Term
|
Definition
QTc >440ms men, >460ms women
increased risk torsades with QTC> 500ms |
|
|
Term
|
Definition
|
|
Term
|
Definition
1: Drugs
2: Electrolytes - hypocalcemia / hypomagnesia / hypokalemia
3: Congenital long QT
4: Hypothermia
5: ischemia
6: raised ICP |
|
|
Term
|
Definition
1: antipsychotics
-chlorpromazine,haloperidol, droperidol, olanzapine, quietapine
2: Type 1a antiarrythmics
-quinidine, procainamide
3: Class 111 antiarrythmics
-amiodarone, sotalol.
4: Antidepressants
-escitalopram, citalopram.
4: Antihistamines
-Diphenhydramine, loratidine,
5: Other,
-Chloroquine, quinine, macrolides - erythromycin. |
|
|
Term
| ECG features of RV infarction |
|
Definition
-Suspect in inferior MI
-Lead 111 STE > Lead 11
-STE V1
-STE V1 > V2 or V1 isoelectric V2 depressed.
-Confirm with V456R |
|
|
Term
| Management of RV infarction |
|
Definition
-Urgent reperfusion is priority
-Preload sensitive --> Fluid bolus 250 + repeat
-Then consider NAD
-Then consider adrenaline
-Then consider IABP |
|
|
Term
| Management of Hyperkalemia |
|
Definition
1: Stablise myocardium
-Calcium Chloride 10ml 10%
-Calcium gluconate 10 ml 10%
2: Drive K+ into cells
-Salbutamol - Nebs
-NaHCO3 50 - 200 mmol NaHCO3
-Insulin + Dextrose 10U - 20 bolus + 25 - 50 ml 50% dextrose
3: Eliminate
-Resonium 20-40g PO / PR
-IVT (N/S)+/- frusemide
-Dialysis |
|
|
Term
| Differentiate VT from SVT |
|
Definition
Absence of typical RBBB or LBBB morphology
Extreme axis deviation (“northwest axis”) – QRS is positive in aVR and negative in I + aVF.
Very broad complexes (>160ms)
AV dissociation (P and QRS complexes at different rates)
Capture beats — occur when the sinoatrial node transiently ‘captures’ the ventricles, in the midst of AV dissociation, to produce a QRS complex of normal duration.
Fusion beats — occur when a sinus and ventricular beat coincides to produce a hybrid complex.
Positive or negative concordance throughout the chest leads, i.e. leads V1-6 show entirely positive (R) or entirely negative (QS) complexes, with no RS complexes seen.
Brugada’s sign – The distance from the onset of the QRS complex to the nadir of the S-wave is > 100ms
Josephson’s sign – Notching near the nadir of the S-wave
RSR’ complexes with a taller left rabbit ear. This is the most specific finding in favour of VT. This is in contrast to RBBB, where the right rabbit ear is taller.
Algorithms (Brugada) are NOT useful in realit in the unstable patient |
|
|
Term
|
Definition
Based on presentation from time of pain + contraindications to thrombolysis
<60 mins - Thrombolysis if PCI > 60mins
60min - 3 hour - Thrombolysis if PCI > 90 mins
3-12 hour - Thrombolyisis if PCI > 2 hours
> 12 hours - no routine revasclarisation (if stable) |
|
|
Term
| Contraindications to Thrombolysis |
|
Definition
Absolute
-Active bleeding / bleeding Diathesis
-significant head trauma < 3/12
-Suspected aortic dissection / new neurology
- Previous ICH
-Cerebral malignancy / vascular anomoly
-CVA < 3/12
Relative
-Anticoagulants
-Non compressible vascular punctures
-Surgery < 3/12
-Traumatic / prolongd CPR
-GI bleed < 1/12
-PUD
-Severe hypertension (>180/110)
-Pregnancy |
|
|
Term
|
Definition
-Priority is to facilitate early reperfusion
-Resus
-oxygen
Specific
-GTN (unless RV infarct)
-Reperfusion (PCI vs Thrombolysis -Tenectaplase)
-aspirin
-Clopidogrel (unless high likelyhood of CABG)
-Heparin vs LMWH - therapeutic
-glycoprotein 11b / 111a inhibitor (eg: tirofibran) if PCI
-B Blocker once HD stable
supportive: Analgesia - morphine,
Disposition: Cath lab / CCU |
|
|
Term
|
Definition
-Acute Bay
-IV access
-monitoring on,
-anticipate arrythmia, Defib available
02 sats > 94
Supportive:
analgesia - morphine 2.5mg / titrate aim for pain free
antiemesis
Specific
-GTN 300mcg SL PRN
-aspirin
-clopidogrel 300mg
- heparin / LMWH therapeutic
-Glycoprotein 11b / 111a (eg tirofibran) for those for early PCI
-B - Blocker (eg: metoprolol 25mg) unless contraindicated
Disposition
CCU
Ideally PCI < 48 hours.
- |
|
|
Term
| ECG criteria for MI with LBBB |
|
Definition
(1) new LBBB
(2) concordant ST elevation of > 1mm
(3) concordant ST depression of > 1mm in V1, V2 or V3
(4) discordant ST elevation of > 5mm |
|
|
Term
Mobitz 1 (Wenckebach) - Mechanism ?
DDX: |
|
Definition
Progressive fatiguing of AV nodal cells -- dropped beat
1: Drugs - (B-Blockers, CCB. Digoxin)
2: Inferior ischemia
3: Myocarditis
4: Structural (post AV valve repair)
5: Increased vegal tone (athletes) |
|
|
Term
| Features of a normal Paediatric ECG |
|
Definition
-HR > 100 normal
-Signs of R heart dominance-
-R axis deviation
-TWI V1-3 (Juvenile T waves pattern)
-RSR V1
-Dominant R in V1
-Marked sinus arrythmia
-Short PR
-Long QTc (<490)
-Q waves in inferior + L precordial leads
PAediatric ECG changes usually resolve by age 4 |
|
|
Term
| DDx regular narrow complex tachycardia |
|
Definition
AVNRT
AVRT
Junctional tachycardia
Atrial Flutter
Sinus tachycardia |
|
|
Term
| DDX narrow complex irregular tachycardia |
|
Definition
AF
MFAT
Aflutter with variable block
sinus arrythmia |
|
|
Term
| Coved STE in > 1 of V123 followed by negative T wave in context of syncope is... |
|
Definition
Brugada Syndrome!
Na+ channelopathy
Genetic
High risk of VF / SCD
Needs: ICD |
|
|
Term
|
Definition
Failure of the His-Purkinje system
+ tends to be structural as opposed to reversible ((ie infarction / fibrosis)
75% below bundle of HIS and wide complex QRS
1: Anterior infarction
2: Idiopathic fibrosis of the conducting system
3: Cardiac surgery
4: Inflammatory - Myocarditis
5: Autoimmune conitions / infiltrative conditions (Eg: Rheumatic fever, Sarcoidosis)
6: Hyperkalemia
7: Drugs ( B block / Ca2+ blockers) |
|
|
Term
Spinal Cord anatomy + decussation
Dorsal collums
Spinothalamic
Cortico spinal |
|
Definition
-Dorsal columns -Vibration, light touch, proprioception
Decussate high
-Spinothalamic - anterior, Decussate at level of entry, pain, temperature
-Corticospinal - Motor function, Decussate @ medulla.
Upper limbs travel centrally, lower limbs travel peripherally. |
|
|
Term
| Complete cord hemisection |
|
Definition
- Anaesthesia, paralysis,below level of injury. Worse progniosis than incomplete syndromes.
-Acutely FLACID paralysis (spinal shock) then hyperreflexia.
Autonomic ecffects - Bradycardia / hypotension, urinary retention, poor thermoregulation |
|
|
Term
|
Definition
-Spnal cord Hemisection
-Ipsilateral Paralysis and loss of vibration / proprioception / light touch
-Contralateral loss of pain / temperature |
|
|
Term
Central Cord syndrome
-Mechanism,
-Clinical presentation |
|
Definition
-Neck hyperextension (compression of cord)
-Upper limb > Lower limb motor and sensory defecit
(upper limb runs centrally, lower limb / sacral peripheral and closer to blood supply) |
|
|
Term
Anterior Cord Syndrome
-Mechanism
-Clinical effects |
|
Definition
Flexion / Compression / Disk protrusion
-Loss of motor function / Pain / temp
-Relative sparing of dorsal columns (vibration /proprioception) |
|
|
Term
Posterior Cord
-Mechanism
-Clinical effects |
|
Definition
RARE
penetrating back inury
-Loss of dorsal column vibration /proprioception
-Relative sparing of motor and pain / temperature. |
|
|
Term
| Determine spinal cord level |
|
Definition
|
|
Term
Bacterial Meningitis pathogens
Neonatal
School aged
Adults
Elderly |
|
Definition
Neonatal
Gram negative (E coli)(Pseudomonas), Listeria, Group B strep, Coag –ve staphylococcus
3/12 - 15
Neiserria meningitidis, Pneumococcus (strep pneumonia), Haemophilus pneumonia
Adult
N meningitidis, s. pneumonia, listeria, klebsiella, s. aureus
Elderly
Gram negatives |
|
|
Term
| Aseptic meningitis pathogens |
|
Definition
Viral
Echovirus, Enterovirus, Mumps
HSV 1 + 2, CMV, VZV, EBV
Other
TB, Nocardia, Leptospira, Treponema
Fungi, rickettsia, parasites
Malignancy, auto-immune |
|
|
Term
|
Definition
3-4 ml x TBSA x Wt (kg)
1/2 in ist 8 hours, 1/2 in second 16 hours. |
|
|
Term
|
Definition
12 Bs
1:Bullshit Story
2:Behaviour(parent / child interaction)
3: Backgrond (drugs, SES factors etc)
4:Burns
5: Bones
6:Brain (shaken baby(
7: Back of eyes (shaken baby)
8; Bottom and Genitals
9: Broken frenulum
10: Bruises
11: Bites
12: Blunt abdominal trauma |
|
|
Term
|
Definition
Suspect harm from mother or father
3 each, 12 in total
S: Spine, scapula, sternal
H: Humerus (except supracondylar) HAnd(non ambulant) Head
M: metaphyseal corner / bucket handle fratures (shaking) multiple fractures
F: Foot (non ambulatory) Femur (non ambulatory) fractred ribs |
|
|
Term
|
Definition
GCS =<14, Altered mental state (agitation, somnolence or signs of skull fracture --> CT (CITBI =4.4%)
None of above but:
occipital / parietial / temporal haematoma, LOC> 5 sec, severe mechanism, not acting normally as per parent
Observe VS CT - 1% CITBI
None of above - No CT (<0.02%CITB) |
|
|
Term
|
Definition
GCS<=14, Signs of basal skull fracture, altered mentation.
CT(4.3% CITBI)
None of above but
LOC, Vomiting, severe mechanism, severe headache -
Observe vs CT (1% risk CITBI)
None of above CT not reccomeded) (<0.05% CIT
BI) |
|
|
Term
CHALICE
(probably leads to increase in CT in AUS pop'n) |
|
Definition
CT if:
Hx: LOC > 5 min,
Amnesia > 5 in
3 or more vomits
Suspicion NAI
Seizure
EX:
GCS< 14 or <15 > 1 hour
Signs of skull #
Signs of Basal Skull #
Neurology
> 5cm lac / haematoma if < 1
Mech:
High Speed MVAFall> 3m
High speed projectile. |
|
|
Term
|
Definition
Adult with Minor head injury (not trivial)
High Risk
GCS<15 2 hours after injury
Suspected open or depressed skull fracture
Signs of basal skull fracture
Vomits > 2 episodes
Age > 65
Moderae risk
Retrograde amnesia > 30min
Dangerous mechanism
Also consider CT if
Coagulopathic
Seizure
Trauma finding above the clavicle
focal neurology
Intoxicated. |
|
|
Term
Paediatric vital signs
<1, 1-2, 2-5, 5-12, >12 |
|
Definition
<1- HR110-160, RR =30-40
1-2: HR =100-150 RR 25-35
2-5: HR =90-140, RR = 25-30
5-12 HR =80-120, RR 20-25,
>12 Adult.
SBP - <6/12 60-90, 6/12-1 90-100, > 1 =100. OR Min SBP =65+ (agex2) |
|
|
Term
Paediatric Calculations
Airway
1: ETT size
2: ETT length
3: LMA
4: Dexamethasone
Circulation
1: Adrenaline
Atropine
Fluid bolus
Maintenance
Defib
Blood volume
Fluids =- PRBC, PLT, FFP, cryo
Drugs
Propofol
Sux
Rocuronium,
Vec
Fentanyl
Midaz |
|
Definition
ETT size=(age/4) +4
ETT length =age/2+ 12 2 @lips
3: LMA - weight based
1 = <6.5,
1.5 <13
2: <20
2.5: <25
3<30
4>30
Dex =0.15mg / kg
C:
Adrenaline 10mcg / kg
Atropine 20mcg / kg
Bolus 20ml / kg NS
Maintenance 4, 2, 1 ml / kg / hr
Defib 4J/ kg
Blood volume =75 ml / kg
PRBC, pLT 10ml / kg, FFP 15 Ml / kg, cryo =5ml / kg
Drugs
Propofol 2-4 mg / kg
Sux 1-2 Mg / kg IV (2 in neonates) 3mg / kg IM,
Rocuronium 0.6-1.2 mg / kg
Vecuronium 0.1mg / kg
Midaz 0.05-0.1mg / kg up to 0.5
Fentany 1-2 mcg / kg IV / IM. |
|
|
Term
Paediatric Life Support
Differences
Drug Doses |
|
Definition
CPR -15:1
Drugs-
Adrenaline 10mcg / kg (1st cycle non shockable) Second shockable)
Amiodarone - 5 mg / kg
Defib - 4 J kg
Increased |
|
|
Term
|
Definition
|
|
Term
| Weight gain of a normal neonate? |
|
Definition
3.5 kg at birth
10kg at 1 year
30g / day for first three months (approx 3 kg)
Loses up to 10% weight in first week. |
|
|
Term
| fluid management in paediatric DKA: |
|
Definition
1: 20 ml / kg NS bolus if shocked
2: Calculate defecit (5% if dehydrated, 10% if shocked) + ongoing requirement (4:2:1) and replace over 48 hours with N/S = 40mmol K+ per litre (+ 5% glucose when BSL < 15). If annueric or K+ > 5.5 withold K+. |
|
|
Term
TIMI score
-?Relevance
-?Components |
|
Definition
-Used to prognosticate in NSTEACS
0-7 --> risk of Death / MI at 14 days
0/1 =3%
7 =20%
Used to predict who will benefit from early angiogram - 2 or less unlikely, 3 or greater likely.
-Age> 65
-Aspirin use past 7 days
-ST segment deviation
-TNI rise
-3 or more CVRF
-Previous coronary artery disease (>50%)
-Two or more episodes of angina last 24 hours |
|
|
Term
Contraindications to fibrinolysis
-Absolute
-Relative |
|
Definition
Absolute
-Any ICH
-Ischemic CVA <3/12
-Known Cerebral malignancy / Vascular malformation
-Significant head / facial trauma < 3/12
-Suspected Dissection
-Active bleeding (excluding menses)
Relative
-Anticoagulation
-Non Compressable cvasc punctures
-Prolonged CPR (10min)
-Major surgery < 3 weeks
-Internal Bleeding < 3 weeks.
-Active PUD
-Chronic Severe, poorly controlled htn
-Ischemic stroke > 3/12 ago / dementia> 3/12
-Pregnancy. |
|
|
Term
|
Definition
approx. 900 pts - STEMI within 6 hours
Randomised to primary PCI vs prehospital thrombolysis then transfer to interventional facilty.
No 5 year mortality difference (Thrombolysis <4 hr from symptom onset)
improved mortality thrombolysis < 2hr from symptom onset |
|
|
Term
Infective Endocarditis
-Pathogens?
-Duke Criteria? |
|
Definition
PAthogens
-Staph - Aureus (epidermidis in prosthetic valve)
-Streptococcus (Esp Viridans)
-Enterococcus
-Gram -ve(HACEK) -Other (fungal etc)
Duke Criteria
2 MAjor, One major 3 minor, or 5 minor.
MAjor
- Typical organisms in 2 blood cultures (in absence of source)
-Persistantly positive Blood cultures (> 12 hours apart 2 or more consistent with IE)
-Echocardiographic evidence of vegitation
-New valvular regurgitation
Minor
-Predisposition (eg prosthetic vave, IVTU)
-Fever (T > 38
-Vascular phenomena (eg arterial emboli)
-Immunological phenomena (eg oslars nodes)
-Microbiological evidence (pos culture NOT major criteria)
-Echocardiographic findings suspicious of. |
|
|
Term
Syncope
-DDX
-Risk stratification |
|
Definition
DDX
1: Vasovagal / neurocardiogenic
2: Cardiac
-Arrythmia
-Structural (Eg AS)
-Cardiomyopathy (eg: HOCM)
-Pacemaker dysfunction
-PE
3: Orthostatic (dehydration / vasodilation)
4: Neurological
-Vertebrobasilar TIA
-mimics (eg seizure)
5: Medications
Eg: BBlockers / Diuretics contribution to orthostatic hypotension
6: Psyciatric
Risk stratifcation
San Fransisco Syncope Rule
None of following = low risk
1: CCF
2: HCT < 30
3: Abnormal ECG
4: SOB
5: SBP<90 @ triage.
CHESS
In practice Hx and exam important : Good hx fr neurocardiogenic vs sudden LOC while supine or exertional syncope |
|
|
Term
Vaughan Williams type 1 antiarythmics
-Types
-Examples |
|
Definition
1a: Prolong AP, Quinidine
1b: Shorten AP, Lignocaine
1c: No effect on AP, Flecainide. |
|
|
Term
| -Name the syndrome that gives syncope and sudden cardiac death in young people with structurally normal hearts (Abnormal Sodium Channels) |
|
Definition
|
|
Term
|
Definition
-AVNRT (60 %)
-AVRT (eg WPW) (orthodromic more common than antidromic |
|
|
Term
|
Definition
1: PAced Chamber
2: Sensed Chamber
3: Response to sensing
4: Programmable functions
5: Anti- tachycardic function (Eg Pace, Defib) |
|
|
Term
| RX of Haemorrhage post thrombolysis |
|
Definition
-Establish Resus
IV access, take blood - FBC, ELFT Coags Xmatch
ABCD
E-Aim normothermia
Specific:
Reverse Fibrinolysis
FFP - 2 U + repeat Q6hr
Cryo- 10 U
Tranexamic Acid - Load 1 g, then infusion 1g / 8 hr
?Role for fact 7 / prothrombinex
-Reverse antiplatelets - 1 pooled bag platelets
-DDAVP 0.3 mcg / kg
-Reverse anticoagulant
-Protamine 1mg /1u LMWH
-1mg / 100U Heparin
Supportive -
Disposition |
|
|
Term
|
Definition
1: ?Need to exclude PE
Chest pain / SOB without other clear cause (eg, Pneumothorax, STEMI) Therefore ECG and CXR first!
