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1

A 34 year old woman with no previous history of cardiac disease has been brought to the A&E department and found to have atrial fibrillation.

Which medication is likely to be the most suitable to cardiovert this patient?

Fleicanide

Digoxin

Amiodarone

Adrenaline

Warfarin

Fleicanide

Atrial fibrillation is rapid, irregular, uncoordinated atrial activity. AF decreases cardiac output by 10-20% regardless of underlying ventricular rate and clinical presentation can vary.

Treatment depends on patient stability, myocardial status and duration of the arrhythmia.

Flecanide is a drug commonly used for chemical cardioversion if the patient is relatively young and they have a structurally normal heart.

2

An elderly gentleman on the ward is complaining of light-headedness and the feeling that “his heart is thumping out of his chest”. On ECG he is found to have a regular pulse, tachycardic (180bpm) with broad QRS complexes. The gentleman is otherwise currently stable.

What is the correct pharmacological management of this patient?

Adenosine

Amiodarone

Adrenaline

Digoxin

Fleicanide

Amiodarone

Ventricular tachycardia usually results from a single focus of abnormal electrical activity within the ventricles that produces rapid ventricular activation (~180-220bpm).

Patients who are unstable with VT (e.g. hypotensive or have chest pain) require immediate electrical cardioversion.

Patients who are stable may be cardioverted with amiodarone.

3

A 60-year-old lady attends A&E complaining of palpitations that started whilst she was sat at home 45 minutes ago. On examination her pulse rate is 160bpm. ECG confirms that this lady has a supraventricular tachycardia; a regular tachycardia with a narrow QRS complex.

What is the first-line treatment for this patient?

Adenosine

Amiodarone

Adrenaline

Valsalva Manoeuvre

CPR

Valsalva Manoeuvre

Commonly causing a ventricular rate of 160-180bpm, SVT’s are caused by an abnormal electrical circuit in or near to the AVN.

Treatment aims to break the electrical circuit by reducing transmission in the AVN. This can be achieved by the Valsava Manoeuvre (asking a patient to blow a plunger out of a 10ml syringe whilst head tilted down) or one-sided carotid sinus massage (in a young patient only); that increases the vagal (parasympathetic) drive to the AVN.

If this does not work, the AVN can be pharmacologically blocked using Adenosine which temporarily upsets the adenosine/cAMP balance. Patients may experience a ‘feeling of impending doom’.

4

A 12-year-old girl was at school playing with her friends when a wasp stung her. She develops shortness of breath, an urticarial rash, and begins feeling generally unwell. The ambulance crew arrives and suspects a diagnosis of anaphylaxis.

What is the most appropriate medication, dose and route for the paramedics to administer?

Adrenaline 500mg IM

Adrenaline 100mg IV

Adrenaline 300mg IM

Hydrocortisone 100mg IM

Hydrocortisone 300mg IV

Adrenaline 300mg IM

Anaphylaxis is a life-threatening reaction to an allergen.

Familiarization with appropriate doses of adrenaline is recommended.

Only intensivists and anaesthetists are trained to give IV adrenaline, so even in the ED adrenaline will always be given intramuscularly.

 

5

An 85-year-old gentleman was admitted 10 days ago with increasing shortness of breath, fever and new onset confusion.

His observations at the time were:

RR 29

BP 90/60

Pulse 112

Urea 7.3mmol/L

He was diagnosed with community-acquired pneumonia and his CURB-65 score was calculated to be 4. He has since been in ICU and has received ventilator support, inotropes and filtration.

His family has been counselled about turning off his ventilator. The transplant coordinator has telephoned to discuss this patient as a potential organ donor.

He has a history of hypertension and a Duke’s B colon cancer 3 years ago, which was successfully treated. His colon screening since than has been normal.

What factor would make you decide against this patient donating his organs?

Systemic infection

History of malignancy

Need for filtration

Need for inotropes

His age 

 

History of malignancy

This gentleman’s history of malignancy is a contraindication to organ donation. It is not yet possible to exclude micrometastases, and thus it would be inappropriate for this organ to be donated to a recipient who will be immunosuppressed.

