The lost managemnts

Question 1

DIC ix and mx

Answer 1

A typical blood picture includes:
↓ platelets
↓ fibrinogen
↑ PT & APTT
↑ fibrinogen degradation products
schistocytes due to microangiopathic haemolytic anaemia

Fresh frozen plasma (FFP) is the preferred agent for replacement of coagulation factors and coagulation inhibitors when significant bleeding is present
Replace platelets below 20

Question 2

Shock meds

Answer 2

Cardiac output down, Peripheral resistance UP–Cardiogenic, Hypovalemic (heamorraghe)

Give IV fluids-Crystalloids (eg Hartmans)
IF NOT BLEEDING—–Use an inotrope (e.g., dobutamine) if there is impaired cardiac function.
Non volume responsive- vasopressors are Norepinephrine

Distributive (sepsis, neuro, Anaphylaxis)
Vasopressors–Noradrenaline/Norepinephrine

Question 3

Head injury CT Guidelines

Answer 3

CT head within 1 hour
GCS < 13 on initial assessment
GCS < 15 at 2 hours post-injury
suspected open or depressed skull fracture
any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
post-traumatic seizure.
focal neurological deficit.
more than 1 episode of vomiting

CT head scan within 8 hours of the head injury - for adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury:
age 65 years or older
any history of bleeding or clotting disorders including anticogulants
dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)
more than 30 minutes’ retrograde amnesia of events immediately before the head injury

If a patient is on warfarin who have sustained a head injury with no other indications for a CT head scan, perform a CT head scan within 8 hours of the injury.

Question 4

Head injury -types of injury

Answer 4

Subdural- banana/cresent shaped-Bridging VEINS–Risk factors include old age, alcoholism and anticoagulation.
Slower onset of symptoms than a epidural haematoma. There may be fluctuating confusion/consciousness

Epidural/extradural–lens shaped–
The majority of epidural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal ARTERY
features of raised intracranial pressure
some patients may exhibit a lucid interval

SAH-Classically causes a sudden occipital headache. Usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen in association with other injuries when a patient has sustained a traumatic brain injury

Intracerebral Bleed–
intracerebral (or intraparenchymal) haemorrhage is a collection of blood within the substance of the brain.
Causes / risk factors include: hypertension, vascular lesion (e.g. aneurysm or arteriovenous malformation), cerebral amyloid angiopathy, trauma, brain tumour or infarct (particularly in stroke patients undergoing thrombolysis).
Patients will present similarly to an ischaemic stroke (which is why it is crucial to obtain a CT in head in all stroke patients prior to thrombolysis) or with a decrease in consciousness.

Diffuse axonal injury occurs as a result of mechanical shearing following deceleration, causing disruption and tearing of axons

The Cushings reflex (hypertension and bradycardia) often occurs late and is usually a pre terminal event

Question 5

Head injury pupil signs

Answer 5

Unilaterally dilated -light reflex -Sluggish or fixed—-3rd nerve compression secondary to tentorial herniation

Bilaterally dilated–light refle–Sluggish or fixed
=>Poor CNS perfusion or Bilateral 3rd nerve palsy

Unilaterally dilated or equal
light reflex–Cross reactive (Marcus - Gunn)
=Optic nerve injury

Bilaterally constricted –light reflex–May be difficult to assess
Opiates
Pontine lesions
Metabolic encephalopathy

Unilaterally constricted–light reflex–Preserved—Sympathetic pathway disruption

Question 6

Head injury management

Answer 6

The Cushings reflex (hypertension and bradycardia) often occurs late and is usually a pre terminal event -need to manage head injury

whilst theatre is prepared or transfer arranged use of IV mannitol/ frusemide may be required –for raised ICP

ICP monitor and intubate if GCS <8
Minimum of cerebral perfusion pressure of 70mmHg in adults

SIADH common cause of hyponatremia

rarely/last resort–decompressive craniotomy/craniectomy

Question 7

Neuroleptic malignant syndrome management

Answer 7

pyrexia
muscle rigidity
autonomic lability: typical features include hypertension, tachycardia and tachypnoea
agitated delirium with confusion
REFLEXES DOWN

A raised creatine kinase is present in most cases.
Acute kidney injury (secondary to rhabdomyolysis) may develop in severe cases. A leukocytosis may also be seen

Mx–
stop antipsychotic
IV fluids to prevent renal failure
dantrolene may be useful in selected cases
bromocriptine, dopamine agonist, may also be used

