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. What would you like to do?
Electric shock at home whilst changing a plug socket- What is the standard electric supply to UK households?
-240 volts AC
Electric shock at home. What investigations do you perform?
- -ECG- that is all that is required.
- -Clearly if you are concerned about higher voltages then other tests will be necessary.
- -Also bear in mind that fatalities can occur from 240 volts supply!
Electric shock at home. Do you admit the patient?
- -ECG is completely normal then there is no need to admit for cardiac monitoring and the patient can go home.
- -If there are any dysrhythmias or other reasons for admission i.e. skin burns etc from the shock then the patient may need to be admitted.
A 66 year old man presents with sudden severe ripping chest pain radiating to his back. He has a history of hypertension. On examination there is a diastolic murmur. You suspect an
Aortic dissection.-What are the risk factors for this condition?(Name four)
- -systemic hypertension.
- -Inflammatory diseases that cause a vasculitis (giant cell arteritis, takayasu arteritis, rheumatoid arthritis, syphilitic aortitis)
- -disorders of collagen (eg, marfan syndrome, ehlers-danlos syndrome, annuloaortic ectasia)
- -bicuspid aortic valve
- -aortic coarctation
- -turner syndrome
- -crack cocaine
- -previous aortic valve replacement
- -cardiac catheterization
- -high-intensity weight lifting or other strenuous resistance
- -history of coronary artery bypass graft surgery are other associations.
What other features(besides a diastolic murmur) in the examination of this patient may indicate an aortic dissection?(Name two)
- -Assymetry or absence of peripheral pulses or a pulse deficit
- -hypotension with features of tamponade
- -neurological signs secondary to carotid or spinal artery involvement.
Aortic dissection-How would you investigate this patient?(Name four)
- -FBC, UE, Glucose, Coag, Blood group and crossmatch
- -CT Angiography.
Aortic dissection-What features on the CXR give additional evidence to the suspected diagnosis?(Give three)
- -widened mediastinum
- -left sided pleural effusion
- -deviation of the trachea or NG tube to the right
- -separation of two parts of the wall of a calcified aorta by >5mm (the ?calcium? sign)
- -double knuckle aorta.
How would you manage this patient if you suspected an aortic dissection?(Give four)
- -2 large bore IV cannulae, cross match blood
- -IV opioid
- -specialist consultation
- -arterial line and BP control.
GCS is 6/15 and the decision is made to intubate. What class of medication is thiopentone?
thiopentone- What are the effects of overdosage?
-Hypotension, respiratory depression.
thiopentone-What is the duration of action?
-Duration of action of 5 to 10 minutes.
thiopentone-What is the induction dose in an adult?
thiopentone-What is the induction dose range in a child?
Considering hyperemesis gravidarum, when is it most common and when would you expect it to have resolved by?
- - 8-12 weeks
- -settled by 20 weeks
- -more likely to get it if you are younger than 30.
hyperemesis gravidarum-Is a family history relevant?
- -Yes there is a genetic component.
- -It is more likely in sisters and daughters of women who have suffered with it.
hyperemesis gravidarum-How is it treated?
- -it is a diagnosis of exclusion; need to rule out other things by investigation.
- -Antiemetics- normally start with antihistamine then proclorperazine or metocloparimde then ondansetron
- -Anti-emetic medication appears to reduce the frequency of nausea in early pregnancy.
- -Of newer treatments, pyridoxine (vitamin B6) appears to be more effective in reducing the severity of nausea.
GCS is 6/15 and the decision is made to intubate-What type of muscle relaxant is suxamethonium?
-Depolarising muscle relaxant.
What is the dose range for suxamethonium in adults?
- 600 micrograms-1mg/kg.
In what circumstances is suxamethonium contraindicated? (Give two)
- -crush injuries.
What is the result of the administration of suxamethonium administration on intracranial pressure(ICP)?.
-Suxamethonium causes a rise in ICP.
What is the normal duration of action of suxamethonium?
-About 5 minutes but longer in patients with abnormal pseudo-cholinesterase enzymes.
painful left eye unbearable and he feels very sick. vision is now blurry in that eye. He has no significant medical history but wears glasses for driving.What are the most important questions to ask in the history?
- -Any history of eye problems/glaucoma?
- -Is he hypermetropic? Much more common in long sited individuals.
- -Any trauma to the eye?
- -Any chance of chemical /FB in the eye?
- -Any discharge?
- -Trying to differentiate the others causes of painful red eye ? Any headache facial pain? (common in orbital cellulites)
- -Arthralgia/urethral discharge (Reiter?s)
- -Ask about systemic disease, atopy, HTN/IHD/diabetes. ?
painful eye What are the key examination points?
- -Pupil size (expect to be dilated in acute close angle glaucoma)
- -What is the acuity? In acute glaucoma the acuity will be markedly diminished whereas in acute iritis or keratitis it is only modestly diminished and in conjunctivitis it is normal.)
- -Intraocular pressure ?
- -Is there clouding of the cornea? ?
From the history what is the most likely diagnosis?
-Acute closed angle glaucoma?
Acute closed angle glaucoma-How would you confirm the diagnosis?
- Combination of the following:
- -measure the intraocular pressure= very high
- -pupil usually dilated and fixed
- -cornea cloudy
- -iris injected.
Acute angle closure is defined as at least 2 of the following symptoms:
- -ocular pain
- -history of intermittent blurring of vision with halos
- and at least 3 of the following signs:
- -IOP >21 mm Hg,
- -conjunctival injection
- -corneal epithelial edema
- -mid-dilated nonreactive pupil
- -shallower chamber in the presence of occlusion.?
Eye casualty is closed for another 5 hours what do you do?
