Emergency Medicine ACC Flashcards
(221 cards)
1
Q
At what time should a troponin level be taken and at what time does it peak?
A
Troponin should be taken atleast 6 hours after the maximal onset of pain, peaks at 24-48 hours
2
Q
what is the difference between unstable angina and a NSTEMI?
A
Unstable angina = normal troponin
NSTEMI = rise in troponin
3
Q
What is the ECG criteria for a STEMI?
A
New or presumed new ST-segment elevation at the J point in 2 or more contiguous leads with the cut-off points of ≥0.2 mV in leads V1, V2, or V3 and ≥0.1 mV in other leads. Note: ST depressions in leads V1-V4 should be considered as a posterior STEMI.
4
Q
in which leads are the ECG changes inferior MI? (RCA)
A
leads II, III, avF
5
Q
in which leads are the ECG changes anterior MI?
A
leads V1-V4
6
Q
in which leads are the ECG changes lateral MI? (circumflex artery)
A
V5,V6, I and aVL
7
Q
What are the common ECG changes in a STEMI?
A
ST-segment elevation Pathological Q waves (>1mm) St-segment depression PR segment elevation/depression New bundle branch block Axis deviation T wave inversion T wave depression
8
Q
Which creatinine kinase enzyme is found in the heart and when does it peak?
A
CK-MB
48 hours
9
Q
Which investiagions are most appropriate in suspected MI?
A
ECG.
U&E, troponin, glucose, cholesterol, FBC
CXR
10
Q
What is the most appropriate treatment in a STEMI?
A
Aspirin + Clopidogrel/Tigagrelor Morphine (+antiemetic) GTN O2 Primary PCI or Fibrinolysis Anticoagulation - injectable anticoagulant in primary PC, if not give enoxaparin +/- GP IIb/IIIa blocker
11
Q
What is the most appropriate treatment in a NSTEMI?
A
Dual anti platelet therapy Anticoagulation - fondaparinox 2.5mg daily or enoxaparin Glycoprotein IIb/IIIa inhibitors Nitrates B-blockers - if increased HR ACEi Lipid management
12
Q
Which drugs are necessary in secondary prevention of MI?
A
ACEi
Dual anti platelet therapy = aspirin + 2nd anti platelet agent
Beta-blocker
Statin
13
Q
what type of drug is fondaparinux?
A
Factor Xa inhibitor
14
Q
What are the criteria for a massive PE?
A
Hypotension
Cardiac arrest
*require thrombolysis
15
Q
What are the criteria for a submassive PE?
A
Hypoxia
Cardiac ECHO or ECG feature of right heart strain]
Positive cardiac biomarkers (eg. troponin)
16
Q
Which score is used for risk stratification of pulmonary embolism after the diagnosis has been made?
A
PESI score: pulmonary embolism severity index. Use to classify and determine treatment/hospital stay.
If PE is confirmed but is not submissive or massive use PESI score to determine hospital stay
17
Q
What are the possible ECG changes seen in PE?
A
Sinus Tachycardia RBBB Right axis deviation (most common) S1Q3T3: prominent S wave in lead 1 A Q wave and inverted T wave in lead 3
18
Q
When is a D-dimer not useful?
A
After surgery
Trauma
Sepsis
Pregnancy
19
Q
In a well’s score for PE what is considered high risk and low risk scores??
A
Score >4
Do a CTPA
Score <4
Do a D-dimer - if positive do a CTPA
20
Q
When is a V/Q scan used to diagnose PE?
A
In pregnancy, young women
21
Q
What are the investigations used in suspected PE?
A
FBC, U&E, D-dimer, ECG CXR CTPA V/Q scan USS lower limb - if results do not confirm clinical suspicion
22
Q
What is the most appropriate treatment for a PE?
A
O2
Start LMWH when PE is suspected
Start warfarin when PE is confirmed, continue LMWH until INR is therapeutic (2-3)
Analgesia
IV fluids if hypotensive
If evidence of haemodynamic instability: consider thrombolysis (alteplase, streptokinase)
23
Q
For how long should anticoagulation therapy be continued following PE?
A
6 weeks if temporary risk factor
3 months for 1st idiopathic causes
at least 6 months for other causes
24
Q
In an unprovoked PE what should be done?
