucose to limit strvation and ketosis

Answer 106

0.9% saline if large volumes are used there is an increased risk of hyperchloraemic metabolic acidosis Hartmann's contains potassium and therefore should not be used in patients with hyperkalaemia

Answer 107

IV fluids required when: the child is > 10% dehydrated, or the child is if 5-10% dehydrated and oral or enteral rehydration is not tolerated or possible.

Answer 108

100 mL/kg for the first 10 kg 50 mL/kg for each 1 kg body weight over 10 kg

Answer 109

100 mL/kg for the first 10 kg 50 mL/kg for each 1 kg body weight between 10-20 kg 20 mL/kg for each 1 kg body weight over 20 kg (max. 2 litres in females, 2.5 litres in males)

Answer 110

The fluid type routinely used is 0.9% sodium chloride + 5% dextrose. Potassium is added as required.

Answer 111

Medical emergency with 20% mortality Hyperglycaemia results in osmotic diuresis, severe dehydration, and electrolyte deficiencies. HHS typically presents in the elderly with type 2 diabetes mellitus (T2DM).

Answer 112

Hyperglycaemia results in osmotic diuresis, severe dehydration, and electrolyte deficiencies. HHS typically presents in the elderly with type 2 diabetes mellitus (T2DM).

Answer 113

- intercurrent illness -dementia -sedative drugs

Answer 114

- occurs over many days, associated with dehydration and metabolic disturbances - volume loft (polyuria, polydipsia, signs of dehydration) Systemic - lethargy - nausea and vomiting neurological -altered level of consciousness -focal neurological deficits haematological -hyperviscosity (may result in myocardial infarctions, stroke and peripheral arterial thrombosis)

Answer 115

hypovolaemia marked hyperglycaemia (>30 mmol/L) significantly raised serum osmolarity (> 320 mosmol/kg) can be calculated by: 2 * Na+ + glucose + urea no significant hyperketonaemia (<3 mmol/L) no significant acidosis (bicarbonate > 15 mmol/l or pH > 7.3 - acidosis can occur due to lactic acidosis or renal impairment)

Answer 116

fluid replacement fluid losses in HHS are estimated to be between 100 - 220 ml/kg IV 0.9% sodium chloride solution typically given at 0.5 - 1 L/hour depending on clinical assessment potassium levels should be monitored and added to fluids depending on the level insulin should not be given unless blood glucose stops falling while giving IV fluids venous thromboembolism prophylaxis patients are at risk of thrombosis due to hyperviscosity

Answer 117

Vascular complications: - MI - stroke

Answer 118

1. Primary hyperparathyroidism 2. Malignancy (SCLS, bone mets, myeloma) 3. Sarcoidosis 4. Vit D intoxication 5. Acromegaly 6. Thyrotoxicosis 7. Milk- alkali syndrome 8. Thiazides 9/ calcium containing antacids 10 dehydatraion 11 Addison’s disease 12 pager’s disease of the bone

Answer 119

bones, stones, groans and psychic moans' corneal calcification shortened QT interval on ECG hypertension

Answer 120

- regulated by a number of factors including aldosterone, acid-base balance and insulin levels - metabolic acidosis is associated

Answer 121

acute kidney injury drugs*: potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers, spironolactone, ciclosporin, heparin** metabolic acidosis Addison's disease rhabdomyolysis massive blood transfusion - salt substitutes - bananas, oranges, kiwi, avos, spinach and tonatoes

Answer 122

- Stabilisation of the cardiac membrane IV calcium gluconate does NOT lower serum potassium levels Short-term shift in potassium from extracellular (ECF) to intracellular fluid (ICF) compartment combined insulin/dextrose infusion nebulised salbutamol Removal of potassium from the body calcium resonium (orally or enema) enemas are more effective than oral as potassium is secreted by the rectum loop diuretics dialysis haemofiltration/haemodialysis should be considered for patients with AKI with persistent hyperkalaemia

Answer 123

mild: 5.5 - 5.9 mmol/L moderate: 6.0 - 6.4 mmol/L severe: ≥ 6.5 mmol/L

Answer 124

peaked or 'tall-tented' T waves (occurs first) loss of P waves broad QRS complexes sinusoidal wave pattern

Answer 125

IV calcium gluconate: to stabilise the myocardium insulin/dextrose infusion: short-term shift in potassium from ECF to ICF other treatments such as nebulised salbutamol may be given to temporarily lower the serum potassium Further management stop exacerbating drugs e.g. ACE inhibitors treat any underlying cause lower total body potassium calcium resonium loop diuretics dialysis

Answer 126

- dehydration -osmotic diuresis e.g. hyperosmolar non-ketotic diabetic coma diabetes insipidus excess IV saline

Answer 127

owering of other osmolytes (and importantly water) occurs at a slower rate, predisposing to cerebral oedema, resulting in seizures, coma and death Should be corrected at 0.5mmol/hour

Answer 128

vitamin D deficiency (osteomalacia) chronic kidney disease hypoparathyroidism (e.g. post thyroid/parathyroid surgery) pseudohypoparathyroidism (target cells insensitive to PTH) rhabdomyolysis (initial stages) magnesium deficiency (due to end organ PTH resistance) massive blood transfusion acute pancreatitis

Answer 129

Contamination of blood samples with EDTA may also give falsely low calcium levels.