- Once diagnosed, the initial intervention includes
- -acetazolamide -Give 500mg acetozolamide IV to reduce intraocular pressure
- -topical beta-blocker
- -topical steroid.-decrease the inflammatory reaction and reduce optic nerve damage. The current recommendation is for 1-2 doses of topical steroids.
- -Treat the other eye prophylactically
- -Addressing the extraocular manifestations of the disease is critical.
- analgesics for pain antiemetics for nausea and vomiting which can drastically increase IOP beyond its already elevated level.
- Placing the patient in the supine position may aid in comfort and reduce IOP. the lens falls away from the iris decreasing pupillary block.
- Laser peripheral iridotomy (LPI) performed 24-48 hours after IOP is controlled, is considered the definitive treatment for AACG.
- While LPI is the current definitive treatment, there is evidence to suggest that argon laser peripheral iridoplasty (ALPI) and anterior chamber paracentesis (ACP) may have increasing roles in the management of AACG.
Are there any demographic predispositions to Acute angle closure?
- -AACG occurs in 1 of 1000 Caucasians
- -about 1 in 100 Asians
- -as many as 2-4 of 100 Eskimos.
- -Sex ? AACG predominately affects females because of their shallower anterior chamber.
- -Age ? Elderly patients in their sixth and seventh decades of life are at greatest risk.
Trauma-How much fluid needs to be in the abdomen to be picked up by FAST scanning?
- -Approximately 500mls-
- -the sensitivity of FAST is clearly operator dependent but it is generally held that there needs to be quite a lot of free fluid present for it to be picked up.
Trauma-What are the induction agents you could use for an RSI in this patient, which one would you use and why?
- -Ketamine, Propofol, Thiopentone, or Etomidate.
- -There are many arguments for and against all of these agents which are beyond the scope of the point of the question.
- -People have worried about the use of ketamine in head injury but this is likely unfounded see (1)
- -Thiopetone = least haemodynamically friendly in a patient who is potentially haemodynamically unstable.
- -Etomidate problems with adrenocortical depression
- -Propfol in good hands likely to be the best option here small dose etc titrated with suxamethonium. ?
- -1Ketamine for rapid sequence induction in patients with head injury in the emergency department: Emerg Med Australas. 2006 Feb;18(1):37-44. Sehdev RS, Symmons DA, Kindl K.
suxamethonium-What is the dose of the muscle relaxant that you use?
About 40 minutes post induction of anaesthesia the patient suddenly becomes tachycardic and his skin looks mottled. His temperature goes up to 41?C. What has occurred? What is the immediate management?
- Malignant hyperthermia-
- -You need to stop the offending anaesthetic agent ASAP clearly in this case you have to balance the risks of what has occurred.
- -Change the anaesthetic circuit
- -give dantrolene ASAP 1mg/kg IV ad repeat if needed.
- -You can maintain anaesthesia with TIVA (Propofol infusion if needed)
- -Ice packs to the groin and axilla.
What would you expect to see on an arterial blood gas sample?
-A high CO2 and a high K+
the morning after pill. She is reluctant to give you any further history.What are the contraindications to providing this 16 year old with levonorgestrel?
- 1. Pregnancy- ensure that she is not pregnant consent her for pregnancy test
- 2. Porphyria
- 3. Focal migraines
How long after unprotected intercourse can lenonorgestrel be given?
-72 hours (therefore not the morning after pill)
What other options are available for emergency contraception?
-Insertion of ICUD can be performed up to 5 days post unprotected intercourse (caution if patient has had recent PID)
What must you ensure at all times when taking a history and examining this girl?
-Always have a female member of ED staff present and document this in the notes.
What do you think is important to address in this consultation/the morning after pill?
- Has the girl been raped? Rape is hugely under reported in the UK.
- You may need to gently encourage this young girl to report the crime.
- -It is common practise for the police surgeon to then take over the care of the patient with regard to collection of samples etc involving social services and safeguarding this girl are crucially important and it is the role of the ED doctor involved to try to arrange this if possible.
Under what circumstances might an admission be required/the morning after pill?
- -Peritonitis can ensue from vaginal wounds caused by rape.
- -There may be extensive vaginal damage that might need exploring and repairing under GA.
A 34 year old man is involved in motor cross accident- he was partially impaled on a wooden stake at the side of the course which penetrated the right side of his back. He is flown in. When he arrives his observations are as follows. -GCS 14, RR 35 sats 88%, BP 145/70 pulse 110. Trauma RR 35 sats 88%, BP 145/70 pulse 110. He is screaming in pain intermittently. large open wound with a wooden stake sticking through it on the right side of the back between T5-L3. What are you most concerned about? And what would you do about it?
- -A pneumothorax! The low sats and high RR rate with tachycardia along with the site of the injury must raise the possibility of a haemopneumothorax.
- -Examine the chest- if not tensioning get a CXR.
- -Insert a chest drain.
Trauma RR 35 sats 88%, BP 145/70 pulse 110. He is screaming in pain intermittently. large open wound with a wooden stake sticking through it on the right side of the back between T5-L3. With fluid resuscitation and good analgesia the BP remains 145/68 and the tachycardia comes down to 85. What analgesia is best in this situation? please give doses.
- -fast acting opioid like fentanyl- 50-100 mcg in increments- start with 50 mcg then titrate the rest
- -Morphine takes too long to work in this situation.
Trauma RR 35 sats 88%, BP 145/70 pulse 110. He is screaming in pain intermittently. large open wound with a wooden stake sticking through it on the right side of the back between T5-L3.What would you do now?
- -FAST scan for free fluid would be good idea:
- if present then should go for a laparotomy
- is haemodynamically stable CT chest/abdomen/pelvis would be the investigation of choice.
