Emergency Medicine (Quesmed)

Question 1

What are the 5 pathogenic causes and 3 other causes of Acute Epiglottitis?

Answer 1

Haemophilus influenzae b (Hib)
Streptococcus spp
Staphylococcus aureus
Pseudonomas
Herpes Simplex

Thermal Causes
Foreign Bodies
Radiotherapy Related Inflammation

Question 2

What are the 5 signs of Acute Epiglottitis and what should be done in these patients?

Answer 2

Fever
Drooling
Stridor
Pain
Children would prefer to sit upright

These patient should not be examined, treated or cannulated but left alone as any upset or distress may lead to total airway obstruction

Question 3

What is the 3 step management of Acute Epiglottitis?

Answer 3

An urgent referral to ENT and anaesthetics should be made urgently

After their airway had been secured, patients need to urgently intubated and ventilation and treatment should be provided

Depending on the cause, oral and IV antibiotics should be started

Question 4

What are the causes of Acute Pancreatitis?

Answer 4

GET SMASHED

Gallstones (most common cause worldwide)
Ethanol (most common cause in Europe)
Trauma
Steroids
Mumps
Autoimmune diseases (Polyarteritis Nodosa/ SLE)
Scorpion fight
Hypercalcaemia, Hypertriglycerideamia, Hypothermia
ERCP
Drugs

Question 5

What are the drug causes of Acute Pancreatitis?

Answer 5

FAT SHEEP

Furosemide
Azathioprine/ Asparaginase
Thiazides/ Tetracycline

Statins/ Sulfonamides/ Sodium Valproate
Hydrochlorothiazide
Estrogens
Ethanol
Protease Inhibitors and NRTIs

Thiazides, Furosemide, some HIV drugs (protease inhibitors and non-nucleoside reverse transcriptase inhibitors), Sulfasalazine and Gliclizide are classed as Sulfonamides

Question 6

What are the 9 signs of Acute Pancreatitis?

Answer 6

-A Stabbing, Epigastric Pain which radiates to the Back and is relieved by sitting forward or laying in the foetal position

• Vomiting
• A Recent Alcohol Binge or a Recent History of Gallstones suggests Acute Pancreatitis
• Hypovolaemia (Tachycardia, Dry Mucosal Membranes due to Third-space Loss of Fluids)
• Fever is only present if the Pancreatitis has been complicated with Infection
• Haemorrhagic Pancreatitis is rare but there may be Grey-Turner’s Sign which is Bruising along the Flanks
• There may be Guarding in the Epigastric Region but this is a Non-Specific Sign
• Cullen’s Sign is bruising around the Peri-Umbilical Region
• Third-space Fluid Sequestration in Pancreatitis is the result of a Combination of Inflammatory Mediators, Vasoactive Mediators and Tissues which leads to Vascular Injury, Vasoconstriction and Increased Capillary Permeability- this leads to Extravasation of Fluid into the Third Space

(This can lead to Acute Respiratory Distress Syndrome, Pleural Effusions and Hypovolaemia which leads to Acute Kidney Injury)

Question 7

What are the 5 Blood Tests should be ordered if Acute Pancreatitis is suspected?

Answer 7

FBC (Leukocytosis can indicates Necrotising Pancreatitis)

Urea and Electrolytes

LFTs may be abnormal in Gallstone Disease

Lipase is a more sensitive and specific marker than Amylase and should be used over Amylase

An Amylase level is 3 times the upper limit of normal, this suggests Acute Pancreatitis

Question 8

What 3 conditions can also elevated Amylase in addition to Acute Pancreatitis?

Answer 8

A Perforated Duodenal Ulcer

Cholecystitis

Mesenteric Infarction

Question 9

What are the 4 Imaging Investigations that should be ordered if Acute Pancreatitis is suspected?

Answer 9

Ultrasound Abdomen can look for Gallstones

MRCP can be used to look for Obstructive Pancreatitis

ERCP is preferred generally over MRCP

A CT Scan can be performed at a later stage if Complications of Pancreatitis are suspected- such as Pseudocysts or Necrotising Pancreatitis

Question 10

What Glasgow Criteria Score suggests transfer to ITU in Acute Pancreatitis and how long after admission should this score be worked out?

Answer 10

A score above 3 suggests admission to ITU and this should be worked out 48 hours after admission

Question 11

What is the Glasgow Criteria Score criteria?

Answer 11

PANCREAS

PaO2<8kPa
Age>55 years old
Neutrophils- WBC>15x10^9/L
Calcium<2mmol/L
Renal Function- Urea>16mmol/L
Enzymes- AST/ALT>200ui/L or LDH>600ui/L
Albumin<32g/L
Sugar- Glucose>10mmol/L

Question 12

What is the 7 step management for Acute Pancreatitis?

Answer 12

(Maintain electrolyte imbalances and compensate for third space losses)

• Aggressive Fluid Resuscitation with Crystalloids
  (Aim to keep urine output>30mL/hour)
  Start with a 1 litre bolus and try to maintain adequate urine output. This usually amounts to a fluid requirement of 3-5ml/kg/hour
• Catheterisation
• Analgesia (strong analgesia in the form of Opioids is needed)
• Anti-emetics
• IV Antibiotics are shown to have No Real Effect in Outcome unless Necrotising Pancreatitis is present. Necrotising Pancreatitis is a complication of Severe Pancreatitis representing inadequate fluid resuscitation in initial management. This is usually diagnosed through a CT scan. Routinely giving antibiotics in Acute Pancreatitis is not in current clinical practice
• Calcium may be given if Hypocalcaemia is present but this is not prescribed prophylactically
• Insulin may also be given if there is Hyperglycaemia due to the damaged pancreas not being able to release the hormone

Question 13

What is Pulseless Electrical Activity and Asystole?

Answer 13

These are both Non-Shockable Rhythms (Use CPR Instead)

Pulseless Electrical Activity is where the ECG shows that a pulse should occur but you do not actually feel a pulse in the patient

Asystole is a Cardiac Arrest Rhythm with no discernible Electrical Activity on the ECG Monitor

Question 14

What is the management of Pulseless Electrical Activity and Asystole?

Answer 14

CPR should be commenced immediately

Adrenaline 1mg IV should be given in the first cycle and if the rhythm continues, then give Adrenaline every other cycle (1st, 3rd, 5th etc)

Question 15

What is Ventricular Fibrillation and Pulseless Ventricular Tachycardia?

Answer 15

These are both Shockable Rhythms

Ventricular Tachycardia is a regular broad complex tachycardia

Ventricular Fibrillation presents as chaotic irregular deflections of varying amplitude

Question 16

What is the management of Ventricular Fibrillation and Pulseless Ventricular Tachycardia?

Answer 16

Defibrillation and CPR should be conducted

However, if the rhythms persist, Amiodarone 300mg IV and Adrenaline 1mg IV can be given after the Third Shock

Amiodarone is given as a One-Off Dose but Adrenaline can be repeated every other cycle (3rd, 5th, 7th etc)

Question 17

What are the 7 causes of Airway Compromise?

Answer 17

Angioedema

Anaphylaxis

Thermal Injury

Neck Haematoma

Wheeze

Surgical Emphysema

Reduced Consciousness

Question 18

What are 3 simple Airway Maneouvres?

Answer 18

Suction- if there is visible vomit, blood or foreign bodies in the Airway
(Turn patient onto their side if they are actively vomiting, unless they have a C-spine injury)

Head-tilt/ Chin lift- Aim for the Sniffing Position- can be achieved manually or by placing a pillow under the head

Jaw Thrust- Using both hands, hook your fingers under the angle of the patient’s jaw and move their mandible forward

Question 19

What are 2 common Airway Adjuncts (ways to keep the airway open after manual manouevres) (3,2)

Answer 19

Oropharyngeal Airway-
- a Rigid Plastic Tube
- Measured from the Incisors to the Angle of the Jaw
- It is inserted upside down and then rotated 180 degrees to keep the tongue away from the Posterior Pharynx

Nasopharyngeal Airway-
- a Flexible Rubber Tube
- This passed through one of the Anterior Nasal Passages and sits Inferiorly at the Base of the Tongue
- This is typically used if the patients have a strong gag reflex to the Oropharyngeal Airway
- This is contraindicated if the patient has a Base of Skull Fracture

Question 20

What is a Supraglottic Airway? (4)

Answer 20

They are Flexible Plastic Tubes with Inflatable Cuffs

They are devices which can be used with Ventilation Machines

Examples include the Laryngeal Mask Airway (LMA) or i-Gel

They sit over the Top of the Larynx

Question 21

What is an Endotracheal Tube? (4)

Answer 21

It is a Flexible Plastic Tube with an Inflatable Cuff

It is inserted through a Laryngoscope and used for Prolonged Mechanical Ventilation

It protects the airways against Aspiration (Cuffed Endotracheal Tube with the Cuff Inflated below the Vocal Cords)

If this is not successful, you can insert a Supraglottic Airway such as an iGel or Laryngeal Mask Airway, or Bag-Valve Mask Ventilation

Question 22

What are the 3 indications for Bag-Valve Mask Ventilation?

Answer 22

Respiratory Failure (Hypoxia or Hypercapnia) associated with a respiratory rate of less than 10

Apnoea

Cardiac Arrest

Question 23

What are the 6 main signs of Opioid toxicity?

Answer 23

Poor Respiratory Rate/ Effort

Bilateral Pinpoint Pupils

Decreased Conscious Level

Multiple Needle/ Track Marks on Skin

Confusion

Cyanosis if severe

Question 24

What 3 things should be identified in a patient presenting with Alcohol Withdrawal?

Answer 24

An Associated Health and Psycho-social problem

The severity of the alcohol misuse (AUDIT Questionnaire and SADQ Questionnaire)

Whether there is any risk to themselves or to others

Question 25

What are the 7 presentation signs of a Simple Alcohol Withdrawal? (6-12 hours after the last drink)

Answer 25

Insomnia Tremor Anxiety Agitation Nausea and Vomiting Sweating Palpitation

Question 26

What is the presentation of Alcohol Hallucinosis? (12-24 hours after last drink)

Answer 26

Visual, Tactile or Auditory Hallucinations

Question 27

What are the 6 signs of Delirium Tremens?

Answer 27

Delusions Confusion Seizures Tachycardia Hypertension Hyperthermia

Question 28

What are the 7 indications for Inpatient Alcohol Withdrawal? (risk factors for them getting withdrawal while admitted)

Answer 28

Patients drinking >30 units of Alcohol per day Scoring over 30 in the SADQ Score High Risk of Alcohol Withdrawal Seizures (Previous Alcohol Withdrawal Seizures or Delirium Tremens or History of Epilepsy) Simultaneous withdrawal from Benzodiazepines Significant Medical or Psychiatric Comorbidity Vulnerable Patients Patients under 18 years old

Question 29

What is the 4 step management for Alcohol Withdrawal? (if drinking >15 units a day or >20 on the AUDIT Questionnaire)

Answer 29

Chlordiazepoxide prescribed in a reducing regimen according to the CIWA Score and Local Protocol If they have Alcohol-Withdrawal Seizure, they should be prescribed a Rapid-Acting Benzodiazepine (like IV Lorazepam) Pabrinex (1 pair of Ampoules a day to prevent Wernicke's Encephalopathy) - If there are signs of Wernicke's Encephalopathy (Confusion, Ataxia, Ophthalmoplegia or Nystagmus), patients should be prescribed 2 pairs of Ampoules In Delirium Tremens (Confusion and Visual Hallucinations 48-72 hours after Abstinence) give Oral Lorazepam first line. If symptoms still continue, then give Parenteral Lorazepam.

Question 30

What are the 6 Gastrointestinal causes of Central Abdominal Pain and 3 Non-Gastrointestinal causes?

Answer 30

Gastrointestinal causes- - Bowel Obstruction - Early Appendicitis - Acute Gastritis - Acute Pancreatitis - Ruptured Abdominal Aortic Aneurysm - Ischaemic Bowel Disease Non-Gastrointestinal causes- - Pneumonia - Acute Coronary Syndrome - Diabetic Ketoacidosis

Question 31

What are the 6 Clinical Features of Ascending Cholangitis?

Answer 31

Charcot's Triad- but only occurs in a Third of Patients (Right Upper Quadrant Pain, Fever, Jaundice) Hypotension, Tachycardia and Confusion if the Sepsis is severe

Question 32

What are the 3 causes of Ascending Cholangitis?

Answer 32

Biliary Calculi (stones)- 50% of cases Benign Biliary Stricture Malignancy

Question 33

What 5 investigations should be ordered if Ascending Cholangitis is suspected?

Answer 33

Bloods- Raised LFTs and Raised Inflammatory Markers (WCCs and CRP) Ultrasound Abdomen- to detect Bile Duct Dilatation- not good at picking up stones in the mid/distal area of the Biliary Duct CT Scan- gives good detail of the Biliary Tree and can show Radiopaque Stones (although the most common stones are actually Radiolucent Stones) MRCP is the most accurate imaging method and can view almost all causes of Biliary Tree Blockage Once the cause is determined, use ERCP to Intervene

Question 34

What is the 6 step management for Ascending Cholangitis?