Answer 130

severe hypocalcaemia (e.g. carpopedal spasm, tetany, seizures or prolonged QT interval) requires IV calcium replacement the preferred method is with intravenous calcium gluconate, 10ml of 10% solution over 10 minutes intravenous calcium chloride is more likely to cause local irritation ECG monitoring is recommended further management depends on the underlying cause

Answer 131

drugs diuretics proton pump inhibitors total parenteral nutrition diarrhoea may occur with acute or chronic diarrhoea alcohol hypokalaemia hypercalcaemia e.g. secondary to hyperparathyroidism calcium and magnesium functionally compete for transport in the thick ascending limb of the loop of Henle metabolic disorders Gitleman's and Bartter's

Answer 132

paraesthesia tetany seizures arrhythmias decreased PTH secretion → hypocalcaemia ECG features similar to those of hypokalaemia exacerbates digoxin toxicity

Answer 133

intravenous magnesium replacement is commonly given. an example regime would be 40 mmol of magnesium sulphate over 24 hours

Answer 134

oral magnesium salts (10-20 mmol orally per day in divided doses) diarrhoea can occur with oral magnesium salts

Answer 135

Hyperlipiddaemia Taking blood from a drip arm

Answer 136

Sodium depletion, renal loss (patient often hypovolaemic) diuretics: thiazides, loop diuretics Addison's disease diuretic stage of renal failure Patient often euvolaemic SIADH (urine osmolality > 500 mmol/kg) hypothyroidism

Answer 137

Sodium depletion, extra-renal loss diarrhoea, vomiting, sweating burns, adenoma of rectum Water excess (patient often hypervolaemic and oedematous) secondary hyperaldosteronism: heart failure, liver cirrhosis nephrotic syndrome IV dextrose psychogenic polydipsia

Answer 138

Symptomatic palpitations and inefficient cardiac function probably the most important aspect of managing patients with AF is reducing the increased risk of stroke which is present in these patients.

Answer 139

- paroxysmal AF- episodes of AF terminate spontaneously. Such episodes last less than 7 days - Persistent AF- non self-terminating AF - permanent AF- continuous atrial fibrillation can’t be cardioverted or deemed inappropriate

Answer 140

palpitations dyspnoea chest pain

Answer 141

Irregular irregular puls

Answer 142

- rate and rhythm control - reducing stroke risk

Answer 143

rate control **bold text control Rate ** : accept that the pulse will be irregular, but slow the rate down to avoid negative effects on cardiac function rhythm control: try to get the patient back into, and maintain, normal sinus rhythm. This is termed cardioversion. Drugs (pharmacological cardioversion) and synchronised DC electrical shocks (electrical cardioversion) may be used for this purpose

Answer 144

Any of the following 2 a betablocker diltiazem digoxin

Answer 145

C- congenital H- hypertension (or treated) A2- age D- diabetes S2- prior stroke, TIA or thromboembolism V- vascular disease (including ischameic heart disease, peripheral artery disease S- sex (female)

Answer 146

C- 1 H-1 A >75 (2 points) A 65-74 (1 points) D (1 points) S2- (2 points) V (1 points) S (1 points)

Answer 147

0 - no treatment needed 1- males consider anticoagulant, females don’t need 2- offer anticoagulants

Answer 148

Orbit score is encouraged to be used by NICE rather than HASBLED score

Answer 149

0-2, low risk which is 2.4 bleeds per 100 pt per year 3, medium, 4.7 4-7, high, 8.1

Answer 150

Haemoglobin ‘ Age >74 Bleeding (GI bleed, intracranial bleed, haemorrhagic stroke) Renal impairment (GFR <60 ml/min) Treatment with antiplatelet agent

Answer 151

H-2 A-1 S B- 2 L E- 1 D- 1

Answer 152

apixaban dabigatran edoxaban Warfarin is recommended as second line if DOAC contradicted Do not prescribe aspirin

Answer 153

electrical cardioversion as an emergency if the patient is haemodynamically unstable electrical or pharmacological cardioversion as an elective procedure where a rhythm control strategy is preferred.

Answer 154

Electrical cardioversion is synchronised to the R wave to prevent delivery of a shock during the vulnerable period of cardiac repolarisation when ventricular fibrillation can be induced.

Answer 155

If AF less than 48 hours, patient should be heparanised Patients with risk of ischaemic stroke should be put on lifelong oral anticoagulation Otherwise cardiovert the patient

Answer 156

electrical - 'DC cardioversion' pharmacology - amiodarone if structural heart disease, flecainide or amiodarone in those without structural heart disease

Answer 157

AF for more than 48 hours then anticoagulation should be given for at least 3 weeks prior to cardioversion. An alternative strategy is to perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus. If excluded patients may be heparinised and cardioverted immediately.

