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Question 1
Correct
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A 2-month-old baby is brought in by his mother with a reported high temperature at home. The triage nurse measures his temperature again as part of her initial assessment.
Which of the following is recommended by NICE as an appropriate method of measuring body temperature in this age group?Your Answer: Electronic thermometer in the axilla
Explanation:In infants who are less than 4 weeks old, it is recommended to measure their body temperature using an electronic thermometer placed in the armpit.
For children between the ages of 4 weeks and 5 years, there are several methods that can be used to measure body temperature. These include using an electronic thermometer in the armpit, a chemical dot thermometer in the armpit, or an infra-red tympanic thermometer.
It is important to note that measuring temperature orally or rectally should be avoided in this age group. Additionally, forehead chemical thermometers are not reliable and should not be used.
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This question is part of the following fields:
- Infectious Diseases
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Question 2
Correct
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There are numerous casualties reported after a suspected CBRN (chemical, biological, radiological and nuclear) incident, with indications pointing towards sarin gas as the responsible agent. In the management of this situation, certain casualties are administered atropine as an antidote.
What is the mode of action of atropine?Your Answer: Muscarinic acetylcholine receptor antagonist
Explanation:The primary approach to managing nerve gas exposure through medication involves the repeated administration of antidotes. The two antidotes utilized for this purpose are atropine and pralidoxime.
Atropine is the standard anticholinergic medication employed to address the symptoms associated with nerve agent poisoning. It functions as an antagonist for muscarinic acetylcholine receptors, effectively blocking the effects caused by excessive acetylcholine. Initially, a 1.2 mg intravenous bolus of atropine is administered. This dosage is then repeated and doubled every 2-3 minutes until excessive bronchial secretion ceases and miosis (excessive constriction of the pupil) resolves. In some cases, as much as 100 mg of atropine may be necessary.
Pralidoxime (2-PAMCl) is the standard oxime used in the treatment of nerve agent poisoning. Its mechanism of action involves reactivating acetylcholinesterase by scavenging the phosphoryl group attached to the functional hydroxyl group of the enzyme, thereby counteracting the effects of the nerve agent itself. For patients who are moderately or severely poisoned, pralidoxime should be administered intravenously at a dosage of 30 mg/kg of body weight (or 2 g in the case of an adult) over a period of four minutes.
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This question is part of the following fields:
- Major Incident Management & PHEM
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Question 3
Incorrect
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A 70-year-old woman presents with a 4-day history of feeling generally unwell and having experienced fevers at home. She has a history of breast cancer for which she is currently undergoing radiation therapy. Her vital signs are as follows: HR 100 bpm, BP 120/80, SaO2 95% on room air, temperature 38.5°C.
The results of her complete blood count are as follows:
Hemoglobin (Hb) 9.2 g/dl
Mean Corpuscular Volume (MCV) 80 fl
Platelets 60 x 109/l
White Cell Count (WCC) 1.2 x 109/l
Lymphocytes 0.4 x 109/l
Neutrophils 0.6 x 109/l
Monocytes 0.1 x 109/l
Which of the following antibiotics would be most appropriate for the initial empiric treatment of this patient?Your Answer: Tazocin and gentamicin
Correct Answer: Tazocin alone
Explanation:The patient is showing signs of pancytopenia along with a fever, indicating a likely case of neutropenic sepsis. Their blood test results reveal microcytic anemia, leucopenia (with significant neutropenia), and thrombocytopenia. Neutropenic sepsis is a serious condition that can be life-threatening, characterized by a low neutrophil count. There are several potential causes of neutropenia, including cytotoxic chemotherapy, immunosuppressive drugs, stem cell transplantation, infections, bone marrow disorders like aplastic anemia and myelodysplastic syndromes, and nutritional deficiencies.
To diagnose neutropenic sepsis in patients undergoing anticancer treatment, their neutrophil count should be 0.5 x 109 per liter or lower, and they should have either a temperature above 38°C or other signs and symptoms indicative of clinically significant sepsis. According to the current NICE guidelines, initial empiric antibiotic therapy for suspected neutropenic sepsis should involve monotherapy with piperacillin with tazobactam (Tazocin 4.5 g IV). It is not recommended to use an aminoglycoside, either alone or in combination therapy, unless there are specific patient-related or local microbiological reasons to do so.
Reference:
NICE guidance: ‘Neutropenic sepsis: prevention and management of neutropenic sepsis in cancer patients’ -
This question is part of the following fields:
- Oncological Emergencies
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Question 4
Incorrect
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A 42-year-old woman with a lengthy history of depression arrives at the Emergency Department after intentionally overdosing on the medication she takes for her heart condition. She informs you that she consumed verapamil immediate-release 240 mg tablets approximately 30 minutes ago. However, her spouse promptly discovered her and brought her to the hospital. Currently, she shows no signs of symptoms. Typically, how much time passes before symptoms manifest in cases of this overdose?
Your Answer: 15-30 minutes
Correct Answer: 1-2 hours
Explanation:Calcium-channel blocker overdose is a serious condition that should always be taken seriously as it can be potentially life-threatening. The two most dangerous types of calcium channel blockers in overdose are verapamil and diltiazem. These medications work by binding to the alpha-1 subunit of L-type calcium channels, which prevents the entry of calcium into the cells. These channels play a crucial role in the functioning of cardiac myocytes, vascular smooth muscle cells, and islet beta-cells.
Significant toxicity can occur with the ingestion of more than 10 tablets of verapamil (160 mg or 240 mg immediate or sustained-release capsules) or diltiazem (180 mg, 240 mg or 360 mg immediate or sustained-release capsules). In children, even 1-2 tablets of immediate or sustained-release verapamil or diltiazem can be harmful. Symptoms usually appear within 1-2 hours of taking standard preparations, but with slow-release versions, the onset of severe toxicity may be delayed by 12-16 hours, with peak effects occurring after 24 hours.
The main clinical manifestations of calcium-channel blocker overdose include nausea and vomiting, low blood pressure, slow heart rate and first-degree heart block, heart muscle ischemia and stroke, kidney failure, pulmonary edema, and high blood sugar levels.
When managing a patient with calcium-channel blocker overdose, certain bedside investigations are crucial. These include checking blood glucose levels, performing an electrocardiogram (ECG), and obtaining an arterial blood gas sample. Additional investigations that can provide helpful information include assessing urea and electrolyte levels, conducting a chest X-ray to check for pulmonary edema, and performing an echocardiography.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 5
Incorrect
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A middle-aged man presents with visual difficulties. Upon examination, it is discovered that he has a quadrantic visual field defect. He is subsequently taken to the hospital for a CT head scan, which confirms a diagnosis of a cerebrovascular accident.