He is an elderly gentleman, although with a long waiting list for transplants this organ would be a good match for an elderly recipient.

Although his creatinine was high on admission, the reassuring normal level now suggests that his baseline renal function is good. Creatinine would rise in the clinical setting of sepsis.

Although he has received intensive intervention, it was in the setting of severe sepsis and septic shock, which would suggest that inotropes were required for acute tubular necrosis, and hence there is the potential for recovery after transplantation.

6

A two-month-old child is brought to the A&E department by her parents. She was crawling on the sofa and fell off onto her buttocks. As a consequence of her fall, she has severe bruising in this region. The child is otherwise well, and is meeting her developmental milestones. On examination, you also notice a small bruise behind the child’s left ear.

What is the most likely cause of this child’s bruising?

Mongolian spots

Capillary haemangioma

Non-accidental injury

Idiopathic thrombocytopenic purpura

Henoch-Schoen purpura

Non-accidental injury

Healthcare professionals must always consider non-accidental injury if there is any hint of a suspicious injury and/or presentation. In this instance it is concerning that a child of a non-ambulatory age has attained bruising across the buttocks. Bruising behind the ear is concerning as it is often referred to as the “triangle of safety” - accidental injuries in this area are unusual.

Mongolian spots are congenital lesions. They are blue-gray areas of pigmentations most commonly found on the sacral area and buttocks. Mongolian spots do not change colour or fade.

Capillary haemangiomas are a common benign vascular malformations, found in 10% of children during the first weeks of life. They have an erythematous or bruised appearance and most commonly occur on the face, but may be seen elsewhere. These lesions blanch with pressure.

HSP could be mistaken as non-accidental bruising as early on in the disease there are ecchymotic lesions present, particularly across the buttock and extensor surfaces. Thus, a recent history of upper respiratory tract infection should be sought.

In the case of idiopathic thrombocytopenic purpura, the parents may give a history in which the child bruises easily. As part of the initial investigations, a full blood count, prothrombin and activated partial prothrombin time should be requested to exclude this diagnosis.

7

A 19-year-old woman fell on her outstretched hand and has injured her wrist. She requires a Colles fracture manipulation.

Which of the following analgesics/analgesic techniques would be most appropriate in an Emergency Department setting?

Paracetamol

Propofol

Haematoma block with or without Entonox

Ketamine

Thiopental

Haematoma block with or without Entonox

A haematoma block is an analgesic technique used to allow painless manipulation of fractures while avoiding the need for full anaesthesia. This technique is most commonly used for fractures of the radius and/or ulna.

If displacement occurs when a bone is fractured, the space separating the fragments fills with blood (haematoma). Injection of local anesthetic into this area should provide adequate relief during manipulation. If this is not adequate, Entonox (50% Nitrous Oxide, 50% Oxygen) may also be inhaled by the patient to provide short acting relief. This can, however, make the patient feel nauseous.

Paracetamol would take longer to work and may not provide adequate relief.

Propofol and thiopental are IV anaesthetic induction agents and would not be required in this circumstance.

Ketamine is used less frequently in adults within the ED due to its potential dissociative side effects.

8

A 5-week-old boy is brought to the ED by his anxious parents who explain that the baby has been projectile vomiting after trying to feed. The vomit doesn’t look like it contains any bile. Their son appears hungry and is keen to feed again but vomits repeatedly after trying. Abdominal palpation reveals an olive sized lump in the epigastrium and confirms the diagnosis of pyloric stenosis.

Which, out of the following blood results would be most expect to find from this child with advanced symptoms?

Normal ranges:

Na+: 135-145mmol/L

K+: 3.5-5.0mmol/L

Cl-:95-105mmol/L

HCO3-: 22-28mmol/L

Mg2+: 1.5-2.0mmol/L

 

Option B

Hypertrophic pyloric stenosis is relatively common, typically presenting with effortless vomiting between 2-10 weeks. It occurs more frequently in boys than girls and in first-born children.