Answer 158

If there is a high risk of cardioversion failure (e.g. Previous failure or AF recurrence) then it is recommend to have at least 4 weeks amiodarone or sotalol prior to electrical cardioversion

Answer 159

- anticoagulants the patient for at least 4 weeks

Answer 160

AF may present with palpitations, dyspnoea, dizziness/syncope many cases are asymptomatic and are found as an incidental finding the pulse is irregularly irregular

Answer 161

ECG: absent P waves a 24 hour ECG or event recorder is useful where paroxysmal atrial fibrillation is suspected echocardiography is not required in all cases

Answer 162

1. reducing the risk of stroke 2. controlling the heart rate

Answer 163

-amiodarone -flecainide (if no structural heart disease) -others (less commonly used in UK): quinidine, dofetilide, ibutilide, propafenone

Answer 164

beta-blockers (including sotalol) calcium channel blockers digoxin disopyramide procainamide

Answer 165

F ollowing a stroke or TIA it is obviously important to exclude a haemorrhage before starting any anticoagulation or antiplatelet therapy for longer-term stroke prevention, NICE Clinical Knowledge Summaries recommend warfarin or a direct thrombin or factor Xa inhibitor the timing of when to start depends on whether it is a TIA or stroke following a TIA, anticoagulation for AF should start immediately once imaging has excluded haemorrhage in acute stroke patients, in the absence of haemorrhage, anticoagulation therapy should be commenced after 2 weeks. Antiplatelet therapy should be given in the intervening period. If imaging shows a very large cerebral infarction then the initiation of anticoagulation should be delayed

Answer 166

- sawtooth appearance - rate often 300/ min - ventricular or heart rate is dependent on the degree of AV block. For example if there is 2:1 block the ventricular rate will be 150/min - flutter waves will be visible following carotid sinus massage or adenosine

Answer 167

is similar to that of atrial fibrillation although medication may be less effective atrial flutter is more sensitive to cardioversion however so lower energy levels may be used radiofrequency ablation of the tricuspid valve isthmus is curative for most patients

Answer 168

AV dissociation fusion or capture beats positive QRS concordance in chest leads marked left axis deviation history of IHD lack of response to adenosine or carotid sinus massage QRS > 160 ms

Answer 169

1. identifying the presence of signs indicating haemodynamic compromise - 'adverse signs' 2. identifying the potential risk of asystole

Answer 170

shock: hypotension (systolic blood pressure < 90 mmHg), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness syncope myocardial ischaemia heart failure

Answer 171

Atropine (500mg IV)

Answer 172

atropine, up to a maximum of 3mg transcutaneous pacing isoprenaline/adrenaline infusion titrated to response If no response, get help with transvenous pacing

Answer 173

complete heart block with broad complex QRS recent asystole Mobitz type II AV block ventricular pause > 3 seconds

Answer 174

shock: hypotension (systolic blood pressure < 90 mmHg), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness syncope myocardial ischaemia heart failure

Answer 175

adverse signs are present then synchronised DC shocks should be given. Up to three shocks can be given, then seek expert help after this

Answer 176

assume ventricular tachycardia (unless previously confirmed SVT with bundle branch block) loading dose of amiodarone followed by 24 hour infusion

Answer 177

seek expert help. Possibilities include: atrial fibrillation with bundle branch block - the most likely cause in a stable patient atrial fibrillation with ventricular pre-excitation torsade de pointes

Answer 178

vagal manoeuvres followed by IV adenosine if the above is unsuccessful consider a diagnosis of atrial flutter and control rate (e.g. beta-blocker

Answer 179

probable atrial fibrillation if onset < 48 hr consider electrical or chemical cardioversion rate control: beta-blockers are usually first-line unless there is a contraindication

Answer 180

- twisting of the points -forms of polymorphic ventricular tachycardia associated with long QT syndrome - can cause VF - can lead to sudden death

Answer 181

congenital Jervell-Lange-Nielsen syndrome Romano-Ward syndrome antiarrhythmics: amiodarone, sotalol, class 1a antiarrhythmic drugs tricyclic antidepressants antipsychotics chloroquine terfenadine erythromycin electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia myocarditis hypothermia subarachnoid haemorrhage

Answer 182

IV magnesium sulphate

Answer 183

Ventricular tachycardia (VT) is broad-complex tachycardia originating from a ventricular ectopic focus. It has the potential to precipitate ventricular fibrillation and hence requires urgent treatment.