Answer 34

Resuscitation (Intravenous Fluids and Antibiotics)- The patient may require Critical Care based on the Severity of Shock and Organ Failure Biliary Drainage may be required Endoscopic Drainage- ERCP (Endoscopic Retrograde Cholangiopancreatography)- stent placement for strictures Percutaneous Drainage- PTC (Percutaneous Transhepatic Cholangiography) Surgical Drainage Assessment and management of Predisposing Cause- Like Cholecystectomy for Gallstones

Question 35

What is the management of a Conscious Choking Adult? (4)

Answer 35

Encourage the patient to cough Give them 5 back blows with the heel of the palm aiming between the shoulder blades Give them 5 abdominal thrusts performed from behind the patient with a fist placed between the umbilicus and the xiphisternum, grasping it upwards and pulling upwards and inwards sharply Continue these motions until the obstruction is dislodged or the patient becomes unconscious

Question 36

What is the management of an unconscious choking patient?

Answer 36

Call for help and start ABC Airway- - Open the mouth and observe if the obstruction is visible and removable. Only attempt to remove an object if under direct vision - Open the airway with a jaw thrust or head tilt/ chin lift Breathing- - If the patient is not breathing, start cardiopulmonary resuscitation

Question 37

What are the 5 signs of Benzodiazepine toxicity?

Answer 37

Lethargy Ataxia Slurred Speech Coma Respiratory Distress

Question 38

What are the 4 signs of Beta-Blocker toxicity?

Answer 38

Bradycardia Hypotension Mild Hypoglycaemia Mild Hyperkalaemia

Question 39

What are the 5 signs of Cyanide toxicity?

Answer 39

Nausea and Vomiting (if small doses) Rapid Loss of Consciousness Apnoea Seizures Cardiac Arrest

Question 40

What are the 5 signs of Phenothiazine (Chlorpromazine) toxicity?

Answer 40

Dystonia Sedation Dry Mouth Hyperthermia Dysrhythmias

Question 41

What are the 7 signs of Organophosphate toxicity?

Answer 41

Salivation Lacrimation Urination Diarrhoea Small pupils Fasciculations Bradycardia

Question 42

What are the 6 signs of MDMA (Ecstasy) toxicity?

Answer 42

Agitation Tachycardia Hypo/ Hypertension Hyperthermia Acute Renal Failure Mydriasis

Question 43

What is Compartment Syndrome?

Answer 43

It is where Muscle Swelling and Inflammation leads to an Increase in Pressure in the Muscle Compartment This is a Limb Threatening Condition as the increase in Pressure causes a Loss of Blood Supply to that limb and Ischaemia

Question 44

What are the 5 signs of Compartment Syndrome?

Answer 44

Severe Pain (specifically in the Passive Flexion of the Toes) Pallor Paralysis of the Limb Pulselessness Paresthesia

Question 45

What is the treatment of Compartment Syndrome (3)?

Answer 45

Urgent Fasciotomy Analgesia Fluids

Question 46

What is Deep Vein Thrombosis?

Answer 46

The Intra-luminal Occlusion of any Vein that is within the Deep System of a Limb (either the arm or leg) or the Pelvis

Question 47

What are the 11 risk factors for Deep Vein Thrombosis?

Answer 47

Age>60 Active Cancer Dehydration Recent Orthopaedic or Pelvis Surgery Long-distance Travel Obesity Previous history of Venous Thromboembolism Family history of Venous Thromboembolism Thrombophilias Combined Oral Contraceptives and Hormone Replacement Therapy Pregnancy

Question 48

What are the 4 signs of Deep Vein Thrombosis?

Answer 48

Unilateral warm, Swollen Thigh or Calf Pain on Palpation of Deep Veins Distension of Superficial Veins Pitting Oedema

Question 49

What 3 investigations should be ordered if Deep Vein Thrombosis is suspected?

Answer 49

D-dimer- - Used when there is a low probability of DVT - It is Highly Sensitive but not Specific so it can Only EXCLUDE DVT but not Confirm it - Other things may raise D-Dimer such as (6) Malignancies, Pregnancies, Strokes, Myocardial Infarctions, Infections and Aortic Dissections Doppler Ultrasound- - This is the Investigation of Choice - Do this if there is a high probability of a DVT - It is not the Gold-Standard as DVTs can be missed if the image quality is suboptimal Digital Subtraction or CT/MR Venogram- - All three can be used to evaluate the extent of the DVT and look for rare underlying causes such as May-Thurner Syndrome - Digital Subtraction Venography is the Gold-Standard but is rarely used as it is Highly Invasive

Question 50

What is the 4 step management of Deep Vein Thrombosis?

Answer 50

Anticoagulation- either a Direct Oral Anticoagulant (DOAC), Low Molecular Weight Heparin (LMWH) or Warfarin (which can be bridged with LMWH). NICE Guidelines recommend a DOAC like Apixaban or Rivaroxaban as First-Line Therapy. - Duration is at least 3 Months - Patients with Active Cancer should be Anticoagulated for at least 3-6 Months - Patients with Unprovoked DVTs should be considered for Anticoagulation for over 3 Months (Typically 6 Months) - Those with Recurrent DVTs should be considered for Life-long Therapy Percutaneous Mechanical Thrombectomy- - Used in Massive DVTS IVC Filter- - This will not treat the DVT itself but will reduce the risk of the DVT embolising into the pulmonary arteries and causing a Pulmonary Embolism - This is used in patients where Anticoagulation is Contraindicated Further Investigations- - Consider an investigation of Occult Malignancy if there are other Relevant Symptoms - Consider a Thrombophilia Screening if this is clinically relevant

Question 51

What are the 4 complications of a Deep Vein Thrombosis?

Answer 51

Pulmonary Embolism Venous Insufficiency Recurrent Deep Vein Thrombosis Post-Thrombotic Syndrome- Pain, Swelling, Hyperpigmentation, Dermatitis, Ulcers, Gangrene and Lipodermatosclerosis= caused by Chronic Venous Hypertension

Question 52

What is Disseminated Intravascular Coagulation (DIC)

Answer 52

This is the inappropriate activation of the clotting cascades which results in Thrombus Formation and Depletion of Clotting Factors and Platelets

Question 53

What are the 7 signs of Disseminated Intravascular Coagulation (DIC)?

Answer 53

Excess Bleeding (Epistaxis, Gingival Bleeding, Haematuria, Bleeding from Cannula Sites) Fever Confusion Coma Petechiae (small pinpoint red/pink spots) Brushing Hypotension

Question 54

What are the 5 risk factors of Disseminated Intravascular Coagulation (DIC)?

Answer 54

Major Trauma/ Burns Multiple-Organ Failure Severe Sepsis or Infection Severe Obstetric Complications Solid Tumours or Haematological Malignancies

Question 55

What is the subtype of Acute Myeloid Leukaemia that is associated with Disseminated Intravascular Coagulation?

Answer 55

Acute Promyelocytic Leukaemia

Question 56

What are the 4 investigation findings of Disseminated Intravascular Coagulation?

Answer 56

Thrombocytopaenia Increased Prothrombin Time Increased Fibrin Degradation Products (such as D-Dimer) Decreased Fibrinogen

Question 57

What 3 signs point to Moderate Asthma Exacerbation and what 4 signs point to Severe Asthma Exacerbation?

Answer 57

Moderate Asthma Exacerbation- - Increasing Symptoms - PEF> 50-75% - No features of Severe Asthma Severe Asthma Exacerbation- - PEF 33-50% - Respiratory Rate is 25 or more - Heart Rate is 110 or more - They are unable to complete a sentence in one breath

Question 58

What are the features of Life-Threatening Asthma? (33,92 CHEST) These patients Must be Admitted

Answer 58

PEF<33% SO2<92% or PO2<8 Cyanosis Hypotension Exhausted, Altered Consciousness Silent Chest Tachyarrhythmias

Question 59

What should be remembered about patients with Life-Threatening Asthma and their PCO2 levels?

Answer 59

They may have normal PCO2 levels (4.6-6) as they are unable to ventilate properly (even though you would expect them to have Low PCO2 levels) A Raised PCO2 is a sign for Near-Fatal Asthma

Question 60

What are the 6 Criteria for referring Asthma Exacerbation Patients to Intensive Care? 2 things about resporation 2 things about o2 and co2 peak flow and one more thing

Answer 60

If they require Ventilatory Support If they have Severe or Life-Threatening Asthma who is failing to respond to therapy which is shown by (5)- - Deteriorating Peak Flow Reading - Persisting or Worsening Hypoxia - Hypercapnia - Exhaustion, Feeble Respiration - Respiratory Arrest

Question 61

What is the 4 step Immediate Management for an Asthma Exacerbation?

Answer 61

Sit up 100% O2 via a Non-Rebreathe Mask (aim for 94-98%) Nebulised Salbutamol (5mg) and Ipratropium (0.5mg) Hydrocortisone 100mg IV or Prednisolone 50mg PO

Question 62

What should be added to the Immediate Management of an Asthma Exacerbation if the patient has Life-Threatening Asthma? (3)

Answer 62

Inform the Intensive Care Team Magnesium Sulphate 2g IV over 20 minutes Nebulised Salbutamol every 15 minutes

Question 63

What should be done if there is no improvement in the Asthma Exacerbation following the Immediate Management? (4)

Answer 63

Nebulised Salbutamol every 15 minutes Continue Ipratropium 0.5mg 4-6 hourly Consider Aminophylline unless they are already on Theophylline ITU Transfer for Invasive Ventilation

Question 64

What 3 things should be done/ monitored in the Monitoring following an Asthma Exacerbation?

Answer 64

SpO2 should be kept above 92% Take Peak Flow Measurements every 15-30 minutes pre- and post- Salbutamol Take Consecutive Arterial Blood Gas measurements

Question 65

What are Unstable Angina (3), NSTEMI (3) and STEMI(3)?

Answer 65

Unstable Angina (the narrowing of coronary arteries caused by Ischaemia) - Chest pain at Rest or at Minimal Exertion which lasts>15 minutes - ECG Changes (new ST Depression or T Wave Inversion) - No Rise in Troponin (no Myocardial Necrosis) NSTEMI (Partially Occluded Coronary Arteries) - Chest pain at Rest or at Minimal Exertion which lasts>15 minutes - ECG Changes (new ST Depression or T Wave Inversion) - Rise in Troponin (Myocardial Necrosis) NSTEMI and Unstable Angina are differentiated by the Rise in Troponin seen in NSTEMI STEMI (Completely Occluded Coronary Artery) - Chest pain at Rest or at Minimal Exertion which lasts>15 minutes - ECG Changes (new ST Elevation or Left Bundle Branch Block) - Rise in Troponin (Myocardial Necrosis) NSTEMI and STEMI are differentiated by their ECG Changes Chest pain may not ALWAYS be there

Question 66

How is a STEMI diagnosed?

Answer 66

New ST-segment elevation in 2 or more contiguous leads (leads next to each other) The ST Elevation should be more that 2mm in the Precordial Leads or more than 1mm in the limb leads

Question 67

What is the management of a STEMI?

Answer 67

MMONAC Morphine Metoclopramide Oxygen (if sats are less than 94%) Nitrates (GTN Spray) Aspirin 300mg Clopidogrel 300 mg (Although drugs like Ticagrelor are sometimes used instead in practice) If the patient is within 12 hours of symptom onset and within 2 hours of medical contact- then consider Percutaneous Coronary Intervention. They should be Haemodynamically stable. If they present within 12 hours of symptom onset but after 2 hours of medical contact- then consider Thrombolysis if they are stable and there are no contraindications. If there are contraindications, then consider Percutaneous Coronary Intervention. If they present more than 12 hours of symptom onset, Pharmacotherapy should be considered if they are Asymptomatic and Unstable. Otherwise, Revascularisation can be considered.

Question 68

What are the 7 Contraindications to Thrombolysis in Myocardial Infarction?

Answer 68

Aortic Dissection Gastrointestinal Bleeding Allergic Reaction Iatrogenic (Recent Surgery) Neurological Disease (Recent Stroke (within 3 months), Malignancy) Severe Hypertension (more than 200/120) Trauma (including Recent CPR)

Question 69

What is an NSTEMI?

Answer 69

It is a type of Acute Coronary Syndrome with typical Acute Coronary Syndrome signs, no ST segment elevation on the ECG and Raised Cardiac Biomarkers

Question 70

What is the management of an NSTEMI?

Answer 70

MMONAC Morphine Metoclopramide Oxygen (if sats<94%) Nitrates (GTN Spray) Aspirin 300mg Clopidogrel 300mg After MMONAC, stratify the patient according to either the Thrombolysis in Myocardial Infarction Score (TIMI Score) or the GRACE model depending on the hospital's choice If the Patient has a high risk of death and further ischaemic events should be offered re-vascularisation within 12-24 hours If the Patient has a low risk of death- they can be managed conservatively with Medications They can be discharged after having stabilised (once they don't have symptoms and their cardiac biomarkers are normal) and they should have Further Cardiac Investigations in the Future

Question 71

What is the 5 step Emergency Management of Chronic Obstructive Pulmonary Disorder (COPD)? (3 points for each category)

Answer 71

Oxygen Therapy - Sit up - Administer 24% Oxygen via Venturi mask: SpO2 88--92% - Vary FiO2 and SpO2 target according to the Arterial Blood Gases Nebulised Bronchodilators (Air Driven) - Salbutamol 5mg/4h - Ipratropium 0.5mg/6h Steroids- - Hydrocortisone 200mg IV - Prednisolone 40mg PO for 7-14d Antibiotics (if evidence of infection) Further treatments if no response - Repeat Nebulisers and consider Aminophylline IV - Consider NIV (BiPAP) if pH<7.35 and/ or Respiratory Rate >30 - Consider Invasive Ventilation if pH<7.26

Question 72

What is Acute-Angle Closure Glaucoma?

Answer 72

It occurs when a high intra-ocular pressure causes damage to the Optic Nerve This occurs due to the Closure of the Iridio-corneal Angle in the eye

Question 73

What are the 3 risk factors for Acute-Angle Closure Glaucoma?