Vomiting becomes projectile and is not bile stained.

This causes progressive dehydration, a metabolic acidosis and marked electrolyte disturbances, in particular; hyponatraemia, hypochloraemia and hypokalaemia.

Operative treatment must be delayed until electrolyte disturbances are corrected via fluid resuscitation.

 

9

Which of the following signs is pathognomonic for measles?

Rose spots

Kernig's sign

Strawberry tongue

Koplik spots

Murphy's sign

Koplik spots

A pathognomonic sign is a sign that is diagnostic of a particular disease.

Koplik spots are ulcerated mucosal lesions marked by necrosis, neutrophilic exudate and neovascularisation. They are often described as ‘grains of salt on a wet background’-clustered white lesions on the buccal mucosa opposite the lower 1st and 2nd molars. They often manifest two to three days before the measles rash itself and often fade as the maculopapular rash develops. They are also important if found before a person reaches maximum infectivity, to aid isolation of contacts and greatly aids control of outbreaks.

Rose spots on the abdomen are linked to enteric fever.

Kernig’s sign is linked to meningitis.

Strawberry tongue is linked to scarlet fever.

Murphy’s sign is linked to cholecystitis.

10

A 31-year-old lady is rushed to the A&E department. She looks shocked; she is tachycardic, hypotensive and appeared confused on the way to the hospital. She has profound muscle weakness, abdominal pain and on arrival she is going in and out of consciousness. It becomes apparent by talking to her husband that she is suffering from an Addisonian crisis due to sudden withdrawal of her chronic steroid therapy for Rheumatoid Arthritis, which has recently worsened, requiring a high dose of steroids.

Her blood tests come back to highlight which of the following results? 

 

Option B

Acute adrenocortical insufficiency (Addisonian crisis) is rare and easily missed. The most common cause is sudden withdrawal of chronic steroid therapy (deliberately or inadvertently). In crisis, the main features may be shock, tachycardia, peripheral vasoconstriction, severe postural hypotension occasionally with syncope, oliguria, profound muscle weakness, confusion and altered consciousness leading to coma. It is a medical emergency.

Hyperkalaemia, hyponatraemia, hypoglycaemia, hypercalcaemia, uraemia, mild acidosis and eosinophilia may be present.

A blood cortisol level should be taken but if an Addisonian crisis is suspected treatment of hydrocortisone sodium succinate (100mg) should be given stat.

Hypoglycaemia should also be treated with glucose to maintain BM.

11

Mary, a 50-year-old chronic alcoholic who is well known to the A&E department, has been brought in today by her neighbour. She had cut her index finger accidentally at home and requires suturing of the wound. While you are suturing her finger you have a conversation with her and pick up that she seems particularly indifferent to the situation and she can’t remember who brought her into the department.

Mary says that a dog bit her finger and caused the injury, however this is inconsistent with the type of laceration and her neighbour had previously explained to you that she had seen Mary cut herself while trying to pick up a broken glass bottle.

You suspect that Mary may be suffering from a neurological disorder.

Which of the following is the most likely in this instance?

Korsakoff's Syndrome

Depression with psychosis

Mania with psychosis

Alzheimer's Disease

Dementia with Lewy Bodies

Korsakoff's Syndrome

Korsakoff’s syndrome is a neurological disorder caused by a lack of thiamine (vitamin B1) in the brain. Its onset is linked to chronic alcohol abuse or severe malnutrition (which may go hand in hand).

Six major symptoms include anterograde amnesia, retrograde amnesia, confabulation, minimal content in conversation, lack of insight and apathy.

Treatment includes the replacement or supplementation of Thiamine by IV or IM injection, together with adequate nutrition and hydration. Treatment is a long course and if successful, recovery can still be very slow and often incomplete but can help maintain/regain some level of independence.

Mary is unlikely to be suffering from mania because of her apathetic attitude and memory problems.

She is unlikely to be suffering from psychosis as does not seem to have had delusions or hallucinations although she has confabulated a story as to why she injured herself.

