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  • Question 1 - A 42-year-old woman with a lengthy history of depression arrives at the Emergency...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      45.2
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  • Question 2 - A 45-year-old woman is about to begin taking warfarin for the treatment of...

    Incorrect

    • A 45-year-old woman is about to begin taking warfarin for the treatment of her atrial fibrillation. She is currently on multiple other medications.
      Which ONE medication will counteract the effects of warfarin?

      Your Answer: Clarithromycin

      Correct Answer: Phenytoin

      Explanation:

      Cytochrome p450 enzyme inducers have the ability to hinder the effects of warfarin, leading to a decrease in INR levels. To remember the commonly encountered cytochrome p450 enzyme inducers, the mnemonic PC BRASS can be utilized. Each letter in the mnemonic represents a specific inducer: P for Phenytoin, C for Carbamazepine, B for Barbiturates, R for Rifampicin, A for Alcohol (chronic ingestion), S for Sulphonylureas, and S for Smoking. These inducers can have an impact on the effectiveness of warfarin and should be taken into consideration when prescribing or using this medication.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      41.6
      Seconds
  • Question 3 - A 42 year old male is brought into the emergency department after being...

    Incorrect

    • A 42 year old male is brought into the emergency department after being discovered unconscious in a park with two empty beer bottles and several empty boxes of painkillers at his side. An arterial blood gas is obtained and the results are as follows:

      Parameter Result
      pH 7.19
      pO2 11.8 KPa
      pCO2 3.2 KPa
      HCO3- 14 mmol/L
      BE -7.8

      Which of the following most accurately characterizes the acid-base imbalance?

      Your Answer: Respiratory alkalosis with partial respiratory compensation

      Correct Answer: Metabolic acidosis with partial respiratory compensation

      Explanation:

      The patient is experiencing acidosis, as indicated by the low pH. The low bicarb and base excess levels suggest that the metabolic system is contributing to or causing the acidosis. Additionally, the low pCO2 indicates that the respiratory system is attempting to compensate by driving alkalosis. However, the metabolic system is the primary factor in this case, leading to a diagnosis of metabolic acidosis with incomplete respiratory compensation.

      Further Reading:

      Salicylate poisoning, particularly from aspirin overdose, is a common cause of poisoning in the UK. One important concept to understand is that salicylate overdose leads to a combination of respiratory alkalosis and metabolic acidosis. Initially, the overdose stimulates the respiratory center, leading to hyperventilation and respiratory alkalosis. However, as the effects of salicylate on lactic acid production, breakdown into acidic metabolites, and acute renal injury occur, it can result in high anion gap metabolic acidosis.

      The clinical features of salicylate poisoning include hyperventilation, tinnitus, lethargy, sweating, pyrexia (fever), nausea/vomiting, hyperglycemia and hypoglycemia, seizures, and coma.

      When investigating salicylate poisoning, it is important to measure salicylate levels in the blood. The sample should be taken at least 2 hours after ingestion for symptomatic patients or 4 hours for asymptomatic patients. The measurement should be repeated every 2-3 hours until the levels start to decrease. Other investigations include arterial blood gas analysis, electrolyte levels (U&Es), complete blood count (FBC), coagulation studies (raised INR/PTR), urinary pH, and blood glucose levels.

      To manage salicylate poisoning, an ABC approach should be followed to ensure a patent airway and adequate ventilation. Activated charcoal can be administered if the patient presents within 1 hour of ingestion. Oral or intravenous fluids should be given to optimize intravascular volume. Hypokalemia and hypoglycemia should be corrected. Urinary alkalinization with intravenous sodium bicarbonate can enhance the elimination of aspirin in the urine. In severe cases, hemodialysis may be necessary.

      Urinary alkalinization involves targeting a urinary pH of 7.5-8.5 and checking it hourly. It is important to monitor for hypokalemia as alkalinization can cause potassium to shift from plasma into cells. Potassium levels should be checked every 1-2 hours.

      In cases where the salicylate concentration is high (above 500 mg/L in adults or 350 mg/L in children), sodium bicarbonate can be administered intravenously. Hemodialysis is the treatment of choice for severe poisoning and may be indicated in cases of high salicylate levels, resistant metabolic acidosis, acute kidney injury, pulmonary edema, seizures and coma.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      100.5
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  • Question 4 - A 35-year-old individual arrives at the emergency department, complaining of feeling unwell for...

    Correct

    • A 35-year-old individual arrives at the emergency department, complaining of feeling unwell for the past 48 hours. After obtaining the patient's medical history, you suspect carbon monoxide poisoning. What is the primary intervention in managing patients with carbon monoxide poisoning?

      Your Answer: 100% oxygen

      Explanation:

      In managing patients with carbon monoxide poisoning, the primary intervention is providing 100% oxygen. This is because carbon monoxide has a higher affinity for hemoglobin than oxygen, leading to decreased oxygen delivery to tissues. By administering 100% oxygen, the patient is able to displace carbon monoxide from hemoglobin and increase oxygen levels in the blood, which is crucial for the patient’s recovery.

      Further Reading:

      Carbon monoxide (CO) is a dangerous gas that is produced by the combustion of hydrocarbon fuels and can be found in certain chemicals. It is colorless and odorless, making it difficult to detect. In England and Wales, there are approximately 60 deaths each year due to accidental CO poisoning.

      When inhaled, carbon monoxide binds to haemoglobin in the blood, forming carboxyhaemoglobin (COHb). It has a higher affinity for haemoglobin than oxygen, causing a left-shift in the oxygen dissociation curve and resulting in tissue hypoxia. This means that even though there may be a normal level of oxygen in the blood, it is less readily released to the tissues.

      The clinical features of carbon monoxide toxicity can vary depending on the severity of the poisoning. Mild or chronic poisoning may present with symptoms such as headache, nausea, vomiting, vertigo, confusion, and weakness. More severe poisoning can lead to intoxication, personality changes, breathlessness, pink skin and mucosae, hyperpyrexia, arrhythmias, seizures, blurred vision or blindness, deafness, extrapyramidal features, coma, or even death.

      To help diagnose domestic carbon monoxide poisoning, there are four key questions that can be asked using the COMA acronym. These questions include asking about co-habitees and co-occupants in the house, whether symptoms improve outside of the house, the maintenance of boilers and cooking appliances, and the presence of a functioning CO alarm.

      Typical carboxyhaemoglobin levels can vary depending on whether the individual is a smoker or non-smoker. Non-smokers typically have levels below 3%, while smokers may have levels below 10%. Symptomatic individuals usually have levels between 10-30%, and severe toxicity is indicated by levels above 30%.

      When managing carbon monoxide poisoning, the first step is to administer 100% oxygen. Hyperbaric oxygen therapy may be considered for individuals with a COHb concentration of over 20% and additional risk factors such as loss of consciousness, neurological signs, myocardial ischemia or arrhythmia, or pregnancy. Other management strategies may include fluid resuscitation, sodium bicarbonate for metabolic acidosis, and mannitol for cerebral edema.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 5 - A 21 year old female is brought to the emergency department by her...

    Correct

    • A 21 year old female is brought to the emergency department by her parents and admits to ingesting 36 paracetamol tablets. You determine that the patient fulfills the requirements for receiving activated charcoal. What would be the appropriate dosage to administer?

      Your Answer: 50 g

      Explanation:

      The recommended dose of activated charcoal for adults and children aged 12 or over to prevent the absorption of poisons in the gastrointestinal tract is 50g.