Answer 73

Being Female, Being Asian, The use of certain medications such as those with Anti-muscarinic properties, such as Amitriptylline

Question 74

What are the symptoms of Acute-Angle Closure Glaucoma (5)? What is seen in examination (3)?

Answer 74

Sudden Headache Nausea Red Eye Symptoms worsen at night Haloes when they look at Bright Lights On Examination- - Red Eye - Cloudy Cornea - Mid-dilated Pupil

Question 75

What is the initial (3) and definitive management for Acute-Angle Closure Glaucoma?

Answer 75

Administering IV Acetazolamine and a Beta Blocker such as Timolol Muscarinic Agonists such as Pilocarpine eye drops may be given An urgent referral to Ophthalmology should be made Definitive- - Peripheral Iridotomy

Question 76

What are the 5 complications of Acute-Angle Closure Glaucoma?

Answer 76

Temporary loss of vision Malignant Glaucoma Iris Sphincter Atrophy Permanently dilated pupil Permanent Blindness

Question 77

What causes an Anaphylactic Shock?

Answer 77

Type 1 IgE-mediated Hypersensitivity which occurs when a patient is exposed to certain medications or food or bee stings. Patients are often Hypotensive

Question 78

What are the 5 signs of an Anaphylactic Shock?

Answer 78

Skin Reactions (Widespread Urticaria, Itching, Flushed Skin) Respiratory Symptoms (Swollen Tongue/ Lips, Sneezing, Wheeze) Gastrointestinal Symptoms (Abdominal Pain, Nausea, Vomiting, Diarrhoea) Tachycardia Hypotension

Question 79

What confirms a diagnosis of Anaphylactic Shock?

Answer 79

Serum levels of Mast Cell Tryptase

Question 80

What is the 8 step management for an Anaphylactic Shock? What is the 3 step management if the relevant skills and equipment are available?

Answer 80

Remove Trigger Call for help early ABCDE Assessment Administer Oxygen Lie Patient Flat and Raise Legs Administer Adrenaline (500mg IM for Adults) Administer Chlorphenamine and Hydrocortisone IV Fluids should be given if they are Hypotensive If skills and equipment are available- - Manage airway - Attach Patient to Monitoring - Consider Intensive Care referral

Question 81

What is Atrial Fibrillation?

Answer 81

Abnormal Electrical Impulses start firing in the atria. These pulses override the heart's natural pacemaker For Fast Atrial Fibrillation, the heart rate is over 100bpm

Question 82

What are the 4 indications for DC Cardioversion in Atrial Fibrillation?

Answer 82

Shock Syncope Acute Pulmonary Oedema (does not include Chronic Heart Failure) Myocardial Ischaemia

Question 83

If there are no indications for DC Cardioversion, how should Atrial Fibrillation be managed?

Answer 83

Atrial Fibrillation with a duration of less than 48 hours can be safely cardioverted If the duration is unknown or is more than 48 hours, Anticoagulation can be started at a minimum of 3 weeks before and 4 weeks after Cardioversion due to the risk of a Stroke from a Left Atrial Appendage Thrombus If patients are not Cardioverted, they may need Life-long Anticoagulation based on their CHA2DS2 VaSc Score

Question 84

When should Carbon Monoxide Poisoning be suspected in patients?

Answer 84

If they have had issues with their boiling or heating at home

Question 85

What are the 5 signs of Carbon Monoxide Poisoning?

Answer 85

Confusion Nausea and Vomiting Cherry Red Skin Tachycardia 100% Oxygen Saturation of Pulse Oximetry

Question 86

What 4 investigations should be ordered if Carbon Monoxide Poisoning is suspected?

Answer 86

VBG/ ABG- A Carboxyhaemoglobin Concentration of over 20% is diagnostic Chest Xray- Evidence of Acute Respiratory Distress Syndrome (Asymmetrical Consolidations) ECG- Ischaemic Changes Bloods- including Creatine Kinase (Rhabdomyolysis)

Question 87

What is the 2 step management for Carbon Monoxide Poisoning?

Answer 87

100% Oxygen via Face Mask- helps unbind Carbon Monoxide from the Haemoglobin Molecule Hyperbaric Oxygen- Controversial but it is the Gold Standard

Question 88

What is Cardiac Tamponade?

Answer 88

It is the accumulation of blood in the Pericardial Sac The volume and pressure of this blood can impact the cardiac filling

Question 89

What is the main cause of Cardiac Tamponade?

Answer 89

Penetrating wounds- caused by road traffic accidents or pacemaker insertions Other causes include (3) - Pericarditis - Malignancy - Inflammatory Conditions- like SLE

Question 90

What are the 4 signs of a Cardiac Tamponade?

Answer 90

Beck's Triad- Raised JVP, Hypotension and Muffled Heart Sounds Kussmaul's Sign- JVP raises with Inspiration Pulsus Paradoxus- A Drop in the Systolic Blood Pressure with Inspiration An ECG may show Electrical Alternans (Alternating Height

Question 91

What is the diagnostic investigation of choice for a Cardiac Tamponade?

Answer 91

An Echocardiogram

Question 92

What is the management of a Cardiac Tamponade?

Answer 92

Pericardiocentesis

Question 93

What characterises Diabetic Ketoacidosis (3)?

Answer 93

Hyperglycaemia (may not always be present) (Blood glucose over 11mmol/L) Acidosis (Bicarbonate below 15mmol/L or Venous pH less than 7.3) Ketonaemia (3mmol/L and over)

Question 94

What are the 4 main causes of Diabetic Ketoacidosis?

Answer 94

Infection (so they may have a Fever, which isn't a symptom of DKA but of a potential cause of it) Dehydration Fasting Presentation of Type 1 Diabetes

Question 95

What are the 8 signs of Diabetic Ketoacidosis?

Answer 95

Smell of Acetone (Fruity Breath) Vomiting Dehydration Abdominal Pain Hyperventilation (Kussmaul/ Deep Sighing) Hypovolaemic Shock Drowsiness Coma

Question 96

What 7 investigations should be ordered if Diabetic Ketoacidosis is suspected?

Answer 96

Blood Glucose (>11.1 mmol/L) Blood Ketones (>3mmol/L) Urea and Electrolytes Blood Gas Analysis Urinary Glucose and Ketones Blood Cultures (if evidence of Infection) Cardiac Monitoring/ ECG- any Ischaemic changes or changes secondary to Hypokalaemia

Question 97

What is the 3 step management of Diabetic Ketoacidosis?

Answer 97

If the patient is Alert, not significantly Dehydrated and able to Orally Intake without vomiting= Encourage Oral Intake and give a Subcutaneous Insulin Injection If the patient is Vomiting, Confused or significantly Dehydrated= give IV Fluids (initial Bolus of 10ml/kg 0.9% NaCl then discuss with a senior) and Insulin Infusion at 0.1 units/kg/hour- 1 hour after starting IV Fluids. If there is evidence of a shock, the initial Bolus should be 20ml/kg If the patient is Shocked or in Comatose- ABCDE Assessment should be carried out Do NOT Stop the Intravenous Insulin Infusion until 1 hour after Subcutaneous Insulin Infusion had been given

Question 98

What is the main complication of Diabetic Ketoacidosis? And what is the theory behind how it may occur?

Answer 98

Cerebral Oedema It results from the rapid correction of dehydration with IV Fluids This is why it is recommended fluid should be taken slowly over 48 hours

Question 99

What is Ethylene Glycol Poisoning?

Answer 99

Ethylene Glycol is found in anti-freeze and can be ingested accidentally or intentionally

Question 100

What are the 9 Early Features of Ethylene Glycol Poisoning (<24 hours)? What are the 4 Late Features of Ethylene Glycol Poisoning? (>24 hours)

Answer 100

Early Features- - Apparent intoxication (similar to that of Alcohol) - Nausea and Vomiting - Haematemesis - Seizures - Ataxia - Ophthalmoplegia - Papilloedema - Raised Anion Gap Metabolic Acidosis - Pulmonary Oedema Late Features- - Acute Tubular Necrosis - Hypocalcaemia - Hyperkalaemia - Hypomagnesaemia

Question 101

What is the 4 step management of Ethylene Glycol Poisoning?

Answer 101

Gastric Lavage or NG Aspiration if <1 hour since ingestion Fomepizole (Competitive inhibitor of alcohol dehydrogenase)- prevents metabolism of Ethylene Glycol into toxic metabolites Alcohol (Ethanol) can be used if Fomepizole is unavailable Haemofiltration can be used in severe cases

Question 102

What is an Extradural Haemorrhage?

Answer 102

It is a collection of blood between the inner surface of the skull and the outer layer of the dura. It is commonly caused by a Torn Middle Meningeal Artery

Question 103

What are the 6 signs of an Extradural Haemorrhage?

Answer 103

Recent Head Injury Headache Nausea and Vomiting An Altered Mental State Sometimes Seizures 6th Nerve Palsy- This nerve has a long Intracranial Course so is susceptible to damage following Herniation secondary to an Increased Intracranial Pressure- this is known as a False Localising Sign

Question 104

How is an Extradural Haemorrhage diagnosed?

Answer 104

CT Head- which shows a Bi-convex (Lentiform) shaped Haematoma which is Hyperdense

Question 105

What is the 3 step management for an Extradural Haemorrhage?

Answer 105

Conservative Monitoring Blood Pressure Reduction Surgery (if Severe) like Burr Holes

Question 106

What are the 4 causes of Hyperosmolar Hyperglycaemic State from Type 2 Diabetes?

Answer 106

Infection Medications that cause Fluid Loss or Lower Glucose Tolerance Surgery Impaired Renal Function

Question 107

What are the 7 signs of Hyperosmolar Hyperglycaemic State? And 4 signs if they are extremely unwell?

Answer 107

Nausea and Vomiting Lethargy Weakness Confusion Dehydration Coma Seizure 4 signs of extreme unwellness - Hypovolaemia - Tachycardia - Hypotension - Exhaustion

Question 108

What are the 3 investigations that suggest a diagnosis of a Hyperosmolar Hyperglycaemic State?

Answer 108

Severe Hyperglycaemia (30mmol/L or more) (not accompanied by Significant Acidosis (pH>7.3 or bicarbonate>15mmol/L) or Ketosis (ketones>3mmol/L)) Hypotension Hyperosmolality (usually more than 320 mosmol/kg)

Question 109

What is the difference between Diabetes Ketoacidosis and Hyperosmolar Hyperglycaemia State?

Answer 109

HHS and DKA, rather than being distinct entities are a spectrum of metabolic disturbance in diabetes. The main difference is that the presence of endogenous insulin production in Type 2 diabetics is sufficient to 'switch off' ketone production and prevent diabetic ketoacidosis

Question 110

What are the management principles for a Hyperosmolar Hyperglycaemic State?

Answer 110

Rehydration to correct the Hypotension and Electrolyte Abnormalities. Correction of Hyperglycaemia- Partially Achieved through Fluid Therapy

Question 111

What are Hyperosmolar Hyperglycaemic State patients at risk of?

Answer 111

Thrombosis due to Hyperviscosity so VTE Prophylaxis is an important part of management. Remember Virchow's Triad (Blood Stasis, Endothelial Injury, Hypercoagulability)- Hyperviscosity leads to Blood Stasis

Question 112

What is the 3 step management of Hyperosmolar Hyperglycaemic State?

Answer 112

- Fluid Resuscitation with 0.9% Saline (1L over 1--2 hours, 1L (+KCl) over 2-4 hours,1L (+KCl) over 4-6 hours, 1L (+KCl) over 6-8 hours, 1L (+KCl) over 8-10 hours) Change to 0.45% Saline if failing to reduce osmolality by 5mOsm/kg/hour - Insulin at 0.05 units/kg/hour (only if ketones>1mmol/L or if Glucose fails to fall). Continue any Long Acting Insulin - Venous Thromboembolism Prophylaxis

Question 113

What is the Anion Gap? (2)

Answer 113

The formula (Na + K) - (Cl + HCO3) The normal anion gap is 10-18 mmol/L When there are lots of Acids in the blood, The H+ depletes the HCO3 in the equation so the anion gap Increases causing Metabolic Acidosis

Question 114

What can cause Metabolic Acidosis?

Answer 114

The accumulation of Endogenous Acids (Lactic Acid, Ketones, Urate) or Exogenous Acids (Salicylates, Ethylene glycol, Methanol) Paracetamol overdose can also cause metabolic acidosis in extreme cases SALICYLATE poisoning can cause Respiratory Alkalosis at early stages due to the respiratory centres being stimulated and hyperventilation occurring as a result

Question 115

What are the 3 signs of Pericarditis?

Answer 115

Sharp Pleuritic Chest Pain relieved by leaning forwards (they may have a had a Flu-Like Prodrome) Pericardial Friction Rub (usually the Only Sign) ECG- PR Depression and Saddle Shaped ST Elevation. Also slightly elevated Troponin levels

Question 116

What is the 4 step management of Pericarditis?

Answer 116

Analgesia (NSAIDs like Aspirin or Ibuprofen) Bed rest Colchicine Steroids Also treat the underlying cause

Question 117

What are the 2 main complications of Pericarditis?

Answer 117

Cardiac Tamponade Chronic Constrictive Pericarditis

Question 118

What 5 signs are seen in the Chest Examination of a Pneumothorax patient?