A
Set of investigations set out by guidelines. 5% with PE will have an active malignancy
25
what should be suspected in a hypertensive patient with sudden, severe chest/back pain?
aortic dissection = longitudinal splitting of the muscular aortic media by a column of blood
26
What classification is used for aortic dissection?
Stanford type A &type B
A: ascending aorta/aortic arch. Managed surgically
B: descending aorta/aortic arch - medical management
27
What are the chest X-ray findings in aortic dissection?
Widened or abnormal mediastinum
Double knuckle aorta
Left pleural effusion
Tracheal deviation or NG tube to the right
Separation of 2 parts of the wall of a calcified aorta by >5mm
28
In a tension pneumothorax where should the air by drained from?
2nd intercostal space, large-bore needle
29
What are definitive airway techniques in emergency medicine & their indication?
Endotracheal intubation
Surgical airways
ind: failure of airway maintenance, failure of ventilation, anticipated clinical course
30
What else should be included in 'A' of an ABCDE assessment?
A = airway maintenance & CERVICAL SPINE protection (measure from top of patient trapezium to point of chin)
31
What algorithm is used in 'B' of ABCDE assessment for lifektrheatnening thoracic injury?
```
ATOM FC
A - airway obstruction
T - tension pneumothorax
O - open chest wound
M - massive haemothorax
F - flail chest
C - cardiac tamponade
```
32
In 'C' of an ABCDE assessment - which algorithm can be used to look for signs of shock?
```
HEP B
H - hands (temp, swelling, cap refill)
E - End organ perfusion (conscious levels, urine output)
P - Pulse (rate regularity etc)
B - Blood pressure
```
33
In 'C' of an ABCDE assessment what does 'on the floor & 4 more indicate'?
```
injuries which could cause shock:
on the floor & 4 more:
Obvious external wont
Chest cavity
Abdominal cavity (incl retroperitoneal)
Pelvic cavity
Long bone fracture
```
34
What is the key aims in 'D' of an ABCDE assessment?
```
Assess for HEAD INJURY (pupils, GCS, Glucose, bruising)
SPINAL INJURY (neurogenic shock, pain only above clavicle, sensation_
Manage neurodisability & avoid secondary brain injury
```
35
What are the key aims of 'E' in an ABCDE assessment?
assess WOUNDS &TEMP
need for antibiotics/tetanus?
avoid hypothermia & hypotension
Limb splinting if necessary
36
After what time interval of abstinence does delirium tremens occur?
>48 hours
37
What is the management of delirium tremens?
IV diazepam
| Refer to medical team/ICU
38
what is the most appropriate management for confirmed ischaemic stroke if thrombolysis is contraindicated?
Aspirin 300mg for 2 weeks then Clopidogrel 75mg/day
39
what is the secondary prevention for stroke?
Clopidogrel 75mg/day OR
| Aspirin 75mg/day + Dipyridamole MR 200mg BD if clopidogrel contra-indicated
40
What are the symptoms of a a TACS (total anterior circulation stroke)?
Large cortical stroke in middle/anterior cerebral artery areas
All of:
1) unilateral weakness (&;/or sensory deficit) of face, arm & leg
2) Homonymous hemianopia
3) higher cerebral dysfunction (dysphagia, visuospatial disorder)
41
What are the symptoms of a PACS (partial anterior circulation syndrome) ?
Middle/anterior cerebral artery areas
any 2 of:
1) unilateral weakness (&/or sensory deficit) of face, arm & leg
2) homonymous hemianopia
3) Higher cerebral dysfunction
42
what are the symptoms of a POCS (Posterior circulation syndrome)?
One of:
1) cerebrally or brainstem syndromes
2) loss of consciousness
3) isolated homonymous hemianopia
43
What are the symptoms of a LACS (lacunar syndrome)
| Subcortical stroke due to small vessel disease. No evidence of higher cerebral dysfunction
one of:
1) Unilateral weakness (&/or sensors deficit) of face, arm leg or all three
2) Pure sensory stroke
3) ataxic hemiparesis
44
What are the symptoms of a subarachnoid haemorrhage?
```
headache - thunderclap
nausea, vomiting, dizziness
impaired consciousness
early focal neurological signs - esp if intracerebral haemorrhage. 3rd nerve palsy if posterior communicating aneurysm
seizures - uncommon
herald bleed - headache few days before
```
45
What is nimodipine?
calcium channel blocker - works preferentially on cerebral vessels to reduce vasospasm & subsequent cerebral ischaemia
46
what score is used for stroke recognition?