Dementia with Lewy bodies is more likely in patients over the age of 65 - patients are likely to experience some hallucinations and day-to-day memory is often affected typically less in the early stages than in Alzheimer’s disease. A

lthough early onset Alzheimer’s disease may form part of your differential diagnosis, the history is more suggestive of Korsakoff’s in this instance.

12

A 45-year-old man presents to the A&E with unsteadiness and double vision. He had been previously well apart from a sore throat, cough and rhinorrhea last week. On examination, he had complete ophthalmoplegia and bilateral facial weakness. He had full strength in all limbs but had difficulty performing finger-nose and heel-shin testing. He was areflexic.

Which of the following is the most likely diagnosis?

Polymyositis

Multiple Sclerosis

Guillain-Barre Syndrome

Myaesthenia Gravis

Miller Fischer Syndrome

Miller Fischer Syndrome

From the options above, this gentleman is most likely to be suffering from Miller Fischer syndrome. MFS manifests as a descending paralysis in comparison to Guillain-Barre, which is generally an ascending paralysis/weakness.

MFS generally affects the eye muscles first and presents with the triad of ophthalmalgia, ataxia and areflexia. Anti-GQ1b antibodies are present in 90% of cases. As in Gullain-Barre syndrome it is often preceded by a viral (respiratory or GI) infection. Treatment as in Guillain-Barre syndrome is by IV Ig antibodies and (generally) complete recovery should be between 2 to 4 weeks.

13

You are first on the scene to see an 18-year-old man, Harry, who has just started at University. You find that he has spent the day watching rugby with a group of people he met last week. The group he is with are intoxicated and explain that they didn’t really know much about Harry before drinking with him since 13:00 this afternoon. They describe that he had become very aggressive and tried to start a fight with another man in the pub for no apparent reason. The group said when they tried to calm him down he looked pale, sweaty and then collapsed and seemed to have a fit, which is when someone called for help. On arrival you check his blood glucose level as you have a suspicion he may be diabetic.

From the answers below, which is the most likely to be his current BM?

2.0mmol/L

3.0mmol/L

5.0mmol/L

10.0mmol/L

20.0mmol/L

2.0mmol/L

Hypoglycaemia must always be excluded in any patient with coma, altered behaviour, neurological symptoms or signs. In diabetics the commonest cause of hypoglycaemia is a relative imbalance of administered versus required insulin. This may results from unforeseen exertion, insufficient or delayed food intake and excessive insulin administration. Another common cause, especially in younger adults, is alcohol intoxication that masks features of hypoglycaemia or by directly causing a low BM.

Common features include: sweating, pallor, tachycardia, hunger, trembling, altered or loss of consciousness, irritability, irrational or violent behaviour, fitting or focal neurological deficits.

Plasma glucose is normally maintained at 3.6-5.8mmol/L. Cognitive function deteriorates at levels below 3mmol/L but symptoms such as these are uncommon above 2.5mmol/L. However the threshold for symptoms can be very variable for diabetics.

Treatment depends on the situation but 5-15g of fast acting oral carbohydrate should be given as soon as possible, 1mg Glucagon (IM, SC or IV) can also be given. Glucose (10/50%) solutions can be given to those unable to take glucose orally. 90% patients fully recover within 20 minutes. Alcohol/delayed Insulin may delay/complicate treatment.

14

A 72-year-old women presents with a 4-month history of tiredness. She presents to A&E as she is increasingly becoming very breathless with minimal exertion.

Her FBC results are in the picture.

What initial management is the most appropriate?

Urgent endoscopy

Ferrous sulphate 200mg BD

2 units packed red blood cells

Chest X-ray

Measure ferritin levels

2 units packed red blood cells

This patient’s results show microcytic hypochromic anaemia, consistent with the clinical picture.

The common causes of microcytic hypochromic anemia are iron deficiency and blood loss.

This patient has a very low haemoglobin count, which suggests chronic blood loss. However, she is currently very symptomatic and so resolution of her anemia is priority.

Investigations should then be geared towards investigation of her blood loss, and are likely to start with an endoscopy.

