Free UKMLA acute and emergency questions with explanations

E. Tranexamic acid

Tranexamic acid reduces death from bleeding in trauma when given early: 1 g intravenously over 10 minutes followed by 1 g over 8 hours, started as soon as possible and within 3 hours of injury, because it inhibits fibrinolysis and the benefit is lost, and possibly reversed, when given later. It is given empirically to any trauma patient with, or at risk of, significant haemorrhage, without waiting for laboratory evidence of coagulopathy. Blood component replacement with plasma alongside red cells, early control of the bleeding source, and avoidance of hypothermia, acidosis and hypocalcaemia are the other pillars of damage-control resuscitation. The remaining agents are targeted therapies: prothrombin complex concentrate and vitamin K reverse warfarin, fibrinogen is replaced when a measured level is low, and recombinant factor VIIa has no routine place.

E. Hydroxocobalamin

Hydroxocobalamin is the first-line antidote for cyanide toxicity in smoke-inhalation victims because it directly chelates cyanide to form non-toxic cyanocobalamin (renally excreted) without inducing methaemoglobinaemia, which is critical when concomitant carbon monoxide poisoning may already be impairing oxygen delivery. Hydroxocobalamin is first-line in suspected cyanide poisoning from fire smoke, given alongside 100% oxygen.

A. Carbon monoxide poisoning

Non-specific headache, nausea and fatigue affecting several members of the same household in winter, improving when they are away from the home, is the classic presentation of chronic low-level carbon monoxide exposure from a faulty boiler or blocked flue. Because carboxyhaemoglobin absorbs light similarly to oxyhaemoglobin, standard pulse oximetry reads a falsely normal saturation, so a reassuring reading does not exclude the diagnosis. The household needs to leave the property, have the appliance checked and have carboxyhaemoglobin measured. A household viral illness would not remit within hours of leaving the building and return on coming home.

B. Admit and refer to the hospital safeguarding lead

A spiral mid-shaft femoral fracture in a pre-mobile infant is a major red flag for non-accidental injury because the rotational force required is incompatible with the developmental stage and the offered history is implausible. Admission to a place of safety is mandated, with urgent referral to children's social care and a child protection medical assessment, including skeletal survey, fundoscopy and neuroimaging for occult injury.

B. Transfusion associated circulatory overload

Transfusion-associated circulatory overload (TACO) is hydrostatic pulmonary oedema from volume excess during transfusion, typically within 12 hours, producing breathlessness, hypoxia, hypertension and a raised JVP, especially in patients with cardiac or renal impairment. The raised JVP and heart failure context in this vignette point specifically to circulatory overload rather than an inflammatory lung injury (SHOT/ISBT definitions).

A. Stop lamotrigine

A painful blistering rash with mucosal erosions within weeks of starting a new drug is Stevens-Johnson syndrome until proved otherwise, and lamotrigine is a well-recognised cause. The single intervention with the clearest effect on survival is immediate withdrawal of the culprit drug: every day of continued exposure increases mortality. Supportive care in a specialist burns or dermatology unit follows, with fluid replacement, wound care and ophthalmology review. Immunomodulating therapies such as corticosteroids, immunoglobulin or ciclosporin have inconsistent evidence and are specialist decisions that never precede stopping the drug.

B. Linear temporal bone fracture

A linear fracture of the squamous temporal bone is the fracture pattern most commonly associated with an extradural haematoma, because the fracture line crosses the groove of the middle meningeal artery, lacerating it and producing rapid arterial bleeding between the dura and skull. Around 75 to 90% of extradural haematomas are associated with a skull fracture, although absence of a fracture (particularly in children with a compliant calvarium) does not exclude the diagnosis.

E. Apply granulated sugar to the prolapse and reattempt manual reduction

An incarcerated rectal prolapse that is still viable should be reduced in the emergency department. Oedema is what prevents reduction, so granulated sugar is applied to the mucosa for 15 to 30 minutes to draw fluid out osmotically, after which gentle sustained pressure with analgesia usually succeeds; the patient is then referred for elective repair. Emergency surgery is reserved for a prolapse that remains irreducible after these measures or that is dusky, ulcerated or necrotic, when an Altemeier perineal rectosigmoidectomy is the usual choice in a frail patient. Waiting with antibiotics allows the oedema and venous congestion to progress towards strangulation.

B. Implantable cardioverter-defibrillator

An implantable cardioverter-defibrillator (ICD) is indicated for secondary prevention after a survived cardiac arrest due to ventricular fibrillation or haemodynamically significant VT when no reversible cause is identified. ICDs continuously monitor rhythm and deliver defibrillation to terminate recurrent life-threatening arrhythmias, with trials such as AVID demonstrating a clear mortality benefit over antiarrhythmic therapy.

C. Erysipelas

Erysipelas is a superficial dermal infection, almost always due to beta-haemolytic streptococci, presenting as a brightly erythematous, sharply demarcated, raised plaque with a clear advancing edge, classically on the face or lower leg. Flucloxacillin is first-line for most sites; for cellulitis or erysipelas near the eyes or nose the first-line antibiotic is oral co-amoxiclav (clarithromycin plus metronidazole if penicillin-allergic).