Which of the following blood vessels is most likely to be impacted?Your Answer: Middle cerebral artery
Correct Answer: Posterior cerebral artery
Explanation:The symptoms and signs of strokes can vary depending on which blood vessel is affected. Here is a summary of the main symptoms based on the territory affected:
Anterior cerebral artery: This can cause weakness on the opposite side of the body, with the leg and shoulder being more affected than the arm, hand, and face. There may also be minimal loss of sensation on the opposite side of the body. Other symptoms can include difficulty speaking (dysarthria), language problems (aphasia), apraxia (difficulty with limb movements), urinary incontinence, and changes in behavior and personality.
Middle cerebral artery: This can lead to weakness on the opposite side of the body, with the face and arm being more affected than the leg. There may also be a loss of sensation on the opposite side of the body. Depending on the dominant hemisphere of the brain, there may be difficulties with expressive or receptive language (dysphasia). In the non-dominant hemisphere, there may be neglect of the opposite side of the body.
Posterior cerebral artery: This can cause a loss of vision on the opposite side of both eyes (homonymous hemianopia). There may also be defects in a specific quadrant of the visual field. In some cases, there may be a syndrome affecting the thalamus on the opposite side of the body.
It’s important to note that these are just general summaries and individual cases may vary. If you suspect a stroke, it’s crucial to seek immediate medical attention.
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This question is part of the following fields:
- Neurology
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Question 6
Correct
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You are summoned to a cardiac arrest in the resuscitation area of your Emergency Department. The patient is experiencing asystole, and adrenaline is given as part of the cardiac arrest protocol.
Which ONE statement is NOT TRUE regarding the utilization of adrenaline in cardiac arrest?Your Answer: In VF arrest it should be given before the 3rd shock
Explanation:Adrenaline should be administered promptly once access to the circulatory system has been established in cases of non-shockable cardiac arrests such as PEA or asystole. The recommended dose is 1 mg, which can be given either as 10 mL of a 1:10,000 solution or as 1 mL of a 1:1000 solution through the intravenous (IV) or intraosseous (IO) routes.
In cases of shockable cardiac arrests like ventricular fibrillation (Vf) or pulseless ventricular tachycardia (pVT), adrenaline should be administered after the third shock has been delivered and chest compressions have been resumed. The same dose of 1 mg can be given using the same concentration options as mentioned earlier.
Subsequently, adrenaline should be administered every 3-5 minutes, alternating with chest compressions, without interrupting the compressions. The alpha-adrenergic effects of adrenaline cause constriction of blood vessels throughout the body, leading to increased pressures in the coronary and cerebral circulation.
The beta-adrenergic effects of adrenaline have positive effects on the heart, increasing its contractility (inotropic) and heart rate (chronotropic), which may also enhance blood flow to the coronary and cerebral arteries. However, it is important to note that these benefits may be counteracted by increased oxygen consumption by the heart, the potential for abnormal heart rhythms, temporary decrease in oxygen levels due to abnormal blood flow in the lungs, impaired microcirculation, and increased dysfunction of the heart after the cardiac arrest.
While there is no evidence supporting the long-term benefits of adrenaline use in cardiac arrest cases, some studies have shown improved short-term survival rates, which justifies its continued use.
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This question is part of the following fields:
- Cardiology
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Question 7
Correct
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You evaluate a 60-year-old man with a previous diagnosis of hearing impairment.
Which tuning fork should be utilized to conduct a Rinne's test on this individual?Your Answer: 512 Hz
Explanation:A 512 Hz tuning fork is commonly used for both the Rinne’s and Weber’s tests. However, a lower-pitched fork, such as a 128 Hz tuning fork, is typically used to assess vibration sense during a peripheral nervous system examination. Although a 256 Hz tuning fork can be used for either test, it is considered less reliable for both.
To perform a Rinne’s test, the 512 Hz tuning fork is first made to vibrate and then placed on the mastoid process until the sound is no longer heard. The top of the tuning fork is then positioned 2 cm away from the external auditory meatus, and the patient is asked to indicate where they hear the sound loudest.
In individuals with normal hearing, the tuning fork should still be audible outside the external auditory canal even after it is no longer appreciated on the mastoid. This is because air conduction should be greater than bone conduction.
In cases of conductive hearing loss, the patient will no longer hear the tuning fork once it is no longer appreciated on the mastoid. This suggests that their bone conduction is greater than their air conduction, indicating an obstruction in the passage of sound waves through the ear canal into the cochlea. This is considered a true negative result.
However, a Rinne’s test may yield a false negative result if the patient has a severe unilateral sensorineural deficit and senses the sound in the unaffected ear through the transmission of sound waves through the base of the skull.
In sensorineural hearing loss, the ability to perceive the tuning fork on both the mastoid and outside the external auditory canal is equally diminished compared to the opposite ear. Although the sound will still be heard outside the external auditory canal, it will disappear earlier on the mastoid process and outside the external auditory canal compared to the other ear.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 8
Correct
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A 40-year-old woman is prescribed haloperidol for a psychiatric condition in the 2nd-trimester of her pregnancy. As a result of this treatment, the newborn develops a malformation.
Which of the following malformations is the most likely to occur as a result of using this medication during pregnancy?Your Answer: Extrapyramidal syndrome
Explanation:Haloperidol, when administered during the third trimester of pregnancy, can lead to extrapyramidal symptoms in the newborn. These symptoms may include agitation, poor feeding, excessive sleepiness, and difficulty breathing. The severity of these side effects can vary, with some infants requiring intensive care and extended hospital stays. It is important to closely monitor exposed neonates for signs of extrapyramidal syndrome or withdrawal. Haloperidol should only be used during pregnancy if the benefits clearly outweigh the risks to the fetus.
Below is a list outlining commonly encountered drugs that have adverse effects during pregnancy:
ACE inhibitors (e.g. ramipril): If given during the second and third trimesters, these drugs can cause hypoperfusion, renal failure, and the oligohydramnios sequence.
Aminoglycosides (e.g. gentamicin): These drugs can cause ototoxicity and deafness in the fetus.
Aspirin: High doses of aspirin can lead to first-trimester abortions, delayed onset of labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g. 75 mg) do not pose significant risks.