2: Risk stratify - Wells
-Clinical Signs DVT =3
-Pulse rate>100 =1.5
-Immobilised >3days =1.5
-Surgery < 4 weeks =1.5
-Past hx DVT / PE =1.5
-Haemoptysis - 1.0
- Active Neoplasm =1.0
-No alternative DX more likely =3
Low 0-1 (1.3%)
int = <=6 (16%)
High > 6 (40%)
OR
PE unlikely if Well's
In Low RISK patients (0-1) or PE unlikely ((rules out PE in pt with <15% pre test probability)
(post test probablility <2%)
-Age<50
-No oestrogens
-No Cancer
-No HR>100
-No prior Hx
-No Haemoptysis
-Sats>95%
-No recent Surgery (<4 weeks)
-No unilateral leg swelling.
(HADCCLOTS)
Hormone, age, prev DVT / PE, Coughing blood, Cancer, leg swelling, O2>95, Tachycardia, surgery
-If PERC not all true in Low ris (<4) not applicable then D-Dimer
If pos then VQ Vs CTPA
If High Risk / physiologically deranged then CTPA vs bedside Echo.
Wells 0/1 =1.3 % PE
Wells 2-6 =16%
Well's7+ =40 %
Wells |
|
|
Term
|
Definition
1: Low risk of deterioration
(small clot load, no RV strain, HD stable)
-Supportive Care (analgesia, 02)
-LMWH probably equal or better than heparin
-Riveroxaban probably non inferior to warfarin / heparin.
2: Submassive - RV strain / myocardial necrosis
HD environment - High risk of deterioration to massive PE (25%)
-Supportive care (anagesia / 02)
-LMWH vs heparin
-Thrombolysis controversial - Recent Metaanalysis (June 2014 JAMA) suggests all cause mortality benefit but increased major bleeding.
-3 Massive PE (Arrest / HD unstable)
-ABCDE
-Cautious IVT (unless concominant hypovolemia)
-Ionotropy / vasopressor- Adrenaline vs NAD
-Thrombolysis (alteplase infusion / tenectaplase (metalyse not licensed but prob effective), embolectomy
-Supportive care
-ICU disposition.
-PETHIO Trial (unpublished)
-1000 pts with submassive PE
randomised heparin vs heparin and tenectaplase
Composite mortality / HD collapse RRR 56% (2 vs 5%) in thrombolysis group. |
|
|
Term
Aortic Dissection
-Epidemiology
-Risk factors |
|
Definition
Peak age 50 --> 70
Male > female
RF: 1: HTN!
2: Connective Tissue Disorder (eg Marfan's / Ehlers-Danlos Syndrome)
3: Congenital Cardiac disease
4: AS - Bicuspid aortic valve
5: Coarctation
Also - Iatrogenic (eg angioplasty, cocaine, pregnancy, giant cell arthritis) |
|
|
Term
| Aortic Dissection Classification |
|
Definition
Stanford = MOST RELEVANT
A = Ascending Aorta +/- Descending
Need for urgent surgery
B = Descending Only - Medical Rx.
De Bakey
1 = Ascending / Descending
2: ascending only
3: Descending only |
|
|
Term
| Aortic Dissection Management |
|
Definition
Establish resus
ABCDE
-Hypotension = ominous (ensure not branch occlusion)
-IBP for optimal BP control
Supportive especially Analgesia
Specific: Rapid control of blood pressure
-Aim SBP 100-120 (+ tirrate to pt)
-HR 60-80
-IV B-Blocker (or non dihydropyridine Ca2+ blocker) 1st!
-Esmolol -0.5mg/ kg IV bolus then 50 - 200 ug/kg.min
Or metoprolol bolus IV (1mg -10mg)
Then GTN (5-50 ug / min) /orSNP
Type A needs immediate surgery
Type B with - leaking aorta, extension despite medical Rx, Ischemic organ failure, intractable pain / htn likely need endovascular grafting.
Disposition = ICU
Needs discharge on B-Blockers + surveillance. |
|
|
Term
|
Definition
1: Drugs = Bboc, Dig, Ca2+ blockers
2: Inferior MI
3: Electrolytes - hypokalemia
4: MVR
5: Myocarditis |
|
|
Term
LAFB
-Define
-ECG criteria
-DDx |
|
Definition
-blocked conduction through anterior fascicle therefore conduction to ventricle from posterior fascicle (inferior - septal region
therfore prdominant vector = up and left
ECG criteria
- LAD
-qR 1 AVL, rS inferiorly
DDx:
ischemia
Cardiomyopathy
valveular disease / surgery
Myocarditis
Degenerative diseae |
|
|
Term
|
Definition
S V1 + R V5/6 >35 mm (1+6 =7)
aVL > 11mm
There are others! |
|
|
Term
| ECG changes in hypokalemia |
|
Definition
-PR prolongation
-ST Depression
-T wave flattening
-U wave
-apparrent QT prolongation (Q wave) |
|
|
Term
| Define Pathological Q wave |
|
Definition
->40ms wide
>2mm deep
>25% QRS voltage
In leads V1 - V3 |
|
|
Term
|
Definition
PUD 40%
Gastroduodenal / oesophageal erosions 15%
Varicies 10 %
Mallory Weiss tear 10 %
Angiodysplasia <1%
Aortoenteric fistula <1% |
|
|
Term
| Risk Stratification upper GI bleed? |
|
Definition
Glascow - Blatchford Score
0 = potentially managed as outpatient (unlikely to require urgent endoscopic intervention)
SBP on presentation
BUN
Hb
HR> 100
Melena?
Recent syncope?
Hx heart failure /
Hx HEpatic Disease |
|
|
Term
| Management upper GI bleed |
|
Definition
Establish Resus
-Team, location, Monitoring, IV x 2 + Xmatch, 02, Notification - esp gastroenterology if unstable.
A- Consider early intubation - if obtunded / airway threatened
-If ongoing HD instability despite agressive resus - (will need RSI for urgent endoscopy and likely to become more unstable with time)
C:-IV NS x 2L, then PRBCs, consider MTP + TXA,
E: Avoid hypothermia
Specific - IVPPI (reduction in re-bleed / surgery but not mortality)
-Somatostatin / octreotide (IF varacies suspected) - Similar to enoscopic Rx in terms of bleeding control and survival
Conflicting evidence for reduced ongoing bleeding in PUD - can consider if delay to OT.
(octreotide 50mg bolus / 50mg /hr infusion.
-Consider Terlipressin if available for variceal bleeding - mortality benefit.
-Consider Antibiosis - cipro or ceftriaxone for upper GI bleed in cirrhosis (poor data but supportive)
-Definative Care = endoscopy - ideally within 24 hours while HD stable but may need urgent scope.
-Consider Blakemore as temporising measure for varices.
-Embolisation evolving option.
Supportive
-analgesia
-sedation
-Head up
Disposition - Ward vs ICU.
Discharge + OPD endoscopic follow up only an otionfor very low risk (Ie young, classic Hx MAllory Weiss, stable. |
|
|
Term
| DDX of bloody Diarrhoea in Children |
|
Definition
1: -Infective (invasive / toxigenic)
>Bacterial, protozoal
-Intersusseption
-Malrotation / Volvulus
-NEC
-Systemic Vasculitis
-IBD
-Hirshprung's disease
-Others less likely - Malignancy |
|
|
Term
HUS
-Define
-PAthogenesis
-Treatment |
|
Definition
-Renal failure with microangiopathic haemolytic anaemia and thrombocytopenia. (Shistocytes, reticulocytes, spherocytes on blood film)
-Typical (post E-coli diarrhoea) D+
-Atypical - Genetic predisposiition, post strep, Drugs, HIV , transplantation, pregnancy. Atypical carries worse prognosis.
-Treatment largely supportive
-?Plasma exchange for D+
-Antihypertensives
-RRT if required. |
|
|
Term
| Spontaneous pneumothorax -Types -Assesment -Management options |
|
Definition
Primary (no underlying lung disease) Secondary (underlying lung disease) Asessment: ?Underlying Lung disease ?Significant dyspnoea ?Size on PTX (large >2cm rim at hilum on CXR, small< 2cm rim at hilum on CXR. Conservative Rx: Re-Xray 24 hours then weekly. For small, primary PTX without chronic lung disease Aspiration: For large primary PTX or small primary PTX with significant dyspnoea. Repeat CXR 6 hours - if small, no ongoing leak can discharge wiith follow up. -ICC (ideally small guage pigtail) For failed aspiration or secondary PTX.
[image] |
|
|
Term
|
Definition
-A (alcohol / other toxins)
-E (Endocrinopathy (eg addinsonian crisis) Encephalopathy
-I - Insulin - DM / hypoglycemia
-O - Hypoxia of any cause, opiates
-U - Uremia / HEpatic encephalopathy
T- Trauma
I-Infection - CNS / other
P- Poisons (porphyria)
S- Seizure , stroke, SAH, SOL. |
|
|
Term
Dix-Hallpike test
-Indications
-Proceedure
-Interpretation |
|
Definition
Indication - Suspected BPPV (brief, severe, episodic vertigo.
Proceedure
-Warn pt
-HEad 45 degree R (tests R sc canal) (L tests L)
-Lie back 45 deg beyond horizontal
-Pos for BPPV if nystagmus induced that is
1: Delayed > 5sec (latency)
2: Torsional or horizontal (pure vertical nystagmus suggests central)
3: Fatiguable -(Should stop in 1 min, should be less pronounced next time) |
|
|
Term
| DDx of critically ill neonate |
|
Definition
SICC - FIT
Sepsis
Intercranial disorder (bleed / tumor)
Congenital cardiac lesion
Congenital metabolic disorder
Feeding problems
Intestinal emergency
Toxins. |
|
|
Term
|
Definition
The five criteria of the Apgar score:
Appearance/Complexion
0:blue or pale all over
1blue at extremities, body pink
(acrocyanosis)
3: no cyanosis
Pulse
0: Absent
1<100
2>100
Grimace
0: no response to stimulation
1: grimace/feeble cry when stimulated
2:cry or pull away when stimulated
Activity
0: none
1:some flexion
2: flexed arms and legs that resist extension
Respiration
0: absent
1:weak, irregular, gasping
2:strong, lusty cry |
|
|
Term
| Approach to poisoned patient |
|
Definition
RESUS RSI DEAD
Resus including emergent antidotes.
Risk asessment
Supportive care and monitoring
Investigations (12 lead / paracetamol + specificly indicated)
Decontamination
Enhanced elimination
Antidotes
Disposition. |
|
|
Term
| Agents poorly bound to activated charcoal. |
|
Definition
-Hydrocarbons / alcohols (eg methanol)
-Metals (lithium, Iron, mercury, lead)
-Corrosives Acids / Alkali |
|
|
Term
|
Definition
1st aid
PIB
Transport
In hospital:
RESUS (rarely required - emergent polyvalent antivenom)
Hx / Ex. Examine for envenomation (VICC, Neurotoxicity, Rhabdomyolysis, Renal impairent)
-Neurological (Descending flaccid paralysis)
-Respiratory function
-Haemorrhage
Labs: Coags, D-Dimer, FBC / ELFT / CK.
If envenomated antivenom prior to removal of PIB.
If not remove PIB and repeat 1 hr, 6 hr 12 hr. - Reapply bandage and antivenom if envenomation ensues. |
|
|
Term
| Features of mushroom poisoning in Australia. |
|
Definition
-Mostly short lived GI sx (self resolving)
-rery Rare but potentially lethal hepatotoxicity -GI sx persisting beyond 6 hours need LFTs monitored Rx in consult with toxicoloist - NAC
Others
- psylocibin (hallucinogenic)
-Muscarinic (lacrimation, salivation, bronchorrhea,
-Glutaminergic - CNS depression / seizures. |
|
|
Term
Plant poisonings - Match plant to clinical syndrome
-Datura (angel's trumpet)
-oleander, foxglove
-Autum crocus
-Hemlock
-Apricot kernals
-Peyote |
|
Definition
Datura - Anticholinergic poisoning (consider physostigmine)
Oleander / foxglove - Cadiac glycosides / Digoxin poisoning (consider digibind)
Autum crocus - Colchicine poisoning
Apricot kernals - cyanogenic glycosides histotoxic hypoxia.
PEyote - hallucinogenic / psychosi |
|
|
Term
Serotonin Syndrome
-Features
-Causes
-Management |
|
Definition
-Tachycardia
-Hyperthermia
-Agitation progressing to Seizures and Coma
-Hyperreflexia / clonus
-Mydriasis
-Sweating.
Causes -often drug interaction
SSRI, TCA, pethidine, fentanyl, MAOI, SNRI, MDMA, st john's wort.
Rx RESUS RSI DEAD
-Supportive w benzodiazapines usually adequate.
-Indications for RSI: Coma, Severe rigidity + compromised ventilation. Severe hyperthermia (T>39.5)
-Investigation: ECG , PAracetamol Bloods inc CK for severe (rhabdomyolysis)
Antidote - Cypraheptadine (symptomatic managment of mild / mod seretoni tox ONLY. Not useful in severe intoxication.
Disposition ICU if PPV
ED / ssu until vitals / Temperature normalised / hypertonia resolves. |
|
|
Term
Define Normal soft tissue width on lateral film of neck
(paediatric and adult) |
|
Definition
-< 7mm @ C2 regardless of age
< 14mm @ C6 in children <15 y, <21 mm in adults
(remember 3 7s are 21 |
|
|
Term
Define Osmolar Gap
Significance? |
|
Definition
Measured osmolality - calculated osmolarity
Calculated osmolarity -2 x Na+ + glucose + urea
> 10 = presence of unmeasured osmotically active substance. Often toxic alcohol. |
|
|
Term
Neonatal Jaundice
DDx
Timeframe
Asessment |
|
Definition
Unconjugated:
-Haemolysis
Normal in neonates after Day 2
Cephalohaematoma
Pathological
ABO incompatability
Sepsis
Thalassemia
spherocytosis
dehydration / poor feeding
G6PD
Conjugated - Always pathological
-Billiary atresia
-Liver diease (esp Hepatitis)
-CF/ alpha 1 at deficiency
Timeline:
Day 1 - always pathological
-ABO incompatability
Day 2 - 14
-Normal physiological jaundice
-sepsis (esp UTI)
-All other causes!
->Day 14 - More likely pathological
-Breast milk jaundice (dx of exclusion)
all others.
Hx - Risks important
(mum's blood group, GBS. PROM, prematurity)
Stool colour (?hepatic / post hepatic)
Ex: Pink /healthy vs limp /tired / pale ??Septic.
level of jaundice unreliable.
?cephalohameatoma ? Hepatomegally ? Septic focus
Stool exam
Ix - If unwell / septic - septic screen and treat
If well -Serum Bili - Split + MSU + GP /coombs test
If conjugated Ix and refer
If haemolysis haem refer
If unconjugated and well -
Refer if above treatment below treatment or prolonged > 2 weeks
IF unconjugated, below treatment line and well - can discharge with Follow up arranged. |
|
|
Term
Investigation of well, immunised. febrile 3/12 -->3 YO
without obvious cause |
|
Definition
MSU
Observtion in ED
D/C with follow up.
Note: Incidence of bacteremia <1% (significantly reduced post pneumococcus vaccine) Most likely viral.
Consider more prolonged observation +/- admission if unimunised.
Very high T (> 39) is associated with risk of bacteremia but still rare in well child. |
|
|
Term
| Management of severe sepsis in Neonates |
|
Definition
Cefotaxime 50mg / kg + Penicillin / ampicillin
Ceftriaxone contraindicated in <3/12 due to ?displacement of bilirubin from binding and jaundice. |
|
|
Term
low voltage QRS
-define
-DDx |
|
Definition
<5m all limb leads
<10mm all precordial leads
DDX:
PEricardial effusion
Pleural effusion
Airways Disease
Obesity
Infiltrative myocardial disease
Constrictive pericarditis. |
|
|
Term
define poor R wave progression
ddx |
|
Definition
| r in V3 ddx: prior anteroeptal MI, LVH, poor lead placement, normal varient. |
|
|
Term
ECG interpretation
-Syndromes to look for in Syncope |
|
Definition
-AV blocks
-Long QT
-Brugada
-HCM
-ARVD
-WPW
-Pacemaker dysfunction
-Short QT (very rare)
Mnemonic
Can Quick BRAD Walk Home
-Conduction blocks (including pacemker)
-QT long (and short)
-Brugada
-RVinfarct (+ other ischemia
-ARVD
-DCM
-WPW
-HCM |
|
|
Term
|
Definition
Causes large R waves L sided (1. aVL. V456) and large S waves in R sided leads 111, aVR (V1-3)
-Voltage criteria
S V1 + R V5or 6 > 35 mm.
R V4/5/6 >26mm
largest precordial R + largest precordial S>45mm
R aVL > 11 mm
Other features
- Lateral ST dep / TWI (LV strain)
-Anterior (discordant) STE
-increased R wave peak time (>50ms in V5/6) - QRS widening
-LAD
-LAE
-prominant U waves
Severe LVH can look like LBBB with increased amplitude. |
|
|
Term
|
Definition
-AMI
-percarditis
-BER
-LBBB / paced rhythm
-LVH
-Brugada
-LV aneurism.
-coronary vasospasm.
-Tako-Tsubo cardiomyopathy. |
|
|
Term
| Relevance of ST elevation aVR |
|
Definition
Mechanism:
-either reciprocal change from lat ST dep or transmural infarct from basal interventricular septum/
1: in context of widespread ST depression
-STE > 1mm aVR implies LMCA, prox LAD or severe 3 vessel disease
-Predicts need for CABG
-STE aVR> V1 differentiates LMCA from prox LAD
2: in anterior MI
STE aVR> V1 implies LAD occlusion proximal to the first septal branch
implies
-increased mortality
-STEMI equivalent requiring urgent re-prefusion
-Discuss with interventionalist before loading with clopidogrel. |
|
|
Term
|
Definition
- In setting of LBBB or paced rhythm.
Concordant ST elevation > 1mm (score 5)
Concordant ST dep V123 (3 points) (score 3)
Discordant ST elevation > 5mm (score 2)
3 + is 90% specific for MI |
|
|
Term
Headache DDx
Aproach to asessment |
|
Definition
Life threats
SAH
Meningitis
SOL
Temporal Arteritis
Pre-Eclampsia
Hypertensive Encephalopathy
Common
Primary:
Migraine
Tension
Cluster
Secondary:
-Intracranial
Life threats
+ venous sinus thrombosis, Post LP headache, post traumatic,
Local:
Sinusitis
Trigeminal Neuralgia
Otalgia, dental pain, musculoskeletal etc.
Systemic
Viral illness, malaria, dengue etc, medication etc.
Approach to headache - Red flags
Hx:
-Sudden onset (? SAH)
-Worst / first headache of life (?meningitis/SAH / temporal arteritis)
(first headache particularly important in age > 50
-Different to previous headache pattern
-Associated neurological Sx (not migrainous aura)
-Trauma (ICH)
-Immunosuppression (meningitis)
-Progressive, unremittant headache, worse in mornings (raised intracranial pressure eg mass)
-Fever
Exam
-Meningism
-ALOC
-Neurological signs
-Fever
-Temporal artery tenderness.
