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  • Question 1 - A 42 year old man visits the emergency department. He had a mishap...

    Incorrect

    • A 42 year old man visits the emergency department. He had a mishap and fell into a glass window, resulting in a significant cut on his left forearm. You suggest that this can be stitched up using local anesthesia. What is the highest dosage of lidocaine with adrenaline that can be administered for this procedure?

      Your Answer: 1 mg/kg

      Correct Answer: 7 mg/kg

      Explanation:

      The recommended dose of adrenaline is 7 mg per kilogram of body weight, with a maximum limit of 500 mg.

      Local anaesthetics, such as lidocaine, bupivacaine, and prilocaine, are commonly used in the emergency department for topical or local infiltration to establish a field block. Lidocaine is often the first choice for field block prior to central line insertion. These anaesthetics work by blocking sodium channels, preventing the propagation of action potentials.

      However, local anaesthetics can enter the systemic circulation and cause toxic side effects if administered in high doses. Clinicians must be aware of the signs and symptoms of local anaesthetic systemic toxicity (LAST) and know how to respond. Early signs of LAST include numbness around the mouth or tongue, metallic taste, dizziness, visual and auditory disturbances, disorientation, and drowsiness. If not addressed, LAST can progress to more severe symptoms such as seizures, coma, respiratory depression, and cardiovascular dysfunction.

      The management of LAST is largely supportive. Immediate steps include stopping the administration of local anaesthetic, calling for help, providing 100% oxygen and securing the airway, establishing IV access, and controlling seizures with benzodiazepines or other medications. Cardiovascular status should be continuously assessed, and conventional therapies may be used to treat hypotension or arrhythmias. Intravenous lipid emulsion (intralipid) may also be considered as a treatment option.

      If the patient goes into cardiac arrest, CPR should be initiated following ALS arrest algorithms, but lidocaine should not be used as an anti-arrhythmic therapy. Prolonged resuscitation may be necessary, and intravenous lipid emulsion should be administered. After the acute episode, the patient should be transferred to a clinical area with appropriate equipment and staff for further monitoring and care.

      It is important to report cases of local anaesthetic toxicity to the appropriate authorities, such as the National Patient Safety Agency in the UK or the Irish Medicines Board in the Republic of Ireland. Additionally, regular clinical review should be conducted to exclude pancreatitis, as intravenous lipid emulsion can interfere with amylase or lipase assays.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 2 - You are informed that a 45-year-old individual is en route to the emergency...

    Incorrect

    • You are informed that a 45-year-old individual is en route to the emergency department after inhaling an unidentified gas that was intentionally released on a commuter train. Authorities suspect a potential terrorist attack and recommend checking the patient for signs of organophosphate poisoning. What clinical feature would be anticipated in a case of organophosphate poisoning?

      Your Answer: Pseudoobstruction

      Correct Answer: Drooling saliva

      Explanation:

      Organophosphate poisoning is characterized by a set of symptoms known as SLUDGE (Salivation, Lacrimation, Urination, Defecation, Gastric cramps, Emesis). Additionally, individuals affected may experience pinpoint pupils, profuse sweating, tremors, and confusion. Organophosphates serve as the foundation for various weaponized nerve agents like Sarin and VX, which were infamously employed by the terrorist group Aum Shinrikyo during multiple attacks in Tokyo in the mid-1990s. While SLUDGE is a commonly used acronym to recall the clinical features, it is important to note that other symptoms such as pinpoint pupils, profuse sweating, tremors, and confusion are not included in the acronym.

      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.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 3 - A 35-year-old woman is given a medication for a medical ailment during the...

    Incorrect

    • A 35-year-old woman is given a medication for a medical ailment during the 4th and 5th month of her pregnancy. As a result, the unborn baby has experienced reduced blood flow and a condition known as oligohydramnios sequence.
      Which of the listed medications is the most probable cause of these abnormalities?

      Your Answer: Aspirin

      Correct Answer: Ramipril

      Explanation:

      During the second and third trimesters of pregnancy, exposure to ACE inhibitors can lead to hypoperfusion, renal failure, and the oligohydramnios sequence. This sequence refers to the abnormal physical appearance of a fetus or newborn due to low levels of amniotic fluid in the uterus. It is also associated with malformations of the patient ductus arteriosus and aortic arch. These defects are believed to be caused by the inhibitory effects of ACE inhibitors on the renin-angiotensin-aldosterone system. To avoid these risks, it is recommended to discontinue ACE inhibitors before the second trimester.

      Here is a list outlining the most commonly encountered drugs that have adverse effects during pregnancy:

      Drug: ACE inhibitors
      Adverse effects: If given in the second and third trimesters, can cause hypoperfusion, renal failure, and the oligohydramnios sequence.

      Drug: Aminoglycosides
      Adverse effects: Ototoxicity (damage to the ear) and deafness.