Benzodiazepines (e.g. diazepam): When administered late in pregnancy, these drugs can cause respiratory depression and a neonatal withdrawal syndrome.
Calcium-channel blockers: If given during the first trimester, these drugs can cause phalangeal abnormalities. If given during the second and third trimesters, they can result in fetal growth retardation.
Carbamazepine: This drug can lead to hemorrhagic disease of the newborn and neural tube defects.
Chloramphenicol: Administration of chloramphenicol can cause gray baby syndrome in newborns.
Corticosteroids: If given during the first trimester, corticosteroids may cause orofacial clefts in the fetus.
Danazol: When administered during the first trimester, danazol can cause masculinization of the female fetuses genitals.
Finasteride: Pregnant women should avoid handling finasteride as crushed or broken tablets can be absorbed through the skin and affect male sex organ development.
Haloperidol: If given during the first trimester, haloperidol may cause limb malformations. If given during the third trimester, there is an increased risk of extrapyramidal symptoms in the neonate.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 9
Incorrect
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You witness the sudden arrival of a baby in one of the rooms in the Emergency Department. Your supervisor evaluates the newborn one minute after birth and informs you that:
The entire body appears pale
The heart rate is 90 beats per minute
The baby reacts with a grimace when suctioned
There is some bending of the limbs
The cry is feeble, and the baby is gasping for breath
What is the Apgar score of the newborn at one minute?Your Answer: 5
Correct Answer: 4
Explanation:The Apgar score is a straightforward way to evaluate the well-being of a newborn baby right after birth. It consists of five criteria, each assigned a score ranging from zero to two. Typically, the assessment is conducted at one and five minutes after delivery, with the possibility of repeating it later if the score remains low. A score of 7 or higher is considered normal, while a score of 4-6 is considered fairly low, and a score of 3 or below is regarded as critically low. To remember the five criteria, you can use the acronym APGAR:
Appearance
Pulse rate
Grimace
Activity
Respiratory effortThe Apgar score criteria are as follows:
Score of 0:
Appearance (skin color): Blue or pale all over
Pulse rate: Absent
Reflex irritability (grimace): No response to stimulation
Activity: None
Respiratory effort: AbsentScore of 1:
Appearance (skin color): Blue at extremities (acrocyanosis)
Pulse rate: Less than 100 per minute
Reflex irritability (grimace): Grimace on suction or aggressive stimulation
Activity: Some flexion
Respiratory effort: Weak, irregular, gaspingScore of 2:
Appearance (skin color): No cyanosis, body and extremities pink
Pulse rate: More than 100 per minute
Reflex irritability (grimace): Cry on stimulation
Activity: Flexed arms and legs that resist extension
Respiratory effort: Strong, robust cry -
This question is part of the following fields:
- Neonatal Emergencies
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Question 10
Correct
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A 65 year old female is brought to the emergency department as her husband is concerned about increasing confusion and unsteadiness. The patient's husband tells you over the past two to three months the patient doesn't seem to be able to remember anything, often appearing confused, and unable to concentrate on things such as books or conversations. The patient has also been urinating more frequently and has had a few accidents where she has wet herself. The patient's husband has also noticed she walks differently, taking slow short steps as if she has lost her confidence. The patient tells you she feels fine. There is no significant medical history. On examination you note the patient has a broad based stance with delay in initiating movement and a shuffling gait where the patient freezes after 3 or 4 steps. What is the most likely diagnosis?
Your Answer: Normal pressure hydrocephalus
Explanation:Normal pressure hydrocephalus is a condition characterized by the classic triad of symptoms: gait instability, urinary incontinence, and dementia. Gait apraxia, which is a common feature, presents as a slow and cautious gait, difficulty initiating movement, unsteadiness, a widened standing base, reduced stride length, shuffling gait, falls, and freezing. The onset of symptoms typically occurs over a period of 3-6 months. This condition is a form of communicating hydrocephalus, where there is a gradual buildup of cerebrospinal fluid (CSF) due to impaired CSF absorption. As a result, the ventricles in the brain enlarge and intracranial pressure increases, leading to compression of brain tissue and neurological complications. Normal pressure hydrocephalus is more commonly seen in individuals over the age of 65, and a CT head or MRI is usually the initial diagnostic test.
Further Reading:
Dementia is a progressive and irreversible clinical syndrome characterized by cognitive and behavioral symptoms. These symptoms include memory loss, impaired reasoning and communication, personality changes, and reduced ability to carry out daily activities. The decline in cognition affects multiple domains of intellectual functioning and is not solely due to normal aging.
To diagnose dementia, a person must have impairment in at least two cognitive domains that significantly impact their daily activities. This impairment cannot be explained by delirium or other major psychiatric disorders. Early-onset dementia refers to dementia that develops before the age of 65.
The most common cause of dementia is Alzheimer’s disease, accounting for 50-75% of cases. Other causes include vascular dementia, dementia with Lewy bodies, and frontotemporal dementia. Less common causes include Parkinson’s disease dementia, Huntington’s disease, prion disease, and metabolic and endocrine disorders.
There are several risk factors for dementia, including age, mild cognitive impairment, genetic predisposition, excess alcohol intake, head injury, depression, learning difficulties, diabetes, obesity, hypertension, smoking, Parkinson’s disease, low social engagement, low physical activity, low educational attainment, hearing impairment, and air pollution.
Assessment of dementia involves taking a history from the patient and ideally a family member or close friend. The person’s current level of cognition and functional capabilities should be compared to their baseline level. Physical examination, blood tests, and cognitive assessment tools can also aid in the diagnosis.
Differential diagnosis for dementia includes normal age-related memory changes, mild cognitive impairment, depression, delirium, vitamin deficiencies, hypothyroidism, adverse drug effects, normal pressure hydrocephalus, and sensory deficits.
Management of dementia involves a multi-disciplinary approach that includes non-pharmacological and pharmacological measures. Non-pharmacological interventions may include driving assessment, modifiable risk factor management, and non-pharmacological therapies to promote cognition and independence. Drug treatments for dementia should be initiated by specialists and may include acetylcholinesterase inhibitors, memantine, and antipsychotics in certain cases.
In summary, dementia is a progressive and irreversible syndrome characterized by cognitive and behavioral symptoms. It has various causes and risk factors, and its management involves a multi-disciplinary approach.
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This question is part of the following fields:
- Neurology
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Question 11
Correct
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A 60-year-old patient arrives at the Emergency Department with a deep cut on their leg. They have a history of alcoholism and typically consumes 10-12 drinks daily. Despite previous attempts at sobriety, they have consistently relapsed within a few days. It is currently 11 am, and they have already consumed alcohol today.