      Further Reading:

      Paracetamol poisoning occurs when the liver is unable to metabolize paracetamol properly, leading to the production of a toxic metabolite called N-acetyl-p-benzoquinone imine (NAPQI). Normally, NAPQI is conjugated by glutathione into a non-toxic form. However, during an overdose, the liver’s conjugation systems become overwhelmed, resulting in increased production of NAPQI and depletion of glutathione stores. This leads to the formation of covalent bonds between NAPQI and cell proteins, causing cell death in the liver and kidneys.

      Symptoms of paracetamol poisoning may not appear for the first 24 hours or may include abdominal symptoms such as nausea and vomiting. After 24 hours, hepatic necrosis may develop, leading to elevated liver enzymes, right upper quadrant pain, and jaundice. Other complications can include encephalopathy, oliguria, hypoglycemia, renal failure, and lactic acidosis.

      The management of paracetamol overdose depends on the timing and amount of ingestion. Activated charcoal may be given if the patient presents within 1 hour of ingesting a significant amount of paracetamol. N-acetylcysteine (NAC) is used to increase hepatic glutathione production and is given to patients who meet specific criteria. Blood tests are taken to assess paracetamol levels, liver function, and other parameters. Referral to a medical or liver unit may be necessary, and psychiatric follow-up should be considered for deliberate overdoses.

      In cases of staggered ingestion, all patients should be treated with NAC without delay. Blood tests are also taken, and if certain criteria are met, NAC can be discontinued. Adverse reactions to NAC are common and may include anaphylactoid reactions, rash, hypotension, and nausea. Treatment for adverse reactions involves medications such as chlorpheniramine and salbutamol, and the infusion may be stopped if necessary.

      The prognosis for paracetamol poisoning can be poor, especially in cases of severe liver injury. Fulminant liver failure may occur, and liver transplant may be necessary. Poor prognostic indicators include low arterial pH, prolonged prothrombin time, high plasma creatinine, and hepatic encephalopathy.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      18.7
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  • Question 6 - A 65-year-old patient presents to the emergency department and informs you that they...

    Incorrect

    • A 65-year-old patient presents to the emergency department and informs you that they have taken an overdose. The patient states that they are unsure of the exact number of tablets consumed but estimate it to be around 100 aspirin tablets. You are concerned about the severity of the overdose and its potential consequences. Which of the following is an indication for haemodialysis in patients with salicylate poisoning?

      Your Answer: Patient with pre-existing chronic kidney disease

      Correct Answer: Salicylate level of 715 mg/L

      Explanation:

      Haemodialysis is recommended for patients with salicylate poisoning if they meet any of the following criteria: plasma salicylate level exceeding 700 mg/L, metabolic acidosis that does not improve with treatment (plasma pH below 7.2), acute kidney injury, pulmonary edema, seizures, coma, unresolved central nervous system effects despite correcting acidosis, persistently high salicylate concentrations that do not respond to urinary alkalinisation. Severe cases of salicylate poisoning, especially in patients under 10 years old or over 70 years old, may require dialysis earlier than the listed indications.

      Further Reading:

      Salicylate poisoning, particularly from aspirin overdose, is a common cause of poisoning in the UK. One important concept to understand is that salicylate overdose leads to a combination of respiratory alkalosis and metabolic acidosis. Initially, the overdose stimulates the respiratory center, leading to hyperventilation and respiratory alkalosis. However, as the effects of salicylate on lactic acid production, breakdown into acidic metabolites, and acute renal injury occur, it can result in high anion gap metabolic acidosis.

      The clinical features of salicylate poisoning include hyperventilation, tinnitus, lethargy, sweating, pyrexia (fever), nausea/vomiting, hyperglycemia and hypoglycemia, seizures, and coma.

      When investigating salicylate poisoning, it is important to measure salicylate levels in the blood. The sample should be taken at least 2 hours after ingestion for symptomatic patients or 4 hours for asymptomatic patients. The measurement should be repeated every 2-3 hours until the levels start to decrease. Other investigations include arterial blood gas analysis, electrolyte levels (U&Es), complete blood count (FBC), coagulation studies (raised INR/PTR), urinary pH, and blood glucose levels.

      To manage salicylate poisoning, an ABC approach should be followed to ensure a patent airway and adequate ventilation. Activated charcoal can be administered if the patient presents within 1 hour of ingestion. Oral or intravenous fluids should be given to optimize intravascular volume. Hypokalemia and hypoglycemia should be corrected. Urinary alkalinization with intravenous sodium bicarbonate can enhance the elimination of aspirin in the urine. In severe cases, hemodialysis may be necessary.

      Urinary alkalinization involves targeting a urinary pH of 7.5-8.5 and checking it hourly. It is important to monitor for hypokalemia as alkalinization can cause potassium to shift from plasma into cells. Potassium levels should be checked every 1-2 hours.

      In cases where the salicylate concentration is high (above 500 mg/L in adults or 350 mg/L in children), sodium bicarbonate can be administered intravenously. Hemodialysis is the treatment of choice for severe poisoning and may be indicated in cases of high salicylate levels, resistant metabolic acidosis, acute kidney injury, pulmonary edema, seizures and coma.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      98.1
      Seconds
  • Question 7 - A 28-year-old woman is given an antibiotic while pregnant. As a result, the...

    Correct

    • A 28-year-old woman is given an antibiotic while pregnant. As a result, the newborn is born with deafness in both ears.
      Which antibiotic is most likely responsible for these abnormalities?

      Your Answer: Gentamicin

      Explanation:

      Aminoglycosides have the ability to pass through the placenta and can lead to damage to the 8th cranial nerve in the fetus, resulting in permanent bilateral deafness.

      ACE inhibitors, such as ramipril, can cause hypoperfusion, renal failure, and the oligohydramnios sequence if given in the 2nd and 3rd trimesters.

      Aminoglycosides, like gentamicin, can cause ototoxicity and deafness in the fetus.

      High doses of aspirin can lead to 1st trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g. 75 mg) do not pose significant risks.

      Benzodiazepines, including diazepam, when administered late in pregnancy, can result in respiratory depression and a neonatal withdrawal syndrome.

      Calcium-channel blockers, if given in the 1st trimester, can cause phalangeal abnormalities. If given in the 2nd and 3rd trimesters, they can lead to fetal growth retardation.

      Carbamazepine can cause hemorrhagic disease of the newborn and neural tube defects.

      Chloramphenicol is associated with grey baby syndrome.

      Corticosteroids, if given in the 1st trimester, may cause orofacial clefts.

      Danazol, if given in the 1st trimester, can cause masculinization of the female fetuses genitals.

      Finasteride should not be handled by pregnant women as crushed or broken tablets can be absorbed through the skin and affect male sex organ development.

      Haloperidol, if given in the 1st trimester, may cause limb malformations. If given in the 3rd trimester, there is an increased risk of extrapyramidal symptoms in the neonate.

      Heparin can lead to maternal bleeding and thrombocytopenia.

      Isoniazid can cause maternal liver damage and neuropathy and seizures in the neonate.

      Isotretinoin carries a high risk of teratogenicity, including multiple congenital malformations, spontaneous abortion, and intellectual disability.

      Lithium, if given in the 1st trimester, poses a risk of fetal cardiac malformations.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      17.2
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  • Question 8 - A 68-year-old man presents with symptoms related to an electrolyte imbalance. It is...