```
ROSIER score. Stroke unlikely if score <0
asymmetrical facial weakness = 1
asymmetrical arm weakness = 1
asymmetrical leg weakness = 1
speech disturbance = 1
visual field defect = 1
LOC or syncope = -1
seizure = -1
```
47
Does a TIA cause syncope?
NO - unlikely TIA will cause syncope as syncope requires global cerebral hypo perfusion
48
what is the definition of syncope?
Transient loss of consciousness without warning due to global cerebral hypo perfusion characterised by rapid onset, short duration &spontaneous complete recovery
49
what are the appropriate investigations in someone presenting with a seizure for the first time?
Capillary Glucose, FBC, U&E, blood culture (if pyrexic), ECG, CXR, pregnancy tests.
All will need brain imaging at some point
50
When is it appropriate to do an emergency CT in a seizure presentation?
```
Focal signs
head injury
known HIV
Suspected intra-cranial lesion
Bleeding disorder (incl. antocoags)
Decreased conscious levels failing to improve
```
51
what is the most appropriate anti-epileptic in status epileptics?
IV lorazepam 4mg or diazepam 10mg
| buccal midazolam or rectal diazepam 10-20mg are alternatives
52
what investigations are warranted in status epileptics?
ABG, blood cultures, FBC, U&E, glucose, calcium , magnesium, LFTs, clotting, toxicology
53
What should be done if a patient is tachycardic and looks shocked/unwell/BP<60?
DC shock immeadiately
54
What diagnosis is inferred form broad complex regular QRS with no P waves and HR >100?
Ventricular tachycardia
55
What is the difference in the QRS complex between ventricular tachycardia and super ventricular tachyrrythmias?
```
VT = broad WRS
SVT = narrow QRS
```
56
What is the secondary prevention for TIA?
Aspirin 75mg + Dipyramidole MR 200mg OR Clopidogrel 75mg
57
What score is used to determine risk of stroke after TIA?
```
ABCD2 score:
Age
BP >140 or <90
Clinical features - unilateral weakness, speech disturbance without weakness
other
Duration of symptoms
Diabetes
```
58
What score is used to identify patients presenting with acute stroke?
ROSIER score
59
what are the 4 common causes of DKA?
```
4 I's:
Infection
Infarction - MI, GI bleed
Insufficient insulin
Intercurrent illness eg. pregnancy, alcohol
```
60
What parameters are used to diagnose DKA?
Academia (pH <3_
Hyperglycaemia (glucose >11)
Ketonaemia (urinary >2, blood >3)
HCO3- <16
61
What are the most appropriate investigations in DKA?
Cap glucose
Urine glucose & ketones
Bloods: glucose, ketones, U&E, amylase, osmolality, FBC, blood culture
ECG (hypo/hyperkaelaemia)
CXR (pneumonia)
ABG - metabolic acidosis, respiratory compensation
62
What is considered significantly high ketones in DKA?
Urinary >2
| Blood >3
63
How should fluids be administered in DKA?
```
0.9& NaCl 1L
1000ml over 1st hour
0.9& NaCl 1L with KCl
1000ml over next 2 hours
0.9& NaCl 1L with KCl
1000ml over next 2 hours
0.9& NaCl 1L with KCl
1000ml over next 4 hours
0.9& NaCl 1L with KCl
1000ml over next 4 hours
0.9& NaCl 1L with KCl
1000ml over next 6 hours
```
64
When should you give potassium in DKA?
Do not give K+ in the 1st Litre or if serum potassium >5.5. All subsequent fluid for next 24hours should contain KCl unless urine output <30mlhr or if K+ >5.5
65
When should you being to give dextrose in DKA?
When glucose falls <15mmol/L
| ie. 10% dextrose 125ml/hr. Give 10% 1L over 8 hours
66
How do you work out the dose of fixed insulin given in DKA?
0.1units/kg/hr
67
How much potassium should you give in DKA?
Give 20mmol/hr & monitor with ECG & ABG
| Potassium must not be given in hourly bag
68
What are the criteria for severe DKA warranting HDU/ICU referral for central venous access?
```
Blood ketones >6
Venous HCO3- <5
pH <7.1
K+ <3.5 on admission
GCS <12
Sat <92% OA
Systolic BP <90
Pulse >100 or <60
Anion gap >16
```
69
In which situation would you use an NG tube in DKA?
