Theme:Breathing

Theme:Breathing

AIntubationBIV coamoxiclavCIV penicillinDMask ventilationEOral erythromycinFOropharyngeal airwayGOral penicillin VHOxygen via facemaskIOxygen via headboxFor each scenario choose the most appropriate mode of immediate management:

A 3 month old boy presents with a 3d history of coryza, cough and progressive difficulty in feeding. Respiratory rate is 60/min with moderate recession, wheeze and crackles. Heart rate is 150/min, good peripheral perfusion. Oxygen saturation is 88% on air.

Correct

The 3 month old child has bronchiolitis, is hypoxic and requires oxygen. This is best provided by headbox or nasal prongs.

A 6 week old boy presents with bilateral purulent conjunctivitis and difficulty in breathing. Respiratory rate is 50/min, mild recession. Heart rate is 120/min. Osygen saturation is 94% on air.

Correct

The 6 week old boy has chlamydia pneumonitis and conjunctivitis, is not hypoxic, and requires erythromycin.

A 3-year-old boy presents with fever and breathing difficulty. On examination he has a respiratory rate of 45/min, painful inspiration, and crackles at the right base. Oxygen saturations are 93% on air and temperature is 38.9oC.

Correct

The 3-year-old boy has bacterial pneumonia with focal consolidation, most likely pneumococcal. IV penicillin is the treatment of choice.

Theme:Blood gas analysis

AMetabolic acidosis - acute, normal oxygenationBMetabolic acidosis - acute with hypoxaemiaCMetabolic acidosis - compensated, normal oxygenationDMetabolic alkalosis - acute, normal oxygenationEMetabolic alkalosis - acute with hypoxaemiaFMetabolic alkalosis - compensated, normal oxygenationGNormal blood gasesHNormal ventilation with hypoxaemiaIRespiratory failure - acuteJRespiratory failure - compensated, normal oxygenationKRespiratory failure - compensated with hypoxaemiaFor each of the following blood gas results, select the most appropriate designation from the list of options. The line labelled Oxygen concentration represents the concentration of oxygen that each individual is inhaling; Normal values are: PaO2 kPa 12.0 - 14.7

PaO2 mmHg 90 - 110

PaCO2 kPa 4.5 - 6.0

PaCO2 mmHg 34 - 45

pH 7.36 - 7.44

H + molarity nmol/l 35 - 45

Bicarbonate mmol/l 24 30

pO2 10.0 kPa(80 mmHg); pCO2 5.8kPa (44mmHg); pH 7.24; H+ molarity 57nmol/l Bicarbonate 18mmol/l; Base Excess -7mmol/l; Oxygen concentration 40%

Correct

The low pH with low bicarbonate indicates a metabolic acidosis, and the low normal O2 on inspired [O2] indicates hypooxaemia. This may occur with poisoning and associated respiratory failure.

pO2 6.7kPa( 50mmHg); pCO2 10.1kPa (76mmHg); pH 7.38; H+ molarity 42nmol/l Bicarbonate 42.4mmol/l; Base Excess +14mmol/l; Oxygen concentration 21%

Correct

This is the typical feature of a corrected respiratory failure with hypoxaemia. The PaO2 is low, the PaCO2 is high, with raised bicarbonate indicating renal correction and a high base excess

pO2 14.3kPa( 108mmHg); pCO2 6.3kPa (48mmHg); pH 7.52; H+ molarity 30nmol/l Bicarbonate 39mmol/l; Base Excess +14mmol/l; Oxygen concentration 30%

Incorrect - The correct answer is Metabolic alkalosis - acute, normal oxygenation

Metabolic alkalosis, for example in a patient with severe vomiting, is characterised by a high pH, high bicarbonate and a raised base excess.

pO2 4.7kPa( 35mmHg); pCO2 12.7kPa (95mmHg); pH 7.12; H+ molarity 76nmol/l; Bicarbonate 29.5mmol/l; Base Excess -4mmol/l; Oxygen concentration 21%

Correct

There is a type 2 respiratory failure with Hypoxia, hypercapnia and acidosis with a normal bicarbonate, indicating an acute respiratory failure, for example in severe asthma or pneumonia. .

pO2 16.3 kPa( 122mmHg); pCO2 7.5 kPa (56mmHg); pH 7.26; H+ molarity 55nmol/l Bicarbonate 24.1mmol/l; Base Excess -2mmol/l; Oxygen concentration 75%

Correct

There is an acidosis with a normal bicarbonate, and hypercapnia, on high flow O2. This is the picture of acute respiratory failure often found in patients with chronic obstructive airways disease who have lost their hypoxic drive and have been given high concentrations of O2.