-Rash
Ix based on suspicion:
?Meningitis LP +/- CT
?SAH CT< 6 hrs + LP> 6 hours
?Mass lesion - CT + contrast / MRI
?Temporal arteritis (age > 50 - ESR) |
|
|
Term
Headache DDx
Aproach to asessment |
|
Definition
Life threats
SAH
Meningitis
SOL
Temporal Arteritis
Pre-Eclampsia
Hypertensive Encephalopathy
Common
Primary:
Migraine
Tension
Cluster
Secondary:
-Intracranial
Life threats
+ venous sinus thrombosis, Post LP headache, post traumatic,
Local:
Sinusitis
Trigeminal Neuralgia
Otalgia, dental pain, musculoskeletal etc.
Systemic
Viral illness, malaria, dengue etc, medication etc.
Approach to headache - Red flags
Hx:
-Sudden onset (? SAH)
-Worst / first headache of life (?meningitis/SAH / temporal arteritis)
(first headache particularly important in age > 50
-Different to previous headache pattern
-Associated neurological Sx (not migrainous aura)
-Trauma (ICH)
-Immunosuppression (meningitis)
-Progressive, unremittant headache, worse in mornings (raised intracranial pressure eg mass)
-Fever
Exam
-Meningism
-ALOC
-Neurological signs
-Fever
-Temporal artery tenderness.
-Rash
Ix based on suspicion:
?Meningitis LP +/- CT
?SAH CT< 6 hrs + LP> 6 hours
?Mass lesion - CT + contrast / MRI
?Temporal arteritis (age > 50 - ESR) |
|
|
Term
SAH
- Grading, -Prognosis
Ix: |
|
Definition
Grading - world federation of neurosurgeons (WFS)
1: GCS15, no motor defecit
2: GCCS13/14, No motor defecit
3: GCS 13/14 motor defecit +
4: GCS 7-12, motor defecit +/-
5: GCS3-6, motor defecit +/-
Prognosis 70% grade 1 , 10% grade 5 survival.
Ix - CT only < 6 hours (needs 3rd gen CT and qualified radiologist)
CT + LP - delayed by 6-12 hours if no contraindications and present >6 hours. |
|
|
Term
SAH - management
-Complications: |
|
Definition
- In resus,
Team approch
IV access, apply 02, NIVM,
-Notifications - neurosurg, radiology
A- High grade (obtunded) SAH will need Airway protection
RSI - fentanyl, propofol, rocuronium (avoid cerebral HTN)
B- Aim normocapnoea - If Coning can hyperventilate CO2 - 30-35) as temp measure
C- Avoid hypotension
-? Blood prssure control - poor evidence but ? Aim fo SBP < 160 to prevent re-bleed. - Use short acting antihypertensives (esmolol or GTN)
D- Exculde hypoglycemia, treat seizures wih benzodiazapines + phenytoin load -consider prophylactic penytoin (controversial)
Supportive
Analgesia / Sedation - Fent / midaz
Correct Coagulopathy (Ca2+, T, prothrombinex , FFP, Vit K if warfarinised, ?Platelets for antiplatelets.
FAST HUGS
Close neurological monitoring for deterioration.
Treat hydrocephalus with IVD
correct electrolytes - SIADH.
Specific - For anneurismal - Needs urgent control of anneurism - Clips vs coils. (MDT decision)
-Consider nimodipine (within 48 hours ) to control late vasospasm.
Disposition - neurosurg vs ICU.
Complications:
Early
Rebleed
SDH / large ICH needing drainage.
CVA (vasopspasm)
Hydrocephalus (within 24 hours)
Fluid and electrolyte disorders (naturesis and hpovolemia vs SIADH)
Hyperglycemia / hyperthermia,
-Pulmonary oedema, arythmias, Sepsis, VTE
Late:
Asomnia
Neuropshycological effects
Late rebleeding
epilepsy |
|
|
Term
CVA
-Types
-Clinical Syndromes |
|
Definition
Ischaemic
Thromboembolic
-Cardiac (AF, mural, valve disease)
-Arterial (carotic / vertebral emboli , small vessel - lacunar, hypercoagulability)
Hypoperfusion (Shock, vasospasm, stenosis)
Other
(dissection, gas embolism, arteritis)
Haemorrhagic
Hypertensive vascular disease
Anneurisms,
Lipohylinosis,
Amaloid
Blleding Diathesis.
Secondary (EG bleed into tumour / infarct)
Anterior
opthalmic artery - amaurosis fugas
ACA- contrlateral sensory motor defectit leg > arm / face
MCA
- Homonymous hemianopia, Contrlateral hemiplegia / hemianaesthesia face / arm > leg
Aphasia (dominant hemisphere (usually L)
Hemineglect (non dominant)
Posterior Circulation
-Homonamuos hemianopia,
-Cerebellar Signs
-Brainstem signs unilateral or bilateral motor and sensory defecit, cranial nerve sgns,
Specific brinstem syndromes
-Lateral Medullary Syndrome.
-Vertigo / nystagmus, ataxia, ipsilateral loss of facial pain and temperature sensation, contralateral limb pain and temp sensation, ipsilateral horner's syndrome, dysarthria / dysphagia.
-'Locked in' syndrome (pontine stroke)
sparing of 3rd / 4th nerve - eye movements intact. |
|
|
Term
| Investigation / management of TIA |
|
Definition
-CT head to exclude haemorrhage
-Other Ix
-ECG - Exclude AF
- FBC
-ELFTs - exclude hypoglycemia / metabolic encephalopathy
-Consider Prothrombotic Screen (especially young patients)
-Inflammatory markers if suspicion of arteritis.
If neurology resolved / normal CT TIA is diagnosed
Risk stratification
ABCD2 score
Age > 60 =1
BP (>140/90) = 1
Clinical
- Unilateral weakness = 2
-Speech disturbance without motor weakness =1
Duration > 60 min 2 , 10 -60 min 1, <10 min 0
Diabetes =1
ABCD < 4 may be investigated as an outpatient
> 4 needs inpatient admission ( high risk of stroke in coming days)
Also admit suspected cardioembolic stroke (eg AF) or creshendo TIAs
Further Ix - Echo, Carotid dopplers, Consider MRI. Should be arranged within 1 week of discharge.
Management (TIA)
-1) aspirin 30mg load then 100mg / day
-Minor additional benefit with dipyridamole but increased side effects)
2: Anticoagulation for cardioembolic source (Except endocarditis)
3: Endartectomy for carotid setnosis > 70 %.
4: Modify vascular risk factors (HTN, DM, Somoking, HC) |
|
|
Term
| Management of Ischemic Stroke |
|
Definition
-Early notification of stroke team
-A- Severe stokes with obtundation / Airway threat. may need airway protection.
C- Avoid hypotension
Hypertension - Lower if > 220/140 or MAP > 130
Aim for 10-15 % reduction with titratable drug (eg GTN, esmolol)
D-Exclude hypoglycemia,
E; Avoid hyperthemia,
Supportive - Analgesia,
VTE prophylaxis
Feeding - speech path review
glycemic control (treat if > 10)
Specific:
asprin 300mg load then 100mg / day
+/- dipyridmole
Thrombolysis - controversial but consider within 4.5 hours in consultation with neurologist.
Anticoagulate with proven cardioemblic source.
Endartectomy ( if carotid stenosis)
Disposition - Stroke unit improves outcome (allied health important) |
|
|
Term
| Thrombolysis for acute stroke. |
|
Definition
-Consider if presents within 4.5 hours and no contraindication
Controversy.
12 trials TPA and stroke
2 positive with primary endpoint
2 stopped early due to ham
8 negative (with most recent IST -3 showing reduced disability when retrospectively statistical analysis was changed)
Trials consistently show icreased ICH and early death (but death = after 3-6 months)
approx 5% rate of ICH
Pos trials
NINDS -1996
(lysis within 3 hours, reduced disability @ 3/12)
ECAS-3 (2008
(3-4.5 hours, excluded age >80, DM + previous stroke, preexisting disability. Found reduced disability @ 3/12)
IST -3
(< 6hours from onset or benefits deemed uncertain (Ie contraindications < 4.5 hours based on NINDS or ECAS 3)
No difference in primary outcome but secondary ordinal analysis detected shift in disbility scores. |
|
|
Term
| WBC : RBC ratio in CSF in pts WITHOUT meningitis |
|
Definition
|
|
Term
| Interpretation of LP to exclude SAH |
|
Definition
- ideally 12 hours post headache
-< 5 RBCs AND negative Xanthochromia adequate to exclude SAH if CT is normal.
Either + Xanthochromia or >5 RCC should prompt CT angiography. |
|
|
Term
Liver Failure
-Types / Definitions
-Eitology |
|
Definition
Types
Acute Liver failure: Jaundice, Coagulopathy and hepatic encephalopathy occurring within 26 weeks of start of illness in a patient without pre-existing cirrhosis.
Less common that Chornic liver failure / acute on chronic liver failure which occur in those with chronic liver disease
Eitiology Acute liver failure-Varies with area. I West, drugs most common cause, in parts o Asia Viral hepatitis much more common.
DDx - ACUTE liver failure
- Viral -HEp A, E, BDC, EBV, CMV, HSV, HZV,
-Drugs - PARACETAMOL,volatile anaesthetics, idiosyncrativ drug reactions (rifamapacin, isoniazid, NSAID, valproate, phenytoin, statin, MDMA)
Rarer
-Toxins - Mushrooms
-Fatty liver of pregnancy,
-Pre-ecampsia / HELLP
-Malignancy, ischemia, heat stroke, Rey's |
|
|
Term
| MAnagement of Acute Liver Failure |
|
Definition
A- Severe hepatic encephalopathy with obtundation / resp failure may need I/V.
C- Optimise haemodynamics
-Consider Albumin for volume resuscitation
-Vasopressors / Ionotropes (esp Na / DA)
D- Hypoglycemia common - Seek and correct .
Supportive - FASTHUG
esp - Ulcer prophylxis (esomeprzole)
Specific - Liver transplant
(to cause)
Paracetamol - NAC
Mushrooms - ? Penicillin - G (poor evidence)
(to complications)
Encephalopathy
-Exclude cerebral edema and raised ICP
-Correct reversble factore (hypoxia, hypotension, acidosis, hyperthermia, drugs esp BEnzo's)
-Lactulose and neomycin probably don't work and have complications
Infection
Sepsis common precipitant,
Give broad spectrum ABs prophylactically or therapeutically
-Peritoneal tap to exclude SBP
Coagulopathy
-VIT K, FFP, platelets for plt <20
-Renal Failure |
|
|
Term
| Indications for Liver transplnt |
|
Definition
Acute Liver Failure
-Paracetamol different to other causes.
pH <7.3, INR> 6
Cr >300
Grade 3 / 4 encephalopathy.
Non paracetamol
INR > 6 (PT > 100s) or any 3 of the following variables:
(1) age < 10 or > 40 yrs
(2) aetiology – non A, non B hepatitis, halothane hepatitis, idiosyncratic drug reactions
(3) duration of jaundice before encephalopathy > 7 days
(4) INR > 3.5 (PT > 50s)
(5) bilirubin > 0.3mmol/L
Chronic Liver Failure
Child Pugh B and C
bilirubin >3-5mg/dL
albumin < 28
INR > 1.7
hepatic encephalopathy
refractory ascites
(BRAIN = bili, refractory ascites, alb, INR, eNcephalopathy) |
|
|
Term
| Complications of Liver Failure |
|
Definition
-Jaundice
-CNS
+Encephalopathy
+Higher risk of SDH
-Metabolic Changes
+Hyponatremia
+Decreased drug metabolism
+Hypoglycemia / reduced gluconeogenesis
-Reduced Synthetic function
+Hypoalbuminemia
+Coagulopathy
-Portal Hypertension
+Varicies
+Ascites
+Splenomegally and thrombocytopenia
+GI Bleed
-Hepatorenal syndrome / Renal failure.
-Immunosuppresion
+Risk of Sepsis
+SBP
-Endocrine
+Hypogonadism
+Gyacomastia
+Spider naevi |
|
|
Term
|
Definition
UFAKE (TNT)
Uremia - Encephalopathy, pericarditis or Urea 30-35.
Fluid overload (and oligouric despite medical Rx)
Acidosis (From renal failure) (pH<7.2)
K + (>6, in conjunction with medical Rx)
Extras
-Toxicology (eg: Valproate, Barbituates, lithium, toxic alcohols, theophyline)
-Temperature control (Rx severe hyperthermia
-Na>160 |
|
|
Term
| ALS - Adult, paediatric, Neonatal |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
In Resus Bay with full NIVM / ALS equipment
Apply O2 via NRBM
IV Access x 2 - Send blood - cultures, VBG , FBC, EUG, Coags.
Team approach - Assume leadership role
A- Intubate if GCS <8, Respiratory failure (Hypoxia despite NRBM, respiratory acidosis)
-Optimise Haemodynamics first
-RSI / Consider Delayed sequence induction with NIV if severe acidosis
-Ketamine - low dos e(0.5mg/kg), Rocuronium 1.2mg/kg
B- Ventilation - (ARDS setings, plat pressure <30cm H20(6ml / kg TV, PEEP 5, 100% 02 and titrate to sats >94% titrate resp rate to Co2 normocapnoea or maintain respiratory compensation for severe metabolic acidosis)
C- -1L IV Ns + reassess fluid status (JVP / CVP + repeat. Optimise intra-vascular filling
-Consider albumin 4% for further fluid boluses
-If persistent hypotension
NAD @0.1mcg/ kg / min + titrate to MAP 65, SBP>90, Urine output 0.5ml /kg/hr, falling lactate
Consider adding vasopressin or Dobutamine if refractory hypotension.
-Central Access
D: Exclude hypoglycemia
Supportive / Monitoring
Close haemodynamic monitoring
-IABP, CVP
-IDC / Urine output
-Serial Lactate / Blood gas
-Analgesia / antipyresis
-Optimise blood O2 carrying capacity - -Consider transfusion if Hb <70
- Hydrocortisone if pt is on regular steroids
-Sedation if Intubated.
-NGT
-Head up
-Ulcer prophylaxis - esomeprazole 40mg
-Glycaemic control - Aim for BSL 6-10
-Thromboembolism prophylaxis - TEDS / SCDS / Heparin SC.
Specific - Appropriate ABS ASAP (must be within 1 hour)
-If unclear source - flucloxacillin 2g + gentamicin 5mg / kg
-Ceftazidime + vancomycin if neutropenic.
-Source control
Disposition -
ICU for Haemodynamic / ventilatory support
Note - Differences between this approach and EGDT
-No Scv02 < 70 % --> transfuse to Hb 100, Dobutamine.
Limitations of Rivers - Very high overall mortality --> ? applicability to Australian setting.
Await ARISE trial comparing Australian routine care to EGDT. |
|
|
Term
Hyperthyroidism and Thyroid Storm
Aetiology
Clinical Features
Management |
|
Definition
Aetiology
-Primary
+Graves Disease
+Thyroiditis
+Toxic MNG / Adenoma
-Central
+Pituitary adenoma secreting TSH
-Drugs
+Amiodarone, T4, Iodine preparations, lithium.
Clinical Features
T3 (active) causes
-Increased metabolism
-Increased sensitivity to catecholamines
CVS - Tachycardia, tachyarrhthmia (ST, SVT, AF w RVR), wide pulse pressure, high output cardiac failur, exertional dyspnoea..
CNS - Anxiety, agitation, Tremulousness, mental disturbances.
Metabolic - Weight loss, Heat intolerance, Hypokalemia.
GI - Diarrhoea, increased appetite
Genera; - Weakness, fatigue, sleep disturbance
Thyroid Storm - Emergency with high mortality. Usually precipitated by an event (sepsis, iodine load, etc) in pt with hyperthroidism.
Charachterised y
- Fever (T>37.6)
-Tachycardia / AF w RVER, Wide pulse pressure, hiugh output cardiac failure)
-ALOC agitation --> Coma / Seizures
-Abdominal pain / vomiting / diarrhoea.
Rx
-Routine hyperthyroidism --> referral and OPD Rx
Thyroid storm Rx
In environment capable of cardiac monitoring.
Supportive - Routine Care, especially.
-Aggressive Rx of hyperthermia
paracetamol and cooling
-IV rehydration (GI fluid loss)
-Closely monitor + replace electrolyes (esp K+)
Specific- B-Blockers
-Propranolol (antagonises conversion of T4-->3 and ameliorates catecholamine effects) - IV 0.5 to 10mg then 40mg Q6 hourly titrated to HR <100,
-Propothyouricil 900mg PO loading 300mg Q6 hourly (inhibits synthesis of T4
-Iodine (30 drops PO daily lugol's solution) - Inhibits synthesis / release GIVE AFTER PTU
-Corticosteroids
Hydrocortisone 100mg IV QID inhibits conversion of T4 -> T3 and treats relative steroid deficiency
-Treat underlying cause / precipitant (eg Sepsis, referral for surgery) |
|
|
Term
Addisonian Crisis
Causes
Clinical Features
Ix
Rx |
|
Definition
Causes of Adrenal Insufficiency
-Primary
+Addison's disease (autoimmune adrenaitis)
+Surgical removal
+Congenital Adrenal hypoplasia
+Haemorrhage / Infarction (Waterhouse -Friedrichson syndrome)
+Infectious adrenitis (TB, viral)
Secondary
+Exogenous steroid use
+Pituitary failure (tumour, infarction (Sheehan's syndrome)
Addisonian crisis occurs when pt with adrenal insufficiency is stressed (Eg: concurrent infection)
Clinical features
-CVS
+Hypotension, often unresponsive to IVT.
-Metabolic
+Hyperkalaemia, hypercalcaemia, NAGMA, hypoglycemia, hyponatremia.
-GI
+Abdominal pain and vomiting - often marked
-CNS
ALOC, confusion
-Other
+Skin hyper-pigmentation (ACTH - primary only), weakness,
Suspect in patients with refractory hypotension!
Ix: Electrolyte / Acid base changes as above
In Acute illness serum cortisol < 80mmol / L diagnostic
Short synaptin test
Rx-
RESUS
Specific- Hydrocortisone 200mg IV stat then 100mg (2mg/kg) QID
Address underlying precipitant (eg: ABs for sepsis)
Long term may need fludrocortisone (not acutely - hydrocortisone has mineralocorticoid effects)P
Supportive
-Treat hypoglycemia
-IVT,
-Correct Electrolyte abnormalities + closely monitor Na+ / K+, acid base status. |
|
|
Term
Hyponatraemia
Causes
Grading
Clinical Features
Management |
|
Definition
Causes
Hypotonic --> hypovolaemic, euvolaemic, hypervoaemic
Isotonic --> Pseudohyponatraemia (eg high lipids)
Hypertonic: Dilution in present of osmotically active substances especially glucose, (corrected +1mmol/L Na+ for 3mmol / L glucose)
Hypovolaemic - Na+ Loss > H20 loss.