If vomiting or drowsy
70
What are the common symptoms of DKA?
Vomiting, abdo pain, polyuria, polydipsia, lethargy, anorexia, ketotic breath, dehydration, coma, deep breathing
71
What is the definition of hypoglycaemia?
Blood glucose <4mmol/L
72
What are the typical ECG changes seen in pericarditis?
Widespread saddle shaped ST elevation
73
What is cardiac tamponade?
When there is a pericardial effusion so big it is compressing the heart and preventing it from pumping effectively
74
What are the chest X-ray signs of a pericardial effusion?
globular enlargement of the cardiac shadow giving a water bottle configuration
75
What diagnosis should be considered if a chest X-ray shows a widened mediastinum with a clinical picture of chest pain?
Aortic dissection
also: double knuckle aorta, left pleural effusion, tracheal deviation to the right, separation of 2 parts of the wall of a calcified aorta
76
what is the name of the classification used in aortic dissection?
Stanford type A & type B
A = involves ascending aorta +/- aortic arch
B = involves descending aorta or the aortic arch distal to the left subclavian artery - initially medical Rx
77
If a patient describes tearing chest pain from the front of the chest to the back which diagnosis should be considered?
Aortic dissection.
| Pain is different in that it can often be unresponsive to morphine - unlike in ACS
78
Which disorders are associated with a greater risk of aortic dissection?
Connective tissue disease
MARFANS
hypertension
Bicuspid aortic valve
79
For a pneumothorax where is thoracentesis performed in the chest?
2nd/3rd intercostal space, mid-clavicular line
80
In which patients would intercostal tube drainage be appropriate in pneumothorax?
in any VENTILATED PATIENT - ie. low sats
Tension pneumothorax after initial needle relief
Persistent/recurrent pneumothorax after simple aspiration
Large SSP pt >50y
81
in which patients does pleurodesis have a role in treating pneumothoraces?
recurrent pneumothorax
82
what is a secondary pneumothorax?
Pneumothorax associated with underlying ling disease, eg. congenital bulla/cyst with COPD
83
what is the dose of salbutamol given in acute asthma or COPD?
5mg nebulised
84
What are the side effects of salbutamol?
Tachycardia
Arrhythmias
Tremor
Hypokalaemia --> monitor with ECG, prolonged QT
85
what dose of ipratropium bromide is given in acute asthma or COPD exacerbation?
500ug nebulised
86
Which steroid is given in acute asthma or COPD exacerbation?
Prednisolone 30-40mg PO
OR
hydrocortisone IV 100mg
87
what are the most appropriate antibiotic treatments for localised infection cellulitis?
Phenoxymethylpenicillin + flucloxacillin OR
| Co-amoxiclav
88
What are the most appropriate antibiotic treatments for systemic or spreading infection cellulitis?
IV antibiotics:
benxylpenicillin + flucloxacillin OR
Co-amoxiclav
*do blood cultures
89
what must you always check for in a patient presenting with cellulitis?
Diabetic status
| also: immunodeficiency, steroid therapy etc
90
which groups of organisms are responsible for cellulitis?
streptococcus, staphylococcus
91
In the modified well's score for DVT what score is required for a DVT to be likely?
>/2
| <2 is unlikely
92
What is the appropriate management for a patient with a modified well's score >/2 for DVT?
Give LMWH while awaiting outpatient USS scan
93
What is the sepsis 6?
1) Give O2 – aim for sats 94%
2) Give IV Fluids
3) Give empiric IV antibiotics
4) Take Lactate & FBC
5) Take Blood cultures
6) Monitor Urine output
94
What are the signs of SIRS?
♣ RR > 20
♣ HR > 90
♣ Temp >38.3 or <36
♣ WCC < 4 or > 12 x1012/L
>2 = significant
95
What does CURB 65 stand for and when is it significant?
```
Community acquired pneumonia. If >3 admit - severe pneumonia with high risk of death
C - confusion
U - urea >7
R - RR>30
B - BP <90 systolic or <60 diastolic
age >65
```
96
in whom is glucagon ineffective in treating hypoglycaemia?
children, cachexia (inadequate glycogen stores)
97
what is the dose go glucagon given in hypoglycaemia?