- -May need MRI of the spine later but that can wait.
Trauma large open wound with a wooden stake sticking through it on the right side of the back between T5-L3. You perform a quick secondary survey: on neurological assessment you discover that the right leg is hyperreflexic and has decreased power but the left leg seems normal. Light touch is normal both sides but the left leg there is no sensation to painful stimulus. What could explain these findings?
-Brown- Sequard syndrome
A 24 year old man is rushed in- he has been stabbed in the right side of the chest and is actively bleeding from the chest wound site. He is barely responsive with a very weak pulse and a BP of 60/25. He then arrests in front of you. What would you do?
- -fits the criteria for an emergency department thoracotomy-
- -he had a witnessed cardiac arrest and has penetrating thoracic trauma.?
With regard to chest trauma in general when would it be inappropriate to act?
- * Blunt thoracic injuries with no witnessed cardiac activity
- * Multiple blunt trauma
- * Severe head injury alongside the thoracic injuries
What are you trying to achieve by your proposed intervention?
- The primary aims of emergency thoracotomy are:
- * Release of cardiac tamponade
- * Control of haemorrhage
- * Allow access for internal cardiac massage
- Secondary manoeuvres include cross-clamping of the descending thoracic aorta.
- Once control is achieved and cardiac activity restored, the patient is transferred rapidly to the operating room for definitive management.
How would you perform the procedure you chose emergency department thoracotomy? (Please describe the steps you would take and the equipment you would use)
- -A supine anterolateral thoracotomy is the accepted approach for emergency department thoracotomy.
- -A left sided approach is used in all patients in traumatic arrest and with injuries to the left chest.
- -Patients who are not arrested but with profound hypotension and right sided injuries have their right chest opened first.
- -Prep skin (fast chest should be open in 2 minutes)
- -Make incision in the 5th intercostal space from the border of the sternum to the mid-axillary line
- -Enter the chest bluntly with a finger through the intercostal muscles (as with a chest tube insertion)
- -The opening is extended with a combination of heavy scissors and blunt dissection.
- -Insert the rib spreaders between the ribs and open.
You find an isolated laceration to the right ventricle. What do you do?
- -Cardiac wounds should be controlled initially with direct finger pressure.
- -Large wounds may be controlled temporarily by the insertion of a foley catheter with inflation of the balloon.
- -The balloon may obstruct inflow or outflow tracts however and it may also lead to extension of the laceration if excessive traction is placed on it.
- -In traumatic arrest, internal cardiac massage should be started as soon as possible following relief of tamponade and control of cardiac haemorrhage.
- -A two-handed technique produces a better cardiac output and avoids the low risk of cardiac perforation with the one-handed manoeuvre.
laceration to his right middle finger over the middle phalanx. There was no associated sensory symptoms or tendon damage. The treating clinician decided to repair the laceration using a digital nerve block.What anaesthetic agents are suitable for this procedure? What additional agent should be avoided?
- -Lignocaine, bupivacaine.
- -Avoid adrenaline.
digital nerve block-What volume of fluid should be used on each side of the finger?
-1-2ml on each side of the finger.
digital nerve block-What alteration should be made to the procedure if the laceration was over the proximal portion of the middle phalanx?
-An additional injection of LA should be given across the dorsum of the base of the proximal phalanx.
digital nerve block-How long does it take anaesthesia to develop?
-About 5 minutes.
digital nerve block-How does the skin feel if the block is working?
-Warm and dry as the autonomic nerves are blocked also.
A 74 year old M found collapsed at home and was unresponsive when they arrived. He had an aneurysm repair 2 years ago. In the primary survey you establish that he is shocked and has a GCS of 14 as he is confused but he is breathing -spontaneously and is maintaining his own airway. You can see a laparotomy scar. You gain IV access and attach fluids aiming to maintain a BP of around?.. what?
-The patient is shocked, you have heard that he had an aneurysm repair 2 years ago. You want to aim for a MAP of around 70 or a systolic of around 90 or less.
How do you calculate MAP?
-Diastolic pressure + 1/3 of pulse pressure (systolic-diastolic)= MAP approx.
In what other circumstances should patients be managed in this way and what is the underlying principle known as?
- -Permissive hypotension; trauma is the other situation.
- -If someone is shocked in trauma the principle should be to maintain a similar MAP whilst aiming to prevent the dilution of clotting factors.
What fairly new agents are you aware of that can help to stem bleeding in the shocked trauma patient?
-Activated factor VIIa
He then proceeds to have a large PR bleed; the blood appears to be fresh. Name 2 differential diagnoses for what is happening?
- 1 large fresh rectal/lower GI bleed could be from numerous causes including diverticular disease, angiodysplasia etc
- 2 aortoenteric fistula, rare but fits with the history.
You alert the surgeons and arrange imaging. You manage to stabilise the patient with resuscitation. What is the best way to ensure that this patient is adequately monitored at this time.
-An arterial line will be very helpful to detect the beat to beat variation in blood pressure, easy and quick to insert.
What is octaplas and in what situations is it used?
-It is Fresh Frozen Plasma used to reverse the effects of warfarin very quickly.
A 29 year old woman presented with severe right lower quadrant pain which had begun during exercise. She had no history of vaginal bleeding and was not sexually active. She was at the mid-point of her menstrual cycle.On examination she had moderate tenderness in her right lower quadrant but had no guarding. She was afebrile and haemodynamically stable. What is the differential diagnosis?(Give five)
- -Ruptured ovarian cyst
- -ectopic pregnancy
- -renal calculi
- -mittelschmerz pain
- -varian torsion
- -pain from a leiomyoma.
