Anaesthetics I Flashcards Preview

► Med Misc 36 > Anaesthetics I > Flashcards

Flashcards in Anaesthetics I Deck (68):
1

Malignant hyperpyrexia syndrome complication

General anaesthetic

Malignant hyperpyrexia is most likely to be secondary to the use of volatile anaesthetic agents.

2

Reduced variability cardiotocograph.

Intramuscular pethidine

Pethidine, other opiates and some anti-hypertensives (alpha methyldopa and labetalol) reduce CTG variability.

3

Severe headache

Spinal anaesthetic

In spinal anaesthesia the needle (25G or smaller pencil point - Whitacre or Sprotte - needle which parts dura rather than tears it) goes through the dura while in an epidural it is supposed to inject around the dura but may inadvertently penetrate the dura.

Postdural puncture headache appears to be higher in association with spinal (3%) than epidural (1%).

4

Aspiration syndrome

General anaesthetic

5

Sudden maternal hypotension

Epidural
Maternal hypotension is more likely to be due to dural penetration during an epidural anaesthetic as this is the generally intended procedure.


6

At 3 am you are called to see a man who complains of a painful, swollen calf three days after an abdomino-perineal resection of the rectum. On examination his leg is hot, the calf is swollen and tender but there are good palpable pulses. Active movement is still present.

LMWH

Therapeutic level heparinisation. Clinically this man has a deep vein thrombosis which does occur after surgery in the lithotomy position despite all standard preventative measures. At 3 am you will be very unlikely to get confirmation of your diagnosis and so treatment should be initiated while waiting for an urgent duplex scan. Early treatment is essential to reduce the risk of clot propagation and pulmonary emboli.

7

Forty-eight hours after a femoro-distal bypass graft for critical limb ischaemia, the nurses note the operated leg is swollen and blistered. The patient has no pain and can move his foot. A palpable pulse is still present in the graft, the leg is warm, sensation is normal and there is no muscle tenderness.

elevation
This limb is swollen due to a reperfusion phenomenon. The limb requires elevation to allow increased venous/lymphatic drainage. If left dependant, swelling will increase and the risk is that suture lines will give way, resulting in graft exposure.

A DVT rarely occurs after vascular surgery. Compartment syndrome - the extreme form of reperfusion injury - usually occurs acutely in the first 24 hours after surgery. There is pain, swelling and usually muscle tenderness. Loss of sensation and function follow if left untreated. The presence of a pulse does not exclude the diagnosis. The treatment is immediate fasciotomy.

8

Five days post abdominal aortic aneurysm repair a 72-year-old man complains of shortness of breath.
On examination he has decreased breath sounds at both bases and a temperature of 38.2°C.
White cell count 13.6 ×106/L
pO2 10.1 kPa
pCO2 4.5 kPa
pH 7.4

Chest infection

Aortic surgery often leads to diaphragmatic splintage, basal atelectasis, and subsequent infection.

His temperature and WBC (but not PaCO2) would also be consistent with SIRS but he has chest signs so this would be sepsis - SIRS in the presence of infection.

Aggressive physiotherapy, sitting out and early mobilisation are methods of avoiding this, but once established treatment should be with antibiotics, physiotherapy, humidified oxygen, urgent culture of both blood and sputum to ensure that the organism is treated before it can infect the graft.

9

Seventy-two hours post left hemicolectomy a 69-year-old male smoker complains of chest pain associated with shortness of breath. On examination he has full air entry in his chest. Full blood count, U&E and troponin have been sent.
His observations reveal the following.
Pulse 110 bpm, regular
Blood pressure 100/75 mmHg
Respiratory rate 32
Temperature 36.5°C
pO2 8.1 kPa
pCO2 3.2 kPa
pH 7.5

PE

With the information currently available you have to treat as a PE, because he is hypoxic despite his tachypnoea with low pCO2 and is apyrexial.

Treatment with supplemental oxygen and heparin should begin whilst waiting for FBC, U&E and troponin to become available.

A chest x ray and ECG should be performed, and if PE remains the most likely diagnosis a CT pulmonary angiogram/VQ scan should be performed.

10

A 62-year-old male undergoing an elective right hemicolectomy following the induction of anaesthetic.

The correct answer is Intermittent positive pressure ventilation (IPPV)
This patient will require administration of muscle relaxants to perform the abdominal surgery. The muscle relaxant will produce narcotic-induced apnoea thus the patient will require tracheal intubation and IPPV. The IPPV allows good relaxation with control of the patient’s oxygenation and elimination of carbon dioxide.

11

A 75-year-old male has under gone an emergency repair of a leaking infrarenal abdominal aortic aneurysm. Following the procedure he was transferred to the intensive care unit ventilated. He has been stable since the procedure and it has therefore been decided to wean him from the ventilator.

The correct answer is Synchronised intermittent mandatory ventilation (SIMV)

The transition from controlled mandatory ventilation to other modes allowing some patient input into ventilation is not an exact science. However, the most common initial step down modes is SIMV. CPAP and PEEP are usually introduced as the patient becomes more conscious.