Answer 184

- monomorphic VT - Polymorphic VT

Answer 185

most commonly caused by myocardial infarction

Answer 186

subtype of polymorphic VT is torsades de pointes which is precipitated by prolongation of the QT interval. The causes of a long QT interva

Answer 187

Jervell-Lange-Nielsen syndrome (includes deafness and is due to an abnormal potassium channel) Romano-Ward syndrome (no deafness)

Answer 188

amiodarone, sotalol, class 1a antiarrhythmic drugs tricyclic antidepressants, fluoxetine chloroquine terfenadine erythromycin

Answer 189

electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia acute myocardial infarction myocarditis hypothermia subarachnoid haemorrhage

Answer 190

- if any adverse signs (systolic BP < 90 mmHg, chest pain, heart failure), then IMMEDIATE CARDIOVERSION -If absence of symptoms, then consider antiarrhythmics - if this fails, then SYNCHRONISED DC shock

Answer 191

amiodarone: ideally administered through a central line lidocaine: use with caution in severe left ventricular impairment procainamide

Answer 192

CONTRADICTED

Answer 193

electrophysiological study (EPS) implant able cardioverter-defibrillator (ICD) - this is particularly indicated in patients with significantly impaired LV function

Answer 194

vomiting / aspiration (e.g. peptic ulcer leading to pyloric stenos, nasogastric suction) diuretics liquorice, carbenoxolone hypokalaemia primary hyperaldosteronism Cushing's syndrome Bartter's syndrome congenital adrenal hyperplasia LOSS OF H+ OR GAIN OR BICARD

Answer 195

COPD decompensation in other respiratory conditions e.g. life-threatening asthma / pulmonary oedema sedative drugs: benzodiazepines, opiate overdose

Answer 196

anxiety leading to hyperventilation pulmonary embolism salicylate poisoning CNS disorders: stroke, subarachnoid haemorrhage, encephalitis altitude pregnancy

Answer 197

gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula renal tubular acidosis drugs: e.g. acetazolamide ammonium chloride injection Addison's disease

Answer 198

lactate: shock, hypoxia ketones: diabetic ketoacidosis, alcohol urate: renal failure acid poisoning: salicylates, methanol

Answer 199

(sodium + potassium) - (bicarbonate + chloride) A normal anion gap is 8-14 mmol/L

Answer 200

gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula renal tubular acidosis drugs: e.g. acetazolamide ammonium chloride injection Addison's disease

Answer 201

Respiratory = Opposite low pH + high PaCO2 i.e. acidosis, or high pH + low PaCO2 i.e. alkalosis Metabolic = Equal low pH + low bicarbonate i.e. acidosis, or high pH + high bicarbonate i.e. akalosis

Answer 202

Metabolic component: What is the bicarbonate level/base excess? bicarbonate < 22 mmol/l (or a base excess < - 2mmol/l) suggests a metabolic acidosis (or renal compensation for a respiratory alkalosis) bicarbonate > 26 mmol/l (or a base excess > + 2mmol/l) suggests a metabolic alkalosis (or renal compensation for a respiratory acidosis)

Answer 203

lactic acidosis type A: sepsis, shock, hypoxia, burns lactic acidosis type B: metformin

Answer 204

activation of renin-angiotensin II-aldosterone (RAA) system is a key factor aldosterone causes reabsorption of Na+ in exchange for H+ in the distal convoluted tubule ECF depletion (vomiting, diuretics) → Na+ and Cl- loss → activation of RAA system → raised aldosterone levels in hypokalaemia, K+ shift from cells → ECF, alkalosis is caused by shift of H+ into cells to maintain neutrality

Answer 205

Mixed respiratory alkalosis and metabolic acidosis

Answer 206

drugs diuretics proton pump inhibitors total parenteral nutrition diarrhoea may occur with acute or chronic diarrhoea alcohol hypokalaemia hypercalcaemia e.g. secondary to hyperparathyroidism calcium and magnesium functionally compete for transport in the thick ascending limb of the loop of Henle metabolic disorders Gitleman's and Bartter's

Answer 207

- similar to hypocalaemia paraesthesia tetany seizures arrhythmias decreased PTH secretion → hypocalcaemia ECG features similar to those of hypokalaemia exacerbates digoxin toxicity

Answer 208

<0.4 mmol/L or tetany, arrhythmias, or seizures intravenous magnesium replacement is commonly given. an example regime would be 40 mmol of magnesium sulphate over 24 hours

Answer 209

oral magnesium salts (10-20 mmol orally per day in divided doses) diarrhoea can occur with oral magnesium salts

Answer 210

Nose bleeds Split into anterior and posterior bleeds Kiesselbach’s plexus (anterior and visible bleed) Posterior node bleeds more common in elderly and higher risk of apritation and airway compromise

Answer 211

most cases of epistaxis tend to be benign and self-limiting. Exacerbation factors include: nose picking nose blowing trauma to the nose insertion of foreign bodies bleeding disorders immune thrombocytopenia Waldenstrom's macroglobulinaemia juvenile angiofibroma benign tumour that is highly vascularised seen in adolescent males cocaine use the nasal septum may look abraded or atrophied, inquire about drug use. This is because inhaled cocaine cocaine is a powerful vasoconstrictor and repeated use may result in obliteration of the septum. hereditary haemorrhagic telangiectasia granulomatosis with polyangiitis

Answer 212

Asking the patient to sit with their torso forward and their mouth open avoid lying down unless they feel faint his decreases blood flow to the nasopharynx and allows the patient to spit out any blood in their mouth it also reduces the risk of aspirating blood Pinch the cartilaginous (soft) area of the nose firmly this should be done for at least 20 minutes also ask the patient to breathe through their mouth.