Question 8

Opioid missuse mx

Answer 8

Iv/IM naloxone is mx

Longer term-#
harm reduce with clean needles

Methadone/buponeprhine for longer term
compliance is monitored using urinalysis
detoxification should normally last up to 4 weeks in an inpatient/residential setting and up to 12 weeks in the community

Question 9

Trigeminal Neuralgia mx

Answer 9

Trigeminal neuralgia is a pain syndrome characterised by severe unilateral pain. The vast majority of cases are idiopathic

a unilateral disorder characterised by brief electric shock-like pains, abrupt in onset and termination, limited to one or more divisions of the trigeminal nerve

red flag symptoms -urgent refer to neuro

Management
carbamazepine is first-line
failure to respond to treatment or atypical features (e.g. < 50 years old) should prompt referral to neurology

Question 10

Parkinsons and parkinsonisms mx

Answer 10

Most Parkinsonisms–
if the motor symptoms are affecting the patient’s quality of life: levodopa
–/second line—not affecting the patient’s quality of life: dopamine agonist (non-ergot derived), levodopa or monoamine oxidase B (MAO‑B) inhibitor

always make sure to avoid- haloperidol/domperidone
if need to tranquilise– use short acting BDZ like lorazepam

CAREFUL- Lewy body is treated more like ALZHEIMERS
neuroleptics should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism. Questions may give a history of a patient who has deteriorated following the introduction of an antipsychotic agent

Question 11

Alhzheimers mx

Answer 11

The three acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) as options for managing mild to moderate Alzheimer’s disease
memantine (an NMDA receptor antagonist) ‘second-line’ treatment for Alzheimer’s

Donepezil
is relatively contraindicated in patients with bradycardia

Question 12

Frontotemporal dementia (Pick’s disease) mx

Answer 12

young onset –personality change and impaired social conduct. Other common features include hyperorality, disinhibition, increased appetite, and perseveration behaviours.

Management
NICE do not recommend that AChE inhibitors or memantine are used in people with frontotemporal dementia
none sepcific

Question 13

vascular dementia mx

Answer 13

Step down degrdation in vasculopath

There is no specific pharmacological treatment approved for cognitive symptoms
Only consider AChE inhibitors or memantine for people with vascular dementia if they have suspected comorbid Alzheimer’s disease, Parkinson’s disease dementia or dementia with Lewy bodies.

Question 13

vascular dementia mx

Answer 13

Step down degrdation in vasculopath

There is no specific pharmacological treatment approved for cognitive symptoms
Only consider AChE inhibitors or memantine for people with vascular dementia if they have suspected comorbid Alzheimer’s disease, Parkinson’s disease dementia or dementia with Lewy bodies.

Question 14

AAA ix and mx

Answer 14

1 USS at 65–
<3cm-nada
3-4.5-screen every year
4.5-5.5-screen every 3m
>5.5 or growing >1cm per year- operate

treat with elective endovascular repair (EVAR) or open repair if unsuitable. In EVAR a stent is placed into the abdominal aorta via the femoral artery to prevent blood from collecting in the aneurysm. A complication of EVAR is an endo-leak, where the stent fails to exclude blood from the aneurysm, and usually presents without symptoms on routine follow-up.

Question 15

Aortic stenosis mx

Answer 15

Management
if asymptomatic then observe the patient is a general rule
if symptomatic then valve replacement
if asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery

options for aortic valve replacement (AVR) include:
surgical AVR is the treatment of choice for young, low/medium operative risk patients. Cardiovascular disease may coexist. For this reason, an angiogram is often done prior to surgery so that the procedures can be combined
transcatheter AVR (TAVR) is used for patients with a high operative risk

balloon valvuloplasty
unstable
may be used in children with no aortic valve calcification
in adults limited to patients with critical aortic stenosis who are not fit for valve replacement

Question 16

Mitrial stenosis Mx

Answer 16

patients with associated atrial fibrillation require anticoagulation
currently warfarin is still recommended for patients with moderate/severe MS
DOACs

A diuretic may reduce left atrial pressure and relieve mild symptoms, although diuretic therapy alone is rarely adequate to relieve symptoms

asymptomatic patients
monitored with regular echocardiograms
percutaneous/surgical management is generally not recommended

symptomatic patients
percutaneous mitral balloon valvotomy
mitral valve surgery (commissurotomy, or valve replacement)

pregnant-diuretics and baloon valvotomy

Question 17

Aortic Regurg mx

Answer 17

Management
medical management of any associated heart failure

surgery: aortic valve indications include
symptomatic patients with severe AR
asymptomatic patients with severe AR who have LV systolic dysfunc

acute–ionotrope, vasopressor and urgent valve replace
if very symptomatic–Open heart
TAVI rarely done