1mg glucagon IM
98
In paracetamol overdose - after what time can you take a paracetamol level?
wait till 4 hours after overdose
| *level inaccurate after 15 hours --> just treat
99
if someone takes a staggered paracetamol overdose, or it has been over 15 hours what is the appropriate management?
treat with parvalex immediately
| *level inaccurate after this time
100
what investigations are appropriate in paracetamol overdose?
```
LFTs
INR
U&Es
Glucose
ABG/VBG
```
101
what is used to treat local anaesthetic toxicity?
intralipid
102
what is the appropriate treatment in paracetamol overdose where the INR level is continually >1.4?
continue to treat with another bag of parvalex over 16 hours
103
Parvalex is given in 3 infusions over 21 hours - what are the timings of these infusions?
150mg/kg in 200ml 5% dextrose over 15 mins
50mg/kg in 500ml 5% dextrose over 4 hours
100mg/kg in 1000mll 5% dextrose over 16 hours
104
what is rivaroxaban?
NOAC: Factor Xa inhibitor.
| Less monitoring than warfarin but no reversal.
105
what is the dose of furosemide given in acute cardiac pulmonary oedema?
50mg IV furosemide
106
what are the treatment & maintenance doses of ticagrelor?
treatment: 180mg
maintenance: 90mg
107
What are the indications for inserting a chest drain in a pneumothorax?
Tension pneumothorax after initial needle aspiration
Any form of mechanical ventilation
Recurrent pneumothorax after initial needle relief
any large SSP pneumothorax in patients >50y
108
How large does a pneumothorax have to be on CXR to instigate treatment?
>2cm
| measuring from the chest wall to the lung edge at the level of the hilum.
109
what drug and dose is given in a nitrate infusion?
Nitrate infusion:
isosorbide denigrate 2-10mg/h IVI
*caution keep systolic BP >90
110
what is the dose and route of GTN used in acute heart failure?
GTN SL 2 puffs OR
| GTN 2 x 0.3m tablets SL
111
what is the main side effect of nitrates?
drop in BP
112
if the systolic BP is consistently less than 100 in acute heart failure what is the appropriate management?
treat as CARIOGENIC SHOCk & refer to ICU
113
what is the appropriate dose of diamorphine in acute heart failure?
1.25mg-5mg IV slowly
114
is adrenaline an inotrope a chronotrope or a vasopressor?
All 3
115
What is an inotrope?
Drug that increases the contractile force of the cardiac muscle, increasing stroke volume therefore increases cardiac output
116
what is a chronotrope?
an agent that increases the heart rate?
117
what is a vasopressor?
an agent that constricts the arterial tree therefore increasing systemic vascular resistance therefore increasing BP
118
is dobutamine an inotrope, chronotrope or vasopressor?
inotrope + chronotrope
| NOT a vasopressor
119
why is dobutamine useful in cardiogenic shock?
Dobutamine does not act as a vasopressor and therefore does not increase vascular tone – this means the failing heart does not have an increased SVR to pump against
Inotrope + chronotrope
120
is noradrenaline an inotrope, chronotrope or vasopressor?
inotrope + vasopressor
121
is phenylephrine an inotrope, chronotrope or vasopressor?
vasopressor
122
on which receptors does adrenaline act?
a1,b1,b2
123
on which receptors does dobutamine act?
b1,b2
124
on which receptors does noradrenaline act?
a1, b1
125
on which receptors does phenylephrine act?
a1
126
why is noradrenaline used in septic shock?
to increase systemic vascular resistance --> increase BP
127
do inotropes work by acting on B or A receptors?
B receptors eg. dobutamine, adrenaline, noradrenaline
128
do vasopressors work by acting on B or A receptors?
A receptors eg. adrenaline, noradrenaline, phenylephrine
129
which vasopressor is used in distributive shock?
noradrenaline
130
what type of shock is septic shock?
Distributive shock
131
MUDPILES is an algorithm for metabolic acidosis with a high anion gap - what does each letter stand for?
```
M - Methanol
U- Uraemia (CKD)
D - DKA
P - propylene glycol
I - infection, iron, isoniazid
L - lactic acidosis
E - ethylene glycol
S - salicylates
```
132
which drugs at what doses are used for chemical cardioversion in AF?
Amiodarone 300mg IV or
| Flecanide 50-150mg IV
133
If symptoms of AF are continuing for over 48 hours what is the most appropriate drug treatment for acute AF?
Metoprolol/Diltiazem + LMWH
134
What are the risks of cardioversion?