How would you investigate this patient in the emergency department?(Give five investigations)
- -urine or serum HCG
- -FBC, UE
- -pelvic ultrasound
- -vaginal swab.
How would you manage this patient in the emergency department if she has an uncomplicated ovarian cyst rupture?(Give two points)
- -IV fluids
- -organise follow up.
What is the indication for surgery if this patient has a complicated ovarian cyst rupture?
-Emergency surgery is performed to control ongoing significant hemorrhage.
How would the presentation of a dermoid cyst rupture vary from that of a simple cyst rupture?
-Shock and hemorrhage are the immediate sequelae of rupture of a dermoid cyst due to spillage of sebaceous material into the abdominal cavity.
A 25 year old woman presented with persistent vomiting at 9 weeks gestation.Ultrasound confirmed a viable intrauterine pregnancy. How would you investigate this patient?(give three investigations)
- -Measurement of weight
- -orthostatic blood pressures
- -serum free T4 concentration
- -serum electrolytes
- -urine ketones.
How would you manage this patient?(Name three points)
- -Gut rest
- -IV rehydration
- -avoidance of precipitants
- -anti-emetic medication.
How is the diagnosis of hyperemesis gravidarum made?
- -is made clinically
- -a woman with onset of persistent vomiting accompanied by weight loss exceeding 5 percent of prepregnancy body weight and ketonuria in the first trimester
- -unrelated to other causes.
List three possible maternal complications of hyperemesis gravidarum?
- -Micronutrient deficiency
- -wernicke encephalopathy (from deficiency of vitamin B1)
- -sequelae of malnutrition (immunosuppression, poor wound healing) have been reported.
- -Oesophageal tears and rupture
What birth defects are associated with hyperemesis gravidarum?
-There is no clear increase in the risk of birth defects among offspring of gravida with hyperemesis gravidarum.
A 39 year old man presents to the department after a fall from a 6 metre ladder onto his right side Describe the most important things that this CT chest shows (fig 1):
- -Pulmonary contusion
- -Fractured ribs
- -Hameothorax (small)
- -Pneumothorax (small apical)
- -Surgical emphysema
Fall 6m ladder to Rt side. What is the most important initial management step? Where should this patient be sent? What is your choice of analgesia?
- -ABCD then as part of that ruling out a tension pneumothorax and insertion of a thoracostomy tube
- -Likely going to need HDU/ITU care
- -Thoracic epidural but mark for mentioning that an intercostal nerve block may be a good intermediate choice
Fall 6m ladder to Rt side. The patient deteriorates in front of you with sats of 85% on 80% FiO2 you decide that he requires intubation and IPPV. Describe the steps required for an RSI (including any drug doses)
- -Pre - oxygenate 3 mins if possible, or ventilate with 100% O2
- -Ensure adequate monitoring ECG, Sats, BP, and secure IV access
- -Cricoid pressure, ensure not released until ET secured
- -Induction agent (Thiopentone 3-5mg/kg, Etomidate 0.3mg/kg, Ketmaine 0.5-2mg/kg) Suxamethonium 1-1.5mg/kg
- -Confirm placement of tube (best by direct visualisation of tube passing through the cords), end tidal CO2.
- -Listen to the chest both sides
- -Inflate cuff and secure ET tube.
- -Request CXR
Fall 6m ladder to Rt side. As part of the primary survey you notice that the patient has a tender abdomen. What do you do next?
- -FAST scan/DPL to rule out liver injury
- -If stable CT Abdomen, if not laparotomy.
Fall 6m ladder to Rt side. The CT is reported and the injuries are worse than you first thought, amongst other things there is a fracture of the first rib. What is it essential to rule out and how will you do this?
-Need to rule out an aortic injury, needs arch aortogram.
20 yo M w/intermittent headaches,malaise since a head injury at work the previous week. Had LOC 1st CT-H N, 3/7 later re-attended the same hospital as he still had headaches and malaise. He had undergone a second CT brain scan, which again was unremarkable. What are the common post concussion symptoms? (Give four)
- -low mood
- -poor concentrating ability
What are the characteristics of post concussion headaches? (Give two)
- -May last for several months
- -become worse during the day
- -become worse on exercise.
What factors may contribute to dizziness caused after a concussion? (Give one)
- -Codeine based analgesia
- -patients are more sensitive to the effects of alcohol.
Name two categories of patients who are prone to developing a chronic subdural haematoma?
- -patients with bleeding disorders
20 yo M w/intermittent headaches,malaise since a head injury at work the previous week. Had LOC 1st CT-H N, 3/7 later re-attended the same hospital as he still had headaches and malaise. He had undergone a second CT brain scan, which again was unremarkable. How would you manage this patient? (Give four)
- -History should cover symptoms of other types of headache e.g. photophobia, meningismus, full neurological exam
- -investigations to out rule other causes of headache if appropriate
- -check the reports of the CT Brain radiologist report from the initial hospital
- -explanation of symptoms to patient
- -arrange follow up with GP.
A 26 yo F vomiting. She is 13/40 pregnant in her first pregnancy. She tells you that she cannot hold anything down and that it has been getting worse over the last few days. The 12 weeks scan showed a healthy intrauterine foetus. On examination she appears dehydrated and is tachycardic. What are the possible diagnoses?
- -Any cause of vomiting
- -normal part of pregnancy
- -hyperemesis gravidarum
- -Acute Ovarian Torsion
- -Molar pregnancy
- -Diabetic Ketoacidosis Pregnancy
- -Cholecystitis and Biliary Colic
- -Gastritis and Peptic Ulcer Disease.
- -Acute fatty liver of pregnancy.