      Drug: Aspirin
      Adverse effects: High doses can cause first trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. Low doses (e.g. 75 mg) have no significant associated risk.

      Drug: Benzodiazepines
      Adverse effects: When given late in pregnancy, respiratory depression and a neonatal withdrawal syndrome can occur.

      Drug: Calcium-channel blockers
      Adverse effects: If given in the first trimester, can cause phalangeal abnormalities. If given in the second and third trimesters, can cause fetal growth retardation.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      75
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  • Question 4 - A 30-year-old woman with a history of schizophrenia comes in with a side...

    Incorrect

    • A 30-year-old woman with a history of schizophrenia comes in with a side effect caused by the antipsychotic medication she is currently using.

      Which ONE statement about the side effects of antipsychotic drugs is accurate?

      Your Answer: Akathisia is an inability to initiate movement

      Correct Answer: Haloperidol is the most common antipsychotic drug to cause extrapyramidal side effects

      Explanation:

      Extrapyramidal side effects are most commonly seen with the piperazine phenothiazines (fluphenazine, prochlorperazine, and trifluoperazine) and butyrophenones (benperidol and haloperidol). Among these, haloperidol is the most frequently implicated antipsychotic drug.

      Tardive dyskinesia, which involves rhythmic and involuntary movements of the tongue, face, and jaw, typically develops after long-term treatment or high doses. It is the most severe manifestation of extrapyramidal symptoms, as it may become irreversible even after discontinuing the causative drug, and treatment options are generally ineffective.

      Dystonia, characterized by abnormal movements of the face and body, is more commonly observed in children and young adults and tends to occur after only a few doses. Acute dystonia can be managed with intravenous administration of procyclidine (5 mg) or benzatropine (2 mg) as a bolus.

      Akathisia refers to an unpleasant sensation of restlessness, while akinesia refers to an inability to initiate movement.

      Elderly patients with dementia-related psychosis who are treated with haloperidol have an increased risk of mortality. This is believed to be due to a higher likelihood of experiencing cardiovascular events and infections such as pneumonia.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 5 - A 62-year-old woman with a history of hypertension comes to the Emergency Department...

    Incorrect

    • A 62-year-old woman with a history of hypertension comes to the Emergency Department with an unrelated medical issue. While reviewing her medications, you find out that she is taking losartan as part of her treatment.
      Which ONE of the following medications should be avoided?

      Your Answer: Amoxicillin

      Correct Answer: Eplerenone

      Explanation:

      Potassium-sparing diuretics, like spironolactone and eplerenone, can raise the chances of developing hyperkalemia when taken alongside ACE inhibitors, such as ramipril, and angiotensin-II receptor antagonists, like losartan. Additionally, eplerenone can also heighten the risk of hypotension when co-administered with losartan.

      For more information, please refer to the BNF section on losartan interactions.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 6 - A 70-year-old woman experiences a sudden rupture of her Achilles tendon after completing...

    Correct

    • A 70-year-old woman experiences a sudden rupture of her Achilles tendon after completing a round of antibiotics.
      Which of the following antibiotics is MOST likely to have caused this rupture?

      Your Answer: Ciprofloxacin

      Explanation:

      Fluoroquinolones are a rare but acknowledged cause of tendinopathy and spontaneous tendon rupture. It is estimated that tendon disorders related to fluoroquinolones occur in approximately 15 to 20 out of every 100,000 patients. These issues are most commonly observed in individuals who are over the age of 60.

      The Achilles tendon is the most frequently affected, although cases involving other tendons such as the quadriceps, peroneus brevis, extensor pollicis longus, the long head of biceps brachii, and rotator cuff tendons have also been reported. The exact underlying mechanism is not fully understood, but it is believed that fluoroquinolone drugs may hinder collagen function and/or disrupt blood supply to the tendon.

      There are other risk factors associated with spontaneous tendon rupture, including corticosteroid therapy, hypercholesterolemia, gout, rheumatoid arthritis, long-term dialysis, and renal transplantation.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 7 - A 45-year-old woman with a history of chronic heart failure presents to the...

    Correct

    • A 45-year-old woman with a history of chronic heart failure presents to the Emergency Department with an infection. Upon reviewing her medications, you discover that she is taking furosemide as part of her management.

      Which ONE of the following antibiotics should be avoided?

      Your Answer: Gentamicin

      Explanation:

      When furosemide and gentamicin are prescribed together, there is a higher chance of experiencing ototoxicity and deafness. It is recommended to avoid co-prescribing these medications. For more information, you can refer to the BNF section on furosemide interactions.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 8 - A 68-year-old man develops hearing loss and renal impairment after inpatient treatment for...

    Correct

    • A 68-year-old man develops hearing loss and renal impairment after inpatient treatment for urinary sepsis.

      Which of the following antibiotics is most likely to have been administered?

      Your Answer: Gentamicin

      Explanation:

      Gentamicin is an antibiotic belonging to the aminoglycoside class. It works by binding to the 30S subunit of the ribosome in bacteria, thereby preventing the binding of aminoacyl-tRNA and ultimately inhibiting the initiation of protein synthesis.

      The two most significant side effects associated with gentamicin are hearing loss and reversible nephrotoxicity. These side effects are directly related to the dosage of the medication and are more commonly observed in elderly individuals.

      Hearing loss occurs due to damage to the vestibular apparatus located in the inner ear. On the other hand, nephrotoxicity is caused by the inhibition of protein synthesis in renal cells. This inhibition leads to necrosis of the cells in the proximal convoluted tubule and results in a condition known as acute tubular necrosis.

      In summary, gentamicin mechanism of action and side effects, such as hearing loss and reversible nephrotoxicity, are closely linked to its interaction with the bacterial ribosome and its impact on protein synthesis. These effects are particularly prevalent in the elderly population.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      13
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  • Question 9 - A 35-year-old patient with a history of schizophrenia comes in with side effects...

    Incorrect

    • A 35-year-old patient with a history of schizophrenia comes in with side effects from haloperidol, which they were recently prescribed. Upon examination, you observe that they have significant muscle stiffness, a decreased level of consciousness, and a body temperature of 40ÂșC.
      What side effect has manifested?

      Your Answer: Serotonin syndrome

      Correct Answer: Neuroleptic malignant syndrome

      Explanation:

      First-generation antipsychotics, also known as conventional or typical antipsychotics, are powerful blockers of the dopamine D2 receptor. However, each drug in this category has different effects on other receptors, such as serotonin type 2 (5-HT2), alpha1, histaminic, and muscarinic receptors.

      These first-generation antipsychotics are known to have a high incidence of extrapyramidal side effects, which include rigidity, bradykinesia, dystonias, tremor, akathisia, tardive dyskinesia, and neuroleptic malignant syndrome (NMS). NMS is a rare and life-threatening reaction to neuroleptic medications, characterized by fever, muscle stiffness, changes in mental state, and dysfunction of the autonomic nervous system. NMS typically occurs shortly after starting or increasing the dose of neuroleptic treatment.

      On the other hand, second-generation antipsychotics, also referred to as novel or atypical antipsychotics, are dopamine D2 antagonists, except for aripiprazole. These medications are associated with lower rates of extrapyramidal side effects and NMS compared to the first-generation antipsychotics. However, they have higher rates of metabolic side effects and weight gain.

      It is important to note that serotonin syndrome shares similar features with NMS but can be distinguished by the causative agent, most commonly the serotonin-specific reuptake inhibitors.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 10 - A 45-year-old patient presents with acute theophylline toxicity. In addition to theophylline, he...

    Incorrect

    • A 45-year-old patient presents with acute theophylline toxicity. In addition to theophylline, he uses salbutamol and beclomethasone inhalers.
      What is the most likely factor that triggered this episode?

      Your Answer: Carbamazepine

      Correct Answer: Heart failure

      Explanation:

      Theophylline is a medication used to treat severe asthma. It is a bronchodilator that comes in modified-release forms, which can maintain therapeutic levels in the blood for 12 hours. Theophylline works by inhibiting phosphodiesterase and blocking the breakdown of cyclic AMP. It also competes with adenosine on A1 and A2 receptors.

      Achieving the right dose of theophylline can be challenging because there is a narrow range between therapeutic and toxic levels. The half-life of theophylline can be influenced by various factors, further complicating dosage adjustments. It is recommended to aim for serum levels of 10-20 mg/l six to eight hours after the last dose.

      Unlike many other medications, the specific brand of theophylline can significantly impact its effects. Therefore, it is important to prescribe theophylline by both its brand name and generic name.

      Several factors can increase the half-life of theophylline, including heart failure, cirrhosis, viral infections, and certain drugs. Conversely, smoking, heavy drinking, and certain medications can decrease the half-life of theophylline.

      There are several drugs that can either increase or decrease the plasma concentration of theophylline. Calcium channel blockers, cimetidine, fluconazole, macrolides, methotrexate, and quinolones can increase the concentration. On the other hand, carbamazepine, phenobarbitol, phenytoin, rifampicin, and St. John’s wort can decrease the concentration.

      The clinical symptoms of theophylline toxicity are more closely associated with acute overdose rather than chronic overexposure. Common symptoms include headache, dizziness, nausea, vomiting, abdominal pain, rapid heartbeat, dysrhythmias, seizures, mild metabolic acidosis, low potassium, low magnesium, low phosphates, abnormal calcium levels, and high blood sugar.

      Seizures are more prevalent in acute overdose cases, while chronic overdose typically presents with minimal gastrointestinal symptoms. Cardiac dysrhythmias are more common in chronic overdose situations compared to acute overdose.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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Pharmacology & Poisoning (3/10) 30%
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