15

A 42-year-old man is brought to the A&E following significant haematemesis of fresh red blood. The patient has clubbing and palmar erythema. You notice some spider naevi on his chest. You suspect this gentleman has ruptured oesophageal varices secondary to alcoholic liver disease. These patients have a prolonged bleeding time.

Which clotting factor, from the list below, is produced by the liver?

IV

V

VI

VII

All of the above

VII

Factors II, VII, IX and X are produced by the liver. These are also the vitamin K dependent factors, and therefore those depleted by warfarin therapy.

Patients with cirrhosis will therefore have an increase in prothrombin time.

Other findings in alcoholic liver disease will be hypoalbuminaemia, increase in bilirubin, coagulation defects and a rise in transferase enzymes, particularly GGT in alcoholic liver disease.

16

A 24-year-old woman presents to A&E with intermittent painless vaginal bleeding. The blood is bright red. She is 36 weeks pregnant. She denies abdominal pain and foetal movements are normal. She is praevia 2 gravida 3, and has had no complications during previous deliveries. She is otherwise fit and well.

Her observations are as follows:

HR: 118bpm

BP: 95/58mmHg

Temp: 36.6 degrees C

Urine Dipstick (+5) haematuria

 

What is the most likely diagnosis?

Premature rupture of membranes

Placenta praevia

Placental abruption 

Pre-term birth

Cervical lesion 

Placenta praevia

The main differential diagnoses with bleeding in late pregnancy are placenta praevia, placental abruption or a cervical lesion depending on the history provided.

Placenta praevia occurs when all, or part of the placenta implants in the lower uterine segment. The placement of the placenta is made in relation to the cervical OS, grades 1-4. The history here fits well with placenta previa as the bleeding is fresh and is not associated with pain. Placenta praevia is more common in multiparous and multigravida women, particularly with previous C-sections.

Placental abruption presents as haemorrhage resulting from premature separation of the placenta from the decidual interface. This is more frequently associated with a history of abdominal trauma. Further, it is more likely to be darker blood associated with pain, nausea and vomiting. The movements of the foetus would be likely to be absent or reduced. This is an important possibility to rule out especially in multiparous women.

Cervical lesions should be considered (erosions, polyps or tumours). However, in the setting above there were no cardinal features of cancer- fatigue, unexplained weight loss, or loss of appetite. The patients smear history would be important to clarify.

17

A 26-year-old gentleman is brought into the A&E by ambulance on a Friday night. He was found lying on a pavement outside a nightclub. He smells strongly of alcohol and on first glance appears to have face and head injuries consistent with a fight. When you begin your initial assessment and speak to the gentleman he does not open his eyes and keeps them closed throughout your assessment. When you ask his name he utters a few incomprehensible words in reply. He pulls his hand away when you press on his finger nail bed.

 

Calculate the Glasgow Coma Scale score for this patient

2

7

11

10

9

7

The Glasgow Coma Scale is used to give an objective and reliable tool to interpret a patient’s neurological status. It is composed of three tests: eyes, verbal and motor response. The three values are considered separately as well as the total. The lowest possible score is 3, which represents deep coma or death; 15 is an alert and conscious person.

The table below demonstrates the scoring system:

 

18

You are asked to review a 73-year-old woman who had a laparoscopic procedure performed 24 hours previously for removal of a Sigmoid Carcinoma. The nurses have called you in view of her continuing hypotension, despite 1L 0.9% saline.

When you arrive, the nurses show you her latest observations:

RR 28

SpO2 93%

Pulse 115

BP 90/65

Temp 38.0*C

Her Arterial blood gas results (ABG) are in the pic.

Which of the following fits best with this ladies clinical picture and ABG results?

Sepsis

Bowel ischaemia

Post-operative bleed

Pulmonary embolism

Acute kidney failure

Sepsis

In this scenario, the ABGs show a metabolic acidosis, most likely due to sepsis syndrome in this clinical post-operative setting.