Theme:Trauma management

ACT Scan headBEndotracheal intubationCIntercostal drainDLaparotomyELarge bore IV Access and fluid resuscitationFLog roll and rectal examinationGNeedle CricothyroidotomyHNeedle decompressionIPressure dressingJThoracotomySelect the most appropriate management step from the list above for the following patients:

A 25-year-old male was brought into the A and E following a motorbike accident. He was found unconscious lying prone about 25 meters from the bike. He had been intubated at the site. His neck was protected with a collar. He was being mechanically ventilated with 100% oxygen in A and E. He had a thready pulse of 100/min, Blood pressure of 70/50, SaO2 of 90%. Trachea is central but air entry is decreased on the left side with a tympanic note on percussion.

Correct

A 20-year-old female horse rider was brought into A and E on a spinal board having fallen of her horse. She was complaining bitterly about being restrained on the spinal board because her back was hurting. On examination, she had a pulse of 120/min, blood pressure of 84/30 mmHg, normal chest examination. Abdominal examination showed a bruise and tenderness on her left hypochondrium and lumbar regions. She had a decreased sensation below her knees and she couldnt move her toes.

Incorrect - The correct answer is Large bore IV Access and fluid resuscitation

A 55-year-old male was admitted after having a high speed accident in his car. He was found with his head on the steering wheel. His airway was patent, neck protected with appropriate collar and IV access secured. His primary survey revealed severe facial injuries, Glasgow Coma Scale of 13/15 and probable pelvic and bilateral femoral fractures. During secondary survey, his respiration was noted to be laboured with gurgling sounds and GCS suddenly dropped to 6/15.

Incorrect - The correct answer is Endotracheal intubation

In situations of trauma, it will help to remember ABCDE. UNDER ALL CIRCUMSTANCES MANAGEMENT OF AIRWAY COMES BEFORE BREATHING; BREATHING BEFORE CIRCULATION; CIRCULATION BEFORE DYSFUNCTION/ DISABILITY. The answers to above scenarios are based on this principle.Clinically this young male in an RTA has a pneumothorax on the left side. The immediate treatment of this is needle thoracotomy/decompression buying time for a more definitive insertion of an intercostal drain. The female involved in a horse riding accident probably has a spinal injury and may also have a splenic haemorrhage but before proceeding further she needs venous access and fluid resuscitation. The 55-year-old male has developed an airway problem and so needs definitive airway management prior to urgent CT headscan.

Theme:Oxygen therapy

A24% oxygenB24% oxygen and antibioticsC24% oxygen and intravenous furosemideD24% oxygen and nebulised bronchodilatorsE24% oxygen, antibiotics and nebulised bronchodilatorsF24% oxygen, diamorphine and intravenous furosemideG60% oxygenH60% oxygen and antibioticsI60% oxygen and intravenous furosemideJ60% oxygen and nebulised bronchodilatorsK60% oxygen, antibiotics and nebulised bronchodilatorsL60% oxygen, diamorphine and intravenous furosemideFor each of the following clinical situations, select the most appropriate option for immediate management from the list above

An 18-year-old woman with a previous history of asthma develops acute dyspnoea following a row with her boyfriend. On examination she is tachypnoeic and distressed, with widespread wheezes.

Correct

This young woman has severe asthma and needs nebulisers and high concentration of oxygen.

A previously healthy 24-year-old man presents with acute dyspnoea, left sided and and cough productive of green sputum tinged with blood. On examination he is pyrexial and looks ill, with signs of consolidation at the left lung base but no wheezes.

Incorrect - The correct answer is 60% oxygen and antibiotics

This is a young man with a lobar pneumonia with systemic sepsis. He should receive high flow oxygen and intravenous antibiotics.

