Volume 2, Issue 2, Pages 39 – 74 (2003)

MCQ Questions Vol 2 No. 2

Regular features, Volume 2, Issue 2, Pages 39 - 74 (2003)

· The following must be assessed in all patients attending hospital with suspected asthma exacerbations:
1. PEF.
2. Pulse & Respiration rate.
3. Clinical history & Speech.
4. Chest X ray.
5. Arterial Blood Gases.

· The following characteristics may identify a patient at risk of fatal or near fatal asthma:
6. Hospital admission within the last year.
7. Repeated A&E attendances.
8. Non compliance with treatment .
9. History of self discharge from hospital.
10. Requirement for 3 or more classes of asthma medication.

· The following treatments are of established value in the management of acute asthma:
11. Antibiotics.
12. Anticholinergic bronchodilators.
13. Intravenous aminophylline.
14. Intravenous Magnesium.
15. Heliox.
16. NIV.

· The Folling indicate a severe asthma excerbation:
17. PEF < 33%. 18. PaO2 < 8 kPa. 19. Normal PaCO2. 20. Respirations > 25 / min.
21. Pulse > 110/min.

· The following features excludes a severe or life threatening asthma exacerbation:
22. Normal pCO2.
23. PEF > 75%.
24. Pulse < 110/min. 25. Resps < 25/min. 26. Able to talk in full sentences. (A F A Merrison & N J Scolding) · Steroid treament should be given to patients with MS: 27. at the time of all relapses. 28. at the time of relapses and disease progression. 29. as soon as possible for significantly disabling relapses. · If steroids are given they should be given orally: 30. following intravenous steroid therapy. 31. if intravenous therapy is impracticable. 32. for disease progression. · Beta-interferon treatment is available for patients with MS who: 33. have two or more relapses in two years and are able to walk 100 metres unaided. 34. with secondary progressive disease. 35. following a single episode of optic neuritis. · Bladder problems in MS are best managed by: 36. Permanent catherisation. 37. Anticholinergics for detrusor instability. 38. Intermittent self catherisation if high residual volume. · When managing spasticity, it is worth considering the following points: 39. Baclofen may induce muscle weakness. 40. Neutropaenia is a common problem with tizanidine. 41. Selective injection of botulinum toxin may be helpful. (S I Kharkoo & W MC Rosenberg) · In the setting of an acute variceal haemorrhage: 42. An INR of 1.8 is associated with a high mortality. 43. Individuals with non-cirrhotic portal hypertension have a better prognosis than those with cirrhotic portal hypertension. 44. Grade I hepatic encephalopathy is an indication for endotracheal intubation and ventilation. 45. Therapeutic endoscopy achieves haemostasis in >90% of cases.
46. Isolated gastric varices respond better to endoscopic therapy than oesophageal varices.

· The sengstaken-Blakemore tube:
47. Has a serious complication rate of up to 35%.
48. Can be passed unaided by a single operator.
49. The oesophageal aspirate port should be spigoted.
50. The oesophageal balloon should be inf lated with 300mls of air.
51. Should be left inf lated and on traction for no more than 24 hours.

· With reference to drugs used in the management of a variceal haemorrhage
52. The main objective of pharmacotherapy is splanchnic vasodilatation.
53. Octreotide is preferable to terlipressin.
54. Antibiotics are of no value.
55. Vasopressin should be used in combination with nitrates.
56. Because of the danger of anaesthetic agents in liver disease there is a high threshold for elective endotracheal intubation and ventilation.

MCQ Questions Vol 2 No. 2 Read More

Thoughts from the darkroom…

Original Articles, Volume 2, Issue 2, Pages 39 - 74 (2003)

One of the commonest requests for out of hours imaging is for cranial CT in patients with possible meningitis. Telephone conversations like this may be familiar: "Hello I’m the medical SHO on call….I’d like to request a CT brain please…to rule out raised intracranial pressure before lumbar puncture…no we couldn’t get a good look at his fundi….they didn’t have any tropicamide in A and E…well, perhaps you’d like to do the LP if you don’t think a CT is necessary…" This type of request in fact may or may not be justified depending on the clinical scenario. The perception of radiologists is that few patients with possible meningitis require head CT before lumbar puncture; the perception of physicians is that the majority do. Pole-positions like this invariably generate conflict between our specialities. Can we use the available literature to guide us to a more evidence-based approach which both groups will find acceptable ?

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Milk-Alkali Syndrome: An Unusual Cause of Acute Renal Failure

A Case to Remember, Volume 2, Issue 2, Pages 39 - 74 (2003)

Milk–alkali syndrome is described as a triad of hypercalcaemia, metabolic alkalosis and renal impairment, resulting from the ingestion of calcium and absorbable alkali1. It was more common in the early part of the century when antacids were used for the symptomatic treatment of peptic ulcer disease. The use of antacids has since been overtaken by H2- receptor antagonists and proton pump inhibitors. More recently, there have been various case reports of milk-alkali syndrome due to the increasing use of calcium carbonate as part of the management of osteoporosis and chronic renal failure, and also the increasing availability of calcium carbonate ‘over the counter’. We describe a case of milk-alkali syndrome due to self-medication with calcium carbonate.

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Emergency Management of Variceal

Clinical Reviews, Volume 2, Issue 2, Pages 39 - 74 (2003)

Abstract

Variceal haemorrhage is a life-threatening condition requiring prompt emergency therapy. This paper summarises the key aspects of management of this condition in the acute setting, including airway management, fluid resuscitation, and pharmacotherapy. The value of therapeutic endoscopy, balloon tamponade and radiological shunt procedures are also highlighted.

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Acute management of multiple sclerosis

Clinical Reviews, Volume 2, Issue 2, Pages 39 - 74 (2003)

Abstract

Multiple sclerosis is one of the commonest causes of disability in young adults. This review highlights some of the acute presentations of this condition, and how these may be managed in the emergency setting. The role of corticosteroids is discussed, along with the value of other drugs in symptom control during an acute relapse.

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Acute Coronary Syndromes i

Clinical Reviews, Volume 2, Issue 2, Pages 39 - 74 (2003)

Abstract

The acute coronary syndromes form a clinical spectrum, which ranges from unstable angina without myocardial injury, non-ST segment elevation and ST segment elevation myocardial infarction. All three conditions share a common pathophysiological basis. The management of acute ST segment elevation myocardial infarction however, is distinct from the other syndromes and therefore forms the basis of another article in this series. In this article we concentrate on the recognition and management of unstable angina and Non ST-segment elevation myocardial infarction (NSTEMI).

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Acute exacerbation of asthma in adults

Clinical Reviews, Volume 2, Issue 2, Pages 39 - 74 (2003)

Abstract

Acute asthma remains an important cause of morbidity adults. The recognition, assessment and appropriate management of acute asthma are essential to avoid unnecessary morbidity and also mortality, which unfortunately still occurs. This article will present an overview of the hospital management of acute asthma exacerbations in adults. The British Thoracic Society(BTS) conjunction with the Scottish Intercollegiate Guidelines Network(SIGN) published the latest British Guidelines on all aspects of asthma management in February of this year .1 This article is a précis of these latest British guidelines as they relate to acute asthma in adults.

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Editorial

Editorials, Volume 2, Issue 2, Pages 39 - 74 (2003)

By the time this is published, summer will be over, “Big Brother” will have evicted its final contestant and, no doubt, many of us will still be waiting for the elusive “lull” in emergency pressures. In practice, most acute medical emergencies occur year-round, and even acute asthma appears to be no exception. Whether it is the high pollen count, atmospheric pollution or ozone, our A&E has been literally ‘buzzing’ with nebulisers throughout recent months. Crighton Ramsay’s review of the ward m a n a gement of this condition is a timely sequel to the intensivist’s perspective published last year. This comprehensive paper includes a useful algorithm, based on the current British Thoracic Society guidelines, as well as an excellent pre-discharge checklist, which I can highly recommend. Chest pain remains at number one in our medical admissions countdown from year to year. The National Service Framework for coronary heart disease emphasised the importance of shortening “pain-to-needle” time for patients requiring thrombolysis, but it is the non-ST elevation patients who make up the majority of the workload. Raybould and Groves’ review summarises the management of the group of these who are determined to have acute coronary syndromes, emphasising the importance of risk stratification for these patients. Merrison and Scolding remind us that multiple sclerosis is a disease of affluent (and no doubt internet-browsing) societies. Armed with their excellent review of its emergency management you should stand a chance of knowing as much as the patient next time he or she presents on your acute medical intake. A shortage of suitable submissions means no “how-to-do-it” section, this time. However, Khakoo and Rosenburg have included a useful guide to Sengstaken tube insertion in their review of management of variceal haemorhage. Our “regular features” section includes a case of an important, but frequently forgotten cause of renal failure, while Andrew Crean presents some more of his controversial “thoughts from the dark room”. Once again, submissions along these lines, as well as original research or audits would be most welcome. I hope you find this edition continues to meet your personal CPD requirement for the coming few months.

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