As part of the sepsis 6 bundle the following should be administered:

1. Oxygen

2. Antibiotics

3. IV Fluid challenge

4. Plasma Lactate and Hb monitored

5. Urine output monitored

6. Blood cultures taken

It would also be necessary to refer this patient to senior with review from the critical care outreach team.

19

Commonly patients who are gasping for breath, or athletes at the end of a race, assume the “tripod position” to engage accessory muscles of respiration.

Which of the options below is not an accessory inspiratory muscle?

Scalene muscles

Sternocleidomastoids

Alae nasi

Pectoralis muscles

Rectus abdominis

Rectus abdominis

In a healthcare setting (where this shortness of breath is not usually preceded by exercise), adopting the tripod position is one sign of respiratory distress.

The accessory muscles of inspiration act by:

-Scalene muscles elevate the first two ribs

-SCM raise the sternum (contract vigorously during exercise)

-When the arms are secure, the Pectoralis muscle also contracts which results in elevation of the anterior wall of the chest

Rectus abdominis is a muscle of expiration, along with other muscles of the abdominal wall (internal/external oblique and transverse abdominis).

 

20

An 85-year-old who is known to have atrial fibrillation presents to the A&E. He describes feeling unwell since the morning, before feeling weakness on one side. An immediate CT scan carried out confirms a CVA. The infarct is within the area of the left lenticulostriate branch.

Which of the following symptoms are most likely to be exhibited in this patient?

Left pure upper motor hemiparesis 

Right pure upper motor hemiparesis

Left hemianopia

Right hemianopia

Behavioural changes

Right pure upper motor hemiparesis

The lenticulostriate branch supplies the basal ganglia (globus pallidus and striatum) and thus an infarct of the left lenticulostriate branch would cause a right pure upper-motor hemiparesis. In larger infarcts of this area, which extend to the cortex, the patient may also exhibit cortical deficits such as aphasia.

Posterior circulation infarcts would produce contralateral homonymous hemianopia due to damage to the visual cortex in the occipital lope. Larger infarcts in the posterior circulation may cause hemisensory loss and hemiparesis due to disruption of the ascending and descending information passing through the internal capsule and thalamus.

Behavioral abnormalities are most commonly associated with injuries to the frontal lobe (for instance: anterior circulation infarcts).

21

Depolarisation during phase 0 of a cardiac action potential is caused by which of the following changes?

Calcium channels opening

Potassium channels opening

Potassium channels closing

Sodium channels opening

Sodium channels closing

Sodium channels opening

A cardiac action potential is split into four phases.

Phase 0- Depolarisation mediated by fast Na+ channels opening and an influx of Na+ ions into the cell.

Phase 1- Initial repolarization is caused by fast Na+ channels closing

Phase 2- Plateau: K+ and Ca2+ channels open, Calcium enters the cell and is balanced by Potassium leaving the cell.

Phase 3- Repolarisation is caused by Ca2+ channel closure, causing a net negative current as K+ ions continue to leave the cell.

Phase 4Resting membrane potential (unable to fire action potentials).

22

A 4-year-old boy is brought to the A&E by his mother. The child has fallen off a step in the garden and hit his head. On examination, the child has a superficial laceration on the scalp that does not breach the aponeurotic layer and measures about 2cm in length. You gently clean the wound; it is linear with regular edges and there has been no loss of tissue.

 

What is the best method for wound closure?

Staple

Steri-strip

Adhesive glue

Simple interrupted stitch

Vertical mattress stitch

Adhesive glue

This question refers to methods of healing by primary intention. This is a small lesion (<5cm) with clean edges and no loss of tissue and should be a simple wound to manage. Adhesive glue is used most commonly in the under 10s due to generally better cosmetic outcomes.

Steri-strips would be appropriate for a lesion of this size in non-hair bearing areas. However, due to the site of injury, the child’s hair would likely prevent adequate adhesion of the strips.

Staples are a fast method for wound closure, and have been associated with decreased wound infection rates. However, it is not suitable for a child.

Suturing in this setting would also be less appealing to the child - the technique includes needles and local anesthesia; unless necessary due to the type of injury.