-Renal: Diuretics, mineralocorticoid deficiency, osmotic diuresis (mannitol)
-Extra-renal: Diarrhoea, sweating, blood loss, third space loss (eg: Burns / pancreatitis)
Euvolaemic
-SIADH
-Drugs (SSRIs, TCAs, ecstasy,, antipsychotics, NSAIDS, Carbemazapine)
-ADH excess (eg post operative)
-Psychogenic polydipsia
-Iatrogenic water intoxication (eg TURP)
Hypervolaemic
-Cirrhosis, CCF, nephrotic syndrome, Renal failure.
Grading
Mild > 125-134
Mod 120-125
Severe<120
Clinical features
Dependant on absolute Na+ level and rate of fall (rapid = less chance for intracellular osmotic compensation)
GI + CNS sx
-Anorexia, nausea, vomiting
-Confusion, ataxia, falls, ALOC, Seizures, Coma
Rx: Rate of correction balences risk of hyponatremic encephalopathy with risk of Osmotic mylenosis with rapid correction.
Severely symptomatic - Coma or seizures warrants rapid correction
-Seizures: - Benzodiazapine + 2ml / kg 3% hypertonic saline bolus Q10 mins until seizing ceases (should raise serum na+ by 2mmol / L.
Coma: Aim for 1mmol / Hr correction serum Na+ = 1ml / kg/ hr 3% NaCL - Serial electrolytes.
End point for rapid correction, resolution of life threatening symptoms / serum Na+ risen by 20mmol / L or Na+125.
At this point slow correction of Na + by - treating underlying cause (eg: stop Thiazide), fluid restriction 1L / day) Aim 10mmol / L / day. |
|
|
Term
Hypernatremia
Cause
Clinical Features
Rx |
|
Definition
Causes
-Defecit of H20> Na+
-Unusual in presence of intact thirst response --> drinking
Causes -
-Alteres thrist perception
+CNS osmoceptor damage
+psychogenic
+drugs
Poor oral intake in setting of normal thirst reponse
+Coma / confusion
+Depression
+Dysphagia
-Increased H20 loss ((with decreased intake)
+Diuresis
+Diabetes Insipidus
+GIT H20 loss
Clinical features
-Primarily CNS (neuronal shrinking!)
+Confusion, anorexia, nausea, vomiting, hyperreflexia, lethargy
+Seizures / Coma
+Risk if SDH from shrinking brain.
Rx: Gradual correction of hypernatraemia inportant because of risk of cerebral oedema. Aim 0.5mmol / L / hr to normonatraemia (IV Free water with 5% dextrose)
Total Body water deficit = 0.6 x weight x(1- [desired Na+]/[measured Na+])
+If hypovolaemic - restore intravascular volume with IV NS first
+If hypervolaemic (rare) diuresis with frusemide |
|
|
Term
Hypokalemia
DDx
ECG changes
Rx |
|
Definition
1:Decreased intake (anorexia / alcoholism)
2: Increased GI loss (vomiting, diarrhoea,fistula / malabsorption
3: Increased Renal loss
DIURETICS(loop + thiazide + Osmotic)
Mineralocorticoid excess (Conn's, Exogenous steroids, secondary hyperaldosteronism - CCF / Cirrhosis)
Congeniotal (gitelman's etc)
RAS
4: Transcellular shift
-alkylosis
-Insulin
-Hypomagnesia, hypernatremia
5: Drugs
Diuretics, penicillins, insulin
ECG: Long PR, ST dep, TW flattening , long QT (apparent) U waves, Arrythmia (AF, flutter, VT, VF, torsades)
Rx - Address cause (eg: stop diuretic)
Correct hypomagnesaemia
Replace K+ (span K =8mmol, chlorvescent =14mmol)
IV - Cardiac monitor, max 20mmol / hr (0.4mmol / kg/ hour) |
|
|
Term
Hyperkalemia
1:Define Mild / Mod / Severe
2: ECG changes
3: DDx
4: Rx |
|
Definition
Mild - 5-6, Mod 6-7, severe >7 / Toxic ECG changes:
Peaked T waves,
Progressive atrial paralysis - long PR, Flat P waves, absent P waves.
Broad QRS
Sine wave
Arrythmia - High grade AV blocks, any ventricular conduction delay, Slow AF, VT / VF, Asystole, PEA
DDx:
1: Increased intake (rare - usually iatrogenic)
2: Increased production - Burns, trauma, rhabdomyolysis.
2: Decreased excretion - Renal failure, Drugs (eg: ACE / AR2 B, spironolactone, amiloride, digoxin)Hypoaldosteronism - addison's.
3: Transcellular shift - acidosis, insulin deficiency, suxamethonium.
Rx
Calcium (except in Dig toxicity)
10 ml CaCl or gCa Gluconate effect lasts 30 min-1hr
Shift into cells
Insulin / Dextrose - 10 u + 50 ml 50%
Na HC03 -50 -->200mmol
Salbutamol nebs x 4 (20mg)
Excretion
Resonium - Po /PR 20g
IV N/S + Frusemide
Dialysis (Especially for renal failure) |
|
|
Term
| Expected CO2 metabolic acidosis |
|
Definition
|
|
Term
| Expected Co2 metabolic alkylosis |
|
Definition
|
|
Term
| Expected HCo3 respiratory acidosis |
|
Definition
24 + 1x(PC02-40)/10 acute
24 + 4 x (PCO2-40)/10 chronic |
|
|
Term
| Expected HCo3 respiratory alkylosis |
|
Definition
24 - 2 x(40-PCO2)/10 acute
24- 5 x(40-PCO2)/10 chronic |
|
|
Term
Hypocalcaemia
Causes
Clinical features
Rx |
|
Definition
Causes
-Hypoparathyroidism
-Dietary: Vitamin D deficiency / Ca2+ deficiency
-Hyperphosphataemia
+Renal failure
+Rhabdomyolysis
-Drugs / Poisons
+Bisphosphonates, Ethylene glycol, Hydrofluric Acid, Frusemisde
Clinical Features:
Neuromuscular - hyperreflexia, muscle cramps, Chvosteck's sign (facial nerve Trousseau'ssign (tetanic contraction with blood pressure cuff) Tetany
Neurological - Perioral paraesthesia, distal paraesthesia, Seizures.
Cardiovascular - Hypotension, bradycardia, arrhythmias, prolonged QT.
Rx - Acute Symptomatic
-IV CaCl, Ca gluconate 10 -->20 mls
-Treat cause,
-Oral supplimentation
-Vitamin D |
|
|
Term
Hypercalcaemia
Causes
Define Severity
Clinical Features
Rx |
|
Definition
Causes
-Malignancy
-Primary hyperparathyroidism
-Other endocrine (hypoadrenalism, thyrotoxicosis)
-Drugs
+Thiazide, vitamin D, lithium,
-Renal Failure
-Exogenous
+Milk alkali syndrome
Severity
Mild 2.55-> 3, moderate 3-3.5 severe > 3.5
Clinical Features
Stones, bones, moans, groans
-GI
+Abdominal pain, constipation, vomiting, nausea,
-CNS
+Confusion, lethargy, ataxia, apathy, seizures,
-Complications of boney destruction (#)
-Renal Calculi
-CVS
+Short QT, hypertension.
Rx:
1: Rehydration with IV NS +/- frusemide diuresis
2: Inhibition of boney resorption
-Bisphosphonate (pamidronate 60mg IV) (Normalise Ca2+ over 1 week and lasts for 1 month.
3: Haemodialysis for Renal failure / Severe hypercalcaemia.
4: Treat underlying cause 9eg malignancy specific Rx) |
|
|
Term
|
Definition
USED CARP
Uretoenterostomy
Small bowel fistula
Excess Saline
DIARRHOEA
Carbonic Annhydrase inhibitors (acetazolamide)
ADDISONS
Renal HCO3 loss - RTA
Pancreatic fistula
OR
ABCD
Addisons
Bicarb loss (GI / Renal)
Cloride excess
Drugs (acetazolamide, spironolactone) |
|
|
Term
|
Definition
DDx GROE
1: GIT H+ loss (vomiting, pyloric stenosis,NGT drainage)
2: Renal H+ loss (Diuretics, rare congenital Bartter's and Gitelman's syndromes)
3: Overdose of base - milk alkali syndrome
4: Endocrine (Hyperaldosteronism, Cushings, Steroid excess. |
|
|
Term
|
Definition
Unmeasured anions
Na+ - (HCO3 + Cl-)
Normal range =12+/-4 |
|
|
Term
|
Definition
Change in anion gap / change in HCO3
therefore ag-12 / HC03 - 24 |
|
|
Term
Urea / Cr ratio
?Normal
?Significance |
|
Definition
Normal Ur =2.5-10 mmol / L
Normal Cr = 60-100 umol / L
Therefore normal Ur/Cr Ratio =40:10 - 100:1
> 100:1 implies
ddx: dehydration / pre-renal failure
corticosteroids
GI haemorrhage
Protein rich diet
Severe catabolic state
(drivers can use GPS)
Low Ur/ Cr ratio
Severe liver dysfunction
INtrinsic renal disease
Malnutrition
Pregnancy
Low protein diet
SIADH
Rhabdomyoloysis
SIMPLE SR |
|
|
Term
|
Definition
MUDPILES
Methanol / Ethylene glycol
Uremia
DKD
Paraldehyde, propylene glycol
Iron, Isoniazid
Lactic Acidosis,
Ethanol
Salicylates |
|
|
Term
Osmolar Gap
Define
Implications |
|
Definition
Measured osmolality vs - calculated osmolarity
Osmolarity = [2xNa]+ + [urea] + [Glucose]
Normal <10, high osmolar gap implies presence of an unmeasured osmotically active substance (eg etoh, methanol) |
|
|
Term
|
Definition
|
|
Term
Pelvic fractures
-Associated Injuries
-Classification
-Management |
|
Definition
Associated Injuries.
-VAscular / Haemorhagic shock
-GI - especially rectal
-GU urethral, bladder, prostate / Genital
-Spinal / Neural
-Abdominal injury
Marker of high energy mechanism.
Classification
1: Tile (Stability)
A: Rotationally and vertically stable (eg: Pubic rami #, pub symph diastasis <2.5cm)
B: Rotationally unstable, vertically stable
(eg: Pubic diastasis >2.5cm + widened SI, or pubic symph overriding)
C: Rotationally unstable / vertically unstable
(Disruprtion of SI joints
Young / Burgess (mechanism + stability
-APC 1 widened pub symphasis <2.5
-APC 2: Pubic symph >2.5, torn anterior sacral ligaments
-APC 3 - Hemipelvis separation
-LC common feature is transverse pubic rami #
-LC 1pubic rami # (stable)
-LC 2 pubic rami + sacral / illiac / SI injury (rot unstable
-LC 3: LC2 + APC injury tocontalateral pelvis (rot + vert unstable)
-Vertical Shear
Vertical pubic Rami # + displacement of SI Joint vertically /
Completely unstable
CM - combined mechanism.
Management of Pelvic fracture
-HD unstable:
Minimum volume resus. Apply pelvic binder
FAST +ve --> Red blanket OT, damage control surgery, pelvic packing, +/- EX fixation. To angiography + embolisation if ongoing instablility
FAST -ve Controversial!
-Options
-Pre-peritoneal packing
-Ex- Fixation
-Angiography
Preference: Immediate OT for EX fix + pre-peritoneal packing. Then angiography for ongoing haemodynamic instability.
Haemodynamically stable patients should have CT + contrast to define injury and plan therapy. |
|
|
Term
Sickle cell crisis
-Precipitants
-Types and clinical features
-RX |
|
Definition
-Sickle cell disease --> haemoglobinopathy, distorted dysfunctional RBCs
-Prone to infection (functional asplenia)
Precipitants
Cold, Sepsis, dehydration, hypoxia
Crises.
-Vaso-occlusive crisis - PAIN.
-Acute splenic sequestration - Hb drop , normal reticulocytes, thrombocytopenia (usually in infants)
-Sepsis - Fever
-Aplasitic crisis - Rapid fall in Hb low reticulocytes.
-Priapism
-Stroke
-Acute chest syndrome (lung infarct)
Rx -
Resus - Oxygenation >95
IV rehydration
Specific:
-Fever - empiric ABs
-Vasooclusive: Analgesia (opiods) rehydration, oxygenation
-aplasia - o2, hydration, transfusion
-Acute splenic sequestation - transfusion (Target Hb >50)
-Priapasm - analgesia, fluid, o2, consider aspiration, washout.
-Refer haematology. |
|
|
Term
CURB 65 score
PSI
CORB
SMART COP |
|
Definition
Used to identify low risk of death / ICU patients suitable for outpatient management.
CURB-65
-Confusion
-Urea>7mmol/ L
-RR >30
-BP <90S <60D
-Age >65
score 0 =0.7 % risk - safe for OPD Rx (providing not hypoxic, adequate support follow up and clinical gestalt conducive
1 may be suitable as well.
PSI - Patient who are < 50 have no major chronic disease and normal Obs/ T<40 >35 andnormal mentation are class 1 and are safe for OPD rx (with above provisos_
Otherwise need to calculate PSI - need table.
CORB - Confusion Hypoxia, RR> 30, BP <90
(2+ = severe)
SMART COP
SBP<90,Multilobar, albumin<35, RR>25, Tachycardia>125, Confusion Oxygen low, pH <7.35
(<= 2 very low incidence off invasive support) |
|
|
Term
Febrile Neutropenia
Define
Likely Organisms
Management |
|
Definition
-T>38 in pt with neutrophils < 1 x1000 cell / uL
Organisms -
Gram neg bacilli
Staph Aureus
Strep Viridans
Less common
MRSA
Fungi
Pseudomonas
Rx
RESUS
Specific:
Early antibiotics -
Pipercillin / Tazobactam
or
Ceftazidime
or
Cefipime
Consider vancomycin if high MRSA prevalence / shocked.
Consider antifungal if persistant fevers x 72 hr
Source control
Isolation
Single room, contact and droplet precautions
GCSF - cease if neut >0.5, contraindicated in acute leukemia.
Supportive Care
Routine
Avoid removing lines unless obviously infected.
Disposition
Haematology / Oncology
+/- ICU |
|
|
Term
Ventilator Settings
ARDS
Asthma |
|
Definition
ARDS
Reasonable default ventilation strategy (except in those with obstructive airways disease)
-ARDSnet trial 2000 --> Mortality benefit and reduced duration of mechanical ventilation with lung protective strategy (evidence of reduced lung injury in a variety of indications)
-TV6 ml/kg ideal body weight)
-Set RR for ideal MV (not >35)
-Adjust PEEP (increasing with increased F1O2) pPlat <30
-pH target 7.3-7.35
-sats88-95
-pO2 55-80mmHg
-I
Severe Asthma
TV 6ml / kg
1/3 normal RR (ie: 6/ min in adult)
PEEP 0
Long expiration (low I:E ratio) High inspiratory flow rate
permissive hypercapnoea (pH>7.1)
pPlat<30 |
|
|
Term
NIV
Indications
Contraindications
Settings |
|
Definition
Indications
-Respiratory failure unresponsive to 02 via Non re-breather
-Evidence for reduced mortality in COPD, reduced need for intubationin APO.
-Evidence for benefit n other causes of respiratory failure less clear but in general it is still reasonable to trial NIV or use as a bridge to intubation
Other: Preoxygenation / Delayed sequence intubation
Contraindications
-ALOC
-Excess resp secretions / vomiting Aspiration risk
Settings:
APO - CPAP 10cm H20 and titrate (note initial association with increased MI has not been borne out in further studies)
COPD - IPAP 12-15 EPAP 4-7
Never exceed 25cm H20 |
|
|
Term
Acute monocular visual loss
DDx |
|
Definition
Painful
-Giant Cell arteritis
-Acute angle closure Glaucoma
-Endopthalmitis
-Uveitis
Painlesss
-CRAO
-CRVO
-Retinal detatchment
-Vitreous haemorrhage
-Optic neuritis |
|
|
Term
Central Retinal Artery Occlusion
-Clinical Features
-Ix
-MAnagement |
|
Definition
Hx:
Sudden painless monocular loss of vision
-underlying cause
(eg: risk factors for embolic CVA, GCA, Sickle cell disease)
Ex:
-VA markedly reduced
-RAPD
-Abnormal red reflex
-Pale retina with cherry red spot.
Ix: Urgent ESR -+/- CRP --> Exclude GCA
Non urgent work up for CVA
Rx:
Specfic (unproven). Aim is to reduce intraocular pressure
-Pulsed occular massage
-Acetazolamide 500mg PO
-Anterior Chamber paracentesis (anethetise, prep with iodine, 27 guage needle horizontally into anterior chamber and allow to drain)
-Breath into paper bag (hypercapnoea dilates artery)
Disposition - Urgent Opthal referral + physician input. |
|
|
Term
Acute Angle Closure Glaucoma
Clinical Features
Rx |
|
Definition
Acute unlateral red eye
Reduced VA
+/- vomiting, halos,
Classically fixed mid dilated pupil, conjunctival and episcleral injection,
IOP > 20 (often 60!)
Fundoscopy - optic nerve cupping.
RX:
Specific-
Urgent opthalmology referral
Acetazolamide - Reduce IOP
Topical BBlocker (Timolol0.5% 1-2 drops)
Topical miotic - pilocarpine 1-2 drops Q15 min until constriction (helps 'open the angle'
Topical apraclonidine (alpha 2 agonist)
If medical Rx fails --> Urgent peripheral iridotomy.
Supportive - esp analgesia / antiemesis. |
|
|
Term
|
Definition
-Periorbital - Cellulitis, Stye, Chalazion, blepharitis
-Conjunctiva - Conjunctivitis (bacterial, viral, allergic
-Sclera - Scleritis / episcleritis
-Cornea - Keratitis, corneal ulcer (inc: dendritic ulcer of HSV), corneal abrasion
-Uvea - Uveitis / Iritis.
-Glaucoma
-Endopthalmitis |
|
|
Term
Retrobulbar Haemorrhage
-Clinical Features / Complication
-Ix
-Management
-Lateral canthotomy procedure |
|
Definition
-Occurs in context of trauma / surgery or retrobulbar injection
-Feared complication is orbital compartment syndrome compressive leading to compressive optic nerve atrophy and blindness
Clinical features of orbital compartment syndrome
-Proptosis
-Periorbital swelling / haematoma. Tense swollen eyelids to palpation.
-Severely reduced VA
-RAPD
-Opthalmoplegia
-Raised IOP (>40)
Ix - Clinical diagnosis but can be confirmed with CT orbits.
Rx.
-OCS is a sight threatening emergency requiring immediate Rx
If evidence of optic neuropathy or severely raised IOP (>40) needs urgent lateral canthotomy
If raised IOP but no optic neuropathy - medical Rx raised IOP (timolol, acetazolamide, manitol + admit ophthal for monitoring)
Lateral canthotomy procedure.
-Ideally by opthalmologist
-topical anaesthetic + / - sedation
-Prep eye with iodine drops
-Incise lateral canthus with scissors
-Retract inferior eyelid and cut lateral canthal tendon (cantholysis) |
|
|
Term
|
Definition
Infectious
-VZV, chickenpox, shingles
-HSV
-Hand foot and mouth disease
-Smallpox!