Answer 213

consider using a topical antiseptic such as Naseptin (chlorhexidine and neomycin) to reduce crusting and the risk of vestibulitis cautions to this include patients that have peanut, soy or neomycin allergies Mupirocin is a viable alternative admission and follow up care may be considered in patients under if a comorbidity (e.g. coronary artery disease, or severe hypertension) is present, an underlying cause is suspected they are aged under 2 years (as underlying causes such as haemophilia or leukaemia are more likely in this age group) self-care advice involves reducing the risk of re-bleeding patients should be informed that blowing or picking the nose, heavy lifting, exercise, lying flat, drinking alcohol or hot drinks should be avoided

Answer 214

cautery should be used initially if the source of the bleed is visible and cautery is tolerated it is not so well-tolerated in younger children! ask the patient to blow their nose in order to remove any clots. Be wary that bleeding may resume. use a topical local anaesthetic spray (e.g. Co-phenylcaine) and wait 3-4 minutes for it to take effect identify the bleeding point and apply the silver nitrate stick for 3-10 seconds until it becomes grey-white. Avoid touching areas which do not require treatment, and only cauterise one side of the septum as there is a risk of perforation. dab the area clean with a cotton bud and apply Naseptin or Muciprocin packing may be used if cautery is not viable or the bleeding point cannot be visualised anaesthetise with topical local anaesthetic spray (e.g. Co-phenylcaine) and wait for 3-4 minutes pack the patient's nose while they are sitting with their head forward, following the manufacturer's instructions pressure on the cartilage around the nostril can cause cosmetic changes and this should be reviewed after inserting the pack. examine the patient's mouth and throat for any continuing bleeding, and consider packing the other nostril as this increases pressure on the septum and offending vessel. patients should be admitted to hospital for observation and review, and to ENT if available

Answer 215

haemodynamically unstable or compromised should be admitted to the emergency department

Answer 216

control bleeding with first aid measures in the interim patients with a bleed from an unknown or posterior source (i.e. the bleeding site cannot be located on speculum, bleeding from both nostrils or profuse) should be admitted to hospital.

Answer 217

sphenopalatine ligation in theatre

Answer 218

- CO positioning causes left shift of the oxygen dissociation curve Causes tissue hypoxia Every year there are approximately 50 deaths due to CO poisoning

Answer 219

carbon monoxide binds readily to haemoglobin, forming carboxyhaemoglobin → reduced oxygen-carrying capacity in carbon monoxide poisoning the oxygen saturation of haemoglobin decreases leading to an early plateau in the oxygen dissociation curve

Answer 220

headache: 90% of cases nausea and vomiting: 50% vertigo: 50% confusion: 30% subjective weakness: 20% severe toxicity: 'pink' skin and mucosae, hyperpyrexia, arrhythmias, extrapyramidal features, coma, death

Answer 221

pulse oximetry may be falsely high due to similarities between oxyhaemoglobin and carboxyhaemoglobin therefore a venous or arterial blood gas should be taken typical carboxyhaemoglobin levels < 3% non-smokers < 10% smokers 10 - 30% symptomatic: headache, vomiting > 30% severe toxicity an ECG is a useful supplementary investgation to look for cardiac ischaemia

Answer 222

- assess in ED -100% high flow 02 non-rebreather mask -Hyperbaric oxygen

Answer 223

abdominal pain peripheral neuropathy (mainly motor) neuropsychiatric features fatigue constipation blue lines on gum margin (only 20% of adult patients, very rare in children) Acute intermittent porphyria Defective ferrochelatase and ALA dehydrates function

Answer 224

the blood lead level is usually used for diagnosis. Levels greater than 10 mcg/dl are considered significant full blood count: microcytic anaemia. Blood film shows red cell abnormalities including basophilic stippling and clover-leaf morphology raised serum and urine levels of delta aminolaevulinic acid may be seen making it sometimes difficult to differentiate from acute intermittent porphyria urinary coproporphyrin is also increased (urinary porphobilinogen and uroporphyrin levels are normal to slightly increased) in children, lead can accumulate in the metaphysis of the bones although x-rays are not part of the standard work-up

Answer 225

various chelating agents are currently used: dimercaptosuccinic acid (DMSA) D-penicillamine EDTA dimercaprol

Answer 226

inhibition of acetylcholinesterase leading to upregulation of nicotinic and muscarinic cholinergic neurotransmission. In warfare, sarin gas is a highly toxic synthetic organophosphorus compound that has similar effects.