Increased risk of cardiac thromboembolism + stroke
135
In patients with CCF what is an appropriate drug treatment in acute AF?
Digoxin 500mg IV
136
what is the treatment of 3rd degree heart block?
1st line: ATROPINE 500ug IV. Can repeat until a total of 3mg is used
ADRENALINE 2-10ug/min - used as a temporary measure prior to transvenous pacing if an external pacemaker not available.
137
in third degree heart block is the QRS complex narrow or wide?
Can be either
Wide - pacemaker
Narrow - proximal block at the AV node
138
in which type of tachycardia emergency is it appropriate to use vasovagal manoeuvres?
Narrow complex tachycardia (ie. SVT)
139
is the rhythm regular or irregular in SVT?
Regular
140
Is the rhythm regular or irregular in VT?
regular
| *irregular = v. fib
141
In SVT what is the most appropriate drug treatment? (non-AF)
Adenosine 6mg rapid IV bolus
If no effect give 12mg
If no effect give further 12mg
If sinus rhythm is not achieved get expert help - probable atrial flutter control rate with B-blocker
142
is the rhythm regular or irregular in atrial flutter?
Regular
143
If the QRS complex is broad but there is known SVT with bundle branch block what is the treatment?
Treat as for regular narrow-complex tachycardia:
| ie. vagal manœuvres, adenosine, monitor ECG
144
In VT or uncertain rhythm what is the most appropriate drug treatment?
amiodarone 300mg IV over 20-60min then 900mg over 24 hours
145
what is the difference in terms of amiodarone and adenosine in their use in tachycardia?
Broad complex tachycardia - Amiodarone 300mg IV over 20-60min then 900mg over 24 h
Narrow complex tachycardia - Adenosine 6mg rapid IV bolus. can give further 12mg twice.
146
if there are adverse features (eg. shock, MI) present in tachycardia then what is the most appropriate treatment?
synchronised DC shock
147
what is the definition of status epileptics?
any seizure >5 minutes
a person who goes into a 2nd seizure without recovering consciousness from the 1st
repeated seizures for >30mins
148
what is the 1st line medical treatment for status epilepticus?
IV bolus Lorazepam 2-4mg.
149
if a patient presents with adverse features (eg. shock, syncope, MI) and complete heart block what is the most appropriate medical management?
```
Atropine 500ug IV
if no response:
Repeat atropine 500ug unto max of 3mg or
transcutaneous pacing or
isoprenaline 5ug.min IV, adrenaline 2010ug/min IV
```
150
in a patient presenting with stroke what measures should be taken regarding the patient's blood pressure?
Monitor BP - hypertension & labile BP common in early post-stroke period. Do not attempt to reduce BP
151
which scoring system can be used to assess stroke severity?
National institutes of health stroke scale (NIHSS)
152
what is the cushing response and what triad of signs does it consist of?
Cushing response - due to increasing ICP.
Hypertension
Bradycardia
Apnoea
153
what score is used to quantify the severity of a subarachnoid haemorrhage?
Hunt & Hess score
154
at what should the systolic BP be aimed in subarachnoid haemorrhage?
>160
155
Why is nimodipine used in Subarachnoid haemorrhage?
Calcium antagonist, reduces vasospasm & prevents secondary ischaemia
156
what is the name of a fracture occurring at the radius within 2.5cm of the wrist?
Colles' Fracture
157
what mechanism is the common cause of a colles' fracture?
Falling on an outstretched hand
158
which type of fracture produces a dinner fork deformity?
Colles' fracture
159
what is the cause of a smith's/reverse colles fracture?
Falling on a flexed wrist
160
in which fracture does the leg appear shortened & externally rotated?
Fractured neck of femur
161
what is a dangerous complication of intracapsular fractures of the neck of femur?
Avascular necrosis of the femoral head
162
what happens if there is sudden force which avulse the insertion of the gluteus medius?
Fracture of the greater trochanter
163
what happens if there is sudden force which avulse the insertion of the iliopsoas?
Fracture of the lesser trochanter
164
in which type of acute shoulder problem is the kosher's method used?
Anterior shoulder dislocation
165
in ankle sprains which is the most common ligament to be injured?
Anterior talofibular ligament (lateral joint capsule)
166
in which situation would you use 10 day immobilisation in a below-knee cast or adhesive strapping in ankle sprains?