23

A nervous 45 year-old woman is admitted to the A&E with palpitations. She reports that her heartbeat feels fast, although she denies chest pain

On examination, you notice some discoloration of the legs bilaterally. 

Her observations are as follows:

Temperature: 37.3°C

Respiratory rate: 16/min

Pulse: 150bpm, irregular

Blood pressure: 125/80

 

What is the most likely diagnosis from the following?

Thyrotoxicosis

Anxiety

Deep Vein Thrombosis

Cellulitis

Myocardial Infarction 

 

 

 

 

Thyrotoxicosis

This lady is mostly likely to be suffering from thyrotoxicosis. The key clinical features of thyrotoxicosis are graves ophthalmopathy, goitre, and pretibial myxoedema (as shown in the picture above). Graves’ is an autoimmune condition, and can be diagnosed with a test for antibodies to thyroid stimulating hormone receptor.

The treatment of thyrotoxicosis is propranolol, for symptomatic control of the tremor and atrial fibrillation and rule out/correct any underlying thyroid pathology.

Anxiety could cause palpitations and tachycardia, but would not account for the ankle discoloration. Cellulitis is an infection of the skin, and thus, you would expect an increased temperature. Further, you would expect a history classically of fluid retention.

24

A 21-year-old man is brought into A&E at 13:00. He has overdosed on an unknown quantity of Paracetamol at around 11am today. He weighs 70kg. His housemates say he has never done anything like this before.

What result below is the most concerning?

Ingestion of 6g paracetamol

Ingestion of 10g paracetamol

2 hour plasma paracetamol level of 200mg/L

4 hour plasma paracetamol level of 200ml/L

Clinically jaundiced and evidence of hepatic tenderness

4 hour plasma paracetamol level of 200ml/L

You should only ever test plasma levels 4 hours after ingestion. This is because plasma levels before this time will not be accurate or reliable. The graph to show concerning levels has two curves. One for high-risk patients and one for normal risk patients.

For this young man, he has no risk factors that would cause him to become high risk (malnourishment or ongoing liver injury). We therefore follow the “normal risk” curve. At 4hrs a level of 200mg/litre or above is concerning and we would need to start treatment with Acetylcysteine.

Overdose Paracetamol levels:

* High risk > 75mg/Kg

* Normal risk: 150mg/kg.

This young man weighs 70kg. A level of >10.5g would be classed as an “overdose.” We would still want to assess him clinically and it is likely we would still perform Plasma levels at 4 hours.

25

A 5 year old is brought into the Emergency Department. Her father says she suddenly developed a high temperature and has now started to become very distressed. She has obvious stridor and you note that she is drooling.

What is the most likely diagnosis?

Croup 

Anaphylaxis

Peritonsillar Abscess

Pharyngitis

Epiglottitis

Epiglottitis

Epiglottitis is inflammation above the glottis. It is most often bacterial and presents with an abrupt onset of symptoms.

They typically present with a fever followed by Drooling, Distress, Dysphonia and Dysphagia. The child would also have a fever. It is a medical emergency and requires urgent assessment form a paediatric anaesthesiologist to control the airway. If not treated quickly it can progress to respiratory arrest and death within a matter of hours.

26

You are asked to see Sophie, a 2 year old who has taken multiple antidepressants. It happened about 20 minutes ago. Her mother says she left her for a couple of minutes and then found her next to her bottle of antidepressants. She is stable however it is unclear how many tablets she has taken.

Which database would you use to ensure this patient was treated effectively?

DRUGDATABASE

BNF

P.O.I.S.O.N.

TOXBASE

TOXINZ

TOXBASE

Toxbase is a widely used Internet resource (provided by the National Poisons Information Service (NPIS)) particularly in Emergency Departments across the UK.

It is the primary clinical toxicology database and first line information resource for guidance in managing and treating any poisoning (accidental, overdose, child-related). Toxbase also provides a 24-hour telephone service for further clinical toxicological enquires.

 

27

A 3 year old is rushed into the ED. His mother says she was in the kitchen preparing dinner when she suddenly heard him coughing and spluttering. He is struggling to breath and his lips are starting to become cyanosed.