Answer 227

accumulation of acetylcholine (mnemonic = SLUD) Salivation Lacrimation Urination Defecation/diarrhoea cardiovascular: hypotension, bradycardia also: small pupils, muscle fasciculation

Answer 228

atropine the role of pralidoxime is still unclear - meta-analyses to date have failed to show any clear benefit

Answer 229

activated charcoal if ingested < 1 hour ago N-acetylcysteine (NAC) liver transplantation

Answer 230

urinary alkalinization with IV bicarbonate haemodialysis

Answer 231

Flumazenil The majority of overdoses are managed with supportive care only due to the risk of seizures with flumazenil. It is generally only used with severe or iatrogenic overdoses.

Answer 232

IV bicarbonate may reduce the risk of seizures and arrhythmias in severe toxicity arrhythmias: class 1a (e.g. Quinidine) and class Ic antiarrhythmics (e.g. Flecainide) are contraindicated as they prolong depolarisation. Class III drugs such as amiodarone should also be avoided as they prolong the QT interval. Response to lignocaine is variable and it should be emphasized that correction of acidosis is the first line in management of tricyclic induced arrhythmias dialysis is ineffective in removing tricyclics

Answer 233

mild-moderate toxicity may respond to volume resuscitation with normal saline haemodialysis may be needed in severe toxicity sodium bicarbonate is sometimes used but there is limited evidence to support this. By increasing the alkalinity of the urine it promotes lithium excretion

Answer 234

Vitamin K, prothrombin complex

Answer 235

Vitamin K Prothrombin complex

Answer 236

if bradycardic then atropine in resistant cases glucagon may be used

Answer 237

fomepizole Can use ethanol as well

Answer 238

fomepizole or ethanol haemodialysis

Answer 239

Digoxin-specific antibody fragments

Answer 240

Desferrioxamine, a chelating agent

Answer 241

Dimercaprol, calcium edentate

Answer 242

Hydroxocobalamin; also combination of amyl nitrite, sodium nitrite, and sodium thiosulfate

Answer 243

CNS: agitation, tremor, anxiety, confusion, somnolence, syncope, hallucinations, changes in perception, acute psychosis, nystagmus, convulsions and coma. Cardiac: tachycardia, hypertension, chest pain, palpitations, ECG changes. Renal: acute kidney injury. Muscular: hypertonia, myoclonus, muscle jerking and myalgia. Other: cold extremities, dry mouth, dyspnoea, mydriasis, vomiting and hypokalaemia

Answer 244

Blocks the uptake of dopamine, noradrenaline and serotonin

Answer 245

coronary artery spasm → myocardial ischaemia/infarction both tachycardia and bradycardia may occur hypertension QRS widening and QT prolongation aortic dissection

Answer 246

seizures mydriasis hypertonia hyperreflexia

Answer 247

agitation psychosis hallucinations

Answer 248

ischaemic colitis is recognised in patients following cocaine ingestion. This should be considered if patients complain of abdominal pain or rectal bleeding hyperthermia metabolic acidosis rhabdomyolysis

Answer 249

- benzodiazepines -if with chest pain add GTN hypertension: benzodiazepines + sodium nitroprusside

Answer 250

neurological: agitation, anxiety, confusion, ataxia cardiovascular: tachycardia, hypertension hyponatraemia this may result from either syndrome of inappropriate ADH secretion or excessive water consumption whilst taking MDMA hyperthermia rhabdomyolysis

Answer 251

supportive dantrolene may be used for hyperthermia if simple measures fail

Answer 252

Amoxicillin Tetracycline Clarithromycin

Answer 253

Amoxicillin (Doxycycline or clarithromycin in penicillin allergic, add flucloxacillin if staphylococci suspected e.g. In influenza)

Answer 254

Clarithromycin

Answer 255

Within 5 days of admission: co-amoxiclav or cefuroxime More than 5 days after admission: piperacillin with tazobactam OR a broad-spectrum cephalosporin (e.g. ceftazidime) OR a quinolone (e.g. ciprofloxacin)

Answer 256

Nitrofurantoin or trimethoprim Alternative amoxicillin or cephalosporin

Answer 257

Broad-spectrum cephalosporin or quinolone

Answer 258

Quinolone or trimethoprim

Answer 259

Topical hydrogen peroxide, oral flucloxacillin or erythromycin if widespread

Answer 260

Flucloxacillin (clarithromycin, erythromycin or doxycycline if penicillin-allergic)

Answer 261

Co-amoxiclav (clarithromycin, + metronidazole if penicillin-allergic)

Answer 262

Flucloxacillin* (clarithromycin, erythromycin or doxycycline if penicillin-allergic)

Answer 263

Co-amoxiclav (doxycycline + metronidazole if penicillin-allergic)

Answer 264

Flucloxacillin

Answer 265

Phenoxymethylpenicillin (erythromycin alone if penicillin-allergic)

Answer 266

Phenoxymethylpenicillin

Answer 267

Amoxicillin (erythromycin if penicillin-allergic)

Answer 268

Flucloxacillin (erythromycin if penicillin-allergic)

Answer 269

Amoxicillin

Answer 270

Metronidazole

Answer 271

Intramuscular ceftriaxone

Answer 272

Doxycycline or azithromycin

Answer 273

Oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline and oral metronidazole

