Acute

Question 1

What are the features of alcohol withdrawal syndrome?

Answer 1

Autonomic hyperactivity
Tremulousness
Restlessness
Hallucinations
Seizures
Delirium tremens

Question 2

What is the cause of AWS?

Answer 2

Body has increased levels of glutamate to balance the GABA/alcohol to glutamate ratio
Sudden withdrawal of alcohol means there is an imbalance of GABA to glutamate

Question 3

What is delirium tremens?

Answer 3

Rapid onset of confusion and AWS features 2-3 days post-withdrawal

Question 4

What are the investigations for AWS?

Answer 4

U+E
LFT
Toxicology screen

Question 5

What is the management for an alcohol-dependant Pt who can be managed at home?

Answer 5

Advice to slowly reduce alcohol

Provide information on local alcohol support services

Question 6

What is the management for a Pt with AWS?

Answer 6

Medically assisted alcohol withdrawal

Question 7

What is the management for a Pt <16yrs with AWS?

Answer 7

Medically assisted alcohol withdrawal

Physical and psychological assessment

Question 8

When should you admit a Pt with AWS?

Answer 8

Vulnerable Pts (frail, young, lack of social support, learning difficulties etc)

Question 9

What is the CIWA-Ar?

Answer 9

10 item assessment tool used to quantify severity of AWS

Question 10

What is the treatment for AWS?

Answer 10

1st line- benzodiazepines (chlordiazepoxide)/clomethiazole
-oral: mild
-IV: moderate/severe
Seizure- lorazepam

Question 11

What are the features of anaphylaxis?

Answer 11

Wheeze
Hives
Facial swelling
Nausea/vomiting

Question 12

What is the immediate management of anaphylaxis?

Answer 12

Call for help
Position Pt with raised legs
ABC
IM adrenaline 1:100
100% oxygen

Question 13

What is the post-resusitation management of anaphylaxis?

Answer 13

Slow chlorphenamine/diphenhydramine and ranitidine (antihistamine)
Slow hydrocortisone
Neb salbutamol/ipratropium if wheezy

Question 14

What is the post-resusitation investigation of anaphylaxis?

Answer 14

Serum tryptase:
-at time of stabilisation
-1/2 hours later
Don’t need to do if diagnosis of anaphylaxis is definite

Question 15

What is acute salicylate exposure?

Answer 15

Single dose equivalent of >150mg/kg or >6.5 g

Question 16

What is chronic salicylate exposure?

Answer 16

Repeated exposure to high dose aspirin or equivalent (150 mg/kg/d)

Question 17

What are the features of salicylate poisoning?

Answer 17

Fever+diaphoresis
SOB
Tachypnoea
Tinnitus and/or deafness
Malaise and/or dizziness
Neurological toxicity- movement disorders, asterixis, stupor
Confusion and/or delirium (+/- irritability, hallucinations)
Coma
Cerebral oedema (papilloedema)
Seizures (highly likely with salicylate levels of >80 mg/dL)
Dry mucous membranes, poor skin turgor

Question 18

What are the investigations for salicylate poisoning?

Answer 18

ABG- initially respiratory alkalosis, later metabolic acidosis (wide anion gap)
Serum electrolytes- hypokalaemia, hypocalcaemia +/- hypomagnesemia
Serum salicylate level- may be positive or negative
CXR- pulmonary oedema
ECG- sinus tachycardia, prolonged corrected QT interval

U+E- may show insufficiency 
Ketones- positive or negative
Blood glucose- hyper or hypo
FBC- ?elevated WBC
LFTs- ?elevated AST, ALT
PT, PTT, INR- coagulopathy 
Toxicology screen- variable

Question 19

What is a single acute overdose of acetaminophen?

Answer 19

> 4g in <1hr

Question 20

What is a staggered overdose of acetaminophen?

Answer 20

Multiple doses over 1hr

Question 21

What is a acetaminophen-induced hepatotoxicity?

Answer 21

Hepatotoxicity post-paracetamol overdose with serum AST >1000 IU/L

Question 22

What are the features of paracetamol overdose?

Answer 22

Asymptomatic for 24hrs

Nausea, vomiting abdo pain 2-3 days after ingestion

Question 23

What are the investigations for paracetamol overdose?

Answer 23

Serum paracetamol level ASAP
Serum AST/ALT
Arterial pH/lactate
U+E

Question 24

What are the causes of opiate overdose?