12

A 19-year-old male presented to the emergency department unconscious following a collision between his motorcycle and an oncoming car. He required a right thoractomy and laparotomy to control bleeding. The patient was transfused 20 units of blood and developed severe inflammatory response syndrome (SIRS). Despite aggressive ventilation, his PaO2 began to drop.

The correct answer is Extracorporeal membrane oxygenation (ECMO)

Extracorporeal membrane oxygenation/extracorporeal life support which involves veno-venous cardiopulmonary bypass may be considered if the patient is deteriorating despite aggressive ventilation. However, no prospective randomised controlled trials in adults have shown an improved survival.

13

A 19-year-old man is admitted to the emergency unit following an assault outside a local nightclub. On examination the trachea is deviated to the right, he has low oxygen saturation, is apyrexial and the left chest is hyper-resonant with no breath sounds.

Tension pneumothorax results when the wound in the parietal pleura seals but air continues to escape from the lung, then tension inside the pleura space rises. Eventually the lung on the affected side collapses completely, and as the volume of air in the pleural cavity continues to increase the mediastinum and the trachea are progressively shifted to the other side, resulting in reduced venous return.

Tension pneumothorax is diagnosed clinically by respiratory distress, tracheal deviation to the contralateral side, absence of breath sounds on the ipslateral side +/- distension of the neck veins. Treatment is immediate needle decompression followed by a chest drain.

14

A 65-year-old man with known chronic obstructive pulmonary disease is noted to have a large left chest radio-opacity, with the mediastinum displaced to the right and the diaphragm flattened on the left on chest radiograph.

Pleural effusion
Pleural effusion. Small effusions may only produce blunting of the costo-phrenic angles. A large effusion can result in lung compression and the radiographic signs described.

Pleural effusions fall into two categories>

1. Transudate - malignancy, congestive cardiac failure, cirrhosis
2. Exudate - infection, iatrogenic, malignancy.

15

A 25-year-old motorist sustained a blunt injury to abdomen in a single car collision with a tree. He is shocked and on examination is found to have diminished chest movements on the left, impaired chest wall resonance on the left and abnormal sounds heard on auscultation of the left chest. On the chest radiograph there is an unusual gas filled structure.

Diaphragmatic rupture.
Diaphragmatic ruptures resulting from blunt trauma are usually large and radial. These large tears are usually on the left and allow easy herniation of the abdominal viscera.

Presentation is

1. Immediate - the patient presents with shock, pain, haemoperitoneum and/or haemothorax.
2. Delayed - effects are due to migration of the abdominal viscera into the thorax.

The diagnosis is confirmed by a coiled NG tube in the left thorax on chest radiograph or by CT. Treatment is urgent laparotomy +/- thoracotomy and repair of hernia.

16

A 25-year-old motorcyclist was involved in a collision with another vehicle. He complains of back pain, and on examination he is found to be hypotensive and tachycardic, with a marked deformity of the right lower limb. He has normal sensation in both lower limbs.


Hypovolaemic. This young man is most likely to be hypovolaemic from extensive blood loss from a femoral fracture. The back pain may be due to a retroperitoneal haematoma, which may also explain his hypovolaemia.

17

A 42-year-old woman is found to be tachycardic, normotensive, is warm with well perfused peripheries. Forty eight hours earlier she underwent an insertion of a ureteric stent for symptomatic renal calculi.

Septic
Septic. This woman has developed sepsis and is now becoming shocked. The haemodynamic response to sepsis is a fall in systemic vascular resistance due to the loss of vascular tone and vasodilatation; this results in a reduced cardiac afterload and a reflex increase in cardiac output. Initially blood pressure is maintained but eventually falls due to falling systemic vascular resistance.

18

A 19-year-old man has sustained a penetrating injury to the anterior chest, on examination he is tachycardic, hypotensive (80/40 mmHg) and has a raised jugular venous pressure (JVP), and muffled heart sounds on auscultation.

Cardiac tamponade

The history suggests cardiac involvement. The signs all point to cardiac tamponade. With blood in the pericardial space the cardiac output will fall, there will be muffled heart sounds and there will be raised JVP due to back pressure which, classically, rises with inspiration (Kussmaul's sign).

19

Kussmaul's sign

Raised JVP due to back pressure which, classically, rises with inspiration

20

A 65-year-old man complains of chest pain. On examination he is tachycardic, hypotensive and has a raised jugular venous pressure with no narrowing of pulse pressure, and normal heart sounds. He is also noted to have cold peripheries.


Cardiogenic shock

Cardiogenic shock shares many features of hypovolaemic shock, although there is no loss of volume, the failing myocardium results in a fall in cardiac output and a catecholamine induced vasoconstriction resulting in cold peripheries.

21

Produces prompt but short-lasting analgesia; it is less constipating than morphine, but even in high doses is a less potent analgesic.

Pethidine
It is used for moderate to severe pain; obstetric analgesia; and peri-operative analgesia.

22

Used for breakthrough pain in patients already receiving opioid therapy for chronic pain. Commonly applied in a patch form. A WHO class 4 analgesic.