What would be the most suitable course of action to pursue?Your Answer: Explore the reasons behind their previous relapses and the methods they have used to stop drinking in the past
Explanation:When addressing the management of long-term alcohol abuse and promoting self-care, it is important to start by exploring the reasons behind the patient’s previous relapses. This will help understand her beliefs and understanding of her condition and identify any simple, supportive measures that can aid in her efforts to stop drinking.
Referral to the Community Drug and Alcohol Team (CDAT) may be necessary at some point. Depending on the severity and duration of her alcohol abuse, she may be suitable for outpatient or community detox. However, if her drinking has been sustained and heavy for many years, she may require admission for additional support. It is important to note that there is often a long wait for available beds, so it would be more prudent to thoroughly explore her history before making this referral.
While arranging for her liver function to be tested could be part of the general work-up, it is unlikely to be necessary for a leg laceration. It is crucial to avoid suddenly abstaining or prescribing chlordiazepoxide, as these actions can be potentially dangerous. Abrupt detoxification may lead to delirium tremens, which can have catastrophic effects. Chlordiazepoxide may be used under the supervision of experienced professionals, but close monitoring and regular appointments with a GP or specialist are essential.
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This question is part of the following fields:
- Mental Health
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Question 12
Correct
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A 45-year-old man comes in with a dry cough that has been going on for a week. He also complains of muscle aches, fatigue, and a sore throat. In the past day, he has developed diarrhea and a mild throbbing headache. During the examination, his temperature is measured at 37.8°C, and faint crackles are heard at the base of his lungs.
What is the SINGLE most probable organism responsible for these symptoms?Your Answer: Mycoplasma pneumoniae
Explanation:This patient is displaying symptoms and signs that are consistent with an atypical pneumonia, most likely caused by an infection from Mycoplasma pneumoniae. The clinical features commonly associated with Mycoplasma pneumoniae infection include a flu-like illness that occurs before respiratory symptoms, fever, myalgia, headache, diarrhea, and cough (initially dry but often becoming productive). Focal chest signs typically develop later in the course of the illness. It is worth noting that Mycoplasma pneumoniae is frequently linked to the development of erythema multiforme and can also be a cause of Steven-Johnson syndrome. The rash associated with erythema multiforme is characterized by multiple red lesions on the limbs that develop into target lesions a few days after the rash first appears.
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This question is part of the following fields:
- Respiratory
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Question 13
Incorrect
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A 52-year-old woman comes in with a persistent sore throat that has lasted for five days. She has also been dealing with cold symptoms for the past few days and has a bothersome dry cough. She denies having a fever and her temperature is normal today. During the examination, there are no noticeable swollen lymph nodes in her neck and her throat appears red overall, but her tonsils are not enlarged and there is no visible discharge.
What is her FeverPAIN score?Your Answer: 1
Correct Answer: 0
Explanation:The FeverPAIN score is a scoring system that is recommended by the current NICE guidelines for assessing acute sore throats. It consists of five items: fever in the last 24 hours, purulence, attendance within three days, inflamed tonsils, and no cough or coryza. Based on the score, different recommendations are given regarding the use of antibiotics.
If the score is 0-1, it is unlikely to be a streptococcal infection, with only a 13-18% chance of streptococcus isolation. Therefore, antibiotics are not recommended in this case. If the score is 2-3, there is a higher chance (34-40%) of streptococcus isolation, so delayed prescribing of antibiotics is considered, with a 3-day ‘back-up prescription’. If the score is 4 or higher, there is a 62-65% chance of streptococcus isolation, and immediate antibiotic use is recommended if the infection is severe. Otherwise, a 48-hour short back-up prescription is suggested.
The Fever PAIN score was developed from a study that included 1760 adults and children aged three and over. It was then tested in a trial that compared three different prescribing strategies: empirical delayed prescribing, using the score to guide prescribing, and combining the score with the use of a near-patient test (NPT) for streptococcus. The use of the score resulted in faster symptom resolution and a reduction in antibiotic prescribing, both by one third. However, the addition of the NPT did not provide any additional benefit.
Overall, the FeverPAIN score is a useful tool for assessing acute sore throats and guiding antibiotic prescribing decisions. It has been shown to be effective in reducing unnecessary antibiotic use and improving patient outcomes.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 14
Correct
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A 42-year-old woman presents with a painful swollen left big toe. The pain began this morning and is described as the most severe pain she has ever felt. It has progressively worsened over the past 8 hours. She is unable to wear socks or shoes and had to come to the appointment in open-toed sandals. The skin over the affected area appears red and shiny.
What is the MOST likely diagnosis?Your Answer: Gout
Explanation:The guidelines from the European League Against Rheumatism (EULAR) regarding the diagnosis of gout state that if a joint becomes swollen, tender, and red, and if acute pain develops in that joint over a period of 6-12 hours, it is highly likely to be a crystal arthropathy. Pseudogout is also a possibility, but it is much less likely. In this case, gout is the most probable diagnosis.
The joint that is most commonly affected in acute gout is the first metatarsal-phalangeal joint, which accounts for 50-75% of cases.
The main cause of gout is hyperuricaemia, and the clinical diagnosis can be confirmed by the presence of negatively birefringent crystals in the synovial fluid aspirate.
For the treatment of acute gout attacks, NSAIDs or colchicine are generally used.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 15
Correct
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A 32-year-old woman with a previous history of salpingitis presents with excessive vaginal bleeding. Her pregnancy test is positive, and a preliminary diagnosis of an ectopic pregnancy is made.
What is the most frequent anatomical site for an ectopic pregnancy to occur?Your Answer: Ampulla of Fallopian tube
Explanation:An ectopic pregnancy happens when the fertilized egg attaches itself outside of the uterus. In over 95% of cases, ectopic pregnancies occur in the Fallopian tubes. Although rare, they can also occur in other locations such as the abdomen, cervix, and ovary.