Answer 24

Substance abuse/recent abstinence
Self harm
Iatrogenic

Question 25

What are the features of opiate overdose?

Answer 25

``` Miosis Bradypnoea Altered mental status Needle marks Decreased GI motility Dramatic response to naloxone ```

Question 26

What are the investigations for opiate overdose

Answer 26

Therapeutic trial of naloxone | ECG- MI/QRS prolongation

Question 27

What are the indications for placing a catheter?

Answer 27

``` Obstruction (BPH) Bladder weakness or nerve damage Childbirth with epidural Before, during and after surgery Delivery of medication directly to bladder (chemo for bladder cancer) Urinary incontinence ```

Question 28

What are the complications of placing a catheter?

Answer 28

``` Recurrent UTIs Trauma Accidental removal Renal complications- kidney stones, hydronephrosis, scarring Pain Recurrent blockage ```

Question 29

What are the indications for epidural injections?

Answer 29

Analgesia - single injection for pain relief - post operative Anaesthesia -slower onset than spinal analgesia – gradual decrease in BP -adjunct to general anaesthesia sole anaesthetic technique: Cesarean sections

Question 30

What are the complications of epidural injections?

Answer 30

``` Failure to achieve analgesia or anaesthesia Accidental dural puncture with headache Bloody tap Catheter placement into vein Misplacement in subarachnoid space Neurological injury Abscess ```

Question 31

What are the indications of ABGs?

Answer 31

``` Respiratory failure- acute or chronic Cardiac failure Liver failure Renal failure Hyperglycaemic states- DM Multiorgan failure Sepsis Burns Poisons/toxins Ventilated patients Severely unwell patients ```

Question 32

What are the complications of ABGs?

Answer 32

``` Local haematoma Arterial vasospasm Arterial occlusion Air or thrombus embolism Local anaesthetic anaphylactic reaction Infection at puncture site Vessel laceration Needlestick injury to health care professional ```

Question 33

How do you take a blood transfusion specimen?

Answer 33

2 G+S pink vials | Label at the bedside handwritten

Question 34

How do you monitor a blood transfusion?

Answer 34

Assess baseline observations Monitor Pt vital signs Document everything Halt transfusion immediately if adverse reaction occurs

Question 35

A 21 yo M is brought in to A&E by his friends because he is unresponsive. On examination you find miosis and a respiratory rate of 8 bpm. The patient is deeply unresponsive to pain. What is the most likely explanation for this presentation? ``` A. Aspirin overdose B. Anaphylactic shock C. Opiate overdose D. Paracetamol overdose E. The patient is sleeping ```

Answer 35

C. Opiate overdose

Question 36

A 40 yo M is brought in to A&E by his friends because he is unresponsive. His friends tell you that he has just had a seizure before coming to A&E. They reluctantly tell you that he is now abstinent from alcohol for 1 week. What is the best immediate management for this patient? ``` A. IV Lorazepam B. Send to ITU C. Watch and wait D. Start 0.9% saline infusion E. Give oxygen 100% ```

Answer 36

A. IV Lorazepam

Question 37

A 50 yo M known alcoholic presents to A&E with restlessness and tremors. He is anxious, pacing in the hallway. His observations show a HR of 121 bpm, BP of 169/104 mmHg. On further questioning he states he is nauseous and you can see he is visibly shaking. He says his symptoms started to develop 5 hours after his last drink. What is the best management for this patient? ``` A. Admit and give IV Lorazepam B. Send him home with some information on contacting local alcohol support service C. Admit and give oral Lorazepam D. Send him home with no treatment E. Watch and wait ```

Answer 37

C. Admit and give oral Lorazepam

Question 38

What is the definition of acute aspirin overdose? A. Single dose equivalent of >150mg/kg or >6.5 g B. Single dose equivalent of >100mg/kg or >4.5 g C. Repeated exposure to high dose aspirin or equivalent D. Taking more than a box of Boots aspirin in one sitting

Answer 38

A. Single dose equivalent of >150mg/kg or >6.5 g

Question 39

What are the first signs of paracetamol overdose? ``` A. Nausea and vomiting B. Stomach cramps C. RUQ pain D. Asymptomatic E. Hallucinations ```

Answer 39

D. Asymptomatic

Question 40

What is the daily maximum recommended dose of paracetamol? ``` A. 1000 mg B. 1500mg C. 4g D. 5g E. 10g ```

Answer 40

C. 4g