Answer 118

Reduced Chest Expansion on the affected side Hyper-resonant Percussion on the affected side Reduced or Absent Breath Sounds on the affected side, with no added sounds Vocal Resonance (or Tactile Vocal Fremitus) is reduced on the affected side Additional signs seen in a Tension Pneumothorax- signs of Haemodynamic Compromise (Tachycardia and Hypotension) and Tracheal Deviation to the Contralateral side

Question 119

Which investigation should be ordered if a Pneumothorax is suspected?

Answer 119

Chest Xray

Question 120

What is the 3 step management of a Tension Pneumothorax?

Answer 120

ABCDE algorithm. High flow Oxygen (15L/min) via a Non-rebreather Mask Emergency management through Immediate Needle Decompression using a 16-gauge Cannula inserted at the Second Intercostal Space, Mid-Clavicular Line on the Affected Side The needle should be inserted above the Third Rib to avoid damaging the Neurovascular Bundle. The needle decompression acts as a bridge before insertion of an Intercostal Chest Drain

Question 121

What is the 2 step management of a Primary Pneumothorax?

Answer 121

If the patient is NOT Short of Breath AND the Pneumothorax is less than 2cm on Chest Xray they can be Discharged and reviewed in 2-4 weeks If the patient IS Short of Breath OR the Pneumothorax is more than 2cm, the patient should be Aspirated with a 16-18 Gauge Cannula under Local Anaesthetic. If this is successful, the patient can be discharged. If not, an Intercostal Chest Drain is needed and the patient must be admitted

Question 122

What is the 3 step management of a Secondary Pneumothorax?

Answer 122

If the patient is NOT Short of Breath AND the Pneumothorax is less than 1cm on the Chest Xray, they do not require further invasive intervention and should be admitted for Observation for 24 hours and Admitted Oxygen If the patient is NOT Short of Breath AND the Pneumothorax is 1-2cm on the Chest Xray, they need to be Aspirated. If this is successful, they can be admitted for 24 hours of Observation. If this is Not Successful, Intercostal Chest Drain is necessary If the patient IS Short of Breath OR the Pneumothorax is more than 2cm on the Chest Xray, an Intercostal Chest Drain is necessary and they should be Admitted

Question 123

What are the 5 signs of a Pulmonary Embolism? 2 of these are Triads

Answer 123

Sudden onset of Shortness of Breath, Pleuritic Chest Pain and Haemoptysis (The Typical Triad although this is Rare) If the Pulmonary Embolism is Massive, there will also be signs of Shock and Syncope A Small Pulmonary Embolism may be Asymptomatic Tachypnoea, Tachycardia and Hypoxia may be present. (Triad 2) There may be Low-grade Pyrexia and Tachycardia may be the only presenting symptom A Massive Pulmonary Embolism may present with Hypotension, Cyanosis and signs of Right Heart Strain (Raised JVP, Parasternal Heave and loud P2)

Question 124

What are the ECG Findings associated with Pulmonary Embolism?

Answer 124

May be normal or may have Sinus Tachycardia If Massive Pulmonary Embolism, there may be evidence of Right Heart Strain (4) (P Pulmonale, Right Axis Deviation, Right Bundle Branch Block and nonspecific ST/T wave changes) S1Q3T3 (deep S waves in lead 1, pathological Q waves in lead 3 and inverted T waves in lead 3) are very rare

Question 125

What 6 blood tests should be ordered in Pulmonary Embolism?

Answer 125

Arterial Blood Gas- Type 1 Respiratory Failure, Hypoxia without Hypercapnia and/ or Respiratory Alkalosis (due to Hyperventilation occurring secondary to Hypoxia FBC (patient may be Anaemic if they have Haemoptysis) CRP may be raised U&Es (to assess their Renal Function before CT Pulmonary Angiogram (CTPA)) Clotting Functions (important if the patient is to be started on LWMH or Warfarin) D-Dimer- useful in Ruling out a Pulmonary Embolism but Not Confirming it

Question 126

What 4 imaging investigations should be ordered in a Pulmonary Embolism?

Answer 126

Chest Xray- Typically Normal in a Pulmonary Embolism but you may see (3) Fleischner Sign (Enlarged Pulmonary Artery), Hampton's Hump (Peripheral Wedge Shaped Opacity) and Westermark's Sign (Regional Oligaemia). Chest Xray can rule out differentials such as Pneumonia and a Pneumothorax CT Pulmonary Angiogram- Diagnostic Test of Choice- will show a Filling Defect in the Pulmonary Vasculature. If the Patient has (3) a Renal Impairment, Contrast Allergy or is Pregnant, a V/Q scan is preferred Lower Limb Duplex- helpful if a Deep Vein Thrombosis (DVT) is thought to be the cause of the Pulmonary Embolism (this is First Line if the patient is Pregnant) Bedside Echocardiogram- Used if the Patient has a Massive Pulmonary Embolism (signs of Right Heart Strain/ Hypotension) in order to assess their suitability for Thrombolysis

Question 127

What should be ordered based on the Well's Score in Pulmonary Embolism?

Answer 127

If the Well's Score is 4 or less, the D-Dimer should be measured. The D-Dimer has a High Negative Predictive value but a Low Specificity so it is only useful if the Suspicion of Pulmonary Embolism is Low A Low D-Dimer Excludes a Pulmonary Embolism. A Raised D-Dimer suggests that they should have Diagnostic Imaging such as CTPA/V/Q scan If the Well's Score is more than 4, further Diagnostic Investigations are needed. Low Molecular Weight Heparin is usually given if the suspicion of a Pulmonary Embolism is high and should be administered if there is a delay in performing a CTPA anyway

Question 128

What is the Acute Management approach to a Pulmonary Embolism? ABCDE + Alteplase if Massive

Answer 128

DR ABCDE Airway- Likely to be patent (normal airway, like if the patient is talking) Breathing- They may be Tachypnoeic and Hypoxic and Oxygen should be Administered Circulation- They may be Tachycardic. Signs of Right Heart Strain suggest a Sub-Massive Pulmonary Embolism. Hypotension suggests a Massive Pulmonary Embolism. Consider IntraVenous Fluids if their Systolic Blood Pressure is less than 90mmHg Disability- Likely to be Unremarkable Exposure- They may have Low-Grade Pyrexia. Check for signs of Deep Vein Thrombosis. Consider Analgesia at this stage, if the patient requires it If there are signs of a Massive Pulmonary Embolism, Thrombolysis (through an IntraVenous Bolus of Alteplase) is needed. There is debate as to whether this should be done in a Sub-Massive Pulmonary Embolism

Question 129

What is the Medical Management approach to a Pulmonary Embolism? (6)

Answer 129

Anticoagulation should be administered If in OutPatients, Direct Oral Anticoagulants like Apixaban or RIvaroxaban should be administered If neither of the Above are suitable, Dabigatran, Edoxaban or Warfarin can be considered. Low Molecular Weight Heparin should be continued for at least 5 days, until 48 hours of an INR lower than 2 has been achieved if they are on Warfarin. If they are on Dabigatran or Edoxaban, then Low Molecular Weight Heparin should be used for 5 days prior The duration of anticoagulation treatment depends on the aetiology of the Pulmonary Embolism. A Provoked Pulmonary Embolism (where the cause can be identified such as Surgery or Pregnancy) should be treated for 3 months. Unprovoked Pulmonary Embolisms should be treated for Life If a patient already on Warfarin has a Venous Thromboembolism (such as PE or DVT), the INR target should be increased 3 or 4 In the Inpatient/ Emergency Setting, Low Molecular Weight Heparin is used instead as it is Short-Acting

Question 130

What is the Interventional Management of a Pulmonary Embolism?

Answer 130

An Embolectomy may be considered in patients with a Massive Pulmonary Embolism when Thrombolysis is Contraindicated An Inferior Vena Cava Filter may be considered in patients with Recurrent DVTs on Warfarin, OR patients who can not have Anticoagulation

Question 131

What is Status Epilepticus?

Answer 131

Any seizure activity that lasts more than 5 minutes or if they experience more than one seizure and does not fully regain consciousness between the two seizures

Question 132

What is the 9 step management of Status Epilepticus?

Answer 132

ABCDE Approach Oxygen Ensure IV Access Arterial Blood Gas Take Bloods for (8) Glucose, FBC, U&Es, CRP, Calcium, Phosphate, Magnesium and Drug Levels if they are on Anti-epileptic Medication Anaesthetic Review to ensure the Airway is managed IV Lorazepam 4mg (a second dose should be given if there is no response) and if there is No IV Access, PR Diazepam or Buccal Midazolam should be given If the initial Benzodiazepine fails, further Anticonvulsants can be used such as (3) Leviteracetam, Phenytoin, Valproate If the Seizures continue to persist, Intubation and General Anaesthesia are needed

Question 133

What is Supraventricular Tachycardia?

Answer 133

Any Narrow Complex Tachycardia (QRS width less than 120ms and Heart Rate more than 100bpm) Three examples of Supraventricular Tachycardia include - Atrial Fibrillation - AV Re-entry Tachycardia - AV Nodal Re-entry Tachycardia

Question 134

What 4 Adverse Effects warrant DC Cardioversion in Supraventricular Tachycardia?

Answer 134

HISS Heart Failure Ischaemia Shock Syncope

Question 135

How is Supraventricular Tachycardia managed in Stable Patients? Regular (2) Irregular

Answer 135

It depends on whether the arrhythmia is regular or irregular Regular- Vagal Manoeuvres such as Carotid Sinus Massage or the Valsalva Manoeuvre should be attempted. If not, IV Adenosine 6mg should be administered. Irregular- manage according to Atrial Fibrillation management

Question 136

What should patients be warned of before IV Adenosine is administered (3)?

Answer 136

Difficulty Breathing Chest Tightness Flushing

Question 137

How should IV Adenosine 6mg be administered in Supraventricular Tachycardia?

Answer 137

It should be given rapidly over 1-3 seconds, followed by 20ml IV Saline bolus If this fails, a second dose of Adenosine 12 mg can be administered, followed by another dose of 12mg

Question 138

What are the 4 cautions and contraindications to the use of Adenosine?

Answer 138

IV Adenosine 3mg should not be administered to Heart Transplant patients, patients with Central Line Access and patients on medications that can potentiate the effects of Adenosine, such as Dipyridamole or Carbamazepine. Asthma is a contra-indication to the use of Adenosine so Verapamil should be used instead

Question 139

What are the 7 complications of Supraventricular Tachycardia?

Answer 139

Syncope Deep Vein Thrombosis Embolism Cardiac Tamponade Congestive Cardiac Failures Myocardial Infarction Death

Question 140

What are the 7 signs of a Tension Pneumothorax?

Answer 140

Haemodynamic Instability (4)- Tachypnoea, Tachycardia, Hypotension and Raised JVP Tracheal Deviation away from the Affected Side Decreased Chest Expansion Increased Resonance on Percussion Decreased Breath Sounds Decreased Vocal Resonance Surgical Emphysema

Question 141

What is the 5 step management of an Upper GI Bleed?

Answer 141

A to E assessment to start with, focussing on IV Resuscitation and Blood Transfusion (if Hb<7) with or without Platelets and Frozen Fresh Plasma (every 4th unit of blood) - Over transfusion Increases Mortality therefore patients should NOT be transfused to a normal Haemoglobin The patient should be Nil By Mouth and given Supplemental Oxygen IV PPI may also be initiated In Variceal Bleeding, IV Terlipressin and Antibiotics are used Once it is stable, Upper GI Endoscopy is carried out to locate the source of the bleeding through (2) Adrenaline Injection and Ulcer Clipping

Question 142

What are the causes of a Long QT Interval?

Answer 142

TIMMES Toxins (4)- Clarithromycin, Anti-arrhythmics, Anti-psychotics and Tricyclic Antidepressants Inherited- Congenital Long QT Syndromes such as Romano-Ward and Jervell and Lange-Nielson Syndromes Ischaemia Myocarditis Mitral Valve Prolapse Electrolyte Abnormalities such as Hypokalaemia and Hypocalcaemia Subarachnoid Haemorrhage

Question 143

What is the management of Torsades de Pointes in Stable and Unstable Patients?

Answer 143

Unstable (Haemodynamic Compromise)- DC Cardioversion Stable- IV Magnesium Sulphate 2g over 1-2 minutes

Question 144

What does Resting Tachycardia, Orthostatic Hypertension and Supine Hypertension suggest in an Upper GI Bleed?

Answer 144

Resting Tachycardia suggests a mild to moderate hypovolaemia (less than 15% of blood loss) Orthostatic Hypertension suggests at least 15% blood volume loss Supine Hypotension suggests over 40% blood volume loss

Question 145

What are the 6 causes of an Upper GI Bleed?

Answer 145

Oesophageal/ Gastric Varices Peptic Ulcer Disease (H. pylori, NSAID use, Smoking) Malignancy Aorto-enteric Fistula (previous Abdominal Aortic Aneurysm or an Aortic Graft) Angiodysplasia Mallory Weiss Tear

Question 146

What is the management of stable Ventricular Tachycardia?

Answer 146

IV Amiodarone If the HISS Features (Heart Failure, Ischaemia, Shock, Syncope) are present, patients should be offered DC Cardioversion

Question 147

What is the 5 step management of an Upper GI Bleed?

Answer 147

A to E assessment to start with, focussing on IV Resuscitation and Blood Transfusion (if Hb<7) with or without Platelets and Frozen Fresh Plasma (every 4th unit of blood) - Over transfusion Increases Mortality therefore patients should NOT be transfused to a normal Haemoglobin The patient should be Nil By Mouth and given Supplemental Oxygen IV PPI may also be initiated In Variceal Bleeding, IV Terlipressin and Antibiotics are used Once it is stable, Upper GI Endoscopy is carried out to locate the source of the bleeding through (2) Adrenaline Injection and Ulcer Clipping

Question 148

According to the Rockall Score, what 7 features warrant a Oesophago-Gastro-Duodenoscopy in an Upper GI Bleed?

Answer 148

Age higher than or equal to 60 Systolic Blood Pressure> 100 Heart Rate> 100 Cardiac Failure Liver Failure Renal Failure Blood in Upper GI (seen in Endoscopy) or Upper GI Malignancy

Question 149

What are the two scoring systems used to decide whether a patient needs Oesophago-Gastro-Duodenoscopy in an Upper GI Bleed?

Answer 149

Glasgow Blatchford Score Rockall Score

Question 150

What is Ventricular Tachycardia?

Answer 150

It is a Broad Complex Tachycardia (QRS Width>120ms) and HR>100 2 Other Types of Broad Complex Tachycardias include Torsades de Pointes and Supraventricular Tachycardia with Aberrant Conduction

Question 151

What are the 4 causes of Ventricular Tachycardia?

Answer 151

Electrolyte Abnormalities (Hypokalaemia and Hypomagnesaemia) Structural Heart Disease (Myocardial Infarction or Hypertrophic Obstructive Cardiomyopathy) Drugs that cause QT Prolongation (Clarithromycin and Erythromycin) Inherited Channelopathies (Romano-Ward Syndrome and Brugada Syndrome)

Question 152

What is the management of stable Ventricular Tachycardia?

Answer 152

IV Amiodarone If the HISS Features (Heart Failure, Ischaemia, Shock, Syncope) are present, patients should be offered DC Cardioversion

Question 153

What are the 5 complications of Acute Kidney Injury?

Answer 153

Hyperkalaemia Pulmonary Oedema Metabolic Acidosis leading to Nausea, Vomiting and Drowsiness Chronic Kidney Disease Death

Question 154

What are the 3 signs of an Acute Kidney Injury?

Answer 154

Increase in Serum Creatinine of 26micromol/L within 48 hours Or an increase in Serum Creatinine at least 1.5 times above the baseline value within 1 week Or urine output less than 0.5ml/kg/hour for more than 6 consecutive hours

Question 155

What are the 3 Different approaches to treating Acute Kidney Injury?

Answer 155

Either Find and Treat the Causes (Sepsis, Drugs, Obstruction) Or Stop the Renotoxic Drugs Or Give IV Fluids, Treat the Complications and Dialyse

Question 156

What are the 6 complications of an Addisonian Crisis?

Answer 156

Low Blood Pressure Vomiting and Diarrhoea Dehydration Shock Coma Death

Question 157

What are 5 Renotoxic Drugs?

Answer 157

ACE Inhibitors/ ARBs Spironolactone Diuretics Gentamicin NSAIDs

Question 158

What are the 5 indications for Dialysis in Acute Kidney Injury?

Answer 158

Persistently high Potassium that is refractory to medical treatment Severe Acidosis (pH<7.2) Refractory Pulmonary Oedema Symptomatic Uraemia (Pericarditis, Encephalopathy) Drug Overdose (Aspirin)

Question 159

What are the 5 complications of Acute Kidney Injury?

Answer 159

Hyperkalaemia Pulmonary Oedema Metabolic Acidosis leading to Nausea, Vomiting and Drowsiness Chronic Kidney Disease Death

Question 160

What is an Addisonian Crisis?

Answer 160

It is the body's inability to produce a sufficient amount of Cortisol

Question 161

What is the 5 step management of an Addisonian Crisis?

Answer 161

Fluid Resuscitation if Hypotensive IV Hydrocortisone 100mg (stat and then regularly) IV Glucose if they are Hypoglycaemic Swap back to their Prescribed Oral Steroids after 3 days Consider Fludrocortisone if there is an Adrenal Disease

Question 162

What are the 6 complications of an Addisonian Crisis?

Answer 162

Low Blood Pressure Vomiting and Diarrhoea Dehydration Shock Coma Death

Question 163

What are the 7 causes of Encephalitis?

Answer 163

Herpes Simplex Virus (most common cause) Cytomegalovirus Adenovirus, influenza virus Tuberculosis Listeria Fungal (Cryptococcosis, Coccidiomycosis, Histoplasmosis) Tick-borne Encephalitis

Question 164

What are the 7 features of Encephalitis?

Answer 164

Fever Headache Altered Mental State Personality Change Focal Neurological Deficits Convulsions HSV1 Encephalitis is associated with Temporal Lobe Involvement so patient may experience Olfactory Symptoms (smell of Rotten Eggs)

Question 165

What 3 investigations should be ordered if Encephalitis is suspected? What would they show?

Answer 165

CT Imaging (Medial Temporal and Inferior Frontal Lobe involvement with Petechial Haemorrhages seen in HSV Encephalitis) MRI should also be performed after CT Lumbar Puncture with CSF Analysis- Microscopy and Serology cultures needed to diagnose Encephalitis

Question 166

What is the management of Encephalitis?

Answer 166

IV Aciclovir and IV Ceftriaxone to cover for bacterial infections

Question 167

What are the 7 causes of Encephalitis and the most common cause of Encephalitis?

Answer 167

Herpes Simplex Virus (Most common cause) Cytomegalovirus Adenovirus/ Influenza Virus Tuberculosis Listeria Fungal Causes (3)- Cryptococcosis, Coccidiomycosis, Histoplasmosis Tick-borne Encephalitis

Question 168

What are the 7 signs of Encephalitis?

Answer 168

Fever Headache Altered Mental State Personality Change Focal Neurological Deficits Convulsions HSV1 is associated with Temporal Lobe Involvement. So the patient may experience Olfactory Seizures such as the Foul Smell of Rotten Eggs

Question 169

What 3 investigations should be ordered if Encephalitis is suspected? What would they show?

Answer 169

CT Scan- Medial Temporal and Inferior Frontal Lobe Involvement with the presence of Petechial Haemorrhages in HSV Encephalitis MRI should be performed after Lumbar Puncture with CSF Analysis- Microscopy, Serology and Cultures is needed to diagnose Encephalitis

Question 170

What is the management of Encephalitis?

Answer 170

IV Aciclovir and IV Ceftriaxone

Question 171

What are the 4 most common symptoms of an Acute Pulmonary Oedema? What are the 5 signs of Fluid Overload seen in Acute Pulmonary Oedema?

Answer 171

Extreme Dyspnoea Restlessness Anxiety Bilateral Reduced Air Entry Inspiratory Crepitations Raised JVP S3 Gallop Peripheral Oedema

Question 172

What are the 7 signs of Aspirin Overdose?

Answer 172

Nausea and Vomiting Tinnitus Fever Confusion Tachycardia Initial Respiratory Alkalosis (caused by activation of respiratory centres in the brain) Later Metabolic Acidosis (caused by wasting of bicarbonate ions due to the ingested acid load)- this is often mixed with the respiratory alkalosis

Question 173

Which 2 investigations should be ordered for the diagnosis of Aspiring Overdose?

Answer 173

Venous Blood Gases- look for acid-base imbalances Salicylate levels

Question 174

What is the 4 step management of Aspirin Overdose?

Answer 174

Activated Charcoal if Ingestion< 1 hour ago IV Fluid, Sodium Bicarbonate and Potassium Chloride - (The aim is to maintain good kidney function and to alkalise the urine in order to increase Salicylate Excretion) - Monitor with Serial Venous Blood Gases Dialysis- may be necessary if blood levels are high Monitor them for complications (3) - Renal Functions - Chest X-ray: Pulmonary Oedema - CT Head: if Signs of Cerebral Oedema

Question 175

What are the 3 main precipitants for Acute Pulmonary Oedema?

Answer 175

Cardiac Ischaemia Arrhythmias Non-compliance with Heart Failure Medication

Question 176

What 6 investigations should be ordered if Acute Pulmonary Oedema is suspected?

Answer 176

Bedside Investigations Arterial Blood Gases ECG Troponin- if there is concern for a new cardiac event Serum BNP Chest Xray

Question 177

What is the 7 step management of an Acute Pulmonary Oedema?

Answer 177

Take an ABCDE Approach Sit the patient up Administer Oxygen Ensure IV Access IV Furosemide Consider Non-Invasive Ventilation such as CPAP if failed medical therapy Consider further therapies in the intensive care setting such as invasive ventilation and inotropic support if the above fails

Question 178

How are patients with both Heart Failure and Renal Impairment managed? (4)

Answer 178

Acute Kidney Injury is largely Pre-renal due to Under-perfusion, which can be managed by Replacing Fluids as most patients are Hypovolaemic But if patients have Heart Failure as well as Acute Kidney Injury, the Under-perfusion is because of a poor output from the heart According to the Starling Curve, when the Left Ventricle End-diastolic Volume is too high, the Stroke Volume falls. This is what happens in Heart Failure patients with Fluid Overload So by Off-loading fluid with Diuresis, the Stroke Volume improves, there is a greater output from the heart, so perfusion to the kidneys improve. Overall, when there is Elevated Central Venous Pressure, the Renal Function may recover with the aid of Diuresis

Question 179

How are patients with both Heart Failure and Hypotension managed? (4)

Answer 179

The use of Diuretics to treat Heart Failure would be detrimental to the patient's Hypotension- this can severely impact the perfusion of vital organs In patients with Heart Failure and a Low Left Ventricular Ejection Fraction, if the Systolic Blood Pressure is low (<85mmHg) or the patient is in Shock (Confusion/ Cold Extremities), then add an Inotrope after discussing with a senior colleague. - Small Fluid challenges of 250ml boluses over 15-20 minutes can be given to keep the blood pressure above 90mmHg and this needs to be carefully titrated Vasopressors (Noradrenaline) may play a role in patients with Heart Failure with Persistent Hypotension, alongside evidence of End-organ Hypoperfusion. But only give Vasopressors if the response to Inotropes is insufficient These measures are only temporary and aim to maintain perfusion to the End-organs until the Acute Trigger for the deterioration (the original cause of it) has been reversed, or a Definitive Treatment (Coronary Revascularisation, Mechanical Circulatory Support or Heart Transplantation) has been employed.

Question 180

What is the definition of Syncope and Seizure?

Answer 180

Syncope is an acute transient loss of consciousness with a lot of Postural Tone Seizures arise from a Sudden Synchronous discharge of Electrical Activity from neurons in the brain

Question 181

What 5 factors are different in Syncope and Seizure?

Answer 181

Risk Factors- - Syncope (3)- Heart disease (Arrhythmias), Peripheral Neuropathy, Drugs that cause Postural Hypotension (Diuretics, Antipsychotics, Antidepressants, Antihypertensives) - Seizures (3)- Family or previous history of Epilepsy, Head Injuries, CNS Infections Triggers- - Syncope (5)- Pain, Heat, Exertion, Prolonged Standing, Emotion - Seizures (4)- Alcohol, Sleep Deprivation, Bright Lights, Infections Before the Episode- - Syncope (4)- Dizziness, Light-headedness, Nausea, Tunnel-vision - Seizures (4)- Aura: Strange Feelings like Epigastric Rising, Deja Vu, Visual or Smell Disturbances During the Episode- - Syncope (4)- Sudden loss of tone, May have tongue biting, May have incontinence, Brief Duration - Seizures (4)- Tonic-clonic Jerking, May have tongue biting, May have incontinence, Brief or Prolonged Duration After the Episode- - Syncope- Complete and Rapid Recovery - Seizures (2)- Post-ictal Confusion and Drowsiness, May have Todd's Palsy- Focal Weakness after Seizure

Question 182

What are the 3 main causes of Syncope?

Answer 182

Cardiac Pathology (3) (Arrhythmias, Valvular Disease, Cardiomyopathies) Postural Hypotension (3) (Drugs, Volume Depletion, Autonomic Dysfunction) Neurogenic Causes (Vasovagal Syncope)

Question 183

What are the 5 main causes of Seizures?

Answer 183

Infections (2)- Meningitis, Encephalitis Electrolyte Disturbances (6)- Hyponatraemia, Hypernatraemia, Hypoglycaemia, Hypocalcaemia, Hypokalaemia, Ammonia (Hepatic Encephalopathy) Drugs (3)- Tricyclic Overdose, Alcohol and Benzodiazepine Withdrawal Neurological Causes (4)- Stroke, Mass Lesions, Degenerative Conditions, Epilepsy Obstetrics (Eclampsia)

Question 184

What are Breakthrough Seizures?

Answer 184

Seizures which occur in known Epileptics Can be caused by (4)- Poor medication compliance, Sleep deprivation, Alcohol, Stress

Question 185

What 4 investigations should be ordered if an Acute Seizure?

Answer 185

Arterial Blood Gases (Hypoxia and Hypercapnia- look for these in Acute Prolonged Seizures) Blood Tests (4) (FBC, U&Es (Serum Calcium, Magnesium, Phosphate), LFTs, Glucose) Urine Test- Urine Toxicology Screen Imaging- CT Head

Question 186

What are the 8 signs of Digoxin Poisoning?

Answer 186

Dizziness Nausea and Vomiting Palpitations (due to Arrhythmias) Bradycardia (usually Without Hypotension) Yellow-Green Colour Disturbance Visual Haloes Confusion Hyperkalaemia (but HypOkalaemia is a Risk Factor for Digoxin Poisoning)

Question 187

What is the 5 step management for Digoxin Poisoning?

Answer 187

Measure the Immediate Digoxin Level IV Fluids Correct Electrolyte Abnormalities Continuous Cardiac Monitoring Give Digibind if (3) - Digoxin Level >15ng/ml after 6 hours of last dose - Digoxin Level >10ng/ml within 6 hours of last dose - Symptomatic

Question 188

What are the 9 signs of Hypoglycaemia?

Answer 188

Shaking/ Trembling Sweating Palpitations Hunger Headache Double Vision and Difficulty Concentrating Slurred Speech Confusion Coma

Question 189

What are the Drug (6) and 5 other causes of Hypoglycaemia?

Answer 189

Drugs- - Insulin - Sulphonylureas - GLP-1 analogues - DPP-4 inhibitors - Beta blockers - Alcohol Acute Liver Failure Sepsis Adrenal Insufficiency Insulinoma Glycogen Storage Disease

Question 190

What 5 investigations may be ordered in Hypoglycaemia?

Answer 190

Check the Medication History for Drug Causes Serum Insulin, C-peptide and Proinsulin- to Distinguish the Presence of Exogenous and Endogenous Insulin (High Insulin and High C-peptide and Proinsulin= Endogenous Production/ High Insulin and Low C-peptide and Proinsulin= Exogenous Administration) 72 hour Fast Test- to demonstrate Episodic Hypoglycaemia 8am Cortisol and/ or synACTHen testing- for Adrenal Insufficiency Abdominal CT/MRI/ PET- to look for an Insulinoma

Question 191

How is Mild (still conscious) and Severe (seizures, unconscious) Hypoglycaemia managed? (4,4)

Answer 191

Mild Hypoglycaemia - ABCDE - Eat/drink 15-20g Fast-acting Carbohydrate such as Glucose Tablets, a small can of Coca Cola, Sweets or Fruit Juice - AVOID Chocolate - Eat some Slow-acting Carbohydrate afterwards (toast) Severe Hypoglycaemia - ABCDE - 200ml 10% Dextrose IV - 1mg/kg Glucagon IM- if there is no IV access (this will NOT work if the Hypoglycaemia is caused by Acute Alcohol as it blocks Gluconeogenesis) - Treat Seizure if Prolonged or Repeated After Care- (2) - Consider Medication Changes - Investigate non-drug causes if necessary

Question 192

What is Pheochromocytoma?

Answer 192

It is a Tumour in the Adrenal Medulla that secretes Catecholamines (Hormones produced by Adrenal Glands such as Noradrenaline) If it arises in Sympathetic Nerve Tissue, it is called a Paraganglioma

Question 193

What are the 14 symptoms of Pheochromocytoma?

Answer 193

Pyrexia Dyspnoea Hypertension Postural Hypotension Tremor Hypertensive Retinopathy Abdominal pain Anxiety Weight loss Fatigue Palpitations Sweating Headaches Flushing

Question 194

What 5 things Precipitate the Symptoms of Pheochromocytoma?

Answer 194

Stress Exercise Surgery Straining and Various Drugs such as Beta Blockers Anaesthetic Agents and Opiates

Question 195

What investigations should be ordered if Pheochromocytoma is suspected? (6)

Answer 195

Plasma Metanephrines and then Urinary Metanephrines have the best Diagnostic Accuracy to Establish a Catecholamine Excess 24 Hour Urinary Catecholamines can be measured as well however they are of less value Adrenal Imaging should not take place until the Biochemical Diagnosis has been confirmed CT Chest Abdominal and Pelvis imaging is the imaging method of choice and should be followed with an MRI Scan (as an Extra-adrenal Pheochromocytoma can occur anywhere from the Base of the Brain to the Bladder as it develops in the Chromaffin Tissue of the Sympathetic Nervous System) PET Scans can also help Other tests include Metaiodobenzylguanide (MIBG) labelled with Iodine (which has a similar composition to Noradrenaline)

Question 196

What is the 3 step management of Pheochromocytoma?

Answer 196

The definitive treatment is to Surgically Resect the Tumour Pre-operatively, Alpha Blockade with Phenoxybenzamine is started First This is followed by Beta Blockade to Expand the Blood Volume. This is to Expand the Blood Volume and Prevent a Hypertensive Crisis

Question 197

What are the signs of Acute Spinal Cord Compression? (5)

Answer 197

Upper Motor Neuron Signs Sensory Disturbance below the level of the lesion Deep localised Back Pain may also be present Also a Stabbing Radicular Sensory Disturbance at the Level of the Lesion Bladder and Bowel Involvement may also be seen

Question 198

What are the 5 causes of Acute Spinal Cord Compression?

Answer 198

Trauma Neoplasia (Spinal Cord Compression is seen in 5-10% of Cancer patients, and is the presenting complaint in 20% of them) Infection (especially Tuberculosis in at-risk patient) Disc Prolapse Epidural Haematoma

Question 199

What is the management of Acute Spinal Cord Compression? (2)

Answer 199

They should have a URGENT Whole Spine MRI with an aim to Surgically Decompress within 48 hours If there is a Malignancy seen on MRI, or if the Clinical Suspicion of a Malignancy is high, Dexamethasone 16mg daily should be Administered- with PPI Cover

Question 200

What is a Thyrotoxic Storm?

Answer 200

It is a life-threatening, hypermetabolic state caused by an excessive release of Thyroid Hormones

Question 201

What are the 3 symptoms of a Thyrotoxic Storm?

Answer 201

High Blood Pressure High Temperature Tachycardia

Question 202

What is the 3 step management of a Thyrotoxic Storm?

Answer 202

Symptom Control (2) - IV Propanolol - IV Digoxin if Propanolol fails or is Contraindicated (Asthma, low BP) Reduce Thyroid Activity (4) - Propylthiouracil through an NG tube- (preferred as it inhibits peripheral thyroxine conversion) - Lugol's iodine 4 hours later - Methimazole/ Carbimazole is considered second line - IV Hydrocortisone/ Prednisolone to reduce Thyroid Inflammation Treat Complications (Heart Failure, Hyperthermia)

Question 203

What are the 9 causes of Secondary Epistaxis?

Answer 203

Alcohol Antiplatelet Agents (Clopidogrel) Aspirin and NSAIDs Anticoagulants (Warfarin) Coagulopathy (2)- Haemophilia, von Willebrand's Disease Trauma (Nasal Fracture) Tumours Surgery Septal Perforation

Question 204

What is the general approach to treating Epistaxis?

Answer 204

DRABCDE Brief history- which side? trauma? anticoagulants/ antiplatelets? relevant past medical history?

Question 205

What are the 4 specific management approaches to Epistaxis? (2,4,2,1)

Answer 205

Direct Compression - Direct Compression of the Nasal Alae (Cartilage part) is the First Line Management as most Anterior Nose bleeds resolve after 10-15 minutes of compression. Patient should be Sitting up and Leaning Forward. Compression of the Nasal Bones isn't what controls the bleeding - If this does not resolve the bleed, the next step is Cautery, especially if there is a Visible Bleeding sight and the patient suffers from Recurrent Nose Bleeds Cautery- - Before Cautery, a Topical Anaesthetic Spray and Vasoconstrictor (Lidocaine with Phenylephrine) is applied to Reduce the Pain and Help Control the Bleeding respectively - Cautery can be Chemical or Electrical (Thermal) - Chemical Cautery involves applying 75% Silver Nitrate sticks to the identified bleed for 3-10 seconds - Afterwards, the cauterised area is dabbed with a clean cotton bud to remove excess Chemical and Blood. A Topical Antiseptic preparation such as Naseptin (Chlorhexidine and Neomycin) is applied to the nostrils 4 times a day for 10 days to reduce Crusting and Vestibulitis Nasal Packing- - If Nasal Cautery fails or if there isn't a Bleeding Point or if there is Severe Bleeding, Nasal Packing should be attempted - Nasal Tampons, Inflatable Packs and Ribbon Gauze Impregnated with Vaseline can be used in Nasal Packing Aggressive Therapies- - Nasal Balloon Catheter and Transnasal Endoscopy with Direct Cautery/ Arterial Ligation are reserved for patients with Posterior Bleeds and Uncontrollable Severe Bleeding unamenable to Nasal Packing

Question 206

What is Glandular Fever?

Answer 206

Also known as Infectious Mononucleosis- it is caused by the Epstein-Barr Virus. It is transmitted by saliva which is why it is known as the Kissing Disease

Question 207

What are the 4 main symptoms of Glandular Fever?

Answer 207

Fever Sore throat Fatigue Hepatomegaly and/or splenomegaly may be found on palpation

Question 208

What is the diagnosis and management of Glandular Fever?

Answer 208

The diagnosis is usually made clinically although the heterophile antibody "Paul Bunnell" test will be positive Management is supportive and patients are advised against contact sports and heavy lifting for 1 month to minimise the risk of Splenic Rupture

Question 209

What are the 11 risk factors for a Haemorrhagic Stroke?

Answer 209

Age Male Sex Family History of a Haemorrhagic Stroke Haemophilia Cerebral Amyloid Angiopathy/Hypertension Anticoagulation Therapy Illicit Sympathomimetic Drugs (Cocaine and Amphetamines) Vascular Malformations (particularly in younger patients) Non-steroidal Anti-inflammatory Drugs Heavy Alcohol Use Thrombocytopaenia

Question 210

What is the 3 step management of a Haemorrhagic Stroke?

Answer 210

Neurosurgical and Neurocritical Care Evaluation due to the potential for surgical intervention (Decompressive Hemicraniectomy) Admission to the Neuro ICU or Stroke Unit (patient may require Intubation and Ventilation or Invasive monitoring of ICPs) Aim to keep Blood Pressure <140/80 as poor blood pressure control in the acute stage is associated with poorer outcomes later on

Question 211

What are the 3 causes of Horner's Syndrome?

Answer 211

Pancoast Tumour (Affecting Sympathetic Nerve Supply) Stroke Carotid Artery Dissection (Red flag: Neck Pain)

Question 212

What are the 3 symptoms of Horner's Syndrome and what is the pathophysiology?

Answer 212

Ptosis Meiosis With or Without Anhidrosis It occurs due to the interruption of the Sympathetic Nerve Supply to the eye and can be classified into Pre-ganglionic, Central and Post-ganglionic causes

Question 213

What are the 4 Peripheral Features, 2 Head and Neck Features, 5 Eye Features, 2 Cardiac Features, 1 Gastrointestinal Feature and 2 Neurological Features of Hyperthyroidism? (6 type of features altogether)

Answer 213

Peripheral Features- - Fine Tremor - Finger Clubbing - Sweating - Pretibial Myxoedema Head and Neck Features- - Goitre (depending on the cause) - Thyroid Bruit Eye Features- - Lid Retraction - Lid Lag - Exophthalmos (Graves' Disease) - Periorbital Oedema (Graves' Disease) - Ophthalmoplegia (Graves' Disease) Cardiac Features- - Atrial Fibrillation - High output Heart Failure (if severe and prolonged) Gastrointestinal Features- - Diarrhoea Neurological Features- - Muscle Wasting - Proximal Weakness

Question 214

What are the 6 primary causes and 7 secondary causes of Hyperthyroidism?

Answer 214

Primary Causes- - Graves Disease - Toxic Thyroid Adenoma - Multinodular Goitre - Silent Thyroiditis - De Quervain's Thyroiditis (Painful Goitre) - Radiation Secondary Causes- - Amiodarone - Lithium - TSH-producing Pituitary Adenoma - Choriocarcinoma (Beta HCG can activate TSH Receptors) - Gestational Hyperthyroidism - Pituitary Resistance to Thyroxine (the failure of the Negative Feedback Mechanism) - Struma Ovarii (ectopic thyroid tissue in Ovarian Tumours)

Question 215

What is prescribed for Symptom Relief in Hyperthyroidism, and what is prescribed as Medical Management in Hyperthyroidism (2)- which one is given in Pregnancy?

Answer 215

Propranolol is given for Symptom Relief Carbimazole and Propylthiouracil are given for Medical Management of Hyperthyroidism Carbimazole is contraindicated in Pregnancy, Propylthiouracil is given in the First Trimester in Pregnancy or in a Thyroid Storm

Question 216

What is the indication and contraindication for Radioiodine in Hyperthyroidism?

Answer 216

Radioiodine is the definitive management for Multinodular Goitre and Adenomas Radioiodine is Contraindicated in Graves Eye Disease as it may worsen the symptoms

Question 217

What are the 3 indications and 4 complications for Thyroidectomy in Hyperthyroidism?

Answer 217

It is indicated for (3) Recurrence, Goitres that obstruct other structures and Potential Cancers Complications- Hypoparathyroidism, Hypocalcaemia, Laryngeal Nerve Damage, Bleeding

Question 218

What are the 7 complications of Hyperthyroidism?

Answer 218

Thyroid Storm (often precipitated by Trauma, Surgery or Infection)- this may present as (5)- High Fever, Tachycardia, Confusion, Nausea, Vomiting Atrial Fibrillation High output Heart Failure Osteopenia/ Osteoporosis Upper Airway Obstruction due to a Large Goitre Corneal Ulcers/ Visual Loss in Graves' Eye Disease

Question 219

What are the 6 ECG Features of Hypothermia?

Answer 219

Bradyarrhythmias (4) (Sinus Bradycardia, Atrial Fibrillation with a Slow Ventricular Response, Slow Junctional Rhythms, Varying degrees of AV block) Osborne Waves (J Waves)- a positive deflection at the J Point- between the end of the QRS and beginning of the ST Segment Prolonged PR, QRS and QT Intervals Shivering Artefact Ventricular Ectopics Cardiac Arrest (Ventricular Fibrillation, Ventricular Tachycardia or Asystole)- patients with hypothermia are at high risk of a Cardiac Arrest

Question 220

How is Hypothermia Managed?

Answer 220

Cover Patients with a Warm Blanket and supply Warm Drinks Passive Warming can be done through the Intravenous Admission of Warm Fluids and Application of Warm Air (like through a Bair-Hugger). Patients are at a high risk of Cardiac Arrest and CPR may be used

Question 221

What is Idiopathic Intracranial Hypertension?

Answer 221

It results in an Intracranial Pressure (opening pressure> 25cmH2O) It occurs commonly in Young and Obese Women

Question 222

What are the Clinical Features of Idiopathic Intracranial Hypertension?

Answer 222

Headache and Visual Disturbance The headache is Non-Pulsatile, Bilateral and Worse in the Morning and after Lying Down or Bending Forward Visual Disturbances include Transient Visual Darkening or Loss- probably due to Optic Nerve Ischaemia. In Fundoscopy, Bilateral Papilloedema is seen. If left untreated, the visual loss may be permanent Patients may even report Morning Vomiting. A Key Differential for Morning Headache in these Obese Patients is Sleep Apnoea

Question 223

What 5 drugs are associated with Idiopathic Intracranial Hypertension?

Answer 223

Oral Contraceptive Pills Steroids Tetracyclines Vitamin A Lithium

Question 224

What is the 4 step management of Idiopathic Intracranial Hypertension?

Answer 224

Weight Loss (First line and only intervention supported by good evidence) Carbonic Anhydrase Inhibitors are given if this doesn't work (Acetazolamide) but it has 3 side effects (Peripheral Paresthesia, Anorexia and Metallic Dysguesia). Topiramate and Furosemide can also be used Invasive Strategies to lower CSF include Therapeutic Lumbar Punctures and Surgical CSF Shunting In patients with prominent visual symptoms, Optic Nerve Fenestration may protect against visual loss

Question 225

What are the 7 Criteria for performing a CT Head within 1 hour of a Head Injury?

Answer 225

GCS less than 13 on initial assessment in the emergency department GCS less than 15 at 2 hours after the injury Suspected Open or Depressed Skull Fracture Any sign of Basal Skull Fracture (4) (Haemotympanum, Panda Eyes, Cerebrospinal Fluid Leak from the Ear or Nose, Battle's Sign) Post-traumatic Seizure Focal Neurological Deficit More than 1 episode of vomiting

Question 226

What are the 4 Criteria for performing a CT Head within 8 hours of a Head Injury in patients who have experienced a Loss of Consciousness or Amnesia since the Injury?

Answer 226

Age 65 or older Any history of Bleeding or Clotting Disorders Dangerous Mechanism of Injury (struck by Motor Vehicle, Ejected from Motor Vehicle, fall from a height greater than 1 metre) More than 30 minutes of Retrograde Amnesia of events immediately before the Injury

Question 227

What are the 5 cardiac and 3 non-cardiac causes of Raised Troponin level

Answer 227

Cardiac Causes- - Myocardial Infarction - Arrhythmias - Coronary Artery Spasms - Aortic Dissections - Severe Hypertension Non Cardiac- - Chronic Kidney Disease - Pulmonary Embolism - Sepsis

Question 228

How are Head Trauma patients managed?

Answer 228

ABCDE Algorithm Stabilising the C-Spine and Airway Recognising Haemorrhage and Treating the Pain

Question 229

What are the 8 signs of a Skull Fracture?

Answer 229

Subcutaneous Haematoma CSF Rhinorrhoea (from the Anterior Nares (Nostrils)) CSF Otorrhoea (leakage of CSF from the External Auditory Meatus) Subcutaneous Haematoma around the Orbits (Panda Eyes) Haemotympanum Subcutaneous Haematoma behind the Ear (Battle Sign) Subcutaneous Emphysema Cranial Nerve Palsies (arise 1-3 days after the Trauma)

Question 230

What 2 interventions are contraindicated in Head Trauma?

Answer 230

Nasopharyngeal Airways are Contraindicated as they can cause further damage to the patients Head tilt, Chin Lift is Contraindicated in Trauma patients at risk of a C-Spine Injury

Question 231

What 4 investigations are ordered in Head Trauma?

Answer 231

First line is Plain CT Head CT Cervical Spine to look for Spinal Fractures CT Angiogram to look for Local Vascular Injuries Plain Skull Xray to look for Orbital Fractures

Question 232

How is Neisseria Meningitidis spread?

Answer 232

Respiratory Droplet Spread The pathology is triggered when the bacteria enters the circulation, initiates the inflammatory process leading to capillary leakage and intravascular thrombosis

Question 233

What is the presentation of a Meningococcal Infection? (5)

Answer 233

Meningococcaemia (Septicaemia) Meningitis (non-specific signs such as (5) Lethargy, Headache, Fever, Rigors and Vomiting) A mixture of both Meningitis and Meningococcaemia associated with a Rapidly Developing Purpuric Skin Rash Hypovolaemic Shock may present with (4) Cold Peripheries, Poor Capillary Refill Time and Tachycardia, with Decreased Urine Output When this is associated with Massive Adrenal Haemorrhage and Septic Shock, the presentation is known as Waterhouse-Friderischsen Syndrome. This is rare

Question 234

How can the diagnosis of a Meningococcal Infection be confirmed? (2)

Answer 234

Blood or CSF Cultures Polymerase Chain Reaction Testing for Neisseria Meningitidis is highly sensitive

Question 235

What is the 3 step management of a Meningococcal Infection?

Answer 235

Early Antibiotic Treatment should be given. This will usually be Broad Spectrum IV Antibiotics until confirmation of the pathogen, after which antibiotics may be narrowed to Penicillin-based drug if Sensitivities permit Patients are likely to need PICU admission is Septicaemia Infections caused by Neisseria meningitidis are notifiable diseases

Question 236

What 2 thing should be done to prevent Menignococcal Infections?

Answer 236

All household or close contacts should receive Ciprofloxacin or Rifampicin as Post-exposure Prophylaxis Multiple strains of Neisseria Meningitidis covered as part of the Routine Immunisation Schedule

Question 237

What is the 8 step management of a Myxoedema Coma?

Answer 237

ITU/ HDU care IV T3/ T4 50-100mg IV Hydrocortisone Mechanical Ventilation and Oxygen (if Hypoventilation) IV Fluid- to correct Hypovolaemia Correct Hypothermia Correct Hypoglycaemia Treat any Heart Failure

Question 238

What is Necrotising Fasciitis?

Answer 238

It is a life-threatening infection of the subcutaneous soft tissue, which spreads along the fascial planes but not the underlying muscle

Question 239

What is the presentation of Necrotising Fasciitis?

Answer 239

Rapidly spreading cellulitis and patients are systemically unwell. There is often a history of risk factors (cutaneous portal of entry for bacteria, like Trauma or Surgery) On physical examination- the affected region will be Blistering and Erythematous. But a Mild Oedema may be the only sign. There will be severe pain or anaesthesia over the site of Cellulitis. In advanced stages, the skin may be grey with overlying Crepitus. The patient is typically (4) Pyrexial, Tachycardic, Tachypnoeic and Hypotensive

Question 240

How is Necrotising Fasciitis managed (3, 1)?

Answer 240

Haemodynamic Support Urgent Debridement Surgery Broad Spectrum Antibiotics Radiography or CT/MRI can confirm the diagnosis but should not delay the surgery

Question 241

What are the 4 causes of Oesophagitis?

Answer 241

Reflux of Gastric Contents Drugs Infections Allergens (Eosinophilic Oesophagitis)

Question 242

What are the 3 symptoms of Oesophagitis?

Answer 242

Heartburn (retrosternal burning pain) Nausea and Vomiting Odynophagia (painful swallowing)

Question 243

What 3 investigations can be conducted if Oesophagitis is suspected?

Answer 243

Endoscopy allows for a direct visualisation of the Oesophagus and can be used to Grade the degree of Oesophagitis (Savary-Miller Grading System, Los Angeles Grading System) Biopsy can be taken with the Endoscopy If reflux is suspected as the cause, Oesophageal pH monitoring can be used to identify whether the timing of the symptoms and the reflux correlates

Question 244

What is the management of Oesophagitis?

Answer 244

As reflux is the most common cause, - Lifestyle changes such as (3) Weight loss, Stopping smoking and Reducing Alcohol intake and... - Pharmacological treatment such as Protein Pump Inhibitors can be administered

Question 245

What two bones are most at risk for an Open Fracture?

Answer 245

the Tibia and the Phalanges

Question 246

What is the 3 step management of an Open Fracture? (1, 2, 2)

Answer 246

The Prompt Administration of Antibiotics (open fractures are at risk of infection) Debridement and Irrigation Reduction and Fixation

Question 247

What are the 8 signs of Paracetamol Overdose?

Answer 247

No symptoms may be present Nausea and Vomiting Loin Pain Haematuria and Proteinuria Jaundice Abdominal Pain Coma Severe Metabolic Acidosis

Question 248

What is the pathophysiology of Paracetamol Overdose?

Answer 248

When overdosed, the metabolism of Paracetamol results in a buildup of a toxic substance called NAPQI (N-acetyle-p-benzoquinone-imine) NAPQI is inactivated by Glutathione usually, however in an overdose, the Glutathione stores are rapidly depleted and NAPQI damages the Kidneys and Livers

Question 249

What is the management of Paracetamol Overdose (6)?

Answer 249

If the ingestion is less than 1 hour ago and the dose is greater than 150mg/kg- Administer Activated Charcoal If they had a Staggered Overdose (duration of overdose>1 hour) or ingestion was more than 15 hours ago or there is any uncertainty about the timing- Start N-acetylcysteine immediately If ingestion <4 hours ago, wait until 4 Hours to take a level (blood paracetamol level) and treat with N-acetylcysteine based on their level (refer to a Nomogram) If ingestion is 4-15 hours ago, take an immediate level and treat based on their level Obtain bloods for (4)- FBC, Urea and Electrolytes, INR and Venous Gases Consider the need for transfer to Liver Unit if blood tests are Worsening

Question 250

What is N-Acetylcysteine associated with?

Answer 250

Anaphylactoid Reactions. These are not true Anaphylactic Reactions and can be managed by stopping the Infusion Temporarily and restarting at a Lower Rate

Question 251

What are 4 things that increase the risk of Paracetamol Toxicity in patients and means the patients should be immediately administered N-acetylcysteine?

Answer 251

Patients on long-term Enzyme Inducers Regular Alcohol Excess Pre-existing Liver Disease Glutathione-deplete States- Eating Disorders, Malnutrition and HIV

Question 252

What are 5 different signs of Type A Dissections (Ascending Aorta and Aortic Arch) and 3 signs of Type B Dissections (Descending Aorta)? Where is the dissection according to each sign? (in brackets)

Answer 252

Type A - Central chest pain (Coronary Ostia- leads to Myocardial Infarction) - Dyspnoea (Ascending Aorta- leads to Aortic Regurgitation and therefore Congestive Heart Failure) - Neck/ Jaw Pain (Aortic Arch) - Horner's (Cervical Sympathetic Ganglia) - Symptoms of Stroke (Carotid Arteries) Type B - Interscapular pain (Thoracic Descending Aorta) - Abdominal pain (Abdominal Descending Aorta or Mesenteric Arteries) - Flank pain (Renal Arteries)

Question 253

What is the difference between the intensity of the pain in Aortic Dissection and Myocardial Infarction?

Answer 253

Aortic Dissection pain is worst at onset and gets better Myocardial Ischaemia pain gets worse as the Ischaemia Worsens

Question 254

What are the 2 differential diagnoses for Seizures in Adult Patients?

Answer 254

Syncopal Episodes and Pseudoseizures

Question 255

What are the features of a Generalised Seizures?

Answer 255

Sudden Onset Lateral tongue biting and Urinary Incontinence may occur. After the event, the patient is usually confused (but may recall the onset especially if secondary generalised seizure). They may be left with a residual focal neurological deficit (Todd's Paresis) There are two groups of Seizures- Provoked and Unprovoked Seizures, where there is an underlying tendency to spontaneous abnormal electrical brain activity (which manifests clinically as seizures), these may be Congenital or Acquired Tendencies

Question 256

What are the features of Syncope?

Answer 256

The Absence of Postictal Confusion. With Vasovagal Syncope, patients report (3) Narrowing of Vision, Sweating and Lightheadedness and have time to safely lower themselves onto the floor. Arrhythmogenic Syncope (Stokes-Adams attacks) are abrupt in onset without any warning and may result in significant injury. Myoclonic Jerks or Tonic Posturing may occur during these episodes which may confound diagnosis

Question 257

What are the features of Pseudoseizures?

Answer 257

They are called Psychogenic NonEpileptic Attacks. They are often Prolonged Episodes (rarely< 1 minute, often> 30 minutes) The patient often has Seizure-like Convulsions and Fluctuating Motor Activity. Video EEG Recording helps to differentiate Pseudoseizures from True Seizures Differential Diagnoses include Hemiplegic Migraine and Cerebrovascular Events, although Consciousness is typically preserved in Pseudoseizures If patients have True Seizure Activity and Focal Weakness, differentiating Seizure plus Todd's Paresis from Stroke plus Seizure Onset is difficult clinically and Requires Imaging

Question 258

What are the 2 types of Seizures?

Answer 258

Focal (or Partial Seizures) may spread to involve the entire brain- these are called Secondary Generalised Seizures. Focal Seizures may be subclassified on the basis of Key Clinical Features, in particular the part of the brain that they involve (Temporal vs. Frontal lobe seizures) and whether consciousness is impaired (Simple vs. Complex) The clinical manifestation of a Generalised Seizure may be described. These are either (4) Tonic, Tonic-Clonic, Myoclonic or Absence. Generalised Tonic-Clonic (or Grand Mal) seizures are the most typical- the patient falls to the ground (Tonic) and has rhythmic jerks (Clonic Absence)

Question 259

What determines whether a patient has Systemic Inflammatory Response Syndrome (SIRS)?