A 68-year-old smoker presents with acute shortness of breath, on a background of chronic productive cough. On examination he is centrally cyanosed and pyrexial, with widespread crackles and wheezes

Incorrect - The correct answer is 24% oxygen, antibiotics and nebulised bronchodilators

The history suggests chronic bronchitis with acute exacerbation and chronic CO2 retention should be suspected.. This man may have Type 2 respiratory failure with CO2 retention. High flow Oxygen may suppress his respiratory drive. Nebulisers and antibiotics should be standard given the pyrexia and chest signs.

A 55-year-old man develops sudden onset of right sided chest pain and dyspnoea in Terminal 2 of Manchester Airport on arrival from Hong Kong. On examination he is ill, cyanosed and apyrexial. There are no localising signs on chest examination

Correct

The history is suggestive of Pulmonary Embolism. The immediate management would be high flow O2. Heparin should be commenced whilst a definitive diagnosis is being sought. 5 The history of coronary artery disease, and presentation with pink frothy sputum, would suggest left ventricular failure and pulmonary oedema. Diamorphine, IV diuretic and high dose O2 is the immediate treatment. IV Nitrates (or sublingual GTN) are also an option.

A 57-year-old man is on the waiting list for coronary artery bypass grafting; he develops acute dyspnoea and cough with frothy pink sputum. On examination he is tachypnoeic and distressed, with profuse basal crackles but no wheeze.

Correct

Acute Asthma requires high dose O2 and bronchodilators, along with IV hydrocortisone.

Principle of oxygen therapy in respiratory failure... Theme:Complications of fractures

AAvascular necrosisBCompartment syndromeCFat emboliDGangreneEHaemorrhagic ShockFMal-unionGOsteoarthritisHOsteomyelitisIRhabdomyolysisJTetraparesisKVenous thromboembolismFrom the above list, select the most likely complication that accounts for each of the following cases:

A 26-year-old male receives lower leg injuries playing rugby. On examination, he has a pulse of 120 bpm, a blood pressure of 90/60 mmHg and he has a compound fracture of both tibias.

Correct

This case has features of shock with tachycardia and hypotension a consequence of large quantities of blood loss associated with the fracture.

A 24-year-old male sustains a forearm injury but fails to attend for medical attention until the following day when he presents with forearm pain, swelling and an inability to flex the wrist.

Incorrect - The correct answer is Compartment syndrome

The patient has developed a forearm compartment syndrome as a consequence of swelling and increased pressure of the muscles within the fascial compartment.

A 40-year-old male receives a compound fracture of his left tibia after falling from a ladder. He undergoes internal fixation. However, several months after discharge from hospital, the patient is aware of a breakdown of skin overlying the tibia and a persistent discharge.

Incorrect - The correct answer is Osteomyelitis

This case has a discharging sinus months after a compound fracture. This would suggest an underlying osteomyelitis.

A 33-year-old male injures his hand whilst playing rugby. He attends casualty but leaves after waiting 2 hours without obtaining medical advice. He represents three months later with pain at the base of the thumb and painful movements of the thumb.

Incorrect - The correct answer is Avascular necrosis

The patient has fractured his scaphoid and has developed avascular necrosis of the scaphoid.

A 55-year-old male is admitted after falling from his horse. Examination and investigations confirm a fractured pelvis. Hours later he becomes dyspnoeic, with a pulse of 120 beats per minute and a blood pressure of 100/70 mmHg and a fall in oxygen saturation to 86%. He is aware of small petechiae.

Correct

This case has developed dyspnoea hours after sustaining a pelvis fracture. This is too early for thromboembolism but, in the presence of the petechiae would suggest fat embolism.

Theme:Back pain

AAbdominal aortic aneurysmBAchalasia of the oesophagusCAcute prolapsed intervertebral discDAnkylosing spondylitisEChronic low back painFChronic pancreatitisGCostochondritisHDissection of thoracic aortaIMetastatic prostatic carcinomaJMultiple myelomaKMyelomeningocoeleLNeurofibromaMOsteomalaciaNOsteoporotic vertebral collapseOPaget s disease of bonePPleural effusionQPsoriatic arthropathyRStaghorn calculiSSyringomyeliaTTuberculosisUUric acid arthropathyThe following patients present to the casualty department with back pain. What is the most likely diagnosis from the list of options given above?

Normal values: serum corrected calcium 2.15 - 2.65mmol/l, creatinine