Where is the foreign object most likely lodged?

Left mainstem bronchus

Larynx

Right mainstem bronchus

Trachea

Soft palate

Right mainstem bronchus

This is a very typical history for inhalation of a foreign object.

This can quite quickly lead to death if the object is not removed.

The right main bronchus enters the right lung at approximately the 5th Thoracic Vertebra and lies more vertically than the left.

(The left main Bronchus enters the lung slightly lower down, approximately the 6th thoracic Vertebra).

This anatomy predisposes the right lung to several problems including the above.

28

A mother brings her 7 year old son into the Children’s assessment unit; he has had a wheeze throughout the morning which does not seem to be improving despite 6 puffs of his inhaler.

His RR is now 33, SpO2 is 91% on air, HR 135.

What is your first line management?

O2 via face mask

B2 agonist 2-10 puffs via spacer

Nebulised salbutamol 5mg and soluble prednisolone 30-40mg

B2 agonist 2-10 puffs via spacer and soluble prednisolone 30-40mg

Nebulised salbutamol 5mg

Nebulised salbutamol 5mg and soluble prednisolone 30-40mg

The SIGN guidelines state that the above treatment is essential in a child >5 with a severe exacerbation of asthma (as above).

O2 must always be given but on its own would not relieve the exacerbation.

Puffs of a B2 agonist are given to children with a moderate exacerbation of asthma – SpO2 >92%, PEF >50% best or predicted, No clinical features of severe asthma.

Prednisolone is a glucocorticoid, similar to cortisol. Anti-inflammatory.

29

You are the F2 on a night shift in the ED. It is 1 in the morning and a young mother comes running in with her child in her arms. Her 3 year old daughter woke up half an hour ago struggling to breath and had developed a barking cough. She has no other symptoms. From your initial assessment she has obvious stridor and an inspiratory wheeze.

 

What is the most likely diagnosis?

Epiglottitis

Croup 

Inhaled foreign body

Anaphylaxis

Severe asthma

Croup 

Croup is common and primarily found in children. It is a viral respiratory tract illness which typically affects the larynx and the trachea. It is the most common cause of acute stridor in febrile children.

Stridor is an audible harsh, high-pitched, musical sound on inspiration produced by turbulent airflow through a partially obstructed upper airway.

 

30

Mr. Harding, a 77 year-old man, is brought to the Accident and Emergency Department by ambulance. He started to have a nose bleed at home three hours ago and this is still going on arrival, despite applying continuous pressure and attempting to pack it himself.

Mr. Harding is on Simvastatin, Warfarin, Bendroflumethiazide and Sertraline. On examination his heart rate was 62bpm and blood pressure; 102/76mmHg. Mr. Harding’s INR is 6.

Which one of the following drugs should be given to this patient as soon as possible?

Vitamin K

Aspirin 

Atorvastatin 

Magnesium 

Paracetamol 

Vitamin K

Epistaxis can be idiopathic or follow minor/major trauma. When it occurs in patients with hypertension and coagulation disorders, haemorrhage can be severe with significant mortality. Check current medications, full blood count and clotting in older patients.

INR or International Normalised Ratio is regularly measured in patients on Warfarin to ensure they are within the therapeutic window and determine the next dose. The target INR is usually 2.0-3.0, a range of factors can cause the INR to become unstable, for example missed doses or illness. If the INR becomes higher than the target range, coagulation is significantly slowed which can increase a patient’s risk of haemorrhage/prolonged bleeding. If major bleeding occurs at any time whilst on Warfarin, the patient should stop taking Warfarin and should be given Vitamin K 10mg via a slow IV and be referred to secondary care for factor replacement. Without major bleeding, if the current INR is between 5 and 9, guidelines indicate Warfarin should be stopped, INR tested daily until it has returned to therapeutic range and restart Warfarin with a reduced dose when INR is <5. Give Vitamin K 1.0-2.5mg orally if INR fails to reduce or patient is at high bleeding/re-bleeding risk