Question 18

Mitrial Regurg Mx

Answer 18

Medical management in acute cases involves nitrates, diuretics, positive inotropes and an intra-aortic balloon pump to increase cardiac output

If patients are in heart failure, ACE inhibitors may be considered along with beta-blockers and spironolactone

In acute, severe regurgitation, surgery is indicated
The evidence for repair over replacement is strong in degenerative regurgitation, and is demonstrated through lower mortality and higher survival rates
When this is not possible, valve replacement with either an artificial valve or a pig valve is considered

Question 19

Arterial ulcer mx

Answer 19

Occur on the toes and heel
Painful
There may be areas of gangrene
Cold with no palpable pulses
Low ABPI measurements

surgery to reopen vessels

Question 20

Venous ulcer mx

Answer 20

Most due to venous hypertension, secondary to chronic venous insufficiency

Features of venous insufficiency include oedema, brown pigmentation, lipodermatosclerosis, eczema
Location above the ankle, painless
Deep venous insufficiency is related to previous DVT and superficial venous insufficiency is associated with varicose veins

Doppler ultrasound looks for presence of reflux and duplex ultrasound looks at the anatomy/ flow of the vein

Management: 4 layer compression banding after exclusion of arterial disease or surgery
If fail to heal after 12 weeks or >10cm2 skin grafting may be needed

Question 21

Gangrene ix/mx

Answer 21

Type 1 is caused by mixed anaerobes and aerobes (often occurs post-surgery in diabetics). This is the most common type (multibacterial)
type 2 is caused by Streptococcus pyogenes (monobacterial)-can use hyperbaric ox

Gram stain of infected tissue may demonstrate gram-positive bacilli

acute onset
pain, swelling, erythema at the affected site
often presents as rapidly worsening cellulitis with pain out of keeping with physical features
extremely tender over infected tissue with hypoaesthesia to light touch
skin necrosis and crepitus/gas gangrene are late signs
fever and tachycardia may be absent or occur late in the presentation

need emergency fascitomy and abx
ischemic gangrene-acute limb- heparin and surgery

Question 22

WPW mx

Answer 22

short PR interval
wide QRS complexes with a slurred upstroke - ‘delta wave’
left axis deviation if right-sided accessory pathway
in the majority of cases, or in a question without qualification, Wolff-Parkinson-White syndrome is associated with left axis deviation
right axis deviation if left-sided accessory pathway

definitive treatment: radiofrequency ablation of the accessory pathway
medical therapy: sotalol***, amiodarone, flecainide
sotalol should be avoided if there is coexistent atrial fibrillation

Question 23

Tricuspid regurg mx

Answer 23

Operation should be considered for medically refractory right heart failure, imminent or existing atrial fibrillation, or progressive right ventricular dilation and dysfunction. –Symtomatic

annuloplasty or valve repair

HF mx needed

Question 24

Rectal prolapse types and mx

Answer 24

Associated with childbirth and rectal intussceception. May be internal or external

Question 25

Heamoroids mx and complications

Answer 25

painless rectal bleeding is the most common symptom
pruritus
pain: usually not significant unless piles are thrombosed
soiling may occur with third or forth degree piles

External
originate below the dentate line
prone to thrombosis, may be painful
Internal
originate above the dentate line
do not generally cause pain

Class 1- no prolapse
2- prolapse and go back in
3-manual reduce
4-cant be reduced

soften stools: increase dietary fibre and fluid intake
topical local anaesthetics and steroids may be used to help symptoms
outpatient treatments: rubber band ligation
surgery is reserved for large symptomatic haemorrhoids which do not respond to outpatient treatments

thrombosed–typically present with significant pain
examination reveals a purplish, oedematous, tender subcutaneous perianal mass
if patient presents within 72 hours then referral should be considered for excision. Otherwise patients can usually be managed with stool softeners, ice packs and analgesia. -lasts 10 days

Question 26

Anal fissure mx

Answer 26

painful, bright red, rectal bleeding
around 90% of anal fissures occur on the posterior midline.
if the fissures are found in alternative locations then other underlying causes should be considered

acute anal fissure (< 1 week)
soften stool
dietary advice: high-fibre diet with high fluid intake
bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried
lubricants such as petroleum jelly may be tried before defecation
topical anaesthetics-GTN
analgesia

chronic anal fissure
the above techniques should be continued
topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure
if topical GTN is not effective after 8 weeks then secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin

Question 27

Liver abscess mx

Answer 27

spread of infection from 1 of the following sources:[6]
Biliary tree-biliary tract is the most common identifiable source
Portal vein
Hepatic vein

The most common organisms found in pyogenic liver abscesses are Staphylococcus aureus in children and Escherichia coli in adults.
(pyogenic=bacterial), can be caused by emeoba hystolica

RF Underlying biliary tract abnormalities, age >50 years, malignancy, diabetes mellitus

Sx fever, chills, fatigue, nausea, vomiting, and abdominal pain
if emeoba- diarrhoea assox, more acute onset

If amoebic abscess is suspected, serology may be diagnostic.
Blood cultures for bacteria

Ix- USS and CT

Management
drainage (typically percutaneous) and antibiotics
amoxicillin + ciprofloxacin + metronidazole

Question 28

Methaemoglobinaemia

Answer 28

Congenital causes
haemoglobin chain variants: HbM, HbH
NADH methaemoglobin reductase deficiency

Acquired causes
drugs: sulphonamides, nitrates (including recreational nitrates e.g. amyl nitrite ‘poppers’), dapsone, sodium nitroprusside, primaquine
chemicals: aniline dyes

Features
‘chocolate’ cyanosis
dyspnoea, anxiety, headache
severe: acidosis, arrhythmias, seizures, coma
normal pO2 but decreased oxygen saturation

Management
NADH methaemoglobinaemia reductase deficiency: ascorbic acid
IV methylthioninium chloride (methylene blue) if acquired

Question 29

Renal stones mx

Answer 29

IM Diclofenac, oral diclo, oral ibuprofen

<5mm - pass on its own
<2cm, non complicated- transcutaneous shockwave lithothialisis
<2cm, non complicated, pregnant- Uteroscopy
>2cm, staghorn, blockages, acutely unwell- Percutaneous lithotripsy

Prevent with- thiazide diuretcs
or uric acid stones- allopurinol

Question 30

Open angle glaucoma mx

Answer 30

The non acute version

Symptoms:
characterised by a slow rise in intraocular pressure: symptomless for a long period
typically present following an ocular pressure measurement during a routine examination by an optometrist

Signs:
increased intraocular pressure
visual field defect
pathological cupping of the optic disc

Investigations:
automated perimetry to assess visual field
slit lamp examination with pupil dilatation to assess optic neve and fundus for a baseline
applanation tonometry to measure IOP

NICE guidelines:
first line: prostaglandin analogue (PGA) eyedrop–e.g. latanoprost) - gives long eyebrows
second line: beta-blocker, carbonic anhydrase inhibitor, or sympathomimetic eyedrop
if more advanced: surgery or laser treatment can be tried2
then reassess

Question 31

Acute glaucoma mx

Answer 31

severe pain: may be ocular or headache
decreased visual acuity
symptoms worse with mydriasis (e.g. watching TV in a dark room)
hard, red-eye
haloes around lights
SEMI DILATED NON REACTIVE PUPILS
corneal oedema results in dull or hazy cornea
systemic upset may be seen, such as nausea and vomiting and even abdominal pain

combination of eye drops, for example:
a direct parasympathomimetic (e.g. pilocarpine)
a beta-blocker (e.g. timolol)
an alpha-2 agonist (e.g. apraclonidine)
intravenous acetazolamide

If the IOP cannot be decreased with medical therapy, an anterior chamber paracentesis can offer immediate resolution

Following resolution of the acute attack, definitive surgical treatment should be performed within 24 to 48 hours–Laser peripheral iridotomy (LPI)

Question 32

Diverticulitis mx

Answer 32

Management
mild cases of acute diverticulitis may be managed with oral antibiotics, liquid diet and analgesia CKS
if the symptoms don’t settle within 72 hours, or the patient initially presents with more severe symptoms, the patient should be admitted to hospital for IV antibiotics

Severe abdominal pain in the left lower quadrant
Nausea and vomiting (20-60%)
Change in bowel habit
constipation is more common (seen in 50%)
Urinary frequency, urgency or dysuria (10-15%)
PR bleeding
pneumaturia or faecaluria may suggest a colovesical fistula
vaginal passage of faeces or flatus may suggest a colovaginal fistula