If after review 2-4 days the patient is still unable to weightbear
167
what are some of the long-term complications of ankle sprains/?
Peroneal tendon sublimation
| Peroneal nerve injury
168
in the ottawa ankle rules what must be present along with other symptoms for an ankle x-ray to be warranted?
Pain in the malleolar zone
169
in the ottawa ankle rules what must be present along with other symptoms for a foot x-ray to be warranted
pain in the mid-foot
170
what is a common reaction to paravalex and how is it manage?
Pseudo-allergic reaction in 20%. Rx: stop infusion, give chloramphenamine & begin infusion again with 1/2 dose.
171
what drug is used in malignant hyperthermia?
Dantrolene
172
Malignant hyperthermia is a common side effect of which drug overdose?
Serotonin syndrome - amphetamine overdose
173
the triad of autonomic hyperactivity, neuromuscular abnormality and mental state changes are features of which syndrome?
Serotonin syndrome
174
In which overdose does the delirium last for 2-3 days?
Tricyclic overdose
175
what is the anecdote used for benzodiazepine poisoning?
Flumazenil
176
what anecdote is used to treat metabolic acidosis TCA poisoning?
Sodium bicarbonate
177
What drug is used to reverse insulin overdose?
Glucagon
178
in diverticulitis where commonly is a mass felt on examination of the abdomen?
LIF
179
What is Grey Turner's sign and what is it indicative of?
Bruising of the flanks.
| Retroperitoneal bleed, acute pancreatitis
180
What is Cullen's sign and what is it predictive of?
Superficial oedema & bruising in the subcutaneous fatty tissue around the umbilicus. Predictive of acute pancreatitis
181
what is a common electrolyte abnormality occurring in acute pancreatitis?
Hypocalcaemia: can --> tetany.
182
what score is used to determine the prognosis of acute pancreatitis?
Glasgow Prognostic score
183
which type of ulcer pain is relieved by eating?
Duodenal ulcer
184
which scores are used in acute GI bleed?
Rockall score = prediction of mortality & mortality
| Blatchford score = used to assess whether UGIB needs intervention such as blood transfusion or endoscopic intervention
185
Which drug is used in variceal bleeding?
Terlipressin 2mg SC QDS
186
what is the definition of AKI?
Rise in creatinine >26 in 48 hours
Rise in creatinine 1.5 from baseline
Urine output <0.5ml/kg/hr for 6 hours
*normal creating = 49-90 (F), 64-104 (M)
187
what grading system is used to stage AKI?
KDIGO
188
what level does the K+ have to be life-threatening & to warrant contacting the renal team?
K+ >7mmol (normal 3.5-5.3)
| OR severe effect on cardiac-conducting tissue (tented T waves broad QRS etc). If >7mmol needs urgent treatment
189
what signs are commonly seen in the ECG of someone with hyperkalaemia?
Tall tented T waves, Shortened QT interval, ST depression, absent P waves, Progressive QRS widening, Bundle branch blocks
190
in the treatment of acute pulmonary oedema PODMAN is an algorithm for the initial management - what does this stand for?
P- Position (sit up)
O- Oxygen 100%
D - Diuretic (furosemide IV 40-80mg IV slowly)
M - Morphine (diamorphine 1.25-5mg slowly)
A - anti-emetic
N - Nitrates:
- GTN SL (2 puffs) or 2 x0.3mg tablets SL
- If SBP<100 = nitrate infusion eg. isosobide dinitrate 2-10mg/h IVI
191
what is whipple's triad and for the diagnosis of what condition is it used for?
Hypoglycaemia:
signs and symptoms of hypoglycaemia
low serum glucose
resolution of symptoms once hypoglycaemia has been treated
192
in which situations of paracetamol overdose do you treat immediately?
Staggered overdose, presentato over 8 hours. Ingestion of >150mg/kg
193
what bloods should be taken in anaphylaxis?
FBC, U&E, LFTs, Ca2+, glucose, mast cell tryptase (at 1 hr & 6h)
194
what is beck's triad ?
signs of pericarditis = backs triad:
1) falling BP
2) rising JVP
3) muffled heart sounds
195
in sepsis what should you aim for the MAP to be?
>65mmHg
196
why is ICU admission for required for treatment with vasopressors & inotropes?
Continuous monitoring - arterial line.
| Certain drugs need to be given in central vein eg. noradrenaline
197
what is the commonest intrinsic renal cause of AKI?