    Incorrect

    • A 68-year-old man presents with symptoms related to an electrolyte imbalance. It is believed that the electrolyte imbalance has occurred as a result of a thiazide diuretic he has been prescribed by the nephrology team.

      Which of the following electrolyte imbalances is most likely to be caused by thiazide diuretics?

      Your Answer: Hypermagnesaemia

      Correct Answer: Hyponatraemia

      Explanation:

      Thiazide diuretics, a commonly prescribed medication, can lead to two main electrolyte imbalances in patients. One of these is hyponatremia, which occurs in around 13.7% of individuals taking thiazide diuretics. The other is hypokalemia, which is observed in approximately 8.5% of patients on this medication. These electrolyte disturbances are frequently encountered in primary care settings. For more information on this topic, please refer to the article titled Thiazide diuretic prescription and electrolyte abnormalities in primary care.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      105.8
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  • Question 9 - A 25-year-old individual is brought to the emergency department by a companion who...

    Incorrect

    • A 25-year-old individual is brought to the emergency department by a companion who discovered the patient in tears next to a bottle of tablets. The patient claims to have ingested about 40 aspirin tablets approximately 1 hour ago. A blood gas sample is collected for testing. Which of the following acid-base imbalances is linked to an overdose of aspirin?

      Your Answer: Metabolic acidosis followed by a respiratory alkalosis

      Correct Answer: Respiratory alkalosis followed by a metabolic acidosis

      Explanation:

      Salicylate poisoning initially leads to respiratory alkalosis, followed by metabolic acidosis. Salicylates, like aspirin, stimulate the respiratory center in the medulla, causing hyperventilation and respiratory alkalosis. This is usually the first acid-base imbalance observed in salicylate poisoning. As aspirin is metabolized, it disrupts oxidative phosphorylation in the mitochondria, leading to an increase in lactate levels due to anaerobic metabolism. The accumulation of lactic acid and acidic metabolites then causes metabolic acidosis.

      Further Reading:

      Salicylate poisoning, particularly from aspirin overdose, is a common cause of poisoning in the UK. One important concept to understand is that salicylate overdose leads to a combination of respiratory alkalosis and metabolic acidosis. Initially, the overdose stimulates the respiratory center, leading to hyperventilation and respiratory alkalosis. However, as the effects of salicylate on lactic acid production, breakdown into acidic metabolites, and acute renal injury occur, it can result in high anion gap metabolic acidosis.

      The clinical features of salicylate poisoning include hyperventilation, tinnitus, lethargy, sweating, pyrexia (fever), nausea/vomiting, hyperglycemia and hypoglycemia, seizures, and coma.

      When investigating salicylate poisoning, it is important to measure salicylate levels in the blood. The sample should be taken at least 2 hours after ingestion for symptomatic patients or 4 hours for asymptomatic patients. The measurement should be repeated every 2-3 hours until the levels start to decrease. Other investigations include arterial blood gas analysis, electrolyte levels (U&Es), complete blood count (FBC), coagulation studies (raised INR/PTR), urinary pH, and blood glucose levels.

      To manage salicylate poisoning, an ABC approach should be followed to ensure a patent airway and adequate ventilation. Activated charcoal can be administered if the patient presents within 1 hour of ingestion. Oral or intravenous fluids should be given to optimize intravascular volume. Hypokalemia and hypoglycemia should be corrected. Urinary alkalinization with intravenous sodium bicarbonate can enhance the elimination of aspirin in the urine. In severe cases, hemodialysis may be necessary.

      Urinary alkalinization involves targeting a urinary pH of 7.5-8.5 and checking it hourly. It is important to monitor for hypokalemia as alkalinization can cause potassium to shift from plasma into cells. Potassium levels should be checked every 1-2 hours.

      In cases where the salicylate concentration is high (above 500 mg/L in adults or 350 mg/L in children), sodium bicarbonate can be administered intravenously. Hemodialysis is the treatment of choice for severe poisoning and may be indicated in cases of high salicylate levels, resistant metabolic acidosis, acute kidney injury, pulmonary edema, seizures and coma.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      41.6
      Seconds
  • Question 10 - A 35 year old male is brought into the emergency department after being...

    Incorrect

    • A 35 year old male is brought into the emergency department after being discovered confused and drowsy by a family member. The family member informs you that the patient has a history of depression and that there were multiple empty bottles of aspirin at the patient's residence. Initial tests are conducted, including a salicylate level. Upon reviewing the salicylate result, you initiate a urinary alkalinisation protocol. Which metabolic imbalance is linked to urinary alkalinisation and necessitates careful monitoring?

      Your Answer: Hyperkalaemia

      Correct Answer: Hypokalaemia

      Explanation:

      Urinary alkalinisation, which involves the intravenous administration of sodium bicarbonate, carries the risk of hypokalaemia. It is important to note that both alkalosis and acidosis can cause shifts in potassium levels. In the case of alkalinisation, potassium is shifted from the plasma into the cells. Therefore, it is crucial to closely monitor the patient for hypokalaemia by checking their potassium levels every 1-2 hours.

      Further Reading:

      Salicylate poisoning, particularly from aspirin overdose, is a common cause of poisoning in the UK. One important concept to understand is that salicylate overdose leads to a combination of respiratory alkalosis and metabolic acidosis. Initially, the overdose stimulates the respiratory center, leading to hyperventilation and respiratory alkalosis. However, as the effects of salicylate on lactic acid production, breakdown into acidic metabolites, and acute renal injury occur, it can result in high anion gap metabolic acidosis.

      The clinical features of salicylate poisoning include hyperventilation, tinnitus, lethargy, sweating, pyrexia (fever), nausea/vomiting, hyperglycemia and hypoglycemia, seizures, and coma.

      When investigating salicylate poisoning, it is important to measure salicylate levels in the blood. The sample should be taken at least 2 hours after ingestion for symptomatic patients or 4 hours for asymptomatic patients. The measurement should be repeated every 2-3 hours until the levels start to decrease. Other investigations include arterial blood gas analysis, electrolyte levels (U&Es), complete blood count (FBC), coagulation studies (raised INR/PTR), urinary pH, and blood glucose levels.

      To manage salicylate poisoning, an ABC approach should be followed to ensure a patent airway and adequate ventilation. Activated charcoal can be administered if the patient presents within 1 hour of ingestion. Oral or intravenous fluids should be given to optimize intravascular volume. Hypokalemia and hypoglycemia should be corrected. Urinary alkalinization with intravenous sodium bicarbonate can enhance the elimination of aspirin in the urine. In severe cases, hemodialysis may be necessary.

      Urinary alkalinization involves targeting a urinary pH of 7.5-8.5 and checking it hourly. It is important to monitor for hypokalemia as alkalinization can cause potassium to shift from plasma into cells. Potassium levels should be checked every 1-2 hours.

      In cases where the salicylate concentration is high (above 500 mg/L in adults or 350 mg/L in children), sodium bicarbonate can be administered intravenously. Hemodialysis is the treatment of choice for severe poisoning and may be indicated in cases of high salicylate levels, resistant metabolic acidosis, acute kidney injury, pulmonary edema, seizures and coma.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      21
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  • Question 11 - A 25-year-old woman is brought to the Emergency Department 'resus' area by ambulance...

    Incorrect

    • A 25-year-old woman is brought to the Emergency Department 'resus' area by ambulance after collapsing from heroin use. She has pinpoint pupils, a respiratory rate of 5 per minute, and a GCS of 6/15. As part of her treatment, you administer naloxone.

      Which SINGLE statement about the use of naloxone is true?

      Your Answer: It has a longer duration of action than most opioids

      Correct Answer: It can be given by a continuous infusion if repeated doses are required

      Explanation:

      Naloxone is a specific antidote for opioid overdose. It effectively reverses respiratory depression and coma when given in sufficient dosage. The initial dose is administered intravenously at 400 micrograms, followed by 800 micrograms for up to 2 doses at 1-minute intervals if there is no response to the preceding dose. If there is still no response, the dosage is increased to 2 mg for one dose. In seriously poisoned patients, a 4 mg dose may be required. If the intravenous route is not feasible, naloxone can also be given by intramuscular injection.

      Due to its shorter duration of action compared to most opioids, close monitoring and repeated injections are necessary. The frequency of doses should be based on the respiratory rate and depth of coma, with the dose generally repeated every 2-3 minutes up to a maximum of 10 mg. In cases where repeated doses are needed, naloxone can be administered through a continuous infusion, which should be adjusted according to the vital signs. Initially, the infusion rate can be set at 60% of the initial resuscitative IV dose per hour.

      It is important to note that in opioid addicts, the administration of naloxone may trigger a withdrawal syndrome characterized by symptoms such as abdominal cramps, nausea, and diarrhea. However, these symptoms typically subside within 2 hours.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      73.1
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  • Question 12 - A 28 year old male is brought into the emergency department in a...

    Correct

    • A 28 year old male is brought into the emergency department in a comatose state with suspected poisoning. An arterial blood gas sample is taken. The results are shown below:

      pH 7.22
      pO2 12.5 kpa
      pCO2 5.9 kpa
      Bicarbonate 14 mmol/l
      Chloride 98 mmol/l
      Potassium 6.1 mmol/l
      Sodium 136 mmol/l

      Overdose or poisoning with which of the following typically leads to this type of acid base disturbance?

      Your Answer: Aspirin

      Explanation:

      Salicylate poisoning often leads to a metabolic acidosis characterized by a high anion gap. The patient in question is experiencing this type of acid-base disturbance. This particular acid-base imbalance is typically seen in cases of poisoning with substances such as glycols (ethylene and propylene), salicylates (aspirin), paracetamol, methanol, isoniazid, and paraldehyde.

      Further Reading:

      Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.

      To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.

      Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.

      The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.

      The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.

      The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.

      Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.

      The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      24
      Seconds
  • Question 13 - A 60-year-old man with a history of hypertension comes to the Emergency Department...

    Incorrect

    • A 60-year-old man with a history of hypertension comes to the Emergency Department with an unrelated medical issue. While reviewing his medications, you find out that he is taking ramipril as part of his treatment.
      Which ONE of the following medications should be avoided?

      Your Answer: Gentamicin

      Correct Answer: Amiloride

      Explanation:

      Potassium-sparing diuretics, like spironolactone and amiloride, can raise the chances of developing hyperkalemia when taken alongside ACE inhibitors, such as ramipril, and angiotensin-II receptor antagonists, like losartan.

      For more information, you can refer to the BNF section on ramipril interactions.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 14 - A 45-year-old man has developed drug-induced lupus after starting a new medication.
    What is...

    Incorrect

    • A 45-year-old man has developed drug-induced lupus after starting a new medication.
      What is the PRIMARY cause of this?

      Your Answer: Bisoprolol

      Correct Answer: Hydralazine

      Explanation:

      The drugs that have the highest association with the development of drug-induced lupus are procainamide and hydralazine. While some of the other medications mentioned in this question have also been reported to cause drug-induced lupus, the strength of their association is much weaker.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 15 - You observe that a patient's temperature has risen to 41.5ºC after rapid sequence...

    Correct

    • You observe that a patient's temperature has risen to 41.5ºC after rapid sequence induction. You are worried that the patient might be experiencing malignant hyperthermia. What is typically the earliest and most frequent clinical manifestation of malignant hyperthermia?

      Your Answer: Increasing end tidal CO2

      Explanation:

      The earliest and most common clinical indication of malignant hyperthermia is typically an increase in end tidal CO2 levels.

      Further Reading:

      Malignant hyperthermia is a rare and life-threatening syndrome that can be triggered by certain medications in individuals who are genetically susceptible. The most common triggers are suxamethonium and inhalational anaesthetic agents. The syndrome is caused by the release of stored calcium ions from skeletal muscle cells, leading to uncontrolled muscle contraction and excessive heat production. This results in symptoms such as high fever, sweating, flushed skin, rapid heartbeat, and muscle rigidity. It can also lead to complications such as acute kidney injury, rhabdomyolysis, and metabolic acidosis. Treatment involves discontinuing the trigger medication, administering dantrolene to inhibit calcium release and promote muscle relaxation, and managing any associated complications such as hyperkalemia and acidosis. Referral to a malignant hyperthermia center for further investigation is also recommended.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 16 - A 35 year old male is brought into the emergency department after being...

    Incorrect

    • A 35 year old male is brought into the emergency department after being found disoriented and lethargic by a family member. The family member informs you that the patient has a history of depression and that there were multiple empty bottles of aspirin at the patient's residence. Initial tests are conducted, including a salicylate level.

      What is the plasma salicylate concentration threshold for initiating urinary alkalinization in adult patients?

      Your Answer: >150 mg/L

      Correct Answer: > 500 mg/L

      Explanation:

      In adults, urinary alkalinisation is initiated when the salicylate level exceeds 500 mg/L (>3.6 mmol/L). For children, the threshold is set at a salicylate concentration of > 350 mg/L (2.5 mmol/L).

      Further Reading:

      Salicylate poisoning, particularly from aspirin overdose, is a common cause of poisoning in the UK. One important concept to understand is that salicylate overdose leads to a combination of respiratory alkalosis and metabolic acidosis. Initially, the overdose stimulates the respiratory center, leading to hyperventilation and respiratory alkalosis. However, as the effects of salicylate on lactic acid production, breakdown into acidic metabolites, and acute renal injury occur, it can result in high anion gap metabolic acidosis.

      The clinical features of salicylate poisoning include hyperventilation, tinnitus, lethargy, sweating, pyrexia (fever), nausea/vomiting, hyperglycemia and hypoglycemia, seizures, and coma.

      When investigating salicylate poisoning, it is important to measure salicylate levels in the blood. The sample should be taken at least 2 hours after ingestion for symptomatic patients or 4 hours for asymptomatic patients. The measurement should be repeated every 2-3 hours until the levels start to decrease. Other investigations include arterial blood gas analysis, electrolyte levels (U&Es), complete blood count (FBC), coagulation studies (raised INR/PTR), urinary pH, and blood glucose levels.

      To manage salicylate poisoning, an ABC approach should be followed to ensure a patent airway and adequate ventilation. Activated charcoal can be administered if the patient presents within 1 hour of ingestion. Oral or intravenous fluids should be given to optimize intravascular volume. Hypokalemia and hypoglycemia should be corrected. Urinary alkalinization with intravenous sodium bicarbonate can enhance the elimination of aspirin in the urine. In severe cases, hemodialysis may be necessary.

      Urinary alkalinization involves targeting a urinary pH of 7.5-8.5 and checking it hourly. It is important to monitor for hypokalemia as alkalinization can cause potassium to shift from plasma into cells. Potassium levels should be checked every 1-2 hours.

      In cases where the salicylate concentration is high (above 500 mg/L in adults or 350 mg/L in children), sodium bicarbonate can be administered intravenously. Hemodialysis is the treatment of choice for severe poisoning and may be indicated in cases of high salicylate levels, resistant metabolic acidosis, acute kidney injury, pulmonary edema, seizures and coma.

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      • Pharmacology & Poisoning
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  • Question 17 - A 42-year-old woman with a long history of anxiety presents having taken a...

    Incorrect

    • A 42-year-old woman with a long history of anxiety presents having taken a deliberate overdose of the pills she takes for insomnia. She informs you that the pill she takes for this condition is zolpidem 10 mg. She consumed the pills approximately 2 hours ago. She is currently hypotensive, with her most recent blood pressure reading being 82/56 mmHg. She weighs 70 kg. You administer a dose of calcium chloride, but there is no improvement in her condition.
      Which of the following treatments is LEAST likely to be helpful in supporting her cardiovascular system?

      Your Answer: Intralipid

      Correct Answer: Magnesium sulphate

      Explanation:

      Calcium-channel blocker overdose is a serious condition that can be life-threatening. The 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 cells. These channels are important for the functioning of cardiac myocytes, vascular smooth muscle cells, and islet beta-cells.

      When managing a patient with calcium-channel blocker overdose, it is crucial to follow the standard ABC approach for resuscitation. If there is a risk of life-threatening toxicity, early intubation and ventilation should be considered. Invasive blood pressure monitoring is also necessary if hypotension and shock are developing.

      The specific treatments for calcium-channel blocker overdose primarily focus on supporting the cardiovascular system. These treatments include:

      1. Fluid resuscitation: Administer up to 20 mL/kg of crystalloid solution.

      2. Calcium administration: This can temporarily increase blood pressure and heart rate. Options include 10% calcium gluconate (60 mL IV) or 10% calcium chloride (20 mL IV) via central venous access. Repeat boluses can be given up to three times, and a calcium infusion may be necessary to maintain serum calcium levels above 2.0 mEq/L.

      3. Atropine: Consider administering 0.6 mg every 2 minutes, up to a total of 1.8 mg. However, atropine is often ineffective in these cases.

      4. High dose insulin – euglycemic therapy (HIET): The use of HIET in managing cardiovascular toxicity has evolved. It used to be a last-resort measure, but early administration is now increasingly recommended. This involves giving a bolus of short-acting insulin (1 U/kg) and 50 mL of 50% glucose IV (unless there is marked hyperglycemia). Therapy should be continued with a short-acting insulin/dextrose infusion. Glucose levels should be monitored frequently, and potassium should be replaced if levels drop below 2.5 mmol/L.

      5. Vasoactive infusions: Catecholamines such as dopamine, adrenaline, and/or noradrenaline can be titrated to achieve the desired inotropic and chronotropic effects.

      6. Sodium bicarbonate: Consider using sodium bicarbonate in cases where a severe metabolic acidosis develops.

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      • Pharmacology & Poisoning
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  • Question 18 - You are summoned to the resuscitation room to aid in the care of...

    Incorrect

    • You are summoned to the resuscitation room to aid in the care of a 48-year-old woman who was saved from a residential fire. The patient has superficial partial thickness burns on the palms of her hands, which she sustained while attempting to open scorching door handles during her escape from the fire. The fire department rescued her from a bedroom filled with smoke. The paramedics inform you that the patient appeared lethargic at the scene. A blood gas sample is obtained. Which of the following findings would indicate a potential diagnosis of cyanide poisoning?

      Your Answer: Potassium >6.5 mmol/L

      Correct Answer: Lactate >10 mmol/L

      Explanation:

      Moderate to severe cyanide poisoning typically leads to a condition called high anion gap metabolic acidosis, characterized by elevated levels of lactate (>10 mmol/L). Cyanide toxicity can occur from inhaling smoke produced by burning materials such as plastics, wools, silk, and other natural and synthetic polymers, which can release hydrogen cyanide (HCN). Symptoms of cyanide poisoning include headaches, nausea, decreased consciousness or loss of consciousness, and seizures. Measuring cyanide levels is not immediately helpful in managing a patient suspected of cyanide toxicity. Cyanide binds to the ferric (Fe3+) ion of cytochrome oxidase, causing a condition known as histotoxic hypoxia and resulting in lactic acidosis. The presence of a high lactate level (>10) and a classic high anion gap metabolic acidosis should raise suspicion of cyanide poisoning in a clinician.

      Further Reading:

      Burn injuries can be classified based on their type (degree, partial thickness or full thickness), extent as a percentage of total body surface area (TBSA), and severity (minor, moderate, major/severe). Severe burns are defined as a >10% TBSA in a child and >15% TBSA in an adult.

      When assessing a burn, it is important to consider airway injury, carbon monoxide poisoning, type of burn, extent of burn, special considerations, and fluid status. Special considerations may include head and neck burns, circumferential burns, thorax burns, electrical burns, hand burns, and burns to the genitalia.

      Airway management is a priority in burn injuries. Inhalation of hot particles can cause damage to the respiratory epithelium and lead to airway compromise. Signs of inhalation injury include visible burns or erythema to the face, soot around the nostrils and mouth, burnt/singed nasal hairs, hoarse voice, wheeze or stridor, swollen tissues in the mouth or nostrils, and tachypnea and tachycardia. Supplemental oxygen should be provided, and endotracheal intubation may be necessary if there is airway obstruction or impending obstruction.

      The initial management of a patient with burn injuries involves conserving body heat, covering burns with clean or sterile coverings, establishing IV access, providing pain relief, initiating fluid resuscitation, measuring urinary output with a catheter, maintaining nil by mouth status, closely monitoring vital signs and urine output, monitoring the airway, preparing for surgery if necessary, and administering medications.

      Burns can be classified based on the depth of injury, ranging from simple erythema to full thickness burns that penetrate into subcutaneous tissue. The extent of a burn can be estimated using methods such as the rule of nines or the Lund and Browder chart, which takes into account age-specific body proportions.

      Fluid management is crucial in burn injuries due to significant fluid losses. Evaporative fluid loss from burnt skin and increased permeability of blood vessels can lead to reduced intravascular volume and tissue perfusion. Fluid resuscitation should be aggressive in severe burns, while burns <15% in adults and <10% in children may not require immediate fluid resuscitation. The Parkland formula can be used to calculate the intravenous fluid requirements for someone with a significant burn injury.

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  • Question 19 - A 28-year-old woman is given an antibiotic while pregnant. As a result, the...

    Incorrect

    • A 28-year-old woman is given an antibiotic while pregnant. As a result, the baby is born prematurely with pale gray skin and cyanosis. The baby also has weak muscle tone, low blood pressure, and difficulty with feeding.

      Which of the following antibiotics is the most probable reason for these abnormalities?

      Your Answer: Trimethoprim

      Correct Answer: Chloramphenicol

      Explanation:

      Grey baby syndrome is a rare but serious side effect that can occur in neonates, especially premature babies, as a result of the build-up of the antibiotic chloramphenicol. This condition is characterized by several symptoms, including ashen grey skin color, poor feeding, vomiting, cyanosis, hypotension, hypothermia, hypotonia, cardiovascular collapse, abdominal distension, and respiratory difficulties.

      During pregnancy, there are several drugs that can have adverse effects on the developing fetus. ACE inhibitors, such as ramipril, if given in the second and third trimesters, can lead to hypoperfusion, renal failure, and the oligohydramnios sequence. Aminoglycosides, like gentamicin, can cause ototoxicity and deafness. High doses of aspirin can result in first-trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses of aspirin (e.g., 75 mg) do not pose significant risks.

      Benzodiazepines, such as diazepam, when administered late in pregnancy, can cause respiratory depression and a neonatal withdrawal syndrome. Calcium-channel blockers, if given in the first trimester, may lead to phalangeal abnormalities, while their use in the second and third trimesters can result in fetal growth retardation. Carbamazepine can cause hemorrhagic disease of the newborn and neural tube defects.

      Chloramphenicol, as mentioned earlier, can cause grey baby syndrome. Corticosteroids, if given in the first trimester, may cause orofacial clefts. Danazol, if administered in the first trimester, can cause masculinization of the female fetuses genitals. Pregnant women should avoid handling crushed or broken tablets of finasteride, as it can be absorbed through the skin and affect male sex organ development.

      Haloperidol, if given in the first trimester, may cause limb malformations, while its use in the third trimester increases the risk of extrapyramidal symptoms in the neonate. Heparin can lead to maternal bleeding and thrombocytopenia. Isoniazid can cause maternal liver damage and neuropathy and seizures in the neonate. Isotretinoin carries a high risk of teratogenicity, including multiple congenital malformations, spontaneous abortion, and intellectual disability

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      • Pharmacology & Poisoning
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  • Question 20 - A 42-year-old man has recently taken an antibiotic for a skin infection. He...

    Correct

    • A 42-year-old man has recently taken an antibiotic for a skin infection. He has been experiencing palpitations and had an ECG performed, which shows the presence of new QT prolongation.
      Which of the following antibiotics is he most likely to have taken?

      Your Answer: Erythromycin

      Explanation:

      Prolongation of the QT interval can lead to a dangerous ventricular arrhythmia called torsades de pointes, which can result in sudden cardiac death. There are several commonly used medications that are known to cause QT prolongation.

      Low levels of potassium (hypokalaemia) and magnesium (hypomagnesaemia) can increase the risk of QT prolongation. For example, diuretics can interact with QT-prolonging drugs by causing hypokalaemia.

      The QT interval varies with heart rate, and formulas are used to correct the QT interval for heart rate. Once corrected, it is referred to as the QTc interval. The QTc interval is typically reported on the ECG printout. A normal QTc interval is less than 440 ms.

      If the QTc interval is greater than 440 ms but less than 500 ms, it is considered borderline. Although there may be some variation in the literature, a QTc interval within these values is generally considered borderline prolonged. In such cases, it is important to consider reducing the dose of QT-prolonging drugs or switching to an alternative medication that does not prolong the QT interval.

      A prolonged QTc interval exceeding 500 ms is clinically significant and is likely to increase the risk of arrhythmia. Any medications that prolong the QT interval should be reviewed immediately.

      Here are some commonly encountered drugs that are known to prolong the QT interval:

      Antimicrobials:
      – Erythromycin
      – Clarithromycin
      – Moxifloxacin
      – Fluconazole
      – Ketoconazole

      Antiarrhythmics:
      – Dronedarone
      – Sotalol
      – Quinidine
      – Amiodarone
      – Flecainide

      Antipsychotics:
      – Risperidone
      – Fluphenazine
      – Haloperidol
      – Pimozide
      – Chlorpromazine
      – Quetiapine
      – Clozapine

      Antidepressants:
      – Citalopram/escitalopram
      – Amitriptyline
      – Clomipramine
      – Dosulepin
      – Doxepin
      – Imipramine
      – Lofepramine

      Antiemetics:
      – Domperidone
      – Droperidol
      – Ondansetron/Granisetron

      Others:
      – Methadone
      – Protein kinase inhibitors (e.g. sunitinib)

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  • Question 21 - A 40-year-old man is prescribed a medication for a neurological condition in the...

    Incorrect

    • A 40-year-old man is prescribed a medication for a neurological condition in the 2nd-trimester of his wife's pregnancy. The baby is born with restlessness, muscle contractions, shaking, and exhibits unsteady, abrupt movements.

      Which of the following medications is the most probable reason for these abnormalities?

      Your Answer: Carbamazepine

      Correct Answer: Haloperidol

      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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      • Pharmacology & Poisoning
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  • Question 22 - A 48-year-old woman, who has recently been diagnosed with hypertension, presents with weakness,...

    Incorrect

    • A 48-year-old woman, who has recently been diagnosed with hypertension, presents with weakness, stiffness, and aching of her arms that are most pronounced around her shoulders and upper arms. On examination, she has reduced tone in her arms and a reduced biceps reflex. She finds lifting objects somewhat difficult. There is no apparent sensory deficit. She has recently been started on a medication for her hypertension.
      A recent check of her U&Es reveals the following biochemical picture:
      K+ 6.9 mmol/L
      Na+ 138 mmol/L
      eGFR 50 ml/min/1.73m2
      Which antihypertensive is she most likely to have been prescribed?

      Your Answer: Amlodipine

      Correct Answer: Ramipril

      Explanation:

      This patient has presented with symptoms and signs consistent with myopathy. Myopathy is characterized by muscle weakness, muscle atrophy, and reduced tone and reflexes. Hyperkalemia is a known biochemical cause for myopathy, while other metabolic causes include hypokalemia, hypercalcemia, hypomagnesemia, hyperthyroidism, hypothyroidism, diabetes mellitus, Cushing’s disease, and Conn’s syndrome. In this case, ACE inhibitors, such as ramipril, are a well-recognized cause of hyperkalemia and are likely responsible.

      Commonly encountered side effects of ACE inhibitors include renal impairment, persistent dry cough, angioedema (with delayed onset), rashes, upper respiratory tract symptoms (such as a sore throat), and gastrointestinal upset.

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      • Pharmacology & Poisoning
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  • Question 23 - A 45 year old male is brought into the emergency department after being...

    Incorrect

    • A 45 year old male is brought into the emergency department after being attacked by a snake while hiking in the mountains. The patient arrives in the emergency department appearing pale and sickly about 15 minutes after the attack and experiences vomiting during the initial assessment. You suspect the presence of systemic envenomation. What is the recommended minimum period of monitoring for individuals with suspected snake bite envenoming?

      Your Answer: 4 hours

      Correct Answer: 24 hours

      Explanation:

      Patients who have been bitten by a venomous snake, such as the adder in the UK, should be admitted to the hospital for a minimum of 24 hours. While most snake bites only cause localized symptoms, there is a small chance of life-threatening reactions to the venom. When patients arrive at the emergency department after a snake bite, they should undergo a quick assessment to determine the severity of the envenoming and receive resuscitation if necessary. If indicated, anti-venom should be administered. Following this, patients should be closely monitored for changes in blood pressure and the progression of envenoming for at least 24 hours.

      Further Reading:

      Snake bites in the UK are primarily caused by the adder, which is the only venomous snake species native to the country. While most adder bites result in minor symptoms such as pain, swelling, and inflammation, there have been cases of life-threatening illness and fatalities. Additionally, there are instances where venomous snakes that are kept legally or illegally also cause bites in the UK.

      Adder bites typically occur from early spring to late autumn, with the hand being the most common site of the bite. Symptoms can be local or systemic, with local symptoms including sharp pain, tingling or numbness, and swelling that spreads proximally. Systemic symptoms may include spreading pain, tenderness, inflammation, regional lymph node enlargement, and bruising. In severe cases, anaphylaxis can occur, leading to symptoms such as nausea, vomiting, abdominal pain, diarrhea, and shock.

      It is important for clinicians to be aware of the potential complications and complications associated with adder bites. These can include acute renal failure, pulmonary and cerebral edema, acute gastric dilatation, paralytic ileus, acute pancreatitis, and coma and seizures. Anaphylaxis symptoms can appear within minutes or be delayed for hours, and hypotension is a critical sign to monitor.

      Initial investigations for adder bites include blood tests, ECG, and vital sign monitoring. Further investigations such as chest X-ray may be necessary based on clinical signs. Blood tests may reveal abnormalities such as leukocytosis, raised hematocrit, anemia, thrombocytopenia, and abnormal clotting profile. ECG changes may include tachyarrhythmias, bradyarrhythmias, atrial fibrillation, and ST segment changes.

      First aid measures at the scene include immobilizing the patient and the bitten limb, avoiding aspirin and ibuprofen, and cleaning the wound site in the hospital. Tetanus prophylaxis should be considered. In cases of anaphylaxis, prompt administration of IM adrenaline is necessary. In the hospital, rapid assessment and appropriate resuscitation with intravenous fluids are required.

      Antivenom may be indicated in cases of hypotension, systemic envenoming, ECG abnormalities, peripheral neutrophil leucocytosis, elevated serum creatine kinase or metabolic acidosis, and extensive or rapidly spreading local swelling. Zagreb antivenom is commonly used in the UK, with an initial dose of 8 mL

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  • Question 24 - A 17 year old girl is admitted to the emergency department following a...

    Correct

    • A 17 year old girl is admitted to the emergency department following a suicide attempt. The patient consumed a container of expired insecticide and reports feeling unwell shortly after ingestion, resulting in two episodes of vomiting. After consulting toxbase, it is determined that the product is an organophosphate.

      Which of the following is an established antidote for organophosphate poisoning?

      Your Answer: Atropine

      Explanation:

      Atropine and pralidoxime are both considered antidotes for treating organophosphate poisoning. Organophosphates work by inhibiting acetylcholinesterase at nerve synapses. In addition to providing supportive care and administering antidotes, it is important to decontaminate patients as part of their treatment plan for organophosphate poisoning.

      While both atropine and pralidoxime are recognized as antidotes, pralidoxime is not commonly used. Atropine works by competing with acetylcholine at the muscarinic receptors. On the other hand, pralidoxime helps reactivate acetylcholinesterase-organophosphate complexes that have not lost an alkyl side chain, known as non-aged complexes. However, pralidoxime is not effective against organophosphates that have already formed or rapidly form aged acetylcholinesterase complexes. The evidence regarding the effectiveness of pralidoxime is conflicting.

      Further Reading:

      Chemical incidents can occur as a result of leaks, spills, explosions, fires, terrorism, or the use of chemicals during wars. Industrial sites that use chemicals are required to conduct risk assessments and have accident plans in place for such incidents. Health services are responsible for decontamination, unless mass casualties are involved, and all acute health trusts must have major incident plans in place.

      When responding to a chemical incident, hospitals prioritize containment of the incident and prevention of secondary contamination, triage with basic first aid, decontamination if not done at the scene, recognition and management of toxidromes (symptoms caused by exposure to specific toxins), appropriate supportive or antidotal treatment, transfer to definitive treatment, a safe end to the hospital response, and continuation of business after the event.

      To obtain advice when dealing with chemical incidents, the two main bodies are Toxbase and the National Poisons Information Service. Signage on containers carrying chemicals and material safety data sheets (MSDS) accompanying chemicals also provide information on the chemical contents and their hazards.

      Contamination in chemical incidents can occur in three phases: primary contamination from the initial incident, secondary contamination spread via contaminated people leaving the initial scene, and tertiary contamination spread to the environment, including becoming airborne and waterborne. The ideal personal protective equipment (PPE) for chemical incidents is an all-in-one chemical-resistant overall with integral head/visor and hands/feet worn with a mask, gloves, and boots.

      Decontamination of contaminated individuals involves the removal and disposal of contaminated clothing, followed by either dry or wet decontamination. Dry decontamination is suitable for patients contaminated with non-caustic chemicals and involves blotting and rubbing exposed skin gently with dry absorbent material. Wet decontamination is suitable for patients contaminated with caustic chemicals and involves a warm water shower while cleaning the body with simple detergent.

      After decontamination, the focus shifts to assessing the extent of any possible poisoning and managing it. The patient’s history should establish the chemical the patient was exposed to, the volume and concentration of the chemical, the route of exposure, any protective measures in place, and any treatment given. Most chemical poisonings require supportive care using standard resuscitation principles, while some chemicals have specific antidotes. Identifying toxidromes can be useful in guiding treatment, and specific antidotes may be administered accordingly.

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  • Question 25 - A 32-year-old man has ingested an excessive amount of medication. He experiences nausea,...

    Correct

    • A 32-year-old man has ingested an excessive amount of medication. He experiences nausea, perspiration, and ringing in the ears. His arterial blood gas reveals a respiratory alkalosis, and his ECG displays an elongation of the QRS complex.
      Which drug is he most likely to have overdosed on?

      Your Answer: Aspirin

      Explanation:

      Salicylate poisoning is a fairly common form of poisoning that can lead to organ damage and death if not treated promptly. Some common symptoms include nausea, vomiting, ringing in the ears, hearing loss, excessive sweating, and dehydration. Additionally, individuals may experience rapid breathing, flushed skin, and high fever, particularly in children. In severe cases, convulsions, swelling of the brain, coma, kidney failure, fluid accumulation in the lungs unrelated to heart problems, and unstable cardiovascular function may occur.

      Early on in the overdose, arterial blood gas analysis typically reveals a respiratory alkalosis due to overstimulation of the respiratory center. As the overdose progresses, especially in moderate to severe cases, a metabolic acidosis with an increased anion gap may develop as a result of elevated levels of protons in the blood.

      Electrocardiogram (ECG) abnormalities that may be observed include widening of the QRS complex, atrioventricular (AV) block, and ventricular arrhythmias.

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  • Question 26 - A 40-year-old man is brought to the Emergency Department by his wife following...

    Incorrect

    • A 40-year-old man is brought to the Emergency Department by his wife following taking an overdose of one of his prescribed medications. Upon further questioning, you discover that he has taken an overdose of quetiapine. You discuss the case with your consultant, and she explains that the clinical features of this type of poisoning are due to central and peripheral acetylcholine receptor blockade.

      Which of the following clinical effects occurs as a result of peripheral acetylcholine receptor blockade?

      Your Answer: Seizures

      Correct Answer: Mydriasis

      Explanation:

      Anticholinergic drugs work by blocking the effects of acetylcholine, a neurotransmitter, in both the central and peripheral nervous systems. These drugs are commonly used in clinical practice and include antihistamines, typical and atypical antipsychotics, anticonvulsants, antidepressants, antispasmodics, antiemetics, antiparkinsonian agents, antimuscarinics, and certain plants. When someone ingests an anticholinergic drug, they may experience a toxidrome, which is characterized by an agitated delirium and various signs of acetylcholine receptor blockade in the central and peripheral systems.

      The central effects of anticholinergic drugs result in an agitated delirium, which is marked by fluctuating mental status, confusion, restlessness, visual hallucinations, picking at objects in the air, mumbling, slurred speech, disruptive behavior, tremor, myoclonus, and in rare cases, coma or seizures. On the other hand, the peripheral effects can vary and may include dilated pupils, sinus tachycardia, dry mouth, hot and flushed skin, increased body temperature, urinary retention, and ileus.

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  • Question 27 - A 25-year-old woman is brought to the emergency department by her roommate after...

    Correct

    • A 25-year-old woman is brought to the emergency department by her roommate after intentionally overdosing on amitriptyline. You administer activated charcoal. Which other medication, listed as an antidote by RCEM/NPIS, can be used to treat tricyclic overdose?

      Your Answer: Sodium bicarbonate

      Explanation:

      Sodium bicarbonate is recommended as a treatment for TCA overdose according to the latest guidelines from RCEM and NPIS in 2021. Previous editions also suggested using glucagon if IV fluids and sodium bicarbonate were ineffective in treating the overdose.

      Further Reading:

      Tricyclic antidepressant (TCA) overdose is a common occurrence in emergency departments, with drugs like amitriptyline and dosulepin being particularly dangerous. TCAs work by inhibiting the reuptake of norepinephrine and serotonin in the central nervous system. In cases of toxicity, TCAs block various receptors, including alpha-adrenergic, histaminic, muscarinic, and serotonin receptors. This can lead to symptoms such as hypotension, altered mental state, signs of anticholinergic toxicity, and serotonin receptor effects.

      TCAs primarily cause cardiac toxicity by blocking sodium and potassium channels. This can result in a slowing of the action potential, prolongation of the QRS complex, and bradycardia. However, the blockade of muscarinic receptors also leads to tachycardia in TCA overdose. QT prolongation and Torsades de Pointes can occur due to potassium channel blockade. TCAs can also have a toxic effect on the myocardium, causing decreased cardiac contractility and hypotension.

      Early symptoms of TCA overdose are related to their anticholinergic properties and may include dry mouth, pyrexia, dilated pupils, agitation, sinus tachycardia, blurred vision, flushed skin, tremor, and confusion. Severe poisoning can lead to arrhythmias, seizures, metabolic acidosis, and coma. ECG changes commonly seen in TCA overdose include sinus tachycardia, widening of the QRS complex, prolongation of the QT interval, and an R/S ratio >0.7 in lead aVR.

      Management of TCA overdose involves ensuring a patent airway, administering activated charcoal if ingestion occurred within 1 hour and the airway is intact, and considering gastric lavage for life-threatening cases within 1 hour of ingestion. Serial ECGs and blood gas analysis are important for monitoring. Intravenous fluids and correction of hypoxia are the first-line therapies. IV sodium bicarbonate is used to treat haemodynamic instability caused by TCA overdose, and benzodiazepines are the treatment of choice for seizure control. Other treatments that may be considered include glucagon, magnesium sulfate, and intravenous lipid emulsion.

      There are certain things to avoid in TCA overdose, such as anti-arrhythmics like quinidine and flecainide, as they can prolonged depolarization.

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  • Question 28 - You assess a 70-year-old woman who is admitted to the clinical decision unit...

    Incorrect

    • You assess a 70-year-old woman who is admitted to the clinical decision unit (CDU) after a fall last night. She has a significant cardiac history, having experienced a heart attack 3 years ago and is currently being evaluated for cardiac arrhythmias. She occasionally experiences episodes of angina. Upon reviewing her medication list, you identify one specific medication that should be discontinued immediately.

      Your Answer: Isosorbide mononitrate

      Correct Answer: Verapamil

      Explanation:

      Verapamil is a type of calcium-channel blocker that is commonly used to treat irregular heart rhythms and chest pain. It is important to note that verapamil should not be taken at the same time as beta-blockers like atenolol. This is because when these medications are combined, they can have a negative impact on the heart’s ability to contract and its heart rate. This can lead to low blood pressure, slow heart rate, problems with the electrical signals in the heart, heart failure, and even a pause in the heart’s normal rhythm. However, the other medications mentioned in this question can be safely used together with beta-blockers.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 29 - A 25-year-old man is brought to the Emergency Department by his friend because...

    Incorrect

    • A 25-year-old man is brought to the Emergency Department by his friend because he took an excessive amount of aspirin 45 minutes ago.
      Which of the following should NOT be included in the treatment plan for severe salicylate poisoning that presents within 1 hour of overdose?

      Your Answer: Aggressive intravenous fluid resuscitation

      Correct Answer: Forced alkaline diuresis

      Explanation:

      Salicylate poisoning is a fairly common form of poisoning that can lead to organ damage and death if not treated promptly. The symptoms of salicylate poisoning include nausea, vomiting, ringing in the ears, hearing loss, excessive sweating, dehydration, rapid breathing, flushed skin, and high fever in children. In severe cases, convulsions, swelling of the brain, coma, kidney failure, fluid in the lungs, and unstable heart function can occur.

      The treatment for salicylate poisoning involves stabilizing the patient’s airway, breathing, and circulation as needed, preventing further absorption of the poison, enhancing its elimination from the body, correcting any metabolic abnormalities, and providing supportive care. Unfortunately, there is no specific antidote available for salicylates. If a large amount of salicylate has been ingested within the past hour (more than 4.5 grams in adults or more than 2 grams in children), gastric lavage (stomach pumping) and administration of activated charcoal (50 grams) are recommended to reduce absorption and increase elimination.

      Medical investigations for salicylate poisoning should include measuring the level of salicylate in the blood, analyzing arterial blood gases, performing an electrocardiogram (ECG), checking blood glucose levels, assessing kidney function and electrolyte levels, and evaluating blood clotting. ECG abnormalities that may be present include widening of the QRS complex, AV block, and ventricular arrhythmias.

      The severity of salicylate poisoning is determined by the level of salicylate in the blood. Mild poisoning is defined as a salicylate level below 450 mg/L, moderate poisoning is between 450-700 mg/L, and severe poisoning is above 700 mg/L. In severe cases, aggressive intravenous fluid therapy is necessary to correct dehydration, and administration of 1.26% sodium bicarbonate can help eliminate the salicylate from the body. It is important to maintain a urine pH of greater than 7.5, ideally between 8.0-8.5. However, forced alkaline diuresis is no longer recommended. Life-threatening cases may require admission to the intensive care unit, intubation and ventilation, and possibly hemodialysis.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 30 - A 32-year-old male patient arrives at the Emergency Department after ingesting an overdose...

    Incorrect

    • A 32-year-old male patient arrives at the Emergency Department after ingesting an overdose of paracetamol tablets 45 minutes ago. He is currently showing no symptoms and is stable in terms of his blood circulation. The attending physician recommends administering a dose of activated charcoal.
      What is the appropriate dosage of activated charcoal to administer?

      Your Answer: 50 g orally

      Correct Answer:

      Explanation:

      Activated charcoal is a commonly utilized substance for decontamination in cases of poisoning. Its main function is to attract and bind molecules of the ingested toxin onto its surface.

      Activated charcoal is a chemically inert form of carbon. It is a fine black powder that has no odor or taste. This powder is created by subjecting carbonaceous matter to high heat, a process known as pyrolysis, and then concentrating it with a solution of zinc chloride. Through this process, the activated charcoal develops a complex network of pores, providing it with a large surface area of approximately 3,000 m2/g. This extensive surface area allows it to effectively hinder the absorption of the harmful toxin by up to 50%.

      The typical dosage for adults is 50 grams, while children are usually given 1 gram per kilogram of body weight. Activated charcoal can be administered orally or through a nasogastric tube. It is crucial to administer it within one hour of ingestion, and if necessary, a second dose may be repeated after one hour.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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