Answer 259

2 or more of: - >38 degrees or <36 degrees temperature - Heart Rate>90 (not 100 like Tachycardia) - Respiratory Rate>20 - WBC> 12,000/mm cubed or <4,000/mm cubed

Question 260

What determines whether a patient has Sepsis?

Answer 260

SIRS and a presumed Infection

Question 261

What determines whether a patient has Severe Sepsis?

Answer 261

Sepsis and evidence of Organ Dysfunction (4)- Confusion, Hypoxia, Oliguria, Metabolic Acidosis

Question 262

What determines whether a patient has Septic Shock?

Answer 262

Severe Sepsis with Hypotension despite (3) Adequate Fluid Resuscitation or Lactic Acidosis (Lactate>3mmol/L)

Question 263

What are the 11 signs of Sepsis?

Answer 263

- Fever, Sweats or Chills - Breathlessness - Headache - Nausea and Vomiting - Diarrhoea - Tachycardia - Hypotension - Pyrexia - Peripherally Vasodilated - Hypoxia - Tachypnoea

Question 264

What is the management approach to Sepsis? What 4 investigations should also be ordered and what 3 additional management steps should be carried out?

Answer 264

ABC (Airways, Breathing, Circulation) + Sepsis Six - Take Bloods (FBC, U&Es, LFT, CRP, Lactate) - Take Blood Cultures - Administer Oxygen if required (Sats<94%) - Administer IV Antibiotics - Administer IV Fluid Resuscitation (Fluid Challenge- Crystalloid if (2) Systolic BP<90mmHg or Lactate>4mmol/L and high risk of Sepsis) - Catheterisation and monitor urine output 4 Investigations- - Imaging (CXR, Echocardiogram, Abdominal Ultrasound) - Viral PCR for any viruses like Influenza for example - Urinalysis, with or without Culture - Lumbar Puncture Ongoing Management (depends on the Source and the Severity) - IV Antibiotic Therapy - Surgical Removal of Source of Infection - Critical Care Involvement

Question 265

What is the Triad of Serotonin Syndrome and what causes it?

Answer 265

Mental State Changes Autonomic Hyperactivity (arousal of the sympathetic nervous system typically- results in signs of Anxiety (5)- Sweating, Lightheadedness, Dry Mouth, Palpitations, Upset Stomach Neuromuscular Abnormalities (muscle weakness, paresthesia) It usually presents within the first couple months of starting an SSRI or because of drug interactions like Tramodalol and Sertraline

Question 266

What are the 6 types of Shock and their causes?

Answer 266

Hypovolaemic Shock (Blood Loss) Septic Shock (Severe Systemic Infections) Anaphylactic Shock (Allergy) Cardiogenic Shock (Poor Cardiac Output) Neurogenic Shock Obstructive Shock (A Physical Obstruction of the Vessels or the Heart)

Question 267

What is the management of Hypovolaemic Shock in Trauma? (5)

Answer 267

1.5-2L Warmed IV Crystalloid Assess for response If the response to the fluid is inadequate, arrange O Negative Blood Give fully cross-matched blood as soon as possible If the patient is Severely Shocked, initiate the Massive Haemorrhage Protocol

Question 268

What are the features of Space Occupying Lesions (5)?

Answer 268

A Prominent Headache worse when (4) Waking up, Lying down, Coughing/ Straining and associated with Vomiting Early symptoms of a Raised ICP are Non-specific and include a Headache associated with morning Nausea and Vomiting Patients may have Cranial Nerve Palsies- especially within the Abducens Nerve In Advanced Cases, Drowsiness and Seizure Activity may occur with Pupillary Abnormalities and Papilloedema The Cushing's Reflex may also be demonstrated where a patient has Raised Blood Pressure, Bradycardia and Abnormal Breathing (including Cheyne-Stokes Respiration)

Question 269

What are the Differential Diagnoses of a Space Occupying Lesion? (4)

Answer 269

There are 4 types of Space Occupying Lesions (Tumours, Vascular Lesions, Infective Processes, Granulomata) Space Occupying Neoplasia can occur secondary to Metastatic Disease (from Breasts, Lungs or Melanoma) or as a Primary CNS Tumour Infective Processes include Cerebral Abscesses and rarer diseases such as Tuberculosis Patients who are immunosuppressed are more prone to Intra-cerebral Infections so look for risk factors such as HIV

Question 270

How are Space Occupying Lesions diagnosed?

Answer 270

Cranial MRI is more useful that Cranial CT

Question 271

What 4 questions should you ask yourself if a patient presents with Sudden Painless Visual Loss?

Answer 271

What is the Time Course? What are the associated symptoms? What is the Medical History? What does the Retina look like?

Question 272

What are the 7 causes of Sudden Painless Visual Loss?

Answer 272

Central Retinal Vein Occlusion (More common than CRAO) Central Retinal Artery Occlusion Ischaemic Optic Neuropathy Giant Cell Arteritis Retinal Detachment Vitreous Haemorrhage Optic Neuritis

Question 273

What are the Fundoscopy Findings and Risk Factors of Central Retinal Vein Occlusion (5) and Central Retinal Artery Occlusion (6)

Answer 273

Central Retinal Vein Occlusion (More common that CRAO)- - Stormy Sunset Appearance on Fundoscopy - Old Age - Hypertension - Diabetes - Polycythaemia - Arteriosclerosis Central Retinal Artery Occlusion- - Pale Retina with Cherry Red Spot at the Macula - Carotid Bruit - Hypertension - Atrial Fibrillation - Diabetes Mellitus - Smoking - Hyperlipidaemia

Question 274

What are 3 facts each about Ischaemic Optic Neuropathy, Giant Cell Arteritis, Retinal Detachment, Vitreous Haemorrhage and Optic Neuritis?

Answer 274

Ischaemic Optic Neuropathy - Optic Nerve Damage due to a lack of blood supply - Different causes and so patients present differently, but generally have Sudden Onset Monocular Vision Loss and Colour Blindness - Relative Afferent Pupillary Defect is seen on examination. On Fundoscopy, Optic Disc Swelling if it is acute and a Pale Optic Disc if it is chronic suggests Optic Atrophy Giant Cell Arteritis - Commonest form of Arteritic Anterior Ischaemic Optic Neuropathy - Typically Elderly Female presenting with Sudden Onset Painless loss of vision with (3) Headache, Jaw Claudication and Scalp Tenderness - There is a strong association between this condition and Polymyalgia Rheumatica Retinal Detachment - Patients present with Floaters and Flashers followed by a Curtain Falling over their Vision - Don't confuse this with Amaurosis Fugax which is the same as this but is Transient - Fundoscopy shows a Pale-grey area of Retina Ballooning forward Vitreous Haemorrhage - If it is minor, patients complain of Floaters, if it is severe then patients complain of a Painless Loss of Vision - When the bleed is large enough to cause visual loss, the retina is Difficult to View on Fundoscopy - Suspect this is in patients with Neovascularisation in Diabetes Mellitus or Central Retinal Vein Occlusion Optic Neuritis - This is not a Sudden loss of vision as it progresses over Hours to Days- it is also Painful - Suspect this if Ocular Movement causes pain or if there is a Red Desaturation - Optic Neuritis is the most common initial feature of Multiple Sclerosis

Question 275

What are the 2 main Surgical Complications? What 2 investigations should be ordered in Post-Surgery Patients with Symptoms? How should a Small (3) and Large Leak be managed?

Answer 275

An Anastomotic Leak- the Contents of a Hollow Organ which was joined Surgically leaks through a fault in the join The bowel contents can leak and contaminate the Peritoneal Content and this can lead to (3) Peritonitis, Abscess Formation and Abdominal Sepsis Suspect this in patients who have had an Intestinal Surgery and have (3) Failure to Thrive, a Persistent Low Grade Fever or Prolonged Ileus (lack of normal muscle contractions of the Intestine) Radiological Investigations can be used to identify any Inappropriate Presence of IV Contrast in the Abdominal Cavity Lactate Levels from a VBG can be used to assess Tissue Ischaemia. Patients require Investigations for Sepsis which is another Complication A small leak can be managed conservatively with (3) Bowel Rest, IV Fluids and Antibiotics. They require repeated Abdominal Monitoring Larger Leaks may require Emergency Laparoscopic Exploration with potential further Surgery

Question 276

What are the parameters for the Glasgow Coma Scale?

Answer 276

Motor Score 6- Obeys Command 5- Localises to Pain 4- Withdraws to Pain 3- Flexor Response to Pain 2- Extensor Response to Pain 1- No Response to Pain Verbal Score 5- Oriented 4- Confused Conversation 3- Inappropriate Speech 2- Incomprehensible 1- None Eye Score 4- Spontaneous 3- Open in Response to Speech 2- Opens to Pain 1- No Eye Opening GCS of 8 or Lower suggests the patient is unable to Maintain their own Airway and warrants urgent assessment by the Anaesthetic Team

Question 277

What constitutes whether Bradycardia is a Medical Emergency? (4)

Answer 277

Systemic Hypotension Signs of Cerebral Hypoperfusion Progressive Heart Failure Angina

Question 278

What are the 8 causes of Bradycardia?

Answer 278

Normal in Athletic Individuals Electrolyte Disturbances Hypothyroidism Myocardial Infarction Sepsis Drugs (Beta Blockers) Increased Intracranial Pressure Heart Block

Question 279

How is Bradycardia managed? (3)

Answer 279

If there is evidence of Haemodynamic Compromise- Medical Therapy should be started immediately regardless of the cause 3 Medications used to increase Ventricular Rate are Intravenous Atropine, Epinephrine (Adrenaline) and Dopamine Patients who do not respond to Medical Therapy require Temporary Pacing (2)- Transcutaneous and Transvenous Pacing are the most common types

Question 280

What are the 8 signs of Tricyclic Antidepressant overdose?

Answer 280

Drowsiness Confusion Arrhythmias Seizures Vomiting Headache Flushing Dilated Pupils

Question 281

What 6 investigations should be ordered in Tricyclic Antidepressant overdose?

Answer 281

FBC U&Es CRP LFTs Venous Blood Gas (look for Evidence of Acidosis) QT interval prolongation- which precipitates Cardiac Arrhythmias

Question 282

How is Tricyclic Antidepressant Overdose managed?

Answer 282

Overall management is based on the patient's symptoms Patients should be reviewed by Intensive Care if (2) there is any concern about their Airway (especially if they are drowsy) or if there is Severe Metabolic Acidosis which may require Renal Replacement Therapy Activated Charcoal can be considered 2-4 hours After the Overdose

Question 283

What causes Wolff-Parkinson-White Syndrome?

Answer 283

It is due to a Congenital Accessory Electrical Pathway which connects the Atria to the Ventricles, bypassing the AV Node This Accessory Pathway leads to the likelihood for Re-entrant Circuits to form leading to Supraventricular Tachycardia

Question 284

What are the Symptoms of Wolff-Parkinson-White Syndrome?

Answer 284

No Symptoms- Patients with Wolff-Parkinson-White are often Asymptomatic Palpitations Dizziness Syncope

Question 285

What are the 4 ECG Features of Wolff-Parkinson-White Syndrome?

Answer 285

Delta Waves (Slurred Upstroke in the QRS) Short PR Interval (<120ms) Broad QRS If a re-entrant circuit has developed, the ECG will show Narrow Complex Tachycardia

Question 286

What 5 investigations can be ordered if Wolff-Parkinson-White Syndrome is suspected?

Answer 286

ECG 24 Hour ECG monitoring if Paroxysmal Symptoms Routine bloods include TFTs if Non-Cardiac causes of Tachycardia are suspected ECHO to assess Ventricular Function Intracardiac Electrophysiological studies to map the Location of the Accessory Pathway

Question 287

What is the 3 step management of Wolff-Parkinson-White?

Answer 287

Radiofrequency Ablation of the Accessory Pathway Drug Treatment (Amiodarone or Sotalol) to avoid further tachyarrhythmias. These are contraindicated in Structural Heart Disease Surgical (open heart) Ablation- rarely done and only done in Complex Cases

Question 288

What is the management of Wolff-Parkinson-White Syndrome in Unstable Patients?

Answer 288

Unstable Patients (3) (Blood Pressure<90/60mmHg or with signs of Systemic Hypoperfusion or Fast Atrial Fibrillation) require Direct Current Cardioversion (DC Cardioversion)

Question 289

What is the 4 step management of Wolff-Parkinson-White Syndrome in Stable Patients? 3 for Orthodromic, 2 for Antidromic

Answer 289

They are managed according to their Rhythm - If they have an Orthodromic AV Reciprocating Tachycardia (Narrow QRS Complex with Short PR Interval), management is with Vagal Manoeuvres (Carotid Sinus Massage or Valsalva Manouevre). If this fails, then IV Adenosine should be Administered - In Orthodromic AV Reciprocating Tachycardia, one limb of the aberrant circuit involves the AV node so slowing conduction through the AV Node helps to Terminate the Tachycardia - In Antidromic AV Reciprocating Tachycardia (Wide QRS Complex), Atrial Fibrillation or Atrial Flutter, Intravenous Antiarrhythmics (such as Procainimide or Flecainide) help prevent Rapid Conduction through the Accessory Pathway - DC Cardioversion may be used if the symptoms still persist