The most common location for an ectopic pregnancy in the Fallopian tube is the ampulla, accounting for approximately 70% of cases. The isthmus and infundibulum each account for 10-15% of cases, while the uterine part only accounts for 2-5%.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 16
Correct
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A 62 year old male is brought into the emergency department by concerned bystanders who witnessed the patient vomit blood outside a local bar. The patient is familiar to the department due to multiple alcohol-related visits in the past and has a previous diagnosis of alcohol-related liver cirrhosis. The patient experiences another episode of large volume bright red hematemesis shortly after arriving in the emergency department and is transferred to resus. The patient's initial vital signs are as follows:
Blood pressure: 98/70 mmHg
Pulse: 126 bpm
Respiration rate: 24 bpm
Temperature: 36.4ºC
Which of the following treatments should be administered as a priority?Your Answer: Terlipressin
Explanation:When a variceal bleed is suspected, it is important to start treatment with either terlipressin or somatostatin as soon as possible. These medications help control the bleeding and are typically continued for 3-5 days if variceal haemorrhage is confirmed. Additionally, an upper GI endoscopy may be performed to either band the varices or inject a sclerosing agent to stop the bleeding. If the bleeding is difficult to control, a Sengstaken-Blakemore tube may be inserted until further treatment can be administered. Once the bleeding is under control and the patient has been resuscitated, antibiotic prophylaxis should be prescribed. Ceftriaxone or fluoroquinolones are commonly used for this purpose. Proton pump inhibitors are not recommended unless there is a specific need for treating peptic ulcer disease. Beta blockers like carvedilol are used to prevent variceal bleeding but are not effective in treating active bleeding. Vitamin K is typically not used in the acute setting of variceal bleeding.
Further Reading:
Cirrhosis is a condition where the liver undergoes structural changes, resulting in dysfunction of its normal functions. It can be classified as either compensated or decompensated. Compensated cirrhosis refers to a stage where the liver can still function effectively with minimal symptoms, while decompensated cirrhosis is when the liver damage is severe and clinical complications are present.
Cirrhosis develops over a period of several years due to repeated insults to the liver. Risk factors for cirrhosis include alcohol misuse, hepatitis B and C infection, obesity, type 2 diabetes, autoimmune liver disease, genetic conditions, certain medications, and other rare conditions.
The prognosis of cirrhosis can be assessed using the Child-Pugh score, which predicts mortality based on parameters such as bilirubin levels, albumin levels, INR, ascites, and encephalopathy. The score ranges from A to C, with higher scores indicating a poorer prognosis.
Complications of cirrhosis include portal hypertension, ascites, hepatic encephalopathy, variceal hemorrhage, increased infection risk, hepatocellular carcinoma, and cardiovascular complications.
Diagnosis of cirrhosis is typically done through liver function tests, blood tests, viral hepatitis screening, and imaging techniques such as transient elastography or acoustic radiation force impulse imaging. Liver biopsy may also be performed in some cases.
Management of cirrhosis involves treating the underlying cause, controlling risk factors, and monitoring for complications. Complications such as ascites, spontaneous bacterial peritonitis, oesophageal varices, and hepatic encephalopathy require specific management strategies.
Overall, cirrhosis is a progressive condition that requires ongoing monitoring and management to prevent further complications and improve outcomes for patients.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 17
Incorrect
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You assess a patient who came in with chest discomfort and difficulty breathing. They have been diagnosed with a spontaneous pneumothorax and their initial attempt at pleural aspiration was unsuccessful. The pneumothorax is still significant in size, and the patient continues to experience breathlessness. You get ready to insert a Seldinger chest drain into the 'safe triangle'.
What is the lower boundary of the 'safe triangle'?Your Answer: 4th intercostal space
Correct Answer: 5th intercostal space
Explanation:The British Thoracic Society (BTS) advises that chest drains should be inserted within the safe triangle to minimize the risk of harm to underlying structures and prevent damage to muscle and breast tissue, which can result in unsightly scarring. The safe triangle is defined by the base of the axilla, the lateral border of the latissimus dorsi, the lateral border of the pectoralis major, and the 5th intercostal space.
There are several potential complications associated with the insertion of small-bore chest drains. These include puncture of the intercostal artery, accidental perforation of organs due to over-introduction of the dilator into the chest cavity, hospital-acquired pleural infection caused by a non-aseptic technique, inadequate stay suture that may lead to the chest tube falling out, and tube blockage, which may occur more frequently compared to larger bore Argyle drains.
For more information on this topic, please refer to the British Thoracic Society pleural disease guidelines.
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This question is part of the following fields:
- Respiratory
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Question 18
Incorrect
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A 22 year old female presents to the emergency department with symptoms of headache, nausea, and vomiting. The patient has a history of being insulin dependent due to diabetes. Initial tests indicate that the patient is likely experiencing diabetic ketoacidosis. As part of the patient's treatment plan, you order an insulin infusion. What is an expected outcome of administering insulin in this situation?
Your Answer: Decrease intracellular glucose
Correct Answer: Increase blood pH
Explanation:Insulin is known to have several effects on the body. One of its important functions is to increase blood pH. In patients with diabetic ketoacidosis (DKA), their blood pH is low due to acidosis. Insulin helps to correct this by reducing the levels of free fatty acids in the blood, which are responsible for the production of ketone bodies that contribute to acidosis. By doing so, insulin can increase the blood pH.
Additionally, insulin plays a role in regulating glucose levels. It facilitates the movement of glucose from the blood into cells, leading to a decrease in blood glucose levels and an increase in intracellular glucose.
Furthermore, insulin affects the balance of sodium and potassium in the body. It decreases the excretion of sodium by the kidneys and drives potassium from the blood into cells, resulting in a reduction in blood potassium levels. However, it is important to monitor potassium levels closely during insulin infusions, as if they become too low (hypokalemia), the infusion may need to be stopped.
Further Reading:
Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs due to a lack of insulin in the body. It is most commonly seen in individuals with type 1 diabetes but can also occur in type 2 diabetes. DKA is characterized by hyperglycemia, acidosis, and ketonaemia.
The pathophysiology of DKA involves insulin deficiency, which leads to increased glucose production and decreased glucose uptake by cells. This results in hyperglycemia and osmotic diuresis, leading to dehydration. Insulin deficiency also leads to increased lipolysis and the production of ketone bodies, which are acidic. The body attempts to buffer the pH change through metabolic and respiratory compensation, resulting in metabolic acidosis.
DKA can be precipitated by factors such as infection, physiological stress, non-compliance with insulin therapy, acute medical conditions, and certain medications. The clinical features of DKA include polydipsia, polyuria, signs of dehydration, ketotic breath smell, tachypnea, confusion, headache, nausea, vomiting, lethargy, and abdominal pain.
The diagnosis of DKA is based on the presence of ketonaemia or ketonuria, blood glucose levels above 11 mmol/L or known diabetes mellitus, and a blood pH below 7.3 or bicarbonate levels below 15 mmol/L. Initial investigations include blood gas analysis, urine dipstick for glucose and ketones, blood glucose measurement, and electrolyte levels.