Fentanyl
Side-effects include local reactions such as

Rash
Erythema
Itching.

23

A WHO class 1 analgesic that is converted to a toxic metabolite, N-acetyl-p-benzoquinoneimine, which is inactivated by conjugation to reduced glutathione.

Paracetamol
This is used for mild to moderate pain and whilst side effects are rare, they include rashes and blood disorders.

24

A WHO class 3 analgesic, which produces analgesia by two mechanisms:
An opioid effect
An enhancement of serotonergic and adrenergic pathways.

Tramadol
Side effects include

Nausea
Hypotension
Occasionally hypertension
Anaphylaxis
Hallucinations
Confusion.

25

Has both opioid agonist and antagonist properties, and may precipitate withdrawal symptoms, including pain, in patients dependent on other opioids.

Buprenorphine
This agent is particularly useful for

Moderate to severe pain
Peri-operative analgesia
Opioid dependence.
In patch form it can be used for moderate to severe cancer pain.

26

A 64-year-old man with dysphagia, dysarthria and right-sided hemiplegia secondary to a massive intracerebral bleed is admitted to the neuro-rehabilitation ward. It appears that he will need nutritional supplementation for a prolonged period.

PEG feeding
Enteral nutrition is the best route for nutritional support since it reduces the incidence of peptic ulceration, decreases liver and renal dysfunctions, decreases bacterial translocation from the gut and reduces the incidence of feeding line and other stoma related complications.

However, it is not possible or appropriate to institute or provide enteral nutrition in certain patients or medical/surgical conditions, as in short bowel syndrome or in oesophagectomy or gastrectomy.

Percutaneous endoscopic gastrostomy (PEG) is the preferred method to feed patients who are unable to eat or swallow food due to a debilitating condition such as stroke or cancer and thus requiring long term nutritional support. It also decompresses the stomach over a prolonged period of time.

27

A 26-year-old male involved in a high-speed road traffic accident is admitted to the neurosurgical ward with moderate head injury. His GCS was 9 on admission but now he is showing signs of gradual recovery.

Naso-enteric fine-bore feeding
Since this patient is recovering from a head injury, naso-enteric fine bore feeding is an appropriate method of nutritional support.

A 71-year-old woman is undergoing Lewis-Tanner procedure for stage 3 oesophageal carcinoma. She is not due to undergo chemo-radiation post-surgery since this surgical procedure is expected to be curative. She has, however, lost three stone in weight in the last few months, secondary to dysphagia and the malignancy. She needs long term nutritional support.

28

A 71-year-old woman is undergoing Lewis-Tanner procedure for stage 3 oesophageal carcinoma. She is not due to undergo chemo-radiation post-surgery since this surgical procedure is expected to be curative. She has, however, lost three stone in weight in the last few months, secondary to dysphagia and the malignancy. She needs long term nutritional support.

Jejunostomy feeding
This patient is undergoing a Lewis-Tanner procedure, where the affected segment of the oesophagus along with the tumour and the surrounding peri-oesophageal tissue with its adjacent lymph nodes are resected through a right-sided thoracotomy along with a laparotomy. A peri-operative jejunostomy is fashioned to feed these patients post-operatively.

29

A patient post retrosternal thyroidectomy resection has sudden onset shortness of breath.
On examination, she is talking clearly but has decreased breath sounds on her right side with hyper-resonance on percussion. Her blood pressure is 110/80 mmHg, pulse 95 beats per minute, respiratory rate 24/min and SpO2 92 on air.
Which of the following would be most appropriate for her initially?

CXR
According to the scenario above this lady has a pneumothorax.

She is not in extremis (suggesting a tension pneumothorax) so needle thoracocentesis is not required.

The history and examination are suggestive of a pneumothorax and therefore, with her being relatively stable, the most appropriate first step would be confirmation with chest x ray followed by chest drain insertion.

Furosemide would not help.

30

A 69-year-old man with hypertension is admitted with severe abdominal pain and a pulsatile abdominal mass.
His blood pressure is 80/50 mmHg, a pulse of 110 bpm and capillary refill time is 3 s.
His urea and electrolytes show:
Sodium 135 mmol/L (137-144)
Potassium 4.9 mmol/L (3.5-4.9)
Urea 18.2 mmol/L (2.5-7.5)
Creatinine 300 µmol/L (60-110)
Aims of resuscitation should be which of the following?

Resus to achieve systolic of 100mg

This man has a leaking aneurysm and needs immediate surgery to save his life (which may be open or endovascular).

Resuscitation should be ongoing as he is taken to theatre. The aim is to maintain blood pressure at systolics of around 100 mm Hg which should restore renal perfusion. This level is thought to minimize further bleeding by maintaining clot at the site of leak, whereas normal blood pressures will increase transmural pressures across the aneurysmal sac and cause further bleeding.

Patients with aneurysms should not be induced for intubation until in theatre with a surgeon ready to operate on a prepared and draped patient. Relaxation of the abdominal muscles can decrease the tamponading effect of the abdominal wall and result in sudden loss of cardiac output.

This man is highly likely to suffer from renal failure regardless of pre-operative measures.

31

Inform anaesthetist and continue therapy up to and after surgery if appropriate.

Antihypertensives

Most antihypertensive therapy can be continued up to surgery and re-introduced postoperatively. One will need carefully to monitor blood pressure postoperatively but generally these agents are once per day.

32

Discontinue and replace with subcutaneous/intravenous equivalent 48-72 hours before surgery.

Oral anticoagulants such as warfarin should be stopped at least 72 hours pre-operatively and replaced with therapeutic LMW SC heparin (or intravenous heparin) prior to the procedure.

33

Discontinue oral administration but replace with intravenous equivalent at induction.

Oral steroids

Hydrocortisone dose needs to be escalated prior to surgery with a bolus IV of 50-100 mg given at induction.

34

Discontinue one week before surgery.

Clopidogrel should be stopped one week before surgery. Aspirin does not need to be stopped.

35

Internal jugular vein anatomy I

On the right side crosses the first part of the subclavian artery

The anatomy of the jugular vein is important given that it is the site of insertion of central venous catheters.

The internal jugular vein originates at the jugular foramen.

It begins posterior to the internal carotid artery and then passes to its lateral side.

As it descends in the carotid sheath it lies lateral first to the internal then the common carotid artery within the carotid sheath.

It then passes anterior to the subclavian artery to join the subclavian vein to form the brachiocephalic vein.

The internal jugular vein receives a lymphatic trunk at its union with the subclavian vein.

The internal jugular vein is usually of considerable size, and the right internal jugular is usually larger than the left.

The external jugular vein drains into the subclavian vein.

36

Internal jugular vein anatomy II

Lies lateral to the common carotid artery

The internal jugular vein originates at the jugular foramen.

It initially lies posterior to the carotid artery, as it descends in the carotid sheath it lies lateral first to the internal then the common carotid artery within the carotid sheath.

It passes anterior to the subclavian artery to join the subclavian vein and then form the brachiocephalic vein; the left and right brachiocephalic veins unite to form the superior vena cava.

The internal jugular vein receives a lymphatic trunk at its union with the subclavian vein.

The external jugular vein drains into the subclavian vein.

37

subclavian vein

Begins at the lateral border of the first rib

The subclavian vein is a continuation of the axillary vein, beginning at the lateral border of the first rib.

It passes anterior to scalenus anterior.

The subclavian and internal jugular vein unite to form the brachiocephalic vein, subsequently the left and right brachiocephalic veins unite to form the superior vena cava.

The brachiocephalic trunk is a branch of the aortic arch, which divides to form the right subclavian and right common carotid arteries.

38

A 6-year-old female presents to the emergency department in status epilepticus of 30 minutes duration.
The airway is maintained using an oropharyngeal airway and high flow oxygen is delivered. Multiple attempts at venous cannulation are unsuccessful.
The blood glucose (BM) is 5.2 mmol/L (3.0-6.0).
Which of the following therapies would be most appropriately used in this patient to terminate the seizure activity?

Midazolam

The protocol for the majority of children in status epilepticus, in whom intravenous or intraosseous access is unsuccessful, is to give either buccal midazolam 0.5 mg/kg or rectal diazepam 0.5 mg/kg.

If these do not terminate the seizure then second line treatment is paraldehyde 0.4 ml/kg given PR.

Lorazepam and phenytoin should be given either intravenously or intraosseously.

Rapid sequence induction with thiopental is a final option.

39

Methane acronym

The METHANE acronym acts as a reminder of the key information to pass to control.

M is to announce that a Major incident is declared or should be brought to standby
E is the Exact location of the incident, ideally with a grid reference
T is the Type of incident
H the present and potential Hazards
A is Access or Approach routes
N is the Number of casualties (and type)
E is the Emergency services present and required

40

Fluids in children

The normal hourly intravenous fluid rate for children can be calculated from their body weight in kg.

For each kg up to the first 10 kg the rate is 4 ml / kg
For the next 10 kg (up to 20 kg) the rate is 2 ml / kg
For each kg body weight after 20 kg the rate is 1 ml / kg.
Thus an 18 kg child receives 56 ml / hour (40 ml for the first 10 kg and 16 ml for the next 8 kg), which is the same as 1344 ml / day (56 ml multiplied by 24 hours).

41

A 78-year-old male who presents with increasing dysphagia is diagnosed with an inoperable carcinoma of the distal oesophagus. Oesophageal spasm causes food to stick after swallowing which causes odynophagia.
Which drug would be most helpful in relieving his chronic pain?

Nifedipine

Nifedipine helps relieve painful oesophageal spasm and tenesmus associated with gastrointestinal tumours and could be used to relieve his odynophagia.

Clodronate inhibits osteoclastic bone resorption and is used to treat malignant bone pain and the associated hypercalcaemia.

Pinaverium is used to reduce the pain duration associated with irritable bowel syndrome (IBS).

Corticosteroids are used to treat pain from central nervous system tumours and painful bladder spasm may be relieved by oxybutynin.