- -Urinary Tract Infection
- -Pseudotumor cerebri
What investigations should be performed?
- -Laboratory Studies
- * Obtain electrolyte levels.
- * Measure urine gravity and ketones.
- * Perform liver function tests (LFTs) if hepatitis is a concern. Of note, LFTs can be slightly elevated with hyperemesis gravidarum.
- * Perform a complete blood count and urinalysis to rule out other causes, with particular concern for pyelonephritis.
- * Hyperthyroidism causing nausea and vomiting is rare, a T3 and T4 level should be drawn if this is a concern. (Thyroid-stimulating hormone [TSH] can be suppressed in hyperemesis gravidarum.)
- * Obtain serum amylase-to-creatinine ratio if pancreatitis is a concern.
- * Serum hCG levels are not clinically useful in a patient with a known intrauterine pregnancy (IUP) and hyperemesis.
- -Imaging Studies
- * The patient should have an ultrasonographic evaluation of her pregnancy to look for molar pregnancy or multiple gestations.
What would prompt you to admit the patient?
-Presence of ketones is an important marker clearly if the blood tests revealed significant renal failure or other concerning features then the patient would need to be admitted
What analgesics are good in the first trimester?
- -Paracetamol or opiod based
- -avoid NSAIDS
The same 46-year-old septic patient that you met in a previous question is now on the ITU. He has sepsis from pneumonia.
- He has a haemoglobin of 8 g/dL and you consider giving a blood transfusion. What is the current best evidence around this?
- -RBC transfusions for adults should occur only when hemoglobin is < 7.0 g/dL to a target hemoglobin between 7 and 9 g/dL
His platelets have been falling and are currently 20,000mm/3 Should you give a platelet transfusion?
- -No unless there is a very high bleeding risk.
- -When drops below 5000/mm3 then they should be given regardless
What platelet level is normally considered minimum when considering surgery or other invasive procedures?
He has sepsis from pneumonia. When considering how a ventilator should be set with this patient what are the important things to consider to reduce the chances of ALI/ARDS?
- -Lower tidal volume mechanical ventilation (6 mL/kg based on ideal body weight) can reduce mortality rates to 22.1% from 39.8% compared with conventional methods (12 mL/kg based on ideal body weight)
- -Tidal volumes should be reduced over 1 to 2 hours to a low tidal volume (6mL/kg predicted body weight) as a goal (grade 1B recommendation) in conjunction with the goal of maintaining peak airway pressures below 30 cm H2O (grade 1C recommendation).
He has sepsis from pneumonia. What other therapies need to be considered in this patient?
- -Stress ulcer prophylaxis
- -DVT prophylaxis
A 48 yo M on Warfarin for a left femoro-politeal DVT. He has recently been started on a short course of erythromycin for an ear infection by his GP. He has presented with epistaxis. His INR comes back at 5.4. What is the likely explanation for this?
-Inhibition of the p450 system- erythromycin is a p450 inhibitor therefore potentiating the effects of warfarin- hence the epistaxis.
List 3 other drugs that could do a similar thing?
- -sodium valproate
What is St John?s wort used for? How does it interact with warfarin?
- -It is used to treat depression.
- -It is a p450 inducer therefore reduces the effects of warfarin.
- -St John depress->decrease Warfarin effects
What treatment would you instigate (he is still actively bleeding and has been for 2 hours)
- -Admit to ENT
- -oral vitamin K- give 1-2mg
- -aim to pack the nose, if unsuccessful try cauterisation.
A 35 year old man suffered a burns injury at work.Name four common signs of significant smoke inhalation injury?
- -Persistent cough
- -stridor, or wheezing, hoarseness
- -deep facial or circumferential neck burns
- -nares with inflammation or singed hair
- -carbonaceous sputum or burnt matter in the mouth or nose
- -blistering or edema of the oropharynx
- -depressed mental status, including evidence of drug or, alcohol use
- -respiratory distress
- -hypoxia or hypercapnia.
Describe immediate burn care and cooling?(three steps)
- -Any hot or burned clothing, any jewelry, and any obvious debris should immediately be removed to prevent further injury and to enable accurate assessment of the extent of injury
- -cool water or saline soaked gauze should be applied
- -ice and freezing should be avoided to prevent frostbite and systemic hypothermia.
Burn-What points are important to attain in the history?(Four points)
- -What burned (eg, chemicals, textiles).
- -The location of the fire (eg, enclosed or open space).
- -Whether an explosion occurred.
- -Whether the patient used alcohol or drugs.
- -Whether there was associated trauma (eg, from falling debris)
Describe burns in terms of superficial, superficial partial thickness, deep partial thickness and full thickness?
- -Superficial burns involve only the epidermal layer of skin. They are painful, dry, red, and blanch with pressure.
- -Superficial partial-thickness burns involve the epidermis and superficial portions of the dermis. They are painful, red, and weeping, usually form blisters, and blanch with pressure.
- -Deep partial-thickness burns extend into the deeper dermis, damaging hair follicles and glandular tissue. They are painful to pressure only. They almost always blister (easily unroofed), are wet or waxy dry, and have variable color from patchy cheesy white to red.
- -Full-thickness burns extend through and destroy the dermis. They are usually painless. Skin appearance can vary from waxy white to leathery gray to charred and black. The skin is dry and inelastic, and does not blanch with pressure.
In an adult what percentage of total body surface area (TBSA) does each leg, arm, anterior and posterior trunk and head represent?
- -Each leg represents 18% TBSA,
- -each arm represents 9% TBSA
- -the anterior and posterior trunk each represent 18% TBSA
- -the head represents 9% TBSA.
A 23 year old who is gravida 2 para 1 attends with PV bleeding in the 8th week of her current pregnancy. She has also had some mild lower back and abdominal pain.What is a threatened miscarriage?
- -Vaginal bleeding through a closed cervical os.
- -50% will go on to miscarry.
What is cervical shock?
-Severe pain and bleeding accompanied by hypotension and bradycardia might be due to cervical shock due to a vagal response caused by the presence of retained products stuck in the cervical os.
cervical shock-How do you treat it?
-Remove any products of conception from the cervical os using sponge forceps.
What is it important to do in a woman who has had an inevitable abortion?
- -Need to be referred to gynaecologists for in patient care
- -may well go on to require a D+C.
- -Also need to consider Rheus status- if mother is +ve and non-immune then will need anti-D.
List 4 risk factors for ectopic pregnancy
- -Previous pelvic surgery
- -Previous ectopic
- -Assisssted fertilisation
A lactating 38 year old woman (G1 P1) presented with a painful red area on her right breast. On her initial presentation there was no fluctuant mass palpable.What is the diagnosis? What is the most common differential diagnosis?
- -The most common differential diagnosis is plugged ducts. Plugged ducts usually present as palpable lumps with tenderness without associated shooting pains or fever.
Mastitis-Name two common aetiological agents?
- -Staphylococcus aureus
- -Escherichia coli.
Mastitis-Name three supportive measures used in the treatment of this condition?
-Supportive measures include continued nursing, bed rest, an antiinflammatory agent such as ibuprofen for pain control.
Mastitis-What is the initial antibiotic of choice for this condition? How long should antibiotic therapy continue for?
- -Antibiotic treatment should be started with flucloxacillin
- -for 10 to 14 days.
Mastitis-Despite antibiotic therapy the above lady represented 4 days later with a breast abscess. Name two risk factors this lady has for the development of a breast abscess?
- -maternal age over 30 years of age
- -gestational age = 41 weeks gestation
A 30 year old women presented with redness and pain around her right eye. What is the most likely diagnosis? What is the most serious differential diagnosis?
- -Preseptal(periorbital) cellulitis
- -orbital cellulitis.(Preseptal cellulitis is much more common than orbital cellulitis)
What are the most common pathogens to cause this condition/preseptal cellulitis?(Name two)
- -Streptococcus pneumoniae
- -Staphylococcus aureus
- -other streptococcal species
- -and anaerobes.
Name two indications for CT scanning?
- -Inability to accurately assess vision
- -gross proptosis
- -bilateral edema
- -deteriorating visual acuity
- -signs or symptoms of central nervous system involvement.
How would you manage this patient?(two points)
- -Broad-spectrum oral antibiotics, consider anaerobic cover
- -opthalmology consultation
- -close observation.
Name some complications of this condition?(Name three)
- -Recurrent preseptal cellulitis
- -orbital cellulitis
- -vision loss
A 29 year old lady presents with nausea and vomiting and RUQ pain. She is 33 weeks pregnant. She has had an uneventful pregnancy up until this point. On examination she appears unwell, looks pale and has marked tenderness in the RUQ. Her BP is 146/84 (was 105/65 2 weeks ago). What investigations do you want to immediately?
- -Urine dip for protein- is this pre-eclampsia? Is it something else?
- -Full blood profile to include FBC, UE, LFT, Coagulation studies, G&S.
- -An ultrasound may also be very helpful and is easily performed by the bedside.
You have some blood tests back Hb 9.3 WBC 13 Plt 40 PT 12 APPT 38 Na+ 133 K+ 3.6 Ur 12 Cr 145 Bili 23 AST 170 ALT 300 Alk P 193 LDH 765 Urinalysis 1+ protein What is the differential diagnosis? And what is the most likely diagnosis here?
- -HUS, TTP fatty liver HELLP- in TTP and HUS you would not usually get hypertension and protienuria. The only haematological abnormalities are microangiopathy and low platelts. You also don?t get DIC with HUS and TTP. Fatty liver would expect higher transaminase levels and almost always get abnormal clotting.
What is the definitive management of this case?
-Delivery of the child- this is HELLP. ?
What would you need to consider prior to delivery of the child (with regard to the child?)
-As she is less than 34 weeks you will need to give steroids to try to mature the immature foetal lungs.
What other treatment goals are critical for the mother?
- -Delivery of the foetus is critical
- -Steroids for the foetus
- -Treat the hypertension
- -Plt and blood transfusion if bleeding occurs
- -Dialysis for rapidly deteriorating renal function
What would you do if the mother started to have a seizure?
-Give IV magnesium sulphate
A 19 year old woman attends with a history of lower abdominal pain. What are the 3 common features of pelvic inflammatory disease?. Minimum criteria for the diagnosis of PID are listed below. Institute empiric treatment of PID when a patient has all of the following minimal clinical criteria in the absence of an established cause other than PID
- Lower abdominal tenderness on palpation
- Adnexal tenderness
- Cervical motion tenderness
- -Additional criteria, especially in women with more severe clinical signs, can be used to increase the specificity of the diagnosis.
- Oral temperature more than 38.3?C (101?F)
- Abnormal cervical or vaginal discharge
- Elevated erythrocyte sedimentation rate (ESR)
- Elevated C-reactive protein
- Laboratory documentation of cervical infection with N gonorrhoeae or C trachomatis.
- It is important to note that PID can occur and cause serious harm without causing any noticeable symptoms.