Answer 274

Benzathine benzylpenicillin Doxycycline Erythromycin

Answer 275

Oral or topical metronidazole Topical clindamycin

Answer 276

First episode: oral vancomycin Second or subsequent: oral fidaxomicin

Answer 277

Clarithromycin

Answer 278

Ciprofloxacin

Answer 279

Ciprofloxacin

Answer 280

- common, usually caused by oesophageal varicose or peptic ulcer disease

Answer 281

- haematemesis the most common presenting feature often bright red but may sometimes be described as 'coffee gound' melena the passage of altered blood per rectum typically black and 'tarry' a raised urea may be seen due to the 'protein meal' of the blood features associated with a particular diagnosis e,g, oesophageal varices: stigmata of chronic liver disease peptic ulcer disease: abdominal pain

Answer 282

Usually a large volume of fresh blood. Swallowed blood may cause melena. Often associated with haemodynamic compromise. May stop spontaneously but re-bleeds are common until appropriately managed.

Answer 283

Small volume of fresh blood, often streaking vomit. Malena rare. Often ceases spontaneously. Usually history of antecedent GORD type symptoms.

Answer 284

Usually small volume of blood, except as a preterminal event with erosion of major vessels. Often associated symptoms of dysphagia and constitutional symptoms such as weight loss. May be recurrent until malignancy managed.

Answer 285

Typically brisk small to moderate volume of bright red blood following a bout of repeated vomiting. Malena rare. Usually ceases spontaneously.

Answer 286

Small low volume bleeds are more common so would tend to present as iron deficiency anaemia. Erosion into a significant vessel may produce considerable haemorrhage and haematemesis.

Answer 287

Frank haematamesis or altered blood mixed into vomit Usual prodromal features of dyspepsia and constitutional bleeding Amount of bleeding variable but erosion of major vessel may produce considerable haemorrhage.

Answer 288

Often no prodromal features prior to haematemesis and melena, but this arteriovenous malformation may produce quite a considerable haemorrhage and may be difficult to detect endoscopically

Answer 289

Usually haematemesis and epigastric discomfort. Usually there is an underlying cause such as recent NSAID usage. Large volume haemorrhage may occur with considerable haemodynamic compromise

Answer 290

These are usually posteriorly sited and may erode the gastroduodenal artery. However, ulcers at any site in the duodenum may present with haematemesis, melena and epigastric discomfort. The pain of a duodenal ulcer is slightly different to that of gastric ulcers and often occurs several hours after eating. Periampullary tumours may bleed but these are rare.

Answer 291

In patients with previous abdominal aortic aneurysm surgery aorto-enteric fistulation remains a rare but important cause of major haemorrhage associated with high mortality.

Answer 292

NICE guidelines 2012 the Glasgow-Blatchford score at first assessment helps clinicians decide whether patient patients can be managed as outpatients or not the Rockall score is used after endoscopy provides a percentage risk of rebleeding and mortality includes age, features of shock, co-morbidities, aetiology of bleeding and endoscopic stigmata of recent haemorrhage

Answer 293

Patients may be considered for an early discharge

Answer 294

ABC, wide-bore intravenous access * 2 platelet transfusion if actively bleeding platelet count of less than 50 x 10*9/litre fresh frozen plasma to patients who have either a fibrinogen level of less than 1 g/litre, or a prothrombin time (international normalised ratio) or activated partial thromboplastin time greater than 1.5 times normal prothrombin complex concentrate to patients who are taking warfarin and actively bleeding

Answer 295

should be offered immediately after resuscitation in patients with a severe bleed all patients should have endoscopy within 24 hours

Answer 296

NICE do not recommend the use of proton pump inhibitors (PPIs) before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding although PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy if further bleeding then options include repeat endoscopy, interventional radiology and surgery

Answer 297

terlipressin and prophylactic antibiotics should be given to patients at presentation (i.e. before endoscopy) band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures

Answer 298

-ABC response then endoscopy - may need blood transfusion correct clotting: FFP, vitamin K, platelet transfusions may be required Vasoactive treatment: telipressin - Octreotide can be used although evidence shows telepressin is better Prophylactic IV antibiotics

Answer 299

Used if original methods of managment fail connects the hepatic vein to the portal vein exacerbation of hepatic encephalopathy is a common complication

Answer 300

- propanalol - Endoscopic variceal band ligation (EVL) -TIPSS used if above doesn’t work

Answer 301

- unilateral dilated pupil - sluggish or fixed to light response

Answer 302

Pupils bilaterally dilated Light response sluggish or fixed

Answer 303

Unilateral dilated or equally dilated Cross reactive (Marcus Gunn light response)

Answer 304

Bilaterally constricted pupil Light response may be difficult to assess

Answer 305

chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)

Answer 306

-6-12 hours: tremor, sweating, tachycardia, anxiety -peak incidence of seizures at 36 hours -peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia

Answer 307

-twist of the spermatic cord resulting in testicular ischaemia and necrosis. -most common in males aged between 10 and 30 (peak incidence 13-15 years)

Answer 308

-pain is usually severe and of sudden onset -the pain may be referred to the lower abdomen nausea and vomiting may be present -on examination, there is usually a swollen, tender testis retracted upwards. -The skin may be reddened cremasteric reflex is lost elevation of the testis does not ease the pain (Prehn's sign)

Answer 309

treatment is with urgent surgical exploration if a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral.