Acute tubular necrosis: often result of pre-renal damage or nephrotoxins, radiological contrast, myoglobinuria in rhabdomyolysis, myeloma
198
what investigations are warranted in AKI?
Bloods: U&E, FBC, clotting, CK, ESR, CRP, auto-antibodies
ABG
199
what are the indications for dialysis in AKI?
Pulmonary oedema, hyperkalaemia, severe metabolic acidosis (<7.2), uraemia complications --> encephalopathy, uraemia pericarditis, drug overdose (BLAST: Barbiturates, Lithium, Alcohol, Salicylates, Theophylline).
200
what HASSLED score indicates a high risk of bleeding?
```
HASBLED >3
1 point for each
H- hypertension
A - abnormal renal or liver function
S - Stroke
B - bleeding
L - labile INR
E - elderly >65
D -drugs predisposing to bleeding
Alcohol use
```
201
what are the 3 components of a GCS score and what does each stand for?
```
GCS:
eye response (4)
verbal response (5)
motor response (6)
```
202
what does extension to pain score on the motor component of the GCS score?
+2
203
what does flexion to pain score on the motor component of the GCS score?
+3
204
is SIADH a cause of hypovolaemic, euvolaemic or hypervolaemic hyponatraemia?
euvolaemic
205
what type of drugs are vaptans and when are they used?
vasopressin receptor antagonists - eg, tolvaptan
| can be used IV in Euvolaemic & hypervolaemic patients.
206
in what type of hyponatraemia may loop diuretics be beneficial?
hypervolaemic
207
what are the indications for an emergency CT head in the ED? (ie. within 1 hour)
```
GCS <13 initial assessment
GCS <15 at 2 hours after injury on assessment in ED
Suspected open or depressed skull fracture
Any sign of basal skull fracture
Post-traumatic seizure
Focal neurological deficit
>1 episode of vomiting
(+anticoagulants)
```
208
what are the signs of a basal skull fracture?
haematympanum
Panda eyes
CSF fluid leak from ear, nose
Battle sign
209
which nerve palsy is common in SAH where the PCA is involved?
3rd nerve palsy
210
on the GCS scale what is the grading for EYE OPENING and how many points can it score?
```
Eye opening (4)
Spontaneous 4
In response to speech 3
In response to pain 2
No eye opening
```
211
on the GCS scale what is the grading for VERBAL RESPONSE and how many points can it score?
Verbal response (5)
orientated 5
Confused conversation with some disorientation 4
Inappropriate speech - random or exclamatory 3
Incomprehensible speech - moaning 2
No verbal response 1
212
on the GCS scale what is the grading for BEST MOTOR RESPONSE and how many points can it score?
Motor response (6)
obeys command 6
Localising response to pain 5
withdrawal to pain - pulls limb away with pain 4
Flexor response to - nail bed pressure causes abnormal flexion of libs 3
Extensor posturing to pain - pain causes extension 2
No response to pain 1
213
what is todd's paresis?
TODD's PARESIS: focal weakness in a part of the body after a seizure. This weakness typically affects appendages and is localized to either the left or right side of the body. It usually subsides completely within 48 hours. Todd's paresis may also affect speech, eye position (gaze), or vision
214
what are the possible complications of status epilepticus?
hypoglycaemia, pulmonary hypertension,pulmonary oedema, increased ICP
215
in what type of stroke can a pure sensory stroke occur?
Lacunar syndrome
216
in which type of stroke is LOC common?
Posterior circulation syndrome
217
on neurological examination of a patient with back pain what would be affected in a defect at L4?
Medial lower leg sensation
Quadriceps power
Knee jerk reflex
218
on neurological examination of a patient with back pain what would be affected in a defect at L5?
Lateral lower leg sensation + big toe
Hallucis longs power
Hamstrings jerk
219
on neurological examination of a patient with back pain what would be affected in a defect at S1?
```
Sensation of lateral foot + little toe
Plantar flexor power
Ankle jerk
Check perineal + perianal sensation
Perform PR- anal tone, masses or blood
```
220
if there is unrinary retention, hyper-reflexia and extensor planters in a patient with acute back pain what diagnosis should be considered?
cord compression
221
in a drug history in a patient with back pain what drugs should be specifically asked about?
CORTICOSTEROIDS -- osteoporosis
analgesics
etc
