Critical Care Emergency

Front 1

Aortic dissection: what classifications need to be operated on.

Back 1

Type A
or Type 1 and 2

Involving ascending arch

Front 2

Does aortic dissection cause hypertension or hypotension?

Back 2

hypertension

Front 3

What's the first line inv for suspected aortic dissection?

Back 3

CT contrast b/c it's fast
Alternative 1st line is TOE

MRI most accurate but slow.;

Front 4

Medical management

Back 4

Pain relief (morphine/fentanyl)
Beta blockers (esmalol, metopralol. Aim for systolic 100-120 to reduce shear forces)
If still hypertensive give sodium nitroprusside AFTER beta blocker to prevent reflex tachy which will increase shear forces)

Front 5

What is the 1 year risk of rupture of AAA between 6-7cm

Back 5

25%

Front 6

What is conservative rx for AAA

Back 6

CVD risk factor control
HTN, lipids, diabetes etc.

Front 7

How does acute pancreatitis present?

Back 7

Gradual or sudden severe, deep, constant epigastric or central abdominal pain (radiating to the back or both costal margins; relieved by sitting forward); vomiting; nausea; anorexia; tachycardia; fever; jaundice; shock; ileus; rigid abdomen ± local/generalised tenderness and periumbilical discolouration (Cullen’s sign) or discolourisation/bruising in the flanks (Grey Turner’s sign); may have absent bowel sounds

Front 8

Which test most sensitive for pancreatitis?

Back 8

lipase

Front 9

Management for pancreatitis?

Back 9

NBM controvesial for mild and severe pancreatitis

IVF resus with NS and morphine
OR lots of NS until vital signs satisfactory and urine >30ml/hr
Urinary ctheter, hourly obs

INV: US or CT if fever developes
ICU if septic, abcess or generalised peritonitis with multi organ failure

Front 10

When is ERCP indicated in pancreatitis?

Back 10

if <48 hours and dx is uncertain or ongoing cholangitis and jaundice
DO NOT do in alcoholic pancreatitis

Front 11

Mx of acute pancreatitis

Back 11

supportive

Front 12

What is Cullen's sign?

Back 12

bluish discoloration umbilicus
sign of pancreatitis with hemorrhage

Front 13

Difference between perforated peptic ulcer and early acute pancreatitis pain

Back 13

perf peptic ulcer: guarding and rebound tenderness present
acute pancreatitis: guarding and rebound tenerness are NOT present because pancreas is retroperitoneal

Front 14

Which type of pancreatitis is associated with alcohol?

Back 14

necrotizing

Front 15

What happens to serum calcium in pancreatitis

Back 15

goes down d/t fat saponification binding the calcium

Front 16

Investigations

Back 16

CXR may show gas under diaphragm
elevated amylase or lipase
AXR shows no psoas shadow

Front 17

Do you give Abx in acute prancreatitis

Back 17

only if there's proven infection

Front 18

T/F: Perforation is a common complication of acute pancreatitis

Back 18

False

Front 19

What are structures are retroperitoneal

Back 19

ACDC Rocker Kids Party Down (+AI)

Ascending Colon
Descending Colon
Rectum
Kidneys
Pancreas head
Duodenum 2,3,4th
Aorta, IVC

Front 20

T/F Hypocalcemia causes acute pancreatitis

Back 20

False, hypercalcemia causes it!

Front 21

T/F Antibiotics are not part of prophylaxis in acute pancreatitis

Back 21

True

Front 22

Management of necrotizing pancreatitis

Back 22

wait 1-2 weeks til stable
resect necrosed parts

Front 23

How big does a pancreatic pseudocyst need to be before removal

Back 23

>6 cm

Front 24

Complication of AAA due to sacrificing the inferior mesenteric artery

Back 24

ischemic colitis

Front 25

List the 5 most common causes of life threatening altered LOC

Back 25

1) SAH
2) Cardiac (MI, tamponade, arrhythmia, structural/valuvular abnormalities
3) Metabolic: Hypoglycaemia, adrenal crisis
4) Drup OD/alcohol intox
5) Status epilepticus

Front 26

What clinical signs differentiate a structural from metabolic cause of coma?

Back 26

Structural:
1) extraoccular movements, and motor signs are usually asymmetric.
2) Pupils unequal/non-reactive
3) Focal or lateralising abnormalities present
Metabolic
1) extraoccular movements and motor findings absent or symmetrical
2) equal and reactive pupils (=upper brainstem intact)
3) caloric unresponsiveness (=lower brainstem NOT intact)

Front 27

Most commonly affected side of ischemic colitis

Back 27

left side of colon especially watershed areas, eg splenic flecture

Front 28

Difference between mesenteric ischemia and ischemic colitis

Back 28

mesenteric ischemia: abdo pain out of proportion to exam, early exam can often be unremarkable
ischemic colitis: bloody diarrhea, can have fever

Front 29

Which artery is usually involved in mesenteric ischemia?

Back 29

superior mesenteric artery

Front 30

Gold standard investigation in mesenteric ischemia

Back 30

Mesenteric angiography

Front 31

Blood results in mesenteric ischemia

Back 31

metabolic acidosis
leukocytosis
increase lactate
increased LDH
increased CK

Front 32

Management of mesenteric ischemia

Back 32

resus and ABs
heparin
early laparotomy if peritonitis/deterioration
angioplasty and thrombectomy +/- stent
resection of infarcted bowel

Front 33

Management of ischemic colitis

Back 33

supportive - bowel rest, fluids
broad spectrum antibiotics
surgery if infarcted bowel

Front 34

Mortality rate of mesenteric ischemia

Back 34

>50%

Front 35

Where is McBurney's point? What is it implicated in?

Back 35

1/3 of distance from ASIS to umbilicus

appendicitis

Front 36

What is Murphy's sign? What is it implicated in?

Back 36

push on right side under costal margin, patient winces when inspiring
cholecystitis, not cholangitis

Front 37

What is the most sensitive investigation in acute appendicitis?

Back 37

CT with contrast most sensitive
U/S also done

Front 38

Antibiotics for acute appendicitis

Back 38

Metronidazole PLUS
gentamicin OR cephalexin

Front 39

Clinical features of subarachnoid hemorrhage

Back 39

abrupt, thunderclap headache, followed by meningism
1/3 pts will have senitnel bleed marked by abrupt headache days/weeks earlier with N&V transient diplopia that completely resolves

Front 40

Most common cause of subarachnoid hemorrhage

Back 40

intracranial aneurysm

Front 41

Investigations in subarachnoid hemorrhage

Back 41

CT with contrast followed by non-contrast CT - look for blood in subarachnoid space
LP if negative CT to look for xanthochromia
once confirmed on CT, angiography

Front 42

Management of subarachnoid hemorrhage

Back 42

1. want to keep relatively hypervolemic and hypertensive to prevent vasospasm
2. nimodipine
3. neurosurgery to clip

Front 43

Cause of subdural hematoma

Back 43

rupture of bridging veins and accumulation of blood between dura and arachnoid

Front 44

Difference between acute and chronic subdural hematoma on CT

Back 44

chronic = liquified clot = hypodense = darker
acute = hyperdense = whiter

Front 45

Which patients are prone to subdural hematoma?

Back 45

alcoholics
elderly
trauma patients

Front 46

Findings on CT of subdural hematoma

Back 46

crescent shaped hyperdensity that does not cross the midline

Front 47

Management of subdural hematoma

Back 47

could resolve or
possible craniotomy with drain
Toronto notes says drain if >1 cm

Front 48

What is a CN 3 palsy with pupillary involvement associated with?

Back 48

berry aneurysms

Front 49

Indications for craniotomy in acute/chronic subdural hemorrhage

Back 49

clot thickness >10 mm
midline shift >5 mm
GCS decreased >2 points from time of injury to hospital admission
+/- fixed and dilated pupils

Front 50

Which artery is involved in epidural hematomas?

Back 50

middle meningeal artery

Front 51

Clinical features of epidural hematoma

Back 51

talk and die
immediate LOC followed by lucid interval

Front 52

What does a CT show on epidural hematoma?

Back 52

lens-shaped convex hyperdensity

Front 53

Management of epidural hematoma

Back 53

craniotomy
burr hole if in the bush

Front 54

How do you reverse warfarin? (used in intracerebral hemorrhage)

Back 54

give FFP, vitamin K
prothrombinex

Front 55

Indications for neurosurgery in intracerebral hemorrhage

Back 55

posterior fossa - neurosurgery good
supratentorial - neurosurgery same as medical management

Front 56

What does contrast in CT show...

Back 56

blood brain barrier breakdown

Front 57

Best way to diagnose basal skull fractures?

Back 57

Clinically (poorly visualised on CT)

Front 58

clinical signs of base of skull fracture?

Back 58

battles sign (bruised mastoid process)
haemotympanum
racoon eyes
CSF rhinorrhea

Front 59

How do you grade brain injury

Back 59

severe = GCS<8
Moderate =GCS 8-13
Mild = GCS14-15

Front 60

How do you calculate cerebral perfusion pressures?

Back 60

CPP = MAP - ICP

Front 61

What CCP, MAP and ICP are you aiming for in severe head injury?

Back 61

CCP > 60mmHg
MAP > 90mmHg
ICP 20-25

Front 62

what are the indications of mannitol

Back 62

for control of raised ICP after severe head injury.
very useful in acute setting
intermittent boluses more effective
0.5-1gm/kg

Front 63

How does mannitol affect ICP

Back 63

rheological effects: in minitus, best response in low cerebral perfusion pressure

osmotic effects
delayed for 15-30 min, lasts 90min-6hrs

Front 64

what are the disadvantages/complications of mannitol use for raised ICP

Back 64

Acute renal failure (if serum osmolarity >320mOsm
raised ICP with prolonged infusion (may open BBB and diffuse into brain)
complicates dx of diabetes insipidus