PID. What combination of drugs would you use to treat this condition?-1st line antibiotics for pelvic inflammatory disease:
- Ceftriaxone 250mg IM stat (for gonococcal cover)
- + Doxycycline 100mg bd for 14 days
- + Metronidazole 400 mg bd PO for 5 days
PID. In what circumstances would you give IV antibiotics?-IV therapy for severe disease is indicated if :
- -A surgical emergency cannot be excluded
- -Lack of response to oral therapy
- -Clinically severe disease (temp >38oC, signs of pelvic peritonitis, signs of a tubo-ovarian abscess)
- -Intolerance to oral therapy
- -Disseminated gonococcal infection.
PID What do you want to rule out in this patient?
- -Ectopic pregnancy.
- -Or other serious cause of abdo pain
PID. What investigations would you do?
- -beta HCG
- -clotting screen
- -G&S=/- cross match.
A 35 year old man who has a known personality disorder says that he has taken 45 /300mg asprin tablets. He is sweating profusely and is agitated, he has been vomiting and says that his ears will not stop ringing. Explain the results of the ABG: pH 7.36 paO2 12.3 paCO2 2.8 BE -16 HCO3- 17
-shows a mixed metabolic acidosis with respiratory alkalosis which is typical in salicylate poisoning, the danger is that the acidosis will worsen.
What dose could be fatal/ salicylate OD?
>500mg/kg could cause fatal poisoning.
Is there a role for activated charcoal with asprin od?
-yes, if 2 levels are taken and the second one increases you could consider giving another dose of 50g of activated charcoal.
A CXR is taken which shows: ARDS What is shown and how would you manage this?
-ARDS needs ITU for ventilation and supportive care, likely to need renal support.
Salicylate OD/ What is the definitive management in severe cases?
-ITU for haemodialysis -Paralysis and ventilation -often helpful IV glucose as brain levels can get very low
A 29 year old who has recently had a baby and is breast-feeding comes to see you as she has developed diarrhoea and is concerned. She takes oral aminophyline for asthma. Which antibiotic should you avoid in this patient?
-Ciprofloxacin and erythromycin are both liver enzyme inhibitors and can therefore increase plasma concentrations of theophyline.
She came off lithium prior to conception but is worried about her depression what do you advice?
-Cannot go on it whilst still breast feeding due to risks to baby of involuntary movements.
What drug can cause cleft lip and palate if taken during pregnancy? And which drug should therefore be used instead?
- -Phenytoin can cause cleft lip/palate.
- -Monotherapy with carbamazepine is probably the safest.
- Risks of major congenital malformations related to specific anti-epileptic drugs
- Carbamazepine taken as a single drug treatment (known as monotherapy) carries the lowest risk, with 2.2 babies born with MCMs in 100 women taking the drug (2.2 per cent)
- Taking sodium valproate as monotherapy at a daily dosage under 1000mg, carries a risk of 5.1 in 100 (5.1 per cent)
- Taking sodium valproate as monotherapy at daily doses over 1000mg carries a risk of 9.1 in 100 (9.1 per cent)
- Drug combinations that include sodium valproate have a significantly higher risk of MCMs than combinations that do not include this drug.
- Taking lamotrigine as monotherapy at daily dosages of 200 mg or less carries a risk of 3.2 in 100 (3.2 per cent)
- Taking lamotrigine as monotherapy at a daily dosage above 200 mg carries a risk of 5.4 in 100 (5.4 per cent)
- Taking carbamazepine and sodium valproate together carries a risk of 8.8 in 100 (8.8 per cent)
- Taking sodium valproate and lamotrigine together carries a risk of 9.6 in 100 (9.6 per cent)
- The information from the study did not include any specific data on vigabatrin, gabapentin, topiramate, tiagabine, oxcarbazepine, levetiracetam and pregabalin.
She is sexually active again and doesn?t want to conceive what advice do you give regarding contraception?
- -Cannot go on the OCP due to risks associated with breast feeding.
- -The progesterone only pill/condoms/cap etc are other options.
A 26 yo F RIQ pain + PV bleeding. afebrile. Urine HCG was positive. What is the diagnosis? What is the differential diagnosis?
- -Ectopic pregnancy.
- -Normal pregnancy with threatened/missed or incomplete abortion
- -ruptured or torsed corpus luteum cyst
- -degenerating uterine leiomyoma.
A 26 yo F RIQ pain + PV bleeding. afebrile. Urine HCG was positive. Name two investigations which should be performed?
- -Transvaginal +/- transabdominal ultrasound
- -serum quantitative HCG.
A 26 yo F RIQ pain + PV bleeding. afebrile. Urine HCG was positive.Name three management steps?
- -Blood group.
- -Anti-D if patient is rhesus negative.
- -Obstetrical consultation.
Ectopic pregnancy-Name five risk factors for this condition?
- -Previous ectopic
- -previous tubal surgery
- -tubal ligation
- -intrauterine DES exposure
- -current IUD use
- -tubal pathology
- -previous cervicitis (gonorrhea, chlamydia)
- -history of pelvic inflammatory disease
- -multiple sexual partners
- -previous pelvic/abdominal surgery
- -vaginal douching
- -early age of intercourse (<18 years).
A 26 yo F RIQ pain + PV bleeding. afebrile. Urine HCG was positive.. The above lady was haemodynamically stable and there was no fetal cardiac activity. It was decided to treat this lady with methotrexate. Below what serum hCG is methotrexate suitable?
-hCG <5000 mIU/mL
17 yo M collapsed at a festival in the dance tent. drowsy. sweating profusely, T 41C rectally. HR 125.BP is 170/83, pupils dilated/react poorly to light. Hb 12.4 WBC 9.2 INR 1.9 Na+ 127 mmol/l K+ 7.1 mmol/l Ur 11 mmol/l Cr 169 ?mol/l Phos 1.6 mol/l Urine 2+ blood . What is the most likely cause for this presentation? Please list 3 alternative causes.
- -MDMA (ecstasy tablets)
- -serotonin syndrome
- -malignant hyperpyrexia due to heat stroke
- -malignant hyperthermia
- -other drug overdose
- -neuroleptic malignant syndrome although this is less likely.
Why is the INR abnormal?
- -other complications include rhabdomyolysis and renal failure (either from reduced renal perfusion or from myoglbin blocking the renal filtering system)?
State 2 possible reasons for the low sodium?
- -Excess loss from the skin due to perspiration
17 yo M collapsed at a festival in the dance tent. drowsy. sweating profusely, T 41C rectally. HR 125.BP is 170/83, pupils dilated/react poorly to light. Hb 12.4 WBC 9.2 INR 1.9 Na+ 127 mmol/l K+ 7.1 mmol/l Ur 11 mmol/l Cr 169 ?mol/l Phos 1.6 mol/l Urine 2+ blood. Outline the treatment priorities-
- -Cooling -Apply evaporative cooling with water and a fan. But not too fast
- -rectal paracetamol or IV paracetamol will probably reduce the temp but unlikely to affect the outcome (generally the advice in the literature is that they are not useful).
- -Tepid sponging and cold packs in the axilla and groin are effective along with IV fluid.
- -In the patient in the question you would be wise to start with CVP measurment as he is hypertensive.
- -The rules for fluid replacement depend on each individual case but generally 1 litre is given and depending on the response i.e. if the pulse comes down and the BP goes up then this is followed by a second litre but then CVP is crucial to effective management to avoid cerebral oedema due to hyponatraemia.
17 yo M collapsed at a festival in the dance tent. drowsy. sweating profusely, T 41C rectally. HR 125.BP is 170/83, pupils dilated/react poorly to light. Hb 12.4 WBC 9.2 INR 1.9 Na+ 127 mmol/l K+ 7.1 mmol/l Ur 11 mmol/l Cr 169 ?mol/l Phos 1.6 mol/l Urine 2+ blood. Which drug therapies could be used in this situation?
- -Benzodiazepenes can be used if the patient has a siezure.
- -Dantrolene- may be of use? There is no high level evidence on this subject
colles fracture -manipulate the fracture using a biers block technique. What should be recorded before the pocedure? (Name two)
- -Patient consent
- -how long the patient is fasted
- -pre-op assessment
What are the contraindications to biers block?(Name four)
- -Severe hypertension
- -peripheral vascular disease
- -raynauds syndrome
- -children < 7 years
- -sickle cell disease or trait
- -uncooperative or confused patient
- -procedures needed in both arms.
biers block- What is the local anaesthetic of choice?
biers block- How much above the systolic BP should the pressure cuff be inflated to?
-The tourniquet should be inflated to at least 100mmHg above the systolic BP.
biers block-At least how long must the tourniquet be inflated for?
-The tourniquet must be inflated for at least 20 minutes.
53 yo M + swollen hot left knee. calf muscle is hurting and there is erythema over the calf. PMH gout, angina and hypertension, allergic to penicillin. no trauma. T 38.2. Give three differential diagnoses in this scenario
- 1: Septic arthritis
- 2: Gout/CPPD with local concurrent cellulitis of the leg
- 3: Reactive arthritis/Rieter's syndrome
- 4: Gonococcal arthritis
Joint swollen/hot/F What are the 2 key investigations that you must perform in the ED?
- 1: Blood cultures
- 2: Joint aspiration, gram stain, microscopy and polarized light microscopy.
What test is used to determine the presences of crystal disease within a joint?
- -The use of polarized light microscopy.
- -Gout negatively birefringent crystals that are needle shaped.
What are the clinical signs to suggest a tension pneumothorax?(Give four)
- -Absent breath sounds on the affected side
- -hyper-resonance over the affected lung
- -distended neck veins
- -tracheal deviation.
What would you do if you suspected a tension pneumothorax on the side of the central venous line?
- -Immediate decompression by inserting an IV cannula
- -into the second intercostal space in the mid-clavicular line just above the third rib.
What is the next step if this initial treatment is successful?
- -Insertion of an axillary chest drain.
- -Obtain a CXR.
Why does tension pneumothorax cause cardiac arrest?
-Movement of the mediastinum causes kinking of the great vessels and a decrease in venous return.
If a patient is receiving intermittent positive pressure ventilation (IPPV) what feature may cause the treating clinician to suspect a tension pneumothorax?
-A sudden increase in airway pressure.
septic shock- What are the 4 most important initial management nterventions?
- -Oxygen and airway protection (+/- intubation and IPPV)
- -Obtaining IV access, taking blood cultures and starting broad spectrum antibiotics early
- -Aggressive fluid therapy
- -Early involvement of ITU
- -Body temperature of >38?C or <36?C
- -HR >90 bpm
- -RR> 20 or PaCO2 <4.3 KPa
- -WCC >12x 109/litre or <4 x 109/litre or > 10% immature band forms
septic shock- What investigations would you like to carry out?
- -Blood cultures
- -Blood glucose
- -CT head
Assuming a working diagnosis of septic shock what parameters would be sensible treatment targets in this previously fit young man? Where should this patient be managed?
- -MAP >65 mmHg
- -CVP 8-12 mmHG (12-15mmHg if ventilated)
- -ITU with arterial and central venous lines
Describe the technique of inserting an internal jugular central line using ultrasound guidance:
- -Full aseptic technique
- -Describe landmarks and how to use probe to identify the vein
- -Description of Selldinger technique
- -Ensure all ports aspirate freely
- -4 point fixation with skin sutures
- -Ensure CXR is ordered prior to use
What would you like to do?
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