Answer 310

Thought to be caused by antibodies reacting with white cell fragments in the blood product and cytokines that have leaked from the blood cell during storage

Answer 311

Fever, chills Red cell transfusion (1-2%) Platelet transfusion (10-30%)

Answer 312

Slow or stop the transfusion Paracetamol Monitor

Answer 313

Thought to be caused by foreign plasma proteins

Answer 314

Thought to be caused by foreign plasma proteins Pruritus, urticaria

Answer 315

Temporarily stop the transfusion Antihistamine Monitor

Answer 316

Can be caused by patients with IgA deficiency who have anti-IgA antibodies

Answer 317

Hypotension, dyspnoea, wheezing, angioedema.

Answer 318

Stop the transfusion IM adrenaline ABC support oxygen fluids

Answer 319

ABO-incompatible blood e.g. secondary to human error

Answer 320

Fever, abdominal pain, hypotension

Answer 321

Stop transfusion Confirm diagnosis check the identity of patient/name on blood product send blood for direct Coombs test, repeat typing and cross-matching Supportive care fluid resuscitation

Answer 322

xcessive rate of transfusion, pre-existing heart failure

Answer 323

Pulmonary oedema, hypertension

Answer 324

Slow or stop transfusion Consider intravenous loop diuretic (e.g. furosemide) and oxygen

Answer 325

Non-cardiogenic pulmonary oedema thought to be secondary to increased vascular permeability caused by host neutrophils that become activated by substances in donated blood

Answer 326

Hypoxia, pulmonary infiltrates on chest x-ray, fever, hypotension

Answer 327

Stop the transfusion Oxygen and supportive care

Answer 328

13-17%, albeit many survivors experience long-term disability.

Answer 329

10% of individuals who experience cardiac arrest outside of a hospital setting survive, while the reported overall success rate of CPR ranges from 5% to 20%.

Answer 330

* 10% of individuals who experience cardiac * overall success rate of CPR ranges from 5% to 20%.

Answer 331

Contralateral hemiparesis and sensory loss, lower extremity > upper

Answer 332

Contralateral hemiparesis and sensory loss, upper extremity > lower Contralateral homonymous hemianopia Aphasia

Answer 333

Contralateral homonymous hemianopia with macular sparing Visual agnosia

Answer 334

Ipsilateral CN III palsy Contralateral weakness of upper and lower extremity

Answer 335

Ipsilateral: facial pain and temperature loss Contralateral: limb/torso pain and temperature loss Ataxia, nystagmus

Answer 336

Symptoms are similar to Wallenberg's ), but: Ipsilateral: facial paralysis and deafness

Answer 337

Amaurosis fugax

Answer 338

'Locked-in' syndrome

Answer 339

present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia strong association with hypertension common sites include the basal ganglia, thalamus and internal capsule

Answer 340

Used to identify strokes in emergency settings. Key symptoms (1 point each): Asymmetrical facial/arm/leg weakness Speech disturbance Visual field defect Exclude: Loss of consciousness or seizure activity (-1 point each) Scoring: ≥1: Stroke likely → Urgent action needed <1: Stroke less likely

Answer 341

Non-contrast CT head scan

Answer 342

Severe systemic reaction to staphylococcal exotoxins, the TSST-1 superantigen toxin. Prominence in the early 1980s following a series of cases related to infected tampons.

Answer 343

fever: temperature > 38.9ºC hypotension: systolic blood pressure < 90 mmHg diffuse erythematous rash desquamation of rash, especially of the palms and soles involvement of three or more organ systems: e.g. gastrointestinal (diarrhoea and vomiting), mucous membrane erythema, renal failure, hepatitis, thrombocytopenia, CNS involvement (e.g. confusion)

Answer 344

removal of infection focus (e.g. retained tampon) IV fluids IV antibiotics

Answer 345

gradually decrease in bone mineral density, so increase likelihood of fragility Fractures are more likely due to fragility.

Answer 346

more common in females than in males. 25% of women will have developed osteoporosis by the age of 80 . The prevalence of vertebral osteoporotic fractures is difficult to determine

Answer 347

advancing age Previous history of a fragility fracture Frequent or prolonged use of glucocorticoids History of falls Family history of hip fracture ow BMI (< 18.5) Tobacco smoking High alcohol intake: > 14 units/week for women, > 21 units/week for men

Answer 348

Loss of height: vertebral osteoporotic fractures of lead to compression of the spinal vertebrae hence a reduction in overall length of the spine and thus the patient becomes shorter Kyphosis (curvature of the spine) Localised tenderness on palpation of spinous processes at the fracture site

acute and emergency Flashcards

presentation and conditions (379 cards)