42

A 30-year-old fit male becomes anuric following abdominal surgery.
Investigations reveal:
Serum urea 9.2 mmol/L (2.5-7.5)
Serum creatinine 120 μmol/L (60-110)
The blood pressure is 110/60 mmHg.
What is the next single most appropriate course of action in the management of the anuria?

1 L normal saline intravenously over one hour

This question deals with postoperative acute renal failure.

Note that even when the glomerular filtration rate is zero, the serum creatinine tends not to rise faster than 200 mmol/L per day - so the patient's creatinine of 120 mol/L may be the beginning of established renal failure.

Immediate management consists of restoring the circulation; debate still continues whether it is better to use colloid or crystalloid.

In this case it would seem to be more appropriate to use 1 L of normal saline, as there is a time limit as well.

If urine output and renal function recover as soon as intravascular volume is restored, the diagnosis of pre-renal uraemia is made; if they do not then the diagnosis is acute tubular necrosis (ATN).

In a seemingly cardiovascularly-well 30-year-old, giving 1 L over an hour will not precipitate any problems.

There is little evidence to suggest that loop diuretics and dopamine are effective in the treatment of ATN.

43

A 64-year-old man is admitted with central epigastric pain.
Abdominal x ray shows a central dilated bowel loop. His temperature is 37.0°C, pulse 130 beats per min, blood pressure 80/50 mmHg, respiratory rate 29/min and SpO2 90 on air.
His full blood count reveals:
Haemoglobin 13.0 g/dL (13.0-18.0)
White cell count 3.2 ×109/L (4-11)
Platelets 108 ×109/L (150-400)
MCV 105 fL (80-96)

Ischaemic bowel and perforated duodenal ulcer would be high in the differential list. However the history and raised mean corpuscular volume (MCV) suggests alcohol use and the severity of his observations would suggest a systemic inflammatory response which is more common with pancreatitis.

Acute pancreatitis has a mortality of 7-10%, often due to sepsis or multi-organ failure. There are a number of scoring systems which can be used to guide prognosis, but they are unreliable within the first 48 hours o f the illness. Gallstones account for 50% of cases, with the majority of the rest being associated with alcohol.

Patients typically present with severe epigastric pain which radiates to the back and vomiting. As seen in this example, there is often a systemic inflammatory response. Amylase is markedly raised, often in excess of four times the normal value. Early complications include ARDS (adult respiratory distress syndrome), acute kidney injury and disseminated intravascular coagulation (DIC).

Treatment is essentially supportive, and high levels of monitoring are usually required (often in the intensive care unit). Those patients who are found to have gallstones should be considered for emergency ERCP, and all should have a cholecystectomy during the same admission.

44

ECG Hypomagnesaemia

Prolonged QT interval

The changes in hypomagnesaemia may be indistinguishable from hypokalaemia. They include flattened T waves, widened QRS complexes, prolonged QT interval prolonged PR interval, small T waves and U waves.

45

ECG Pericarditis

ST elevation

Pericarditis is associated with concave upward ST segment elevation on the ECG, versus convex upward ST segment elevation in MI.

46

ECG Wolff-Parkinson-White disease

Delta waves
WPW is associated with an accessory bundle, which causes a delta wave (notch) preceding the QRS complex, giving the impression of a shorter PR interval. However, the delta wave is characteristic.

Other causes of prolonged QT include

Congenital prolonged QT (Lown-Ganong-Levine syndrome)
Hypocalcaemia
Drug therapy
Amiodarone
Sotalol.

47

A 14-year-old girl attends for removal of a facial naevus. On examination she has a blood pressure of 110/72 mmHg and a soft murmur at the second left intercostal space without any radiation.

Flow murmur
The 14-year-old provides a good description of a flow murmur where there is no radiation of the murmur, it appears to be over the pulmonary area and she is otherwise quite well.

48

A 13-year-old girl with Down’s syndrome is admitted for umbilical hernia surgery. On examination, she has typical features of Down’s syndrome, a blood pressure of 108/74 mmHg and a loud harsh systolic murmur best heard over the fourth left intercostal space.

Ventricular septal defect
Down's syndrome is associated with both atrial septal defects (AV canal defects) and ventricular septal defects. In this patients case, with her otherwise well condition, the normal blood pressure and the loud systolic murmur at the fourth left intercostal space suggests a small VSD so called Maladie de Roger.

49

A 73-year-old woman is admitted for left hip replacement. On examination, both cheeks appear rather ruddy, she has a blood pressure of 122/82 mmHg, a faint mid- diastolic murmur with no other sounds.

Mitral stenosis
The elderly woman with a mid-diastolic murmur associated with a malar flush suggests mitral stenosis. The absence of a pre-systolic click or loud first heart sound would suggest that the valve may be calcified.

50

Eisenmengers

Ventricular septal defect
Eisenmenger’s syndrome is the right to left shift associated with deteriorating pulmonary hypertension and RV overload in conditions such as large ventricular septal defects.

51

Ankylosing spondylitis

Aortic regurgitation
Ankylosing spondylitis like other sero-negative arthropathies is associated with aortic regurgitation more so than mitral regurgitation.

52

Syphilitic aortitis

Aortic regurgitation
Syphilitic aortitis is asscoaited with aortic aneurysmal formation and dilatation of the aortic ring with associated aortic regurgitation.

53

A 67-year-old man who is three days post-operation for a sigmoid colectomy. He has insulin dependent diabetes mellitus. He complains of dizziness and faintness.
His blood pressure is 80/50 mmHg, his pulse is 110 bpm, he has a respiratory rate 24/min, and he has SpO2 99% on air. His blood glucose is 18 mmol/l (3.06.0 fasting).
His electrocardiogram shows ST depression of 2 mm in leads II, III and AVF.
Which of the following is the initial drug therapy for this patient?
(Please select 1 option)
Aspirin 300 mg CorrectCorrect
Clexane 1 mg/kg subcutaneously
Clopidogrel 75 mg
Diamorphine 2.5 mg
Glycerol trinitrate 800 mcg sublingually

Initial treatment of an acute coronary syndrome is aspirin 300 mg. This should be safe in the post-surgical patient with no signs of bleeding at three days post operation. Clexane would also be given, but aspirin initially.

The dose of clopidogrel is 300 mg in an acute coronary syndrome.

Diamorphine is used to treat anxiety and pain, neither of which is commented upon.

GTN would be reasonable to try, however the blood pressure is low.

Remember that in the diabetic chest pain may not be a feature of acute coronary syndrome due to autonomic dysfunction, and in most post surgical patients myocardial infarct is silent.

54

A 67-year-old man complains of dizziness and faintness.
He has insulin dependent diabetes mellitus and he had a sigmoid colectomy 3 days previously . His blood pressure is 80/50 mmHg, his pulse 110 beats per min, his respiratory rate 24/min, and he has SpO2 99% on air. His plasma glucose concentration is 18 mmol/L (3.0-6.0 Fasting)

Which of the following is the most appropriate investigation for this patient?
(Please select 1 option)
Arterial blood gas
Chest x ray
Electrocardiogram CorrectCorrect
Serum Lactate
Urine ketones

This man may have a cardiac cause for his dizziness. The highest prevalence of myocardial infarction (MI) is 72 hours post operation.

Patients with diabetes may not have chest pain due to autonomic dysfunction. The differential diagnosis would include pulmonary embolus. It may also include diabetic ketoacidosis, but this would be unlikely with his glucose at 18 mmol/L and would not directly explain his hypotension. Also, he would be expected to have a slightly higher respiratory rate than 24/min.

The most appropriate immediate investigation in this scenario would be ECG.

55

A 74-year-old man with ischaemic heart disease is in the surgical high dependency unit following a Hartmann's procedure completed 12 hours previously..
He is in pain. He has drained 100/200/300 mls of blood into his drains in each of the last three hours. His blood pressure is 110/80 mmHg, his pulse 105/min. He has a respiratory rate 32/min, SpO2 100% on oxygen by face mask.
Crossmatched blood is available.
Haemoglobin 8.1 g/dL (13.0-18.0)
White cell count 4.5 ×109/L (4-11)
Platelets 132 ×109/L (150-400)
Which of the following is the next most appropriate intervention?
(Please select 1 option)
2 units of crossmatched packed red blood cells
1000 ml of crystalloid stat
Morphine 5 mg intravenously
1000 ml of colloid stat
Return to theatre

2 units of blood

He is still actively bleeding and haemodilution will not have been achieved so his Hb will be lower than the result given. It will take at least 30-60 minutes before he is back in theatre and anaesthetized (CEPOD lists/emergency sections/crash calls/no porter etc). With IHD he is at at high risk of a perioperative MI. He should have the blood first as crossmatched blood is available.

His observations could be caused by pain. However in the face of a falling haemoglobin, a rising pulse rate and an increasing loss into his drains this patient needs to return to theatre.

His blood pressure is not critically low and although many would give crystalloid or colloid it is reasonable in an elderly man with ischaemic heart disease to give blood if it is easily available. Overload with non-oxygen carrying fluid should be avoided (although the red cells are not functional for a while).

56

A 64-year-old man is admitted with central epigastric pain. Abdominal x ray shows a dilated bowel loop.
His temperature is 37.0°C, pulse 130 bpm, blood pressure 80/50 mmHg, respiratory rate 29/min, SpO2 90% on air.
His full blood count reveals:
Haemoglobin 13.0 g/dl (13.0-18.0)
White cell count 3.2 ×109/l (4-11)
Platelets 108 ×109/l (150-400)
MCV 105 fl (80-96)
Which of the following is the most appropriate initial treatment of this patient?
(Please select 1 option)
100% oxygen
2 × 14 gauge venflons and 2 litres Hartmann's
Intensive care
Intubation and ventilation
Invasive monitoring

Oxygen

This patient has systemic inflammatory response syndrome, possibly caused by acute pancreatitis given the finding of an isolated dilated loop of bowel on adbominal radiograph. However, the initial treatment is the same independent of the underlying cause.

