ASSCC 2

Question 1

Define DIC:

Answer 1

Pathological consumptive coagulopathy, due to activation of both the coagulation and fibrinolytic systems, leading to formation of micro thrombi in many organs and consumption of clotting factors and platelets

Question 2

Treatment of DIC:

Answer 2

FFP
Platelets
Cryprecipitate

Question 3

Shelf life of platelets:

Answer 3

5 days

Question 4

Indication for platelet infusion:

Answer 4

• Platelet loss/consumption/dysfunction

- Thrombocytopenia <50 x 10^9

Question 5

3 stages of haemostasis:

Answer 5

1) Vasoconstriction
- SMC contraction via local reflex, thromboxane A2 and serotonin released from activated plts
2) Platelet activation
- Adherence, aggregation and thrombin plug
3) Coagulation
- Intrinsic + extrinsic pathway: fibrinogen –> fibrin

Question 6

Definition of massive blood transfusion:

Answer 6

1) Replacement of >1 blood volume in <24hrs
2) >50% of blood volume in 4 hrs
3) In children: Transfusion of >40ml/kg

Question 7

6 Complications of massive blood transfusion:

Answer 7

1) Hypothermia
2) Fluid overload
3) ARDS / TRALI
4) Electrolyte disturbance - hyperkalaemia + hypocalcaemia
5) Thrombocytopenia
6) Coagulopathy

Question 8

3 Intraoperative measures to reduce blood loss:

Answer 8

1) Cell saver machine
2) Hypotensive technique
3) Good haemostasis

Question 9

4 early post-op complications of AAA repair:

Answer 9

1) Colonic ischaemia
2) Renal failure
3) Sexual dysfuction
4) Spinal cord ischaemia

Question 10

1st degree burn:

Answer 10

Epidermis

Red, painful, mild swelling

Question 11

2nd degree burn:

Answer 11

Papillary region of dermis

White/red, intense pain, severe swelling, blisters, spares hair follicles/sweat glands

Question 12

3rd degree burn:

Answer 12

Reticular region of dermis

White, relatively painless, leathery

Question 13

Define ARDS:

Answer 13

Acute Respiratory Distress Syndrome

Diffuse alveolar damage + lung capillary endothelial injury

Question 14

Diagnosis of ARDS:

Answer 14

1) CXR: Diffuse bilateral pulmonary infiltrates, not fully explained by effusion/fluid overload/lung collapse
2) Pulmonary artery capillary wedge pressure < 18mmHg
3) PaO2 / FiO2 < 26.6 kPa

Question 15

Resp support for ARDS:

Answer 15

• Low tidal volume
• Moderate PEEP
• Prone position
• High frequency oscillation
• ECMO for refractory hypoxaemia

Question 16

Pharmacological support for ARDS:

Answer 16

• Low dose steroids
• Inhaled nitric oxide/prostacyclin
• Antibiotics

Question 17

Difference between tension and simple pneumothorax:

Answer 17

In tension:

1) Trachea and mediastinum shifted to opposite side
2) Tachycardia and hypoxia
3) Emergency requiring urgent needle thoracostomy then tube thoracostomy
4) Continuous entry of air through one way valve

Question 18

Borders of safe triangle for chest drain insertion:

Answer 18

1) Lat border of pec major
2) Lat border of lat dorsi
3) Line drawn from nipple backwards

Question 19

6 indications of central line insertion:

Answer 19

1) Monitoring of fluid balance and fluid resuscitation
2) TPN
3) Certain fluids and medications ie chemo
4) Failed peripheral venous access
5) Haemodialysis
6) Transvenous cardiac pacing

Question 20

Complications of CVL insertion:

Answer 20

1) Infection
2) Thrombosis
3) Arterial puncture: haemorrhage, pseudoaneursym, haemothorax
4) Pneumothorax
5) Left IJV: chylothorax
6) Perforation of RA -> cardiac tamponade
7) Arrhythmias

Question 21

Post CVL insertion CXR for:

Answer 21

1) Tip in SVC just superior to RA

2) Pneumothorax

Question 22

Anatomical landmarks for CVL in IJV:

Answer 22

1) Mastoid process
2) Carotid pulse
3) 2x heads of sternocleidomastoid

Question 23

How to remove CVL in IJV?

Answer 23

Head down

- Prevent air embolism

Question 24

Sites for inserting CVL:

Answer 24

1) IJV
2) Subclavian
3) Femoral
4) PICC

Question 25

Most likely organisms to cause line infection in CVL:

Answer 25

1) Staph epidermidis 2) Staph aureus 3) MRSA

Question 26

5 sterile barrier precautions while inserting CVL:

Answer 26

1) Sterile gloves 2) Sterile gown 3) Hat 4) Drape 5) Mask

Question 27

3 layers of adrenal cortex + hormones produced:

Answer 27

1) Zona glomerulosa: mineralocorticoids, aldosterone 2) Zona fasciculata: glucocorticoids, cortisol 3) Zona reticularis: androgens

Question 28

Actions of cortisol on carbs, proteins and fats:

Answer 28

``` Carbs: - Antagonises insulin = hyperglycaemia - Stimulates gluconeogenesis Proteins: - Stimulates AA uptake and protein synthesis in liver - Inhibits AA uptake in peripheral tissues Fats: - Stimulates lipolysis ```

Question 29

How do corticosteroids affect bone?

Answer 29

1) Directly inhibit osteoblast activity 2) Direct stimulation of bone resorption 3) Inhibit calcium absorption in GIT 4) Stimulates calcium loss in kidneys 5) Inhibits sex steroids

Question 30

4 General actions of cortisol:

Answer 30

1) Anti-inflammatory 2) Mineralocorticoid actions 3) Metabolic effects 4) Control of stress response

Question 31

Side effects of long term corticosteroids:

Answer 31

1) Cushingoid features 2) CVS: HTN, fluid retention 3) MSK: proximal myopathy, AVN, osteoporosis 4) Endocrine: Diabetes 5) Opportunistic infections

Question 32

6 steps in hypo-pit-adrenal axis:

Answer 32

1) Hypothalamus releases 2) CRH 3) Anterior pituitary releases 4) ACTH 5) Adrenal cortex releases 6) ) Cortisol

Question 33

9 Advice to patients starting steroid:

Answer 33

1) Don't stop them suddenly 2) Tell Dr that you take steroids - consider med-alert bracelet/card 3) May weaken bones ^risk fractures 4) May ^blood glucose and cause diabetes 5) May ^ weight 6) May ^ risk infections, delayed wound healing 7) ^ risk of peptic ulcers: do not take NSAIDs 8) May cause mood changes 9) May cause muscle weakness

Question 34

Causes Addisonian crisis:

Answer 34

1) Addison's disease 2) Trauma 3) Surgery 4) Sudden stopping of steroid medication 5) Infection

Question 35

5 cardinal features of addisonian crisis:

Answer 35

1) Abdominal pain 2) Nausea/vomiting 3) HypOnatraemia, hypERkalaemia 4) Unexplained shock