Autoimmune:
-Pemphigoid / pemphigus
-Contact dermatitis
Medications
-Drug reaction
Traumatic
-Burs
Others / Mimics:
eg Pustular psoriasis, impetigo.
In severe widespread rash that progresses to exfoliation consider
TEN, SJS, (with MM involvement) Staphlococcal scalded skin syndrome and erythroderma. |
|
|
Term
Erythroderma
Features
Aetiology |
|
Definition
Widespread erythema that progresses to exfoliation.
Either progression of previously localised skin condition, drug reaction, @ndary to underlying systemic illness or idiopathic.
Clinical features:
Widespread erythemia progressing to desquamation
-Devere disease can loss of thermoregulation, Fluid and electolyte disturbance and hypoalbuminaemia akin to a severe burn
Aetiology
Underlying skin disorger
-Aopic dermatitis, psoriasis, contact dermatitis, pemphigoid
Drug reaction
(many drugs possibly indicated)
Underlying Systemic Disease
-Malignancy, graft vs host, HIV |
|
|
Term
Stevens- Johnson Syndrome / Toxic Epidermal Necrolysis
Definition
Clinical Features
Classification
Aetiology
Rx |
|
Definition
Severe desquamating rash with MM involvement. Drug reaction. Most commonly - Sulphonamides (other common precipitants B-Lactams, NSAIDs, anticonvulsants.
Features:
Skin:
Targets (erythema multiforme)
Widespread macules or purpura
Progresses to blisters that confluess and desquamate in sheets
MM envolvement - at least two sites (GI, GU, conjunctive, genitals)
Pt very unwell, severe pain, fluid / electrolyte disturbance, Shock, DIC + Multioggan failure + death.
Classification based on severity at peak (therefore impossible to differentiate at presentation)
TEN = >30 % TBSA desquamation, SJS <10 %.
Rx - RESUS
Life threats - Airway involvement, Resp compromise (eg: ARDS), Hypovolaemia. Hypothermia.
Specific:
Cessation of all unnecessary drugs
Dressings - Chlosig
Steroids / immunomodulators remain controversial
Isolation
Supportive:
Fluid / electrolyte monitoring / replacement . Monitor volume status and U/ O. Parklands formula
Analgesia - very painful
Thromboembolism prophylaxis
Disposition
ICU
Ideally burns unit
ENT for MM involvement
opthal for eye involvement etc. |
|
|
Term
erythema multiforme
Causes
Features
Rx |
|
Definition
Hypersensitivity reaction- usually precipitated by infection
Most commonly HSV
Others : VZV, adenovirus, hepatitis viruses, HIV , CMV
Drug reactions may also cause EM.
Rash usually starts on distal limbs and spreads proximally. Often involves face, neck and trunk.
Initial erythemous macules become papuled then enlarge to become plaques. Surface changes - blisters and crusting occur.
Clasic Target lesion: central purpura +/- vescicle / crusting, surrounded by ring of pale pink (oedema, surrounded by bright pik (inflammation)
MM involved = EM major (1 site)
No MM involve = MM minor
Rx: Treat underlying infection (e: aciclovir for HSV)
Cease any implicated drug
Hospital based Supportive Care sometimes necessary (eg IVT with severe MM involvemt)
Good prognosis - resolves spontaneously. |
|
|
Term
|
Definition
Hypersensitivity reacution - Panniculitis
Common causes
-Infetive
Strep or viral sore throat
TB
-Autoimmune
Sarcoidiosis
-Pregnancy and OCP
-Drug reaction
esp: Sulphonamides, NSAIDS
Presentation
Most often young adult women
-Erytematous raised nodules, predominantly on anterior lower leg.
-Progresses to bruising colour change over weeks and usually resolves spontaneously.
Associated fevers, arthralgias and myalgias. |
|
|
Term
|
Definition
(note: small purpura (<2mm = petechiae, large purupra = ecchymosis)
-Thrombocytopenic
Primary- ITP vs secondary (infections, hypersplenism, marrow failure etc)
Vascular Disorders
-Vasculitis (eg: HSP)
Septic Emboli (eg meningococcemia)
High intravascular pressure (eg: petechiae in SVC distribution in setting of coughing illness)
Trauma!
-Coagulation Disorders
eg: DIC, HITS, Haemophillias
-Vascular Disorders |
|
|
Term
|
Definition
Identification, projection, Supine vs erect.
Gasses, Masses, Stones and Bones
Gasses:
-Pattern of bowel Gas (Ie Central vs one side
-?Dilated bowl loops (>5 cm large, > 3.5 cm small)
(large bowel has haustra - partially across bowel, small bowel has valvulae all the way across)
-Air fluid levels (> 5 >2.5cm A/F levels pathological - gastro / ileus / obstruction)
-Intramural Gas --> ischemic colitis
-Intraperitoneal gas 'Rigler's sign - can see both the inner and outer bowel wall
Masses:
_Identify soft tissue shadows - liver, spleen, kidneys, psoas, Aorta,
Bones- Comment on Boney structures
Stones:
Follow renal tract to look for calculi
(over transverse processes, over SI joint to Ischeal spines then medial to bladder. |
|
|
Term
|
Definition
Ix:
Bedside
Urinalysis: Nitrites suspicious for Infection
10% have no haematuria
BHCG
Path - leukocytosis common, >15 rasies suspicion of infection
UEG- Renal function
LFT / Lipase (ddx)
imaging - CTKUB - highly sensitive + specific. Allows exclusion of potentially lethal mimics eg AAA.
AXR useful for follow up.
Alternatives to reduce ionising radiation exposure.
USS - less sensitive, will show hydronephrosis.
MRI - less available!
Rx-
Supportive - Analgesia opiods, NSAIDS, Paracetamol
IV hydration to support renal function
antiemesis
Specific: ?Role for alpha antagonists (prazosin or tamsulosin) - may increase spontaneous passage
-Large stones (>7mm) have less chnance of passing spontaneously and may warent urology removal.
Disposition: OPD urology follow up
Stain urine and catch stones
Follow up AXR if visable to ensure passage.
Indications for Urol referral
-Infected / obstructed kidney
-Renal impairment
-Single kidney or bilateral obstruction.
-Persistent pain / opioid requirement
-?Large stone (>5mm) |
|
|
Term
Testicular Torsion
-DDx
-Aproach to the investigation of the acute scrotum
-Management |
|
Definition
Classical presentation
-Swollen, acutely painful high riding testicle wioth loss of cremasteric reflex
-Most common in adolescence but can occur at any age.
->100% salvage with repair within 4 hours 50% at 24. case reports of salvage at 30 hr.
-Poor sensitivity of clinical hx and exam
DDx:
-Epididymo-orchitis
-Trauma / rupture
-Hernia / incarceration
-Tumor
-Hydrocele
-Torsion of testicular appendage
Approach to investigation.
-Torsion likely --> urgent exploration without delay.
-Torsion unlikely but needs exclusion - Role for colour flow doppler
Management - Urgent surgical exploration, detorting and orchidopexy is priority.
If delay to OT (eg remote) consideer manual detort (opening book)
Supportive - analgesia, antiemesis |
|
|
Term
Anti D
-RANZCOG guidelines |
|
Definition
-125 U 1st trimester
Indications:
-Miscarriage
-CVS
-Ectopic
-Termination
No evidence for threatened miscarriage despite widespread use
2/3rd trimester - 625 Units
-Abdominal Trauma
-Cephaloversion
-Obstetric Haemorrhage.
-Amniocentisis / Cordocentesis
Should check for pre-existing antibodies (note if Anti - D given this will be positive) Therefore group and antibody screen. |
|
|
Term
USS in Early pregnancy
-Sensitivity |
|
Definition
-TV USS can see gestational sac @ 31 days
-Can See yolk sac at 5-6 weeks (BHCG 1500)
-Embryonic cardiac activity visualised approx 5.5 weeks (CRL 5mm)
TA USS
-Reliably detects intrauterine pregnancy about 6 weeks / BHCG 6500. |
|
|
Term
| Asessment of PV bleeding in Early pregnancy |
|
Definition
DDx Pregnancy - Threatened Miscarriage,Inevitable miscarriage ectopic.
Non prenancy eg vault traum, malignancy (unlikely)
Hx
-Bleeding: Quantify loss
-Associated Pain / nature
-Sx of hameodynamic compromise eg syncope / presyyncope.
Full obstetric hx
RF for Ectopic : Past hx, IUD, assisted reproduction, PID / Scarring/ gynae surgery age / smoker
Exam - Focus on vitals
-HD unstable - ectopic, heavy bleeding or cervical products
-Temp - Septic abortion / endometritis
Abdo: Tenderness - ?ectopic,
Sterile Spec - Mandatory if unstable.
?Open Os, identify site of bleeding
Ix - Bedside: VBG (if unstable -- lactate with hyperperfusion, Hb estimate
Urine Dip - UTI needs exclusion as precipitant of MC
HCG
Lab - FBC - ?Hb
GP + AB screen ? need for Anti -D.
Coags if HD compromised / Very heavy bleeding (DIC)
Serum BHCG - useful for correlation with USS and serial HCGs for viability
USS - TV ideal - Threshold for detection =1500 HCGTV, 6500 TA.
Note possibility of heterotopic pregnancy especially in high risk patient. |
|
|
Term
APH
-Define
-DDX
-Assessment
-Rx. |
|
Definition
-PV bleed > 20 weeks
DDX
-Placenta Previa
-Placental Abruption
-Vasa previa
-Incidental - Cervical erosion, malignancy,trauma, Non vaginal bleedin (eg haemorrhoids)
Assessment-
Hx: Full obstetric hx.
Especially previous USS and placental localisation.
Quantify blood loss
Systemic signs eg: presyncope / syncope
Abdominal pain - abruption.
Ex: Vitals - ? HD instability.
Abdominal exam - fundal height. / tenderness --> abruprion
Only Sterile Spec AFTER exclusion of placenta previa
Foetal wellbeing (movements, auscultation)
Ix - Bedside - MSU
VBG if hd compromise
CTG if >24 weeks for Foetal wellbeing.
Bloods - FBC (Hb)
Coags - ?DIC
Blood group + Hold + Kleihauer (Anti D dosing)
USS - Foetal wellbeing , liquor volume, placental positioning.
Management:
Massive APH
-Resus including transfusion
-Specific: Early obstetric involvement + may need early delivery, often by C-section.
-Steroids (Dex) for preterm infants
-Usual supportive care and monitoring (mother and child), correct coagulopathy |
|
|
Term
Abnormal Vaginal bleeding outsside pregnancy
-DDx
-Assessment
-Management |
|
Definition
DDX-
1: Exclude pregnancy!
2: Ovulatory Menhorragia (regular, heavy bleeding)
3: Anovulatory menhorrhagia (irregula cycles or <21 ays >35 day cycles)
4: Uterine / ovarian pathology
-Fibroids, polyps
-Endometrial hyperplasia / malignancy
-Adenomyosis / endometriosis (painful)
-PCOS
-PID
-Cervical / Vaginal bleeding (Ca / Trauma etc)
5: Systemic disease (eg: Coagulpathy, liver failure, hypothyroidism)
Assessment
Hx:
- Menstrual hx (timecourse , quantify loss)
-Post coital bleeding - cervical / vaginal pathology
-Risk factors for malignancy (egDES, pap hx, nulliparity)
Ex: Haemodynamics
Anaemia and complications
Abdominal exam - masses,
Spec - site of bleeding
Ix - Bedside - HCG!
Labs - Bloods - HB
Coags - Screen for coagulopathy
ELFTS - Renal / hepatic failure
TFTs - exclude hypothyroidism
USS - OPD adequate if stable / well.
Management
Resus if indicated by HD instability
Routine supportive care.
Specific - Vaginal tears --> usually heal spontaneously. Gynae repair if severe
Cervical bleeding - Consider Cautery with silver nitrate if heavy ongoing bleeding
Ovulatory Menhorrhagia
Options
- TXA 1g TDS x 4 days PO
- NSAIDS
Anovulatory menhorrhagia
TXA / NSAIDS
OCP
Progesterone
(Norethisterone 5-10mg tds taper to 5mg /day over 3 weeks)
Disposition- Gynae follow up essential to exclude malignancy.
-Admission for very heavy ongoing bleeding / HD unstable or profound anaemia. |
|
|
Term
Pre- Eclampsia
-Definition
-Clinical Features and Complications
-Ix
-Management |
|
Definition
-Hypertension (DBP >90mmhg) in pregnancy associated with proteinuria (1+ on urine dipstick or 300mg /day )or end organ dysfunction. Usually occurs after 20 weeks
Cinical Features:
Risk factors: Maternal
No anti-natal care,
Gestational hypertension
Primip
Past hx / FH
High BMI
Renal Disease / DM, Hypercoagulable states (eg SLE)
Risk Factors (fetal)
-LArge placenta, multiple pregnancy, molar pregnancy.
Clinical features
-Hypertension
-Oedema (common in normal preg)
-Neurological Manifestations
headache,blurred vision, hyperreflexia. progessing to ALOC and COMA. Eclampsia (seizures)
-APO
-Hepatic syndrome
Hepatocellular enzymosis, subcapsular bleeding, HELLP
-Renal Dysfunction
Ix:
Bedside: BSL, VBG,ECG, Urine Dip (proteinuria)
Lab- FBC (?Low plt --> HELLP)
Blood film --> Shistocytes in HELLP
UEG -. ?Renal Dysfunction
LFT - ? HEpactocellular enzymosis
Coags - DIC in HELLP
Consider: CT head if persistant neurological dysnfuction (/CVA, Exclude ICH)
USS pregnancy - Wellbeing, ?Molar ? Twin pregnancy
Management
Resus
- Treat Seizures with MgS04 6g load Q20min and Titrated Benzodiazapines
Specific
-Severe PET / Ecclampsia / HELLP warrent emergent delivery--> Early obstetric notification
- Antihypertensives if BP >170/110 (target SBP 140-160)
-Hydralazine 2.5 -5mg bolus K 20min.
-Fluid load to limit reflex tachycardia.
-MgSO4 6g IV load over 20 min then 2g / hr.--> End point = hyporeflexia
Supportive - Analgesia
IVT maintenence, monitor urine output
Ongoing HD, neuro and foetal monitoring with CTG.
Thromboembolism prophylaxis
Ulcer prophylaxis. |
|
|
Term
| Management of Pre-term labour |
|
Definition
-Onset of regular contractions
Resus - Attention to life threats if present
-APH (placenta previa, accreta, abruption, vasa previa, uterine rupture)
Specific:
1:Early involvement / discussion with obstetric service
2: Tocolysis
Indicated for labour between 24 and 34 weeks duration. (Also consider for retrieval of >34 weeks in consultation with obstetric team)
-effective at delaying labour @ 48 hours and 7 days
-Theoretical benefit to foetus of minimising prematurity
-Benefit to mother = delaying delivery until in a location with appropriate services.
Nifedipine, 20mg PO followed by 20mg Q30m x 3 if contractions continue.
Other options (salbutamol, MgS04, oxytocin antagonist)
Contraindications:
-APH
-Chorioamnionitis
-Advanced cervical dilation / imminent
-Non reassuring CTG.
delivery
-Pre-eclampsia / ecclampsia
3: Steroids to reduce foetal lung disease of prematurity.
-Dexamethasone 6mg Q12 hour x 4 doses
(or betamethasone)
-Active management of labour if delivery imminant including 3rd stage.
-Oxytocin after 2nd stage complete.
Supportive: Analgesia
-IV opiods (eg fentanyl - avoid peri-delivery)
-Nitrous oxide for contractions
Monitoring
-Maternal - NIVM
-Foetal - Ideally continuous CTG, FHR at minimum.
Disposition:
Obstetric service with onsite paediatric service capable of managing premature neonate. |
|
|
Term
Management of Labour / Emergent Delivery.
-Preparation
-Management
-Complications |
|
Definition
Preparation
-Plan for immediate transfer to obstetric service if available unless presenting part on view / delivery imminant.
-Separate teams + resus bay for mother and child
-IV access mandatory for high risk pregnancy (previous LSCS, placenta previa/ accreta, hx PPH, multigravid,
-Notify - paediatrics / obstetrics and ask to attend if delivery in ED anticipated.
Management:
1st stage: Onset of regular contractions (<10 min apart, towards end of 1st stage 3-4 mins apart and painful) until full cervical dilation
-14 hr primigravid, 6- 8 hr mulitigravid.
-Examine Mother + sterile PV - Document progress of labour and presenting part - USS may be useful adjunct.
-Measure FHR post contraction for 30 sec to detect decellerations
-Consider CTG if any concerns (high risk pregnancy, decellerations noted)
Analgesia - IV/ IM opioids / NOS
2nd stage - Full cervical dilation through to delivery of baby.
Urge to push at this time
30 - 60 min primip, 10 -30 min multip.
Position: Dorsal lithotomy, wedge under R.
Management -
a) Delivery of head - Control exit through perineum, (avoid pt pushing- pant or breath)
-Remove cord from around the neck if present
-Suction if gross mec staining.
b) Restitution + delivery of shoulders
Once Head delivered restitution occurs (from OA to either lateral position)
-Usually anterior shoulder slips below the symphysis pubis
May need gentle traction in a downward direction on head (Very carful, avoid brachial plexus injury)
Once anterior shoulder delivered lifting will aid delivery of posterior shoulder.
-Grasp with two hands and place on mothers lap if well.
-Clamp and cut cord + measure APGAR score
-Administer syntocinon (once second foetus excluded !) 5 U IV or 10 U IM
Third Stage:
Once uterus firmly contracted / placenta separated (gush of blood / lengthening of cord)
Gentle traction on Cord to deliver placenta.
-inspect placenta to ensure completeness
-Massage uterus to prevent PPH. +/- further syntocinon if bleeding.
Management of Neonate:
Neonatal resus as required.
Measure / record APGAR + vitals
Vitamin K 1mg IM
Complications
a)Shoulder Dystocia.
-Chin pulls back into perineum after delivery of head
-Delivery under 5 min essential to prevent asphyxia.
-Rx
1: McRobert's manouvour
-Exagerated hip flexion widens birth canal
2: Suprapubic pressure:
-Attempts to dislodge the anterior shoulder impacted on symphysis.
(usually 1+2 will result in delivery)
3: Woods corkscrew - Rotate shoulders to transverse position
4: Delivery of posterior shoulder (associated with humeral fractures)
Breech Delivery
- Minimal interference is best
-Maternal effort to deliver baby to umbilicus
-Rotate to deliver anterior shoulder then opposite direction for posterior shoulder.
Primary PPH:
DDX:
Retained products,
Uterine Atony
Uterine rupture / inversion
Soft tissue laceration
Coagulopathy
Resus - Potentially massive transfusion
Specific:
Early O+ G involvement
Deliver placenta / retained prooducts
-Rub uterus / give syntocinon 10 U IV slow push (over 5 mins to avoid hypotension) + infusion 10 U / hr
other option = ergotamine)
-Exploration of Uterine cavity / removal of clots under GA
-Bakri Balloon
-Uterine artery ligation
-Hysterectomy
Supportive :
Correct coagulopathy
Analgesia
Hameodynamic monoitoring
IDC + monitor Urine output.