All of the above answers are reasonable, however resuscitation of the sick patient still follows the ABC algorithm:

Airway
Breathing
Circulation
Airway control and oxygen to maintain normal saturations is the first part of that algorithm. Subsequent fluid resuscitation and treatment of the underlying cause can then be initiated. The need for invasive monitoring and intensive care is then assessed, depending on the response to initial treatment.

57

A 56-year-old man is admitted with epigastric pain after drinking heavily.
He has a temperature of 36.9°C, a pulse of 95/min, a blood pressure of 85/60 mmHg, and a respiratory rate of 32/min.
Investigations reveal:
Haemoglobin 12.6 g/dL (13.0-18.0)
Platelets 169 ×109/L (150-400)
White cell count 3.9 ×109/L (4-11)
Which of the following is the diagnosis?
(Please select 1 option)
Leaking aortic aneurysm
Multi-organ dysfunction syndrome (MODS)
Severe sepsis
Septic shock
Systemic inflammatory response syndrome (SIRS)

SIRS

This patient has features of pancreatitis. He also has hypotension, and leucopenia. He therefore fulfils the criteria for systemic inflammatory response syndrome. This is equivalent to sepsis, but occurs in the absence of infection (e.g. in pancreatitis).

SIRS is defined as two or more of the following:

Temperature more than 38°C or less than 36°C.
Heart rate more than 90 beats/min.
Respiratory rate more than 20 breaths/min or PaCO2 less than 4.3 kPa.
WBC count 12,000/mm3, less than 4000/mm3 , or more than 10% immature (bands) form.
A leaking aortic aneurysm is still a possibility, however a decreased white cell count would not be expected.

We do not have enough information to diagnose multi-organ dysfunction. There is no evidence of infection to make a diagnosis of septic shock or severe sepsis. For information, sepsis is defined as the association of systemic inflammatory responses with evidence of microbial origin. Severe sepsis also has hypoperfusion or dysfunction of at least one organ system, and septic shock is this plus hypotension refractory to fluid resuscitation.

58

A 47-year-old man presents with progressive right hand swelling two days after being bitten by a dog.
On examination there is a puncture wound with pus over the dorsum of the hand, cellulitis, ascending lymphangitis and tender axillary lymphadenopathy.
What is the most appropriate antibiotic therapy in this case?
(Please select 1 option)
Benzylpenicillin and flucloxacillin
Ceftriaxone
Ciprofloxacin
Co-amoxiclav CorrectCorrect
Erythromycin

Augmentin

Only 15 - 20% of dog bites become infected, and providing the wound is appropriately cleaned and not considered at risk (for example, crush or deep wounds) then antibiotic prophylaxis may not be required.

However, this patient has an infected wound and infective organisms include Pastuerella spp, Staph. aureus and anaerobes like Corynebacterium.

The most appropriate antibiotic therapy in dog bites associated with cellulitis would be co-amoxiclav.

59

A patient needs central venous access for total parenteral nutrition (TPN).
Which of the following is the cleanest site for placement?

Right or left subclavian is regarded as the cleanest site for central venous access. It also the most tolerated by patients.

However the incidence of subclinical pneumothorax even in the hands of experienced clinicians has led to it falling out of favour.

60

You are asked to see a 64-year-old man post-oversew of a duodenal ulcer. He is confused.
His SpO2 is 97 on oxygen. Pulse 110 beats per min, blood pressure 100/50 mmHg, respiratory rate 32/min and his urine output is 10 ml in the last hour.
Which of the following is the most appropriate treatment for this man?
(Please select 1 option)
100% oxygen via face mask
Central line and arterial line
Normal saline 500 ml stat
Haloperidol 2.5 mg intravenously
Noradrenaline via central line

Normal saline

Postoperative confusion is common in the elderly however this can be caused by a low perfusion state.

His observations are indicative of underfilling/dehydration. (He could also have atelectais or have developed a chest infection. Post-operative problems are often multifactorial.)

Of the options given a fluid bolus is appropriate. This is what you would expect your FY1 to do while waiting for the blood test results and before calling you.

Some would argue that 100% oxygen comes before fluids but with an SpO2 of 97 it is unlikely that hypoxia is contributing to his problems. (nonetheless oxygen therapy would be recommended).

The other options would come further down the line if initial interventions were unsuccessful and he deteriorated.

61

An 18-year-old with cerebral palsy is admitted after a respiratory arrest having been intubated by paramedics.
Nobody can gain intravenous access as the patient is too shut down. A femoral line is not possible due to contractures. You do not have the experience to perform central venous cannulation.

Which of the following is the best option for administering intravenous fluids/emergency drugs in this situation of inability to gain venous access?
(Please select 1 option)
Down the endotracheal tube
Intramuscular
Intraosseous
Nasogastric
Subcutaneous

Intraosseous

Nasogastric, intramuscular and subcutaneous are too slow and unreliable for emergency situations (although in cardiac arrest the endotracheal route is recognised). Venous cut down is a possibility but requires skill in the procedure.

Intraosseous is still perfectly viable in the adult patient 2 cm below the tibial tuberosity on the antero-medial side or 2 cm proximal to the medial malleolus.

62

A 56-year-old man with septic shock is fully ventilated, on continuous veno-venous haemofiltration receiving noradrenaline, vancomycin and ciprofloxacin.
He has a mean arterial pressure (MAP) of 60 mmHg which is then not improved after changing from noradrenaline to adrenaline. There is no evidence of myocardial dysfunction.
Which of the following would be the most appropriate next step in managing this patient?
(Please select 1 option)
ACTH stimulation test
Activated protein C
Change of inotropes
Hydrocortisone
Nitric oxide

Hydrocortisone

The Surviving Sepsis Campaign (a partnership of the Society of Critical Care Medicine, the European Society of Intensive Care Medicine, and the International Sepsis Forum) has teamed up with the Institute for Healthcare Improvement to develop severe sepsis bundles. A 'bundle' is a group of interventions related to a disease process that, when executed together, result in better outcomes than when implemented individually.

Sepsis Resuscitation Bundle:

Should begin immediately, but must be accomplished within the first six hours of presentation.

Serum lactate measured.
Blood cultures obtained prior to antibiotic administration.
From the time of presentation, broad-spectrum antibiotics administered within three hours for ED admissions and one hour for non-ED ICU admissions.
In the event of hypotension and/or lactate > 4 mmol/l (36 mg/dl):
Deliver an initial minimum of 30 ml/kg of crystalloid (or colloid equivalent).
Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg.
In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/l (36 mg/dl):
Achieve central venous pressure (CVP) of > 8 mm Hg.
Achieve central venous oxygen saturation (ScvO2) of > 70%.
Sepsis Management Bundle:

To be accomplished as soon as possible may be completed within twenty-four hours of presentation.

Steroids administered for septic shock in accordance with a standardised ICU policy. ACTH stimulation test not required prior to this.
Glucose control maintained > lower limit of normal, but

63

A 56-year-old man diagnosed with systemic inflammatory response syndrome (SIRS) secondary to pancreatitis is admitted to the High Dependency Unit. He has a pulse of 109 beats/min and a blood pressure of 89/74 mmHg despite receiving IV fluids and urine output of 25 ml/hour after catheterisation.
Which of the following is the most appropriate course of action for this patient?

Early goal-directed therapy (EGDT) in cases of SIRS or septic shock is becoming increasingly recognised as potentially beneficial. If fluids are not achieving haemodynamic stability, and there is indication of hypoperfusion as indicated by oliguria or lactataemia, then vigorous resuscitation is indicated.

EGDT aims to increase organ perfusion through restoration of mean arterial pressure using inotropes if necessary, maintaining central venous pressure (CVP), maintaining oxygenation, and using SjVO2 (jugular venous oxygen saturation) as a guide to oxygen utilisation at the tissue level. SjVO2 higher than 70% is indicative of organ hypoperfusion, as oxygen is not being extracted.

Insertion of a central line above allows measurement of CVP, SjVO2 and the use of inotropes.

64

A 34-year-old man with a known history of Crohn's disease was admitted to hospital with abdominal pain and features of perforation.
He underwent laparotomy and a perforation of the terminal ileum was found with free faecal fluid in the abdominal cavity. He was transferred to the intensive care unit (ITU).

Together with traditional antimicrobial and supportive ITU therapy, which of the following therapeutic measures is most likely to improve this patient's outcome?

(Please select 1 option)
High-dose intravenous corticosteroids
Low-dose intravenous corticosteroids
Recombinant anti-endotoxin antibody
Recombinant human antithrombin III
Recombinant human tissue-factor pathway inhibitor

The use of corticosteroids in sepsis remains controversial.

Meta-analyses of all the trials of high-dose steroids (for example, methylprednisolone 1 g) have confirmed that there is either no benefit, or even that there is an adverse effect in septic patients. However, more recent randomised controlled trials have suggested that there is a benefit in sepsis when lower physiological doses of steroids are given.

The precise mechanism is not fully understood, although it is well known that septic patients have low levels of endogenous steroids.

The production of recombinant human anticoagulants has gathered pace in recent years and several products have been tested. There have been randomised clinical trials of recombinant human antithrombin III (Kyber Sept trial), activated protein C (PROWESS trial) and tissue-factor pathway inhibitor ( OPTIMIST trial). Of these, only recombinant activated protein C has shown any significant survival benefit at 28 days. However, subsequent studies have failed to demonstrate a survival benefit, and have shown an increased bleeding risk. Activated protein C is therefore no longer recommended for the treatment of sepsis.

65

ECG hypothermia

J waves

Although prolonged PR and QT elongation are associated, J waves are pathognomonic of hypothermia.

66

ECG Hypocalcaemia

Prolonged QT interval
Other causes of prolonged QT include congenital prolonged QT (Romano-Ward syndrome, Jervell and Lange-Nielsen syndrome), hypocalcaemia and drug therapy such as amiodarone and sotalol.

67

ECG Pulmonary embolism

Right axis deviation

With pulmonary embolism, there is often a sinusus tachcardia with right heart strain. There is right axis deviation with the typical SI QIII TIII pattern. There may also be right bundle branch block.

68

ECG Hypokalaemia

U waves

The U wave becomes prominent with hypokalaemia.