Management of DKA involves fluid replacement, electrolyte correction, insulin therapy, and treatment of any underlying cause. Fluid replacement is typically done with isotonic saline, and potassium may need to be added depending on the patient’s levels. Insulin therapy is initiated with an intravenous infusion, and the rate is adjusted based on blood glucose levels. Monitoring of blood glucose, ketones, bicarbonate, and electrolytes is essential, and the insulin infusion is discontinued once ketones are below 0.3 mmol/L, pH is above 7.3, and bicarbonate is above 18 mmol/L.
Complications of DKA and its treatment include gastric stasis, thromboembolism, electrolyte disturbances, cerebral edema, hypoglycemia, acute respiratory distress syndrome, and acute kidney injury. Prompt medical intervention is crucial in managing DKA to prevent potentially fatal outcomes.
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This question is part of the following fields:
- Endocrinology
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Question 19
Incorrect
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There are numerous casualties reported after a suspected CBRN (chemical, biological, radiological, and nuclear) incident. It is believed that sarin gas is the responsible agent. What is the mode of action of sarin gas?
Your Answer: Prevention of re-uptake of adrenaline and norepinephrine
Correct Answer: Inhibition of acetylcholinesterase
Explanation:The nerve agents, also known as nerve gases, are a group of highly toxic chemical warfare agents that were initially developed just before and during World War II.
The first compounds to be created are referred to as the G agents (with G representing German, as they were discovered and synthesized by German scientists). These include Tabun (GA), Sarin (GB), and Soman (GD).
In the 1950s, the V agents (with V standing for venomous) were synthesized, and they are approximately 10 times more poisonous than sarin. These include Venomous agent X (VX), Venomous agent E (VE), Venomous agent G (VG), and Venomous agent M (VM).
One of the most well-known incidents involving the use of a nerve agent was the March 1995 Tokyo subway sarin attack. During this attack, Sarin was released into the Tokyo subway system during rush hour. As a result, over 5,000 people sought medical attention. Among them, 984 were moderately poisoned, 54 were severely poisoned, and 12 lost their lives.
The nerve agents are organophosphorus esters that are chemically related to organophosphorus insecticides. They work by inhibiting acetylcholinesterase (AChE), an enzyme that breaks down the neurotransmitter acetylcholine (ACh). This leads to an accumulation of ACh at both muscarinic and nicotinic cholinergic receptors.
Nerve agents can be absorbed through any body surface. When dispersed as a spray or aerosol, they can be absorbed through the skin, eyes, and respiratory tract. When dispersed as a vapor, they are primarily absorbed through the respiratory tract and eyes. If a sufficient amount of agent is absorbed, local effects are followed by generalized systemic effects.
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This question is part of the following fields:
- Major Incident Management & PHEM
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Question 20
Incorrect
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A 30-year-old construction worker comes in with intense pain in his right eye following an incident at the job site where a significant amount of cement dust entered his right eye.
What is the potential pathological condition that this patient's eye may be susceptible to?Your Answer: Caseous necrosis
Correct Answer: Colliquative necrosis
Explanation:Cement contains lime, which is a powerful alkali, and this can cause a serious eye emergency that requires immediate treatment. Alkaline chemicals, such as oven cleaner, ammonia, household bleach, drain cleaner, oven cleaner, and plaster, can also cause damage to the eyes. They lead to colliquative necrosis, which is a type of tissue death that results in liquefaction. On the other hand, acids cause damage through coagulative necrosis. Common acids that can harm the eyes include toilet cleaners, certain household cleaning products, and battery fluid.
The initial management of a patient with cement or alkali exposure to the eyes should be as follows:
1. Irrigate the eye with a large amount of normal saline for 20-30 minutes.
2. Administer local anaesthetic drops every 5 minutes to help keep the eye open and alleviate pain.
3. Monitor the pH every 5 minutes until a neutral pH (7.0-7.5) is achieved. Briefly pause irrigation to test the fluid from the forniceal space using litmus paper.After the initial management, a thorough examination should be conducted, which includes the following steps:
1. Examine the eye directly and with a slit lamp.
2. Remove any remaining cement debris from the surface of the eye.
3. Evert the eyelids to check for hidden cement debris.
4. Administer fluorescein drops and check for corneal abrasion.
5. Assess visual acuity, which may be reduced.
6. Perform fundoscopy to check for retinal necrosis if the alkali has penetrated the sclera.
7. Measure intraocular pressure through tonometry to detect secondary glaucoma.Once the eye’s pH has returned to normal, irrigation can be stopped, and the patient should be promptly referred to an ophthalmology specialist for further evaluation.
Potential long-term complications of cement or alkali exposure to the eyes include closed-angle glaucoma, cataract formation, entropion, keratitis sicca, and permanent vision loss.
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This question is part of the following fields:
- Ophthalmology
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Question 21
Correct
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A 65-year-old woman with a history of Parkinson's disease and depression has experienced a gradual decline in her cognitive abilities over the past year. Her memory and ability to focus have been noticeably impaired recently. Additionally, she has experienced a few episodes of unexplained temporary loss of consciousness and occasional visual hallucinations.
What is the SINGLE most probable diagnosis?Your Answer: Dementia with Lewy bodies (DLB)
Explanation:Dementia with Lewy bodies (DLB), also known as Lewy body dementia (LBD), is a progressive neurodegenerative condition that is closely linked to Parkinson’s disease (PD). It is the third most common cause of dementia in older individuals, following Alzheimer’s disease and vascular dementia.
DLB is characterized by several clinical features, including the presence of Parkinsonism or co-existing PD, a gradual decline in cognitive function, fluctuations in cognition, alertness, and attention span, episodes of temporary loss of consciousness, recurrent falls, visual hallucinations, depression, and complex, systematized delusions. The level of cognitive impairment can vary from hour to hour and day to day.
Pathologically, DLB is marked by the formation of abnormal protein collections called Lewy bodies within the cytoplasm of neurons. These intracellular protein collections share similar structural characteristics with the classic Lewy bodies observed in Parkinson’s disease.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 22
Incorrect
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A 72-year-old woman is evaluated in the cardiac care unit 2 days after experiencing a heart attack. She complains of significant shortness of breath. During the physical examination, a pansystolic murmur is audible and is most prominent at the lower left sternal border.
What is the SINGLE most probable diagnosis?Your Answer: Mitral regurgitation
Correct Answer: Ventricular septal defect
Explanation:Post myocardial infarction ventricular septal defect (VSD) is a rare but serious complication that occurs when the cardiac wall ruptures. It typically develops 2-3 days after a heart attack, and if left untreated, 85% of patients will die within two months. The murmur associated with VSD is a continuous sound throughout systole, and it is loudest at the lower left sternal edge. A palpable vibration, known as a thrill, is often felt along with the murmur.
Dressler’s syndrome, on the other hand, is a type of pericarditis that occurs 2-10 weeks after a heart attack or cardiac surgery. It is characterized by sharp chest pain that is relieved by sitting forwards. Other signs of Dressler’s syndrome include a rubbing sound heard when listening to the heart, pulsus paradoxus (an abnormal drop in blood pressure during inspiration), and signs of right ventricular failure.
Mitral regurgitation also causes a continuous murmur throughout systole, but it is best heard at the apex of the heart and may radiate to the axilla (armpit).
Tricuspid stenosis, on the other hand, causes an early diastolic murmur that is best heard at the lower left sternal edge during inspiration.
Lastly, mitral stenosis causes a rumbling mid-diastolic murmur that is best heard at the apex of the heart. To listen for this murmur, the patient should be in the left lateral position, and the stethoscope bell should be used during expiration.
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This question is part of the following fields:
- Cardiology
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Question 23
Incorrect
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A 6-year-old child experiences an anaphylactic reaction after being stung by a bee.
What is the appropriate dose of IM adrenaline to administer in this situation?Your Answer: 300 mcg
Correct Answer: 150 mcg
Explanation:The management of anaphylaxis involves several important steps. First and foremost, it is crucial to ensure proper airway management. Additionally, early administration of adrenaline is essential, preferably in the anterolateral aspect of the middle third of the thigh. Aggressive fluid resuscitation is also necessary. In severe cases, intubation may be required. However, it is important to note that the administration of chlorpheniramine and hydrocortisone should only be considered after early resuscitation has taken place.
Adrenaline is the most vital medication for treating anaphylactic reactions. It acts as an alpha-adrenergic receptor agonist, which helps reverse peripheral vasodilatation and reduce oedema. Furthermore, its beta-adrenergic effects aid in dilating the bronchial airways, increasing the force of myocardial contraction, and suppressing histamine and leukotriene release. Administering adrenaline as the first drug is crucial, and the intramuscular (IM) route is generally the most effective for most individuals.
The recommended doses of IM adrenaline for different age groups during anaphylaxis are as follows:
– Children under 6 years: 150 mcg (0.15 mL of 1:1000)
– Children aged 6-12 years: 300 mcg (0.3 mL of 1:1000)
– Children older than 12 years: 500 mcg (0.5 mL of 1:1000)
– Adults: 500 mcg (0.5 mL of 1:1000) -
This question is part of the following fields:
- Allergy
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Question 24
Correct
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A 35-year-old Caucasian woman comes in with itchy, hyperpigmented patches on her chest and back. She recently returned from her vacation in Ibiza and the areas have become much more noticeable since being exposed to the sun.
What is the SINGLE most probable diagnosis?Your Answer: Pityriasis versicolor
Explanation:Pityriasis versicolor, also known as tinea versicolor, is a common skin condition caused by an infection with the yeasts Malassezia furfur and Malassezia globosa. It typically presents as multiple patches of altered pigmentation, primarily on the trunk. In individuals with fair skin, these patches are usually darker in color, while in those with darker skin or a tan, they may appear lighter (known as pityriasis versicolor alba). It is not uncommon for the rash to cause itching.
The recommended treatment for pityriasis versicolor involves the use of antifungal agents. One particularly effective option is ketoconazole shampoo, which is sold under the brand name Nizoral. To use this shampoo, it should be applied to the affected areas and left on for approximately five minutes before being rinsed off. This process should be repeated daily for a total of five days.
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This question is part of the following fields:
- Dermatology
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Question 25
Correct
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You assess a client with a history of schizophrenia who is currently experiencing acute psychosis. He reports a sensation in which he believes that individuals in close proximity to him are inserting their thoughts into his mind.
Which ONE of the following thought disorders is he exhibiting?Your Answer: Thought insertion
Explanation:Thought insertion is one of the primary symptoms identified by Schneider in schizophrenia. This symptom refers to the patient’s belief that their thoughts are being controlled or influenced by external sources, such as other individuals or entities. In some cases, they may even experience auditory hallucinations, hearing distinct voices.
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This question is part of the following fields:
- Mental Health
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Question 26
Correct
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A 6 month old infant is brought to the emergency department by his father due to a 24 hour history of fever, fussiness, and crying. On examination, the infant is alert and responsive, with a temperature of 38.3ºC. The capillary refill time is less than 2 seconds, and there is mild redness in the throat. The left tympanic membrane appears red and bulging, while the chest is clear and the abdomen is soft with no rashes.
What is the most suitable course of action?Your Answer: Admit under paediatrics
Explanation:If a child under 3 months old has a temperature of 38ºC or higher, it is considered a red flag according to the NICE traffic light system. This indicates that the child may have acute otitis media and it is recommended that they be admitted for further evaluation and treatment.
Further Reading:
Acute otitis media (AOM) is an inflammation in the middle ear accompanied by symptoms and signs of an ear infection. It is commonly seen in young children below 4 years of age, with the highest incidence occurring between 9 to 15 months of age. AOM can be caused by viral or bacterial pathogens, and co-infection with both is common. The most common viral pathogens include respiratory syncytial virus (RSV), rhinovirus, adenovirus, influenza virus, and parainfluenza virus. The most common bacterial pathogens include Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pyogenes.
Clinical features of AOM include ear pain (otalgia), fever, a red or cloudy tympanic membrane, and a bulging tympanic membrane with loss of anatomical landmarks. In young children, symptoms may also include crying, grabbing or rubbing the affected ear, restlessness, and poor feeding.
Most children with AOM will recover within 3 days without treatment. Serious complications are rare but can include persistent otitis media with effusion, recurrence of infection, temporary hearing loss, tympanic membrane perforation, labyrinthitis, mastoiditis, meningitis, intracranial abscess, sinus thrombosis, and facial nerve paralysis.
Management of AOM involves determining whether admission to the hospital is necessary based on the severity of systemic infection or suspected acute complications. For patients who do not require admission, regular pain relief with paracetamol or ibuprofen is advised. Decongestants or antihistamines are not recommended. Antibiotics may be offered immediately for patients who are systemically unwell, have symptoms and signs of a more serious illness or condition, or have a high risk of complications. For other patients, a decision needs to be made on the antibiotic strategy, considering the rarity of acute complications and the possible adverse effects of antibiotics. Options include no antibiotic prescription with advice to seek medical help if symptoms worsen rapidly or significantly, a back-up antibiotic prescription to be used if symptoms do not improve within 3 days, or an immediate antibiotic prescription with advice to seek medical advice if symptoms worsen rapidly or significantly.
The first-line antibiotic choice for AOM is a 5-7 day course of amoxicillin. For individuals allergic to or intolerant of penicillin, clarithromycin or erythromycin a 5–7 day course of clarithromycin or erythromycin (erythromycin is preferred in pregnant women).
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This question is part of the following fields:
- Paediatric Emergencies
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Question 27
Correct
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You evaluate a 38-year-old woman who was hit on the side of her leg by a soccer player while spectating the match from the sidelines. You suspect a tibial plateau fracture and order an X-ray of the affected knee. Besides the fracture line, what other radiographic indication is frequently observed in individuals with acute tibial plateau fractures?
Your Answer: Lipohaemathrosis evident in suprapatellar pouch
Explanation:Lipohaemathrosis is commonly seen in the suprapatellar pouch in individuals who have tibial plateau fractures. Notable X-ray characteristics of tibial plateau fractures include a visible fracture of the tibial plateau and the presence of lipohaemathrosis in the suprapatellar pouch.
Further Reading:
Tibial plateau fractures are a type of traumatic lower limb and joint injury that can involve the medial or lateral tibial plateau, or both. These fractures are classified using the Schatzker classification, with higher grades indicating a worse prognosis. X-ray imaging can show visible fractures of the tibial plateau and the presence of lipohaemathrosis in the suprapatellar pouch. However, X-rays often underestimate the severity of these fractures, so CT scans are typically used for a more accurate assessment.
Tibial spine fractures, on the other hand, are separate from tibial plateau fractures. They occur when the tibial spine is avulsed by the anterior cruciate ligament (ACL). This can happen due to forced knee hyperextension or a direct blow to the femur when the knee is flexed. These fractures are most common in children aged 8-14.
Tibial tuberosity avulsion fractures primarily affect adolescent boys and are often caused by jumping or landing from a jump. These fractures can be associated with Osgood-Schlatter disease. The treatment for these fractures depends on their grading. Low-grade fractures may be managed with immobilization for 4-6 weeks, while more significant avulsions are best treated with surgical fixation.
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This question is part of the following fields:
- Trauma
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Question 28
Incorrect
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A 70-year-old woman with a history of chronic heart failure presents to the Emergency Department with an unrelated medical condition. Upon reviewing her medications, you discover that she is taking furosemide as part of her management.
Which ONE of the following drugs should be avoided?Your Answer: Warfarin
Correct Answer: Citalopram
Explanation:When furosemide and SSRI drugs are prescribed together, there is a higher chance of developing hyponatraemia, which is a condition characterized by low levels of sodium in the blood. Additionally, there is an increased risk of hypokalaemia, which can potentially lead to a dangerous heart rhythm disorder called torsades de pointes. It is important to note that co-prescribing furosemide with citalopram should be avoided due to these risks. For more information, you can refer to the section on furosemide interactions in the BNF.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 29
Incorrect
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A 72-year-old man with a history of COPD complains of a headache, dizziness, and palpitations. He is currently taking modified-release theophylline for his COPD. You suspect theophylline toxicity and schedule a blood test to check his levels.
When should the blood sample be taken after his last oral dose?Your Answer: 24 hours
Correct Answer: 4-6 hours
Explanation:In order to achieve satisfactory bronchodilation, most individuals require a plasma theophylline concentration of 10-20 mg/litre (55-110 micromol/litre). However, it is possible for a lower concentration to still be effective. Adverse effects can occur within the range of 10-20 mg/litre, and their frequency and severity increase when concentrations exceed 20 mg/litre.
To measure plasma theophylline concentration, a blood sample should be taken five days after starting oral treatment and at least three days after any dose adjustment. For modified-release preparations, the blood sample should typically be taken 4-6 hours after an oral dose (specific sampling times may vary, so it is advisable to consult local guidelines). If aminophylline is administered intravenously, a blood sample should be taken 4-6 hours after initiating treatment.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 30
Incorrect
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You diagnose a pediatric trauma patient with a right sided tension pneumothorax and plan to perform needle thoracentesis. Which of the following is the most appropriate anatomical landmark to use for needle insertion?
Your Answer: 5th intercostal space midclavicular line
Correct Answer: 5th intercostal space midaxillary line
Explanation:A pneumothorax is an abnormal collection of air in the pleural cavity of the lung. It can be classified by cause as primary spontaneous, secondary spontaneous, or traumatic. Primary spontaneous pneumothorax occurs without any obvious cause in the absence of underlying lung disease, while secondary spontaneous pneumothorax occurs in patients with significant underlying lung diseases. Traumatic pneumothorax is caused by trauma to the lung, often from blunt or penetrating chest wall injuries.
Tension pneumothorax is a life-threatening condition where the collection of air in the pleural cavity expands and compresses normal lung tissue and mediastinal structures. It can be caused by any of the aforementioned types of pneumothorax. Immediate management of tension pneumothorax involves the ABCDE approach, which includes ensuring a patent airway, controlling the C-spine, providing supplemental oxygen, establishing IV access for fluid resuscitation, and assessing and managing other injuries.
Treatment of tension pneumothorax involves needle thoracocentesis as a temporary measure to provide immediate decompression, followed by tube thoracostomy as definitive management. Needle thoracocentesis involves inserting a 14g cannula into the pleural space, typically via the 4th or 5th intercostal space midaxillary line. If the patient is peri-arrest, immediate thoracostomy is advised.
The pathophysiology of tension pneumothorax involves disruption to the visceral or parietal pleura, allowing air to flow into the pleural space. This can occur through an injury to the lung parenchyma and visceral pleura, or through an entry wound to the external chest wall in the case of a sucking pneumothorax. Injured tissue forms a one-way valve, allowing air to enter the pleural space with inhalation but prohibiting air outflow. This leads to a progressive increase in the volume of non-absorbable intrapleural air with each inspiration, causing pleural volume and pressure to rise within the affected hemithorax.
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This question is part of the following fields:
- Resus
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