-NBM, Maintenence fluids (prepare for OT if required) |
|
|
Term
Perimortum C-Section
-Indications
-Proceedure |
|
Definition
-Cardiac arrest in pregnant pt >24 weeks.
Procedure:
-Start CPR
-Push uterus L laterally (either ramp or physically push.
-Likely non-shockable rhythm - Proceed down non shockable algorithm.
-Simultaneously (While CPR in progress)
-Midline laparotomy.
-Incision in midline to lower anterior uterus
-Cut vertically with scisors towards the fundus.
-Deliver Baby + Cut Cord
-Deliver placenta
-Continue CPR! If ROSC will need further surgical control of bleeding. |
|
|
Term
Supracondoylar fractures
-epidemiology / mechanism
-Diagnosis / Xray findings
-Classification
-Complications
-Management |
|
Definition
-Common between ages 5 and 8
-Mechanism usually FOOSH, with posterior displacement of distal humerus (although flexion / anterior displacement injuries occur)
-Xray
-FAT pads - posterior always abnormal (75 % have associated #) Anterior Sail sign
-Check anterior humeral line (should pass through the middle third of the capitellum
Classification (of predominant extension type supracondoylar)
-Gartland 1 = undisplaced (often fat pad only visible on Xray
-Gartland 2 - Posteriorly displaced capitellum but intact posterior cortex.
-Gartland 3 - Off ended.
Complications: Early
N/V compromise - especially anterior interosseous branch of median nerve but radial, median and ulnar nerve can be involved.
Brachial artery injury common.
Rx - Gartland 1: Above elbow backslab + ortho OPD
2: Can be reduced in ED + close ortho follow up
3: Need operative intervention (therefore early ortho notification)
Vascular compromise in supracondoylar fracture
-Brachial artery injury is common.
If limb pulse less and pale / blue needs urgent OT. IF not practically available can attempt reduction in ED but there is a risk of further brachial artery injury. --> This requires urgent vascular and ortho involvement.
If limb is warm and pink but pulseless splint and arrange urgent OT for reduction and stablisation
(Vascular compromise usually only occurs with Gartland 3 #s) |
|
|
Term
|
Definition
1: Through growth plate only - shearing or distraction.
2: Through growth plate and metaphysis / diaphysis (most common)
3: Through growth plate and epiphysis
4: Through growth plate, diaphysis and epiphysis
5: Crush injury. |
|
|
Term
Galazzi's fracture
Monteggia fracture |
|
Definition
-Galazzi
Commonly missed in ED
Fracture of distal 1/3 of radius and dislocation / subluxation of distal radial / ulnar joint.
#ulnar styloid should always point towards triquetrum (Slightly oblique AP views may falsley give the impression of a wide radial - ulna joint)
Monteggia:
Fracture of the proximal 1/3 of ulna and dislocation / subluxation of radial head. |
|
|
Term
# of distal radius
-Normal anatomy and acceptable post reduction position |
|
Definition
Dorsal / Volar angulation:
Normally 10-25 degrees volar angulation of articular surface. Correct>neutral dorsal angulation, >20 degree volar angulation
Radial / Ulnar angulation:
-normal 15 - 25 degrees angulation towards ulnar aspect of arm. Correct if < 15 degrees.
-Radial shift - correct any
-Dorsal shift - correct any
-Radial shortening - radial styloid should extend 9-12mm beyond articular surface of ulna. Correct >2mm shortening.
-Intraarticular step - correct >1mm. |
|
|
Term
Scapholunate dislocation
-Diagnosis
-Complications |
|
Definition
-Usually FOOSH with extreme dorsiflexion + wrist pain.
-Diagnosis suggested by Scapholunate distance >3mm (may need provocation with clenched fist views.
(Notm low sensitivity / specificity MRI - gold standard is arthroscopy)
Complication = avascilar necrosis of Lunate
Needs ortho referral for ORIF. |
|
|
Term
Perilunate dislocation
-Clinical features
-Diagnosis
-Management |
|
Definition
Part of a spectrum of carpal instability
1: Scapholunate dislocation
2: Peri lunate dislocation
3: Perilunate dislocation with associated dislocation / fracture of triquetrum)
4: Lunate dislocation
Usually from FOOSH with dorsiflexion.
Capitate usually displaced dorsally, lunate still in place
Xray: - Loss of contiguous 4 C's on lateral films (radius, proximal surface of lunate, distal surface of lunate, capitate.
Needs ortho referral for ORIF to prevent long term arthritis . loss of function.
(Note Lunate dislocation occurs when the lunate is diplaced in a volar direction but the alignment of the capitate and the radius remains intact) |
|
|
Term
Heatstroke
-Definition
-Clinical features / complications
-Predisposition
-Investigation
-Management |
|
Definition
Definition:
Life threatening medical emergency. Core Temp > 40.6- 41 (don't be strict!) neurological dysfunction, classically dry warm skin.
Multi-organ dysfunction.
Clinical features
-Hyperthermia > 40.6
-Sweating often absent
-Altered mental state.
-Complications
>Rhabdomyolysis
>ATN / ARF
> DIC
> Hepatic dysfunction
>Neurological Dysfunction
>APO / Cardiac failure / Vasodilatory shock
Predisposition:
-Environmental factors - Heat / Humidity
-Individual: Athletes, extremes of age, -MedS: (anticholinergics, phenothiazines, stimulants / hallucinogens)
-Concurrent illness
Ix:
FBC: leukocytosis / thrombocytopenia
Coags - DIC
ELFT - ARF, elevated LFT, Rhabdo --> Hypocalcemia
CK - Rhabdo
Urinalysis - Myoglobin
Management
RESUS
-A - Intubate if obtunded
-C- Risk of shock - hypovolemic, vasodilatory, cardiogenic
Fluid bolus, vasopressor / ionotropes
E:
-Active cooling to T < 40. (Rapid, should aim for 0.1 degree / min) Expect overshoot of 2 degrees.
Cold fluids, expose, Ice pack groin and armpits, wet with tepid spray and fan warm air (prevents vasoconstriction and shivering.
May require benzo sedation +/- I+ V +/- skeletal NM blockade
Note: Antipyretics useless and should be avoided.
Rhabdomyolysis: Aim for copious urine output (2-3 ml/ kg / hr)(IVT infusion)
Early RRT.
Routine supportive care
Disposition: = ICU
Note: Heat STROKE = medical emergency described above.
Heat exhaustion = Hypovolemia / electrolyte disturbance +/- Mildly raised core body temp in setting of heat stress. |
|
|
Term
Hypothermia
-Define
-Clinical Features
-Ix
-Rx |
|
Definition
Mild = 32-35 degrees, moderate 29-32, severe < 29
-Either secondary to exposure to cold environment in healthy person or more commonly secondary to another injury / illness
eg: Trauma, intoxication, Stroke,
Clinical featurs:
-Mild:
Shivering, apathy, dysarthria, ataxia, tachycardia.
-Moderate / Severe:
Altered mental state, loss of shivering. Bradycardia, bradyarrythmia, esp: Slow AF can degenerate to VF / asystole. hypotension, muscular rigidity.
Severe hypothermia - signs of life may be barely detectable with fixed / dilated pupils.
CVS- bradyardia, viasoconstriction, hypotension. Malignant arrythmias below 30 degrees.
Resp: Reduced CO2 production
GI - splanchnic vasoconstiction, reduced hepatic flow,
Metabolic - reduced BMR, reduced drug metabolism,
CNS - Altered mental state.
Haem - Coagulopathy.
Ix: Blood gasses should be interpreted uncorrected.
-ECG: Changes - Osborne waves (positive deflections of J point particularly precordial leads), slow AF, PR, QT, QRS prolongation.
Rx: -
RESUS,
A: - Intubate for Airway protection with obtundation or for ventilatory support.
B: Titrate ventilation to normal ph / normocapnoea
C: Expect hypotension with severe hypothermia.
-Cautious IVT bolus (warmed)
-CPR / ALS as indicated
-prolonged CPR appropriate in conjunction with warming
-If VT / VF and initial shock unsuccessful warm and repeat shocks at 1 degree intervals.
'Not dead until warm and dead' - 30-32 degrees.
E: Rewarming (see specific)
Specific: Rewarming
-Mild - passive rewarming (dry + insulate)
-Mod / Severe --> Active (external vs core)
External - Forced air warmet
Heat packs
Core:
Warmed fluids
Peritoneal / pleural / bladder lavage of warmed fluids
Warmed / humidified ventilation.
Extracorporeal techniques (RRT / CPB)
(forced air warmers and warmed , humidified inhalation for mod / severe, consider bypass or invasive methods for arrensted patients) |
|
|
Term
Drowning:
-Pathophysiology
-Management |
|
Definition
-primary respiratory impairment after immersion in a liquid.
Pathophysiology
-Voluntary apnoea
-Involuntary breath
-Bronchospasm, pulmonary vasoconstriction, pulmonary hypertension, shunting / VQ mismatch alveolar damage / surfactant loss
Clinical features.
Repiratory distress - Hypoxia, VQ mismatch, delayed pneumonitis (gastric aspiration)
CV - hypothermia and complications including arrythmia
GI - vomiting common
Injuries - especially c-spine injuries. +/- head injuries.
RX -
Intubate if obtunded or for respiratory support (poor sats despite High flow O2, marked WOB, aniticipate deterioration from pneumonitis)
C-spine precautions
B: Consider bronchodilators
Ventilate as per ARDSnet protocol, titrate PEEP / O2 to sats 94%, TV =6, Titrate RR to pH 7.3-7.45
Pplat <30
Routine HD support.
C: Anticipate arrhythmias with severe hypothermia, cautios handling, ALS and rewarming,
PEA --> Astystole with severe hypoxia.
Case reports of good neurological outcome after drowning and prolonged CPR in cold waters (<10 degrees) --> prolonged ALS appropriate.
E: Rx hypothermia with re-warming
Specific - Consider IVABs for grossly contaminated water.
Supportive Care
Routine FASTHUGS.
Neuro injury - MAP 80, head up, benzo's for seizures
Disposition - Observe all drowning / near drownings for 6 hours, asymptromatic patients with normal oxygenation can be discharged.
Admit fopr observation those with CXR infiltrates / persistant respiratory symptoms.
ICU if ventilatory support. |
|
|
Term
Decompression Illness
-Clinical Features
-Investigation
-Management |
|
Definition
Decompression Illness
Decompression Sickness (nitrogen bubbles precipitate out of tissues as pressure lowers)
Arterial Gas embolism
-Usually from pulmonary barotrauma (trapped gas is forced into systemic circulation and embolises).
Note - Clinically difficult to differentiate and initial manangement is the same!
Describe - timecourse (AGE usually early, as is severe DCS, mild DCS can be subacute)
-Evolution or regression of symptoms
Body system effected,
-Presence or absence of barotrauma.
Clinical Features: Multiple possible presentations! Consider any new symptoms soon after diving DCI until proven otherwise
Neuro: Cerebral Gas embolism - Rapisd ALOC, focal neuro deficits, DCS usually slower and progressive unless severe, headache, seizures, nystagmus, vertigo., spinal cord involvement - back pain / neuro defecits.
MSK - Joint pains, (commonly elbow / knee) myalgia,
Resp: 'chokes' hypoxia, haemoptysis chest pain
Skin - Rashes- varied.
Associated Barotrauma - Middle ear, inner ear, sinus, teeth, GI,
Ix - Don't unnecessarily delay re-compression.
BSL for ALOC
ELFTS / FBC - Expect dehydration with DCI
CK - ? Marker of muscle injury
CXR - Essential if Pulmonary barorauma suspected - Exclude PTX
Note: Neurological presentation should be nursed flat until re-compression therefore CT may be more appropriate for PTX (also ?CAGE)
RX -
RESUS
I+V if obtunded - fill ETT cuff with H20
B- 100% 02 until re-compression arranged
Seek and treat PTX
C- CPR / ALS if arrest
Expect hypovolaemia and Rx hypotension with IVT bolus
D- Expect - Seizures - midaz, exclude hypoglycemia.
E- Exclude hypothermia.
Specific - Priority is prompt hyperbaric therapy. Indicated even if symptoms resolve (relapse may be more severe)
Main risk =- oxygen toxicity (twitching , seizures)
Supportive
- Manage in flat position to prevent CAGE
Analgesia
- Maintenence fluids IV (avoid PO given risk of seizures with DCS and hyperoxia wwith re-compression)
Disposition - hyperbaric centre.
Sea level transfer
Avoid flying for at least 1 week. |
|
|
Term
Altitude Illness
-Clinical Features
-Management |
|
Definition
1: AMS /HACE
-Spectrum of disease from alterations in cerebral vasculature, resulting in cerebral oedema.
-Headache, dizzyness, fatigue / weakness, poor sleep, GI upset (anorexia / vomiting).
Progression to ATAXIA or Altered mental State marks HACE.
Can grade score with Lake loiise score (0-15, 0-3 in each above catagory)
HAPE
-Separate entity to HACE /E. Hypoxic pulmonary vasocostriction --> High pulmonary artery pressures, favours oedema.
Cough, dyspnoea, fatigue POOR EXCERCISE TOLERANCE. Progresses to frank pulmonary oedema with frothy sputum, hypoxia.
Risk factors. RATE OF ASCENT, young males, previous altitude illness, Live at sea level.
May occur over 2500m, becomes common above 3500 (30% AMS)
AMS / HACE more common than HAPE
Management:
1: Prevention - Graded ascent (recommendations vary but sleep no higher than 300m - 500m above previous night above 2500m)
Acetazolamide - 125mg BD effective AMS prevention.
Dexamethasone - effective but potentially risky - may mask symoptoms without increasing acclimatisation. Most appropriate for emergency ascents eg rescue)
2: Rx-
AMS - Halt ascent, acclimatisation, acetazolamide. Don't ascend until symptom free. Dexamethasone 8mg PO then 4mg PO Q6 hr effective but should not ascend until 16 hours after dose.
HACE
- Urgent descent
-Oxygen
-Dexamethasone 8mg IM
-Can temporise in Gammow bag if descent impossible.
HAPE - Urgent descent
-oxygen
-Nifedipine 20mg Q 6hr
-Can temporise with Gammow bag
Supportive Care
-Keep warm (hypothermia aggrivated pulmonary hypotension. |
|
|
Term
Radiation Illness
-Pathophysiology
-Syndromes / Clinical Features.
-Management |
|
Definition
Pathophysiology
-alpha , Beta and gamma rays / X rays
Gamma and X rays clinically relevant. alpha and Beta rays can cause skin damage but are stopped before deeper tissues
measured in Gy (1 joul / kg)
Seivert = biological effect
maximum safe dose = 50mSv / year.
Rapidly dividing cells (Haemopoietic, GI, Germinal) cells most sensitive.
Sub lethal doses lead to DNA damage. 100mSv --> 0.8% increase in lifetime risk of fatal cancer.
Contamination VS exposure.
Acute Radiation Syndrome. (Whole body irradiation)
survival likely only from haemopoetic syndrome / milder GI syndromes
Prodromal phase
latent period
Manifest phase
Recovery / Death
+1-4 Gy - Haemopoetic Syndrome
6 Gy Gastrointestinal syndrome (+HP)
20 Gy - Neurovascular syndrome
Triage:
Gastrointestinal symptoms and lymphocyte count can predict severity of illness. Early GI symptoms - Vomiting within 4 hours sgnifies at least 2 Gy. No vomiting / asymptomatic at 6 hours can probably be managed as outpatient with follow up
Lymphocyte count @ 48 hours - >1500 / mm3 - clinical support unlikely necessary
800 -1500 - Haemopoetic syndrome + support likely
100-800 - Life threatening
<100 lethal.
Rx - Scene - Management, decontamination, controlled zones
ED - RESUS takes precidence over decontamination.
Decontamination- External - outside for low acuity
Protocols for managing patients / relatives / staff / media
Monitoring radiation levels.
Isolation zones for sick contaminated patients
Staff PPE
Internal contamination:
Consider Chelation / Uptake inhibitors (eg: iodine for radioactive iodine prevents thyroid uptake)
Supportive Rx
-expect hypovolemia form GI injury - IVT
Antiemesis
Leukopenia
-Isolation
-Monitor WCC
-GCSF / platelet transfusion (irradiated)
Aggressively seek and treat febrile neutopenia
Prophylactic antibiotics - especially for those with sever neutopenia / GI symptoms.
- Consider Bone marrow tranplant for severe survivable illness.
-Ulcer prophylaxis
-Early reintroduction enteral nutrition, |
|
|
Term
Penetrating Neck Trauma
-Potential Injuries
-Assessment
-Management |
|
Definition
-zone 1 inferior aspect of cricoid to thoracic outlet
-Zone 2 Cricoid cartelige to angle of mandible
-Zone 3 above angle of mandible
Potential injuries
-Vascular - Shock, CVA, Expanding Hameatoma + airway compression
-Airway - lacerations, compression
GIT - Oesophageal injury and subsequent collection /mediastineitis
-Neurological - Horner's syndrome, phrenic, autonomic dysfunction (vegus)
-Spinal Cord injury
-Laryngeal
-Thyroid / Parathyroid
-Intrathoraccic (PTX, great vessel,)
Asessment
Routine trauma approach
RESUS
-Airway - potentially difficult + at risk.
Allow pt to assume comfortable position
Do not RSI unless complete airway obstruction - prefer transfer to OT (ENT / anaesthetist)
Prepare for surgical airway.
C -spine precautions (but pt unlikely to tolerate collar)
B: Exclude PTX. High flow o2.
C- Seek and control external bleeding. Minimum volume resus.
D- Careful neuro asessment - ?CVA, ?ALOC, ?Horner's synd
Specific:
Hard Signs of neck injury --> Urgent OT.
No Hard signs + injury through platysma --> CT angiogram neck + surgical referral.
Routine supportive care including ADT and AB's.
Hard signs of penetrating neck injury
-Expanding / pulsatile haematoma
-Shock
-Air bubbling through wounds
-Voice or airway disturbance
-Active bleeding
-Haemoptysis / Haematemesis
-Thrill / Bruit
-Neurological Defecit. |
|
|
Term
Australasian Triage Scale
-Waiting times
-Performance indicator% |
|
Definition
1: immediate, 100%
2:10 min 80%
3: 30 min, 75 %
4: 1 hour 70%
5: 2 hour 70 % |
|
|
Term
Rheumatic Fever
Jones Criteria
Rx |
|
Definition
Evidence of recent strep infection (elevated antistreptolysin / anti DNAse B)
+
2 Major criteria
or 1 major and 2 minor criteria
or indolent carditis / St Vitus dance alone
Major Criteria
1: Carditis (pericarditis, Myocarditis, new murmurs, CCF,)
2: Sydenham's Chorea
3: Subcutaneous Nodules
4: Erythema Marginatum
5: Migratory Polyarthritis
Minor:
1: Fever
2: Arthralgia
3: ECG heart block
4: Leukocytosis
5: raised ESR / CRP
Rx - penicillin
Anti-inflammatories - aspirin vs NSAIDS vs steriods |
|
|
Term
Croup
-Clinical features
-DDx
-Pathogenesis
-Grading severity
-Rx |
|
Definition
-
Viral Laryngotracheobronchitis age 6/12 to 6 years - usually parainfluenza
Airway swelling +/- obstruction
Barking cough
Peak night 2-3
DDx - Epiglotittis, bacterioal tracheitis inhaled foreign body.
Severity
Mild - No stridor at rest, undistressed, No WOB
Mod - some Stridor at rest, mod WOB, tachypnoea.
Severe, Stridor at rest, severe WOB, altered mental state / agitation.
Rx - Calm child, do not examine throat , mum's lap
Steroid for Moderate: Dexamethasone 0.15mg/ kg PO
Severe: 02 (waft over face)
Nebulised adrenaline (5 ml 1:1000)
Dexamethasone 0.6mg (max 12mg IV / IM)
Disposion: Discharge (if appropriate + safe situation) 4 hours post nebulised adrenaline and stridor free at rest. |
|
|
Term
Community Acquired Pneumonia
-Pathology
-Assess Severity
-Management - adults, children |
|
Definition
-Common pathogens
Strep Pneumoniae, HI,Staph Aureous
Mycoplasma pneumonia, legionella
Burkholderia Pseudomallei in tropics
Asess Severity - Curb-65 performs as well as PSI and is simpler!
1 point each for
Confusion
Urea> 7mmol / L
RR> 30
BP<90systolic / 60 diastolic
Age > 65 years
Correlates with prognosis
Scores of 0 or 1 can mostly be managed as OPD if used with sound clinical judgemnet.
Mild: Amoxyl OR -clarythromycin OR doxy
Mod: IV Benzylpen / amoxicillin + doxy or clarythromycin
Severe: 3rd 2g Ceftriaxone + Azithromycin 500mg
Tropical Areas severe pneumonia = meropenem , 1g Q8hr + azithromycin.
Paediatric:
<1/52 - benzylpenicillin 30mg/kgQID + gentamicin 3.5mg/kg
<4/12 - azithromycin 10mg /kgPO, (Cefotaxime 25mg / kg tds for severe)
<5 amoxyl 25mg/kg tds, (cefotxime 25mg / kg tds for severe)
>5 amoxyl or roxithromycin 4mg/ kg BD
(benpen +roxithromicin for more severe) |
|
|
Term
ARDS
Definition
Causes
Severity
Management |
|
Definition
-Bliateral pulmonary infiltrates Not explained by Cardiogenic pulmonary oedema, onset over 1 week or less, PaO2. /Fi O2 < 300
Severity via P/F ratio
Mild 200-300, mod 100-->200, severe <100.
Causes 1: Direct (Pneumonia, contusion, aspiration,inhalation injury etc)
2: Indirect - Sepsis , trauma, pancreatitis etc/
Managemeent
-Treat underlying cause
Ventilation goals
1: Oxygenation: sats 88-->95 (titrate 02 + PEEP >5)
2: Pplat <30
3: pH 7.3-7.35
6 ml / kg PBW, RR to approximate Minute Volume required, (RR max = 35) |
|
|
Term
Pleural Tap
-Causes of pleural effusion
-Interpretation |
|
Definition
Exudate (local disease )
-Malignancy
-Infection (pneumonia / empyema / subphrenic abscess)
-PTE / infarction
-Autoimmune
-Haemothorax /Chylothorax.
Transudate (systemic dissease)
-CCF
-Cirrhiosis
-Hypoalbuminaemia
-Hypothyroidism
Interpretation
1: Lights criteria determines exudate vs transudate
-Pleural protein / serum protein > 0.5
-Pleural LDH / Serum LDH > 0.6
-Pleural LDH > 2/3 upper normal serum LDH.
For Exudates
WCC:
- Neutrophillia (infective / malignancy)
-Lymphocytosis : malignancy / TB
-Monocytes - chronic inflammatory process
Gram Stain - infection
Glucose - Low in infction / malignancy
pH - low in infection / malignancy (<7.2 needs draining in pneumonic effusion, < 7.2 with malignancy = life expectancy of 30 days. |
|
|
Term
Cavitating Lung Lesion
-DDx |
|
Definition
1: TB
2: Malignancy - primary vs metastasis
3: Pneumonic Abscess
-Bacterial esp: Staph Aureus, Klebsiella, mellioidosis
-Fungal (actinomycosis, candida)
4: Non infective granuloma (eg: rheumatoid nodule) |
|
|
Term
paracentesis interpretation
-DDx of Ascitic fluid
-Interpretation |
|
Definition
Transudate
-Cirrhosis
-CCf
-Hypoalbuminemia
Exudate:
-Malignancy
-Infection (TB / SBP)
-Pancreatitis
-Lymphatic Obstruction
Protein: - <30g / L = transudate, > 30 g/ L exudate
Protein Serum : Ascitic ratio> 0.5 = exudate
SAAG: Serum albumin - Ascitic Albumin -<1.1mg / dL = Exudative, > 1.1mg / dL = transudative
LDH: Seum LDH / ascitic LDG ratio> 0.6 = exudate
ascitic LDH> 400 = exudate
Glucose - low in malignancy / infection
Microscopy:
WCC<300/ uL normal, > 300 abnormal
-Neutrophilia - SBP (90%), cirrhosis (50%)
-Lymphocytes - TB |
|
|
Term
|
Definition
Prep
-Early notification of Stroke team
Resus -
A- consider I + V if - airway threatened / GCS <8)
C- Expect and tolerate hypertension. (up to 220/140 MAP 130)
D- Exclude hypoglycemia
Specific
- aspirin - 300mg Load after CT
(reduced death / repeat stroke)
-dipyramidole may confer extra benefit
-Thrombolysis in conjunction with stroke service
Consider up to 6 hours post onset (IST -3) 6% incidence of major haemorrhage.
alteplase 0.9mg / kg infusion over 1 hour.
-Anticoagulation - Only with clear cardioembolic source in consult with stroke team.
-Work up for cardioembolic source (as inpatient echo / carotid doppler)
Supportive -
Haemodynamic / Neuro monitoring - cautious reduction in BP for severe HTN only (220/140, MAP 130) with titratable agent - GTN @ 0.5-5 mcg / kg . min. Aim for 15% reduction.
TEDS / SCDS
glycemic control - 6-10
Diet - NBM until speech asessment
Stroke Unit MDT
Disposition - Stroke units provide best outcomes. |
|
|
Term
Status Epilepticus
-Causes
-Management |
|
Definition
-Epilepsy +/- antiepileptic dosing
-Hypoxic
-Cerebral insult - tumour, ICH, meningoencephalitis.
-Metabolic - hypoglycemia, hypo / hypernataemia
-Toxins - TCA, LAs, antiepileptics, antidepressants esp: venlafaxine.
-Hyperthermia
-Eclampsia
Management
1: RESUS
-May need I/V
-Prevent hypoxia / hypoventilation
-optimise CPP
-Exclude hypoglycemia
2: Terminate Seizure
1: Titrate Midazolam - 0.05- 0.1 mg /kg IV boluses.
2: Phenytoin load - 20mg / kg IV over 20 min. (No place in toxicological seizures)
3: RSI with Propofol + xconsider sux for minitoring purposes.
-2 - 3 mg / kg IV RSI
- infusion @5-10 mg / kg / hour (anaesthetic doses!)
-Locate and treat Cause
(workup - ABG, Electrolytes, CT head +/- LP)
Routine Supportive Care
-Monitoring - routine, consider EEG if intubated / ventilated
-Neuro Obs |
|
|
Term
| Management of a major disaster |
|
Definition
CSCATTT
-Command + control
(scene, operations centre, casualty clearing station, roles, heirachy, identification)
-Safety
(scent, PPE, Toxins, crowd / violence)
-Communicate
(METHANE)
(major incident (declare)
(Exact location)
(Type)
(Hazards)
(Access / Eggress)
(Number + type of casualties)
(Emergency services present / required)
-Assessment of Scene
-Triage
(Seive and Sort)
-Treatment
-Transport |
|
|
Term
| Interpretation of VQ scans |
|
Definition
Normal / Near Normal - PE excluded.
High probability (85% prob PE)
-High PTP --> anticoagulate
-Low PTP (55% chance PE --> Further Ix)
Low / intermediate probability
-Low PTP --> USS leg veins if neg <5% chance --> D/C
-High PTP --> further Ix. |
|
|
Term
| Light's criteria for diagnosing Exudative pleural effusion |
|
Definition
One of:
-Pleural protein : Serum protein>0.5
-Pleural LDH: Serum LDH > 0.6
-Pleural LDH > 2/3 upper limit of normal seru value.
Exudative - Infective, malignancy, Collagen vascular disease, PE,
Transudative: CCF, Cirrhosis, Hypoalbuminemia, myxoedema, |
|
|
Term
|
Definition
-Septic Arthritis
-Trauma / fracture
-NAI
-Intra abdominal / Genitourinary pathology.
-MAlignancy
-Transient Synovitis
-Rheumatological disorders (eg: RA)
-Perthes disease (usually 4-10 YO)
-SUFE ((M>F, obese, mean age 12 - conicident with puberty)
SUFE - externally rotated, antalgic gait. obligate external rotation with flexion. All need NWB + orthopaedic referral for fixation.
Risks (osteonecrosis, OA, impingement (fem neck vs acetabulum when stabilised)
Perthes: AVN of femoral epiphysis.
Needs: Rest +/- Bracing +/- operative Rx. |
|
|
Term
Novel Anticoagulants
-Mechanism
-Uses
-Reversal |
|
Definition
-Dabigatran
Direct thrombin inhibitor
Used for DVT prevention and Stroke prevention in non valvular AF.
Reversal
1: Stop Drug
2: Ensure reasonable urine output (renally excreted)
3: Oral Activated charcoal if < 2hours from ingestion
4: TXA 1g stat + 1 g / 8 hours
5:Consider Recombinant factor 7 and haemodialysis
6: Reverse other contributions to coagulopathy (eg platelets, Ca, acidosis fibrinogen etc)
Riveroxiban
Factor 10 a inhibitor
Prevention and treatment of DVT
Rx of bleeding as per dabigatran EXCEPT
-Treat with Prothrombinex, novoseven is second line
-No haemodialysis (hepatic metabolism and renal excretion) |
|
|
Term
| Targeted Temperature Management / Therapeutic hypothermia |
|
Definition
- 2002 - 2 trials - HACA / Bernard Et all show increased rates of neurologically intact survival after VT / VF OOHCA.
Bernard used discharge to home or rehab, HACA used neurological assessment.
Poor quality trials but Cochrane review summarising evidence suggests NNT of 10.
(T 33 degrees)
TTM trial recently showed no difference in target of 3 and target of 36 in all patients post cardiac arrest. End posts 1: survival
2: Composite end point of death / poor neurological outcome,.
Cooled within 6hours for 36 hours then rewarmed. Temperature actively managed for 72 hours. |
|
|
Term
Pharyngitis
DDx
MAnagement Strategy |
|
Definition
-GAStrep
-EBV
-Other viral
-Epiglottitis / BActerial Tracheitis (more likely if not immunised HI)
-Quinsey
-Retropharyngeal Abscess.
Antibiosis for pharyngitis controversial - Reduces supperative complications and incidence of RHeumatic fever in at risk groups.
1: ? evidence of complications (stridor, drooling, dysphonia, swelling below mandible) - Treat and refer as appropriate
2: None of above but Risks for RH fever - (ATSI, pacific islander) - Rx for GAS with penicillin + culture throat. Arrangereview and cease antibiotics if culture negative.
3: None of abvove - manage expectantly + arrange follow up and advice to repressent if deteriorates.
Rx: Uncomplicated pharyngitis - Pen V - 15mg/ kg BD+/- Dex 0.15mg /kg
Ben Pen 60mg/kg IVV QID if can't take orals
Supperative complications add metronidazole 10mg/kg tds. |
|
|
Term
Rash DDX
1: Erythroderma, Skin Emergencies
2: Purpura / Pethechiae
3: Blisters / Vescicles / Ulcers
4: Redness/ MAcules / PApules
5: Scaling / Exudate
Special areas
-Mouth
-Face
-Palms
-Neonatal pustules |
|
Definition
1: Erythroderma / Skin failure.
-Staph Scalded Skin (<5YO)
-SJS (<10%) TEN (>30%)
-Toxic Shock Syndrome
-Burns
-Bullous Pemmphigoid / Pemphigus Vulgarus
2: Pethechiae / Purpura
a) febrile / unwell
-Meningococcus
-DIC
-Henoch Schonlein purpura (abdo pain, joint pain, vasculitic rash - legs +/- renal involvement)
-ITP (often post viral, plt<50 --> steroids)
-HUS / TTP
-Leukaemia / Marrow failure
b) Well child
-SVC distribution / cough / vomit
-Mehanical
-Coagulopathy
3: Blisters / Vescicles / Ulcers
-VZV
-HSV
-Moluscum contagiosum
-Coxsackie virus (Hand, foot and mouth disease)
4: Redness / Macules / papules
-Measles (morbiliform rash, face down spread, koplick spot
-Rubella
-Erythema infectiosum (parvovirus B19, slapped cheeck, fifth disease) Avoid pregnant females /immunosuppressed)
-Roseola infantum (6th disease, fever 3-5 days, macular rash body on defervescence usually age under 2)
-EBV
-Scarlet Fever (Gp A strep, sandpaper rash, strawberry tongue, cervical LNs)
-Erythema Nodosum (Red on shins - Drugs, IBD, idiopathic, autoimmune, postinfectious)
-Erythema Multiforme (Targets) 90% post infective esp HSV, 10 % Drug reaction. Major if MM involvement.
KAwasaki Disease
-Fever >5 days
Conjunctivitis, Rash (variable), Adenopathy- lymph nodes, Strawberry tongue / mouth involvement., Hands/ Feet - swelling, desquamation
CRASH and burn.
Needs IViG and aspirin for coronary anneurism
5: Scaling / Exudate
-Impetigo
-Eczema herpeticum (disseminated HSV usually complicating eczema - needs antivirals)
-Psoriasis
Mouth
-EM maj
-SJS / TEN
-Kawasakis
-HSV
-Coxsiackie
Face
-Eczema Herpaticum
-VZV
-Eczema
-Impetigo
-Psoriasis
-Burns / neglect
Palms
-Kawasakis
-Coxsiackie
-syphylis
-SJS
NEonatal Pustules
-erythema toxicum neonatorum
-Infection (eg staph, GBS)
-Congenital neutropenia
-eosinophillic pustular folliculitis. |
|
|
Term
| DDX Ring enhancing lesion on CT head |
|
Definition
1: Malignancy
+Metastatic (eg lung CA)
+Primary (esp glioblastoma)
2: Abscess
+ Immunocompetent (Strep, staph, mixed with anerobes + G-ve)
+ Immunosuppressed (Toxoplasmosis, Nocardia, fungal inc aspergillosis)
+TB
3: Resolving haematoma
4: Post surgical change
5: Infarct |
|
|
Term
|
Definition
-ID and Neurosurg consultation
-Likely need aspiration to guide antimicrobial infection
Resus / Supportive Care
-Anticipate seizures - Titrate Benzodiazapine. Consider Phenytoin loading in consult with neurosurg
Analgesia
Maintenance fluid
Aviod raising ICP
Neuro observations
Specific:
-Antibiosis
Metronidazole + Ceftriaxone
Add vanc if post neurosurgical abscess.
If immunosuppressed - cover nocardosis
triprim + sulfamethoxazole + meropenem (ID involvement)
?Role for Dexamethasone if cerebral oedema - ID + neurosurg involvemtn
Disposition - neurosurg / ID. |
|
|
Term
3rd nerve lesion
-Clinical features
-DDx |
|
Definition
-Ptosis (complete vs partial)
-Opthalmoplegia / divergent strabismus(down and out effected eye)
-Mydriasis (unreactive pupil to light)
DDX- central
-Brainstem CVA, Neoplasia, Demylenation
Peripheral
-Compression (posterior fossa annuerism, Neoplasia, meningoencephalitis)
-Orbital or nasopharyngeal carcinoma.
-Ischemia (Diabetic neuropathy, arteritis,) |
|
|
Term
Bier's Block
-Proceedure
-Dose |
|
Definition
-Consent
-Proceeduralist / anaesthetist/ NIVM / resus facilities.
-Prep- 2x IVC (1 each arm). Proceedural Prep
-Elevate + exanguanate arm
-Inflate torniquet (proximal) - 100mmhg above systolic
-Inject prilocaine 2.5mg / kg (more in lower limb - 3-4)
-Test anaesthesia, perform proceedure
Min torniquet time 20 min max 1 hour, |
|
|
Term
| Anorexia Nervosa - admission criteria |
|
Definition
->30% premorbid weight loss
-> Bradycardia (<50)
-> Hypothermia
-Dehydration / postural hypotension
-Electrolyte disturbence (hypokalemia, hypophosphatemia.
-Psychiatric considerations (suicidality)
-Social considuations (safety / care at home / support etc) |
|
|
Term
Neonatal Sepsis
-Antibiotic Choice |
|
Definition
<6m - ampicillin 50mg/kg IV Q6 hr AND cefotaxime 50mg / kg Q6 hr
(+ vanc if pneumococcal meningitis likely)
Can use ampicillin and genta if meningitis excluded. |
|
|
Term
Hypoglycemia
-Definition
-Management |
|
Definition
Hypoglycemia requiring correction = BSL < 2.6 mmol/ L
Rx -
Conscious / asymptomatic: Trial of oral carbohydrates, recheck BSL 15 mins
Persistant / Symptomatic
-Children -2-5ml/ kg 10% Dextrose
-Adults: 25-50ml D50 |
|
|
Term
Hypothyroidism / Myxoedema Coma
-Clinical features
-Rx |
|
Definition
Clinical features
-General features of hypothyroidism,
-lethargy, cold intolerance, weight gain, delayed deep tendon reflexes
-Myxoedema coma
-ALOC
-Respiratory depression
-Hypotension / Bradycardia. ECG changes (bradycardia, widespread TWI, 1st degree HB)
-Hypothermia
-Inter current Illness (eg sepsis) common precipitant - must seek and address)
Rx - myxoedema coma
Life threats:
-ALOC / Airway threat
-Hypoventilation may require vent support
-Hypotension (Cautious Fluid, Steriod, T3/4 supplimentation, vasporessors / ionotropes)
-Address hypoglycemia
-Hypothermia ( may require active rewarming)
Specific Rx:
-Steroid replacement (Concominent Addisonism possible, thyroid supplimentation can precipitate hypoadrenalism)
100mg hyprdrocortisone QID
Thyroid replacement controversial (T3 vs T4)
-500mcg T4 IV load then 50 mcg /day
-Suportive care -routine |
|
|
Term
Hypertensive Crisis
-Definition
-Management |
|
Definition
Hypertension with end organ dysfunction
Rare with DBP<130
End Organ dysfunction:
-Hypertensive encephaopathy
-CVA (Ischaemic vs Haemorrhagic)
-MI
-APO
-Dissection
-Renal Failure
-(Pre-eclampsia)
Emergent Rx only required in the presence of end organ dysfunction. Choice depends on syndrome. In general, lowering blood pressure 25% should be achieved over 1-2 hours (exception is aortic dissection in which rapid lowering to SBP100-120 is preferred)
1: Address life threats:
-Obtundation / Airway threat (eg hypertensive encephalopathy / CVA)
-Respiratory support - (eg: APO)
-Control Hypertension (see below) volume depletion is common and should be replaced to avoid a precipitous fall in BP.
Specific:
Control HTN:
1: Hypertensive encephalopathy, ARF, APO, MI
-GTN 0.5-5mcg/ kg/min.
Titrated to lower BP 25 % in 1-2 hours.
Closely monitor clinical status, be prepared to reduce / cease Rx - eg if worsening neurological function with BP control in hypertensive enephalopathy)
2: CVA
GTN 0.5-5mcg/kg/min
-Ischemic Rx BP>220/110 aim for 20-25 % reduction (may need more aggressive control if thrombolysis)
-Haemorrhagic (Rx 180/110, aim 160/90)
3.Aortic Dissection:
-BBlocker! (shear forces!) Metoprolol IV 1mg boluses / 2 min up to 10mg. Aim HR 60-80, SBP100-120. Once BBlocker initiated, GTN may be started.
Routine Supportive care / monitoring esp:
-Invasive BP monitoring
-Regular Neuro Obs
-Renal function / urine output. |
|
|
Term
Needle Cricothyroidotomy vs Surgical Cricothyroidotomy
-Age differences |
|
Definition
| - Children < 10 opt for needle cric |
|
|
Term
| -STEMI equivalents and other high risk ACS ECG findings |
|
Definition
1: LMCA occlusion.
-In the context of widespread ST depression + symptoms of ischemia STE aVR > 1mm indicates LMCA, proximal LAD obstruction or severe 3 vessel disease
+Indicates likely CABG requirement therefore discuss before giving clopidogrel. Avoid prasugrel.
+STE avR>V1 differentiates LMCA from proximal LAD.
2: De-winter's T waves
-ST segment depression 1-3 mm@ J point, upsloping into a tall symmetric T wave in the precordial leads.
-Highly suggestive of acute proximal LAD obstruction. Increasingly recognised as STEMI equivalent. Probably needs emergent Cath (controvesial)
3: Welle's Syndrome
-Deep W aves V2, V3, (A)
-Biphasic T waves V2 V3 (B)
Highly suggestive of critical LAD lesion - not necessarily acute obstruction.
Needs Urgent (as opposed to emergent) PCI
4: Posterior Wall STEMI
-Horizontal ST dep V1-3. Tall broad R waves, dominant R V2, upright T waves. (common with inferior or lateral) Can confirm with V789 |
|
|
Term
|
Definition
-Ischemia
-BER
-pericarditis
-LBBB / paced rhythm / Accessory pathway
-Brugada
-LV aneurysm
-LVH
-Coronary vasospasm
-Takatsubo Cardiomyopathy
-Hyperkalaemia |
|
|
Term
| ECG changes in hypothermia |
|
Definition
Bradyarrythmias
Osborne (J wave) positive deflection of the terminal QRS
Long QT
Shivering artifact
Arrest - VT / VF / Asystole.
Note Long QT / Osborne waves also seen in hypocalcemia and neurological insults such as SAH |
|
|
Term
| DDx irregular broad complex tachycardia |
|
Definition
AF + abherent conduction
AF + accessory pathway (WPW)
Polymorphic VT
*AF + conduction defecit likely stable with rate <200
PVT generally profoundly unstable --> Shock
AF + WPW often deteriorates rapidly and has tachycardia > 200 (shock is usually required)
PVT and AF with WPW have variable QRSmorphology
AF + conduction defecit has consistent QRS complexes. |
|
|
Term
Needlestick injuries
-Risks of transmission
-PEP |
|
Definition
-HIV =0.3%, Hep C 3%, Hep B 30% (in susceptable pts with positive source)
PEP
HIV - Antiretrovirals (effective up to 72 hours)
Hep B - Hep B IGG + vaccine course for non immune
Hep C - No prophylaxis
Needs baseline serology and folllow up at 6 weeks (HIV
3 months (HCV)
6/12 HBV + HCV)
Important - reassurance (transmission rate low)
Counselling - supporive + safe sex advice etc
ADT
ID involvement in decision making.
Follow up
Reporting of exposure. |
|
|
Term
Broad Complex Tachyarrhythmias
-Types
-Preferred management |
|
Definition
A: Regular Broad complex tachycardia
+VT until proven otherwise
Rx
- HD unstable: 1: Sync DC cardioversion - 100, 150, 200J +/- amiodarone
-HD stable: 1: Amiodarone (150mg / 10min + repeat x 1 if ineffective + infusion 900mg/24 hours)
2: lignocaine or procainamide
3: Electrical cardioversion if chemical unsuccessful.
+DDx - SVT w abherent conduction, SVT with accessory pathway
B: Broad Complex Irregular Tachycardia
+Polymorphic VT (including torsades)
+AF w accessory pathway
+AF w aberrant conduction
Rx Torsades:
1: MgSo4 (2g / 2 mins)
2: Electrical cardioversion if unstable (often resistant)
3: If recurrent episodes consider increasing HR (isoprenaline / external pacing to HR 110)
AF w WPW Rx:
-HD unstable: DC cardioversion
-HD stable - can consider flecainide / procainamide but probably safest to just cardiovert. |
|
|
Term
Narrow complex tachycardia
-Types / DDx
-Management preferances |
|
Definition
Regular
+ST
+A flutter
+SVT - AVRT, AVNRT
Irregular
+AF
+A flutter with variable block
+MFAT
Rx: SVT
1: Instability (unusual) --> cardioversion.
2:Vagal manœuvres
3: Adenosine (6,12,18mg (0.1mg/kg 0.2, 0.3) Bolus
4: If adenosine fails - DC cardioversion Or verapamil would be options.
Atrial Flutter Rx
-HD unstable --> DC cardioversion
-Treat underlying cause (rare without heart disease)
-Cardioversion vs rate control as per AF
AF:
Acute (<48 hours) - In general rhythm control (pharm vs electrical)
Chronic (> 48 hours) Rate control and consideration of anticoagulation.
Options: Acute:
1: Observation, (+ correct reversable causes eg electrolyte disturbance) (90% spontaneous resolution for acute episode in 24hr)
2: DCCV (mandatory if HD unstable)
3: Pharm cardioversion (amiodarone 300mg/ 1 hour, 900mg / 24 hours) (other option flecainide)
4: Rate control (metoprolol IV img boluses --> 10mg ) oral 25mg BD)
-Anticoagulation for acute AF cardioverted in ED
Poor evidence but heparin bolus prior to cardioversion reccomended.
If high risk for stroke (CHADS2) 2+ consider 1 month OAC after crdioversion
AF > 48 hours old
-Rate control
-Anticoagulate (based on risk CHADS2)
-Consider referral for delayed cardioversion
CHADS 2
Congestive heart disease
Hypertension
Age>75
Diabetes
Previous stroke / TIA (x 2)
0 - No AC or aspirin
1- Aspirin or OAC
2+ OAC recommended unless high risk for haemorrhage. |
|
|
Term
|
Definition
High Risk (Inpatient Ix and Rx)
-Positive biomarker
-ECG changes
-Ongoing repetitive / prolonged pain
-HD compromise
-VT
-Typical sx ACS with DM or CKD
-Recent PCI / CABG (6 months)
Intermediate
-No high risk features
-Resolved Repetitive / prolonged pain
• Age >65 years;
• Known coronary heart disease
• Two or more of the following risk factors: known hypertension,
family history, active smoking or hyperlipidaemia;
- diabetes / CKD (with atypical symptoms of ACS);
• Prior aspirin use.
-Rest are low risk (not many!)
Intermediate / low risk pts after negative serial ECGs should have EST ideally as an inpatient as a prognostic test. Neg biomarkers / ECG and normal EST has low risk of cardiac event in coming month. |
|
|
Term
|
Definition
0-1: HR 110-->160, RR 30-40
1-2:100->150 RR 25-35
2-5: 90-->140 RR 20-30
5-12:80-120 RR 20-->25
>12 as per adults
SBP 2xage +70 (1-10), <1 sbp min70 (cap refil a better test! |
|
|
Term
Paediatric calculations:
Weight:
A:: ETT, LMA, Dexamethasone,
B: Vent settings
C: Defib, adrenaline dose, atropine, Fluid bolus, PRBCS FFP Plt cryo.
D: Midaz. Ketamine propofol, Roc, Sux, Glucose. |
|
Definition
Weight: (age+4) x2
A:
ETT age/4 + 4 (uncuffed) age/ 4+3.5 (cuffed)
LMA 1<6.5kg 2<20 3<30 4>30
Dexamethasone 0.15mg / kg
B: TV 6ml/ kg (ARDSNET) Approximate normal RR + titrate appropriately
C: Total blood volume75ml/kg
Shock: 4 J/kg
adrenaline 10mcg/kg
atropine 20mcg / kg
IVT 20ml / kg
PRBCs 10ml/kg
FFP 15ml/kg
PLt 10ml / kg
Cryo 5 ml/ kg
end points: cap refil < 2 sec SBP age70 + (2 x age)
D:
Midaz: IV 0.05-0.1mg/kg
Glucose: 2.5ml/kg 10% dextrose
Ketamine: induction: 2mg/kg sedation 0.5mg/kg and titrate
Propofol: 2-4mg/ kg (induction)
Rocuronium 1.2mg/ kg RSI
Sux: 1-2mg/ kg IV induction. 3mg / kg IM |
|
|
Term
Antibiotic Choice ADULT
-Sepsis no clear Source
-CAP
-Meningitis / Meningococcal sepsis
-Quinsey
-Abdominal
-Skin / Soft tissue
-Urinary tract
-Neutropenic Sepsis
-PID |
|
Definition
1: Unclear Source
Flucloxacillin 6g QID + gentamicin 7mg / kg
(Vanc if penicillin hypersensitive)
2: Respiratory
Benzylpenicillin 1.2g QID + Azithromycin (+gentamicin 5mg/kg if severe)
Tropical + RF for melliodosis: Meropenem 1g tds + Azithromycin 500g OD)
Add fluclox 2g Q4 hr or vanc 30mg/kg or 1.5 g BD if Staph aureus /MRSA suspected (immunosuppressed eg dialysis)
3 Meningitis / Meningococcal Sepsis
-Cefotaxime 50mg / kg (2g) tds
-Dexamethasone 10mg with first dose for meningitis
-Add ben pen (2.4g q4 hr)if listeria likely (>50, debilitated, alcoholic)
-Consider aciclovir 10mg/kg q8hr
4: Quinsey
-Benpen 1.2g QID + metronidazole 500mg (12.5mg / kg) tds
5: Abdominal:
-ampicillin 1g QID, metronidazole 500mg tds + gentamicin 5mg/kg OD
6: Skin / Soft Tissue:
-Flucloxacillin 1g QID
-lincomycin 10mg/kg (600mg) tds if allergic / MRSA likely
-For Nec. Fasc. Give lincomicin 10mg/ kg + meropenem 1g tds.
7: Urinary tract:
-ampicillin 1g QID + gentamicin 5mg/kg O
8: Neutropenic:
-Piperacillin / Tazobactam 4.5g (100mg/kg) TDS
-Add vanc 1.5g (30mg/kg) if Shocked, Indwelling catheter or known MRSA
9: PID
-Severe: ceftriaxone 1g, azithromycin 500mg IV OD, metronidazole 500mg BD
-OP treatment: Ceftriaxone 500mg, metronidazole 400mg PO BD x14/7, doxycycline 100mg PO BD x 14/7 |
|
|
Term
Paediatric Antibiotic choice
-Sepsis with no apparent source
-Meningitis / Meningococcal sepsis
-CAP |
|
Definition
1: Sepsis - No clear source
-<6/12 ampicillin 25mg /kg QID + cefotaxime 50mg/kg tds (+ vanc 30mg/kg if pneumococcal meningitis likely)
->6/12 cefotaxime 50mg/kg (2g) tds
Add vancomycin 30mg/kg BDif pneumococcal meningitis is likely
-Meningitis: As above. Add dexamethasone 0.15mg/kg with first dose of ABs
-CAP:
<1/52: Maternally aquired pathogen -eg: GBS, listeria Benpen 60mg/ kg BD + gentamicin 3mg/kg OD x7/7
1/52 --> 5 years
-benzylpenicillin 30mg/kg Q6 hr if non- severe. -Cefotaxime 25mg/kg tds if severe.
5-15
amoxyl 25mg/kg tds x7/7 orally or Roxithromycin 4mg/kg max 150mg BD x 7/7 if mild and outpatient
benpen 30mg/kg QID + roxithromycin if Inpatient
-Meropenem 25mg/kg tds + roxithromycin for tropical, severe + immunosuppressed. |
|
|
Term
Bier's Block
-Proceedure
-Dose |
|
Definition
-Consent
-Proceeduralist / anaesthetist/ NIVM / resus facilities.
-Prep- 2x IVC (1 each arm). Proceedural Prep
-Elevate + exanguanate arm
-Inflate torniquet (proximal) - 100mmhg above systolic
-Inject prilocaine 2.5mg / kg (more in lower limb - 3-4)
-Test anaesthesia, perform proceedure
Min torniquet time 20 min max 1 hour, |
|
|
Term
Sepsis EBM
-EGDT
-Jones Study
-Process
-Arise |
|
Definition
EGDT:2001 RCT, septic shock or lactate>4
30 vs 46 % mortality (High)
Parameters
CVP 8-12 mmHg (mandatory CVL)
MAP 65 – 90 mmHg
Urine output >0.5 ml/kg/hr
Mixed venous oxygen saturation >65% / ScvO2 >70%
Haematocrit >30% (Aggressive transfusion)
Interventions
Reduce work of breathing by early use of mechanical ventilation
Fluid resuscitation
Use of vasoactive agents: noradrenaline, dobutamine
Transfusion
Jones 2010
-Lactate clearance as treatment goal non inferior to ScvO2
Process 2014
-No significant mortality difference between EGDT, protocolised care without mandated CVL, ionotropes and transfusion or 'standard care'
Arise
-Pending Australian study of EGDT vs standard care. |
|
|
Term
|
Definition
1: GI loss (esp vomiting with pyloric stenosis)
2: Drugs - Diuretics, HC03, laxatives
3: Renal loss (salt losing nephropathy, diuretics
4: Other losses (sweating)
5: Endocrine (adrenocortical insufficiency SIADH |
|
|
Term
|
Definition
1: Dehydration (absent thirst response or inability to drink)
2: Renal - failure, DI
3: Metabolic (NAGMA)
4:Endocrine (adrenocortical hyperfunction)
5: Drugs - eg hypertonic saline |
|
|
Term
Clearing C-spine
NExus criteria
Canadian C-spine rule |
|
Definition
Nexus
1: No Neurology
2: No midline Tenderness
3: No Distracting Injury
4: Not intoxicated
5: No ALOC
Canadian C spine
High risk - rad
Age >65
High risk mechanism
Paraesthesias in Extremities
Low risk (need one to asess clinically)
Simple Rear end MVC
Walked
No midline tenderness
Delayed onset neck pain
Sitting in ED
3: Asess ROM (45 degrees each way) |
|
|
Term
| Steps in preparing hospital for a Major Disaster |
|
Definition
-Hospitals should have Disaster plan - implement this
Preparation:
-Declare Disaster + communicate EMS, Inpatient teams, management.
-Hospital management notification
They have responsibility for implementing hospital wide preparation
-Cancel and clear outpatients area
-Coordinate discharge of appropriate patients from wards // clear inpatient beds
-Cancel non emergent surgery
-Establish command centre
-Media liason
ED preparation
-Staff - call in extra staff if required
-Allocate roles (Triage, Resus Teams etc)
Department:
-Inform patients of disaster
-Arrange discharge / admission of those that can be
- Clear space for new arrivals
-Prepare reception / triage area for arrivals (larger - often ambulance bay used)
-Flow plan (eg - ED for seriously injured, OPD for walking wounded)
-Decontamination Zones for CBR disaster
-Specific patient management issues
-Overwhelming numbers may need compromised approach to care
Eg limit investigation to that urgently necessary
-Experience RNs may have role in assesment and treatment of minor trauma
-Expectant management of unsalvagable patients. |
|
|
Term
| Disaster Triage Seive and sort |
|
Definition
Seive by most experienced clinician in disaster field
-Walking? --> Cat 3 (delayed)
?Not Breathing (can open airway) --> Dead
HR>120, RR>30 <10 cap refil < 3 --> Cat 1 (immediate)
If not Cat 2 (urgent)
Sort once moved to casualty clearing station
Determines transport priority
Revised trauma score
GCS (0-4)
RR (0-4)
BP (0-4)
12 --> Delayed
11--> urgent
1-10 immediate |
|
|
Term
| Risk stratification ACS ( heart foundation) |
|
Definition
1: High risk
-Presentation consistent with ACS and
-Ongoing pain
-Elevated biomarkers
-ECG changes
-HD compromise
-VT
-Syncope
-PCI < 6/12 or past CABG
-DM or CKD and typical features ACS.
intermediate
-Repeditive / prolonged pain now resolved
-Age > 65
-2+ CVRF
-Known CAD
-DM / CKD with atypical chest pain
-past aspirin use
-No high risk feature
-Low - None of the above |
|
|
Term
|
Definition
GRIMUS
Galleazzi Radius inferior (Distal radius and radio ulnar dislocation)
Monteggia Ulna superior (# Uln and radial head dislocation) |
|
|
Term
CSF interpretation + DDX for meningitis
DDX of infectiveorganisms
Neonatal
<5
3/12-15
Adult
Elderly |
|
Definition
-Bacterial: WCC>500 /HPF, low glucose, elevated protein. 60-90 % positive gram stain
-Viral <1000, normal glucose, protein normal or mildly elevated. predominantly monocytes although 50% have > 30-50% PMN
Fungal / TB:WCC100-500, low glucose,mildly elevated protein.
Neonatal: G -ves esp ecoli,GBS, Listerioa
<15: N. Meningitidis, HI, Strep P.
Adult. N. Meninitidi, S. Pneumoniae, listerioa, s. Aureus
Elderly - G -ves.
Aseptic / Atipical
Viral (HSV, enterovirus etc)
Partially treated
TB
Cryptococcus
Syphylis
Mallignancy / parasites / autoimmune |
|
|
Term
CSF interpretation + DDX for meningitis
DDX of infectiveorganisms
Neonatal
<5
3/12-15
Adult
Elderly |
|
Definition
-Bacterial: WCC>500 /HPF, low glucose, elevated protein. 60-90 % positive gram stain
-Viral <1000, normal glucose, protein normal or mildly elevated. predominantly monocytes although 50% have > 30-50% PMN
Fungal / TB:WCC100-500, low glucose,mildly elevated protein.
Neonatal: G -ves esp ecoli,GBS, Listerioa
<15: N. Meningitidis, HI, Strep P.
Adult. N. Meninitidi, S. Pneumoniae, listerioa, s. Aureus
Elderly - G -ves.
Aseptic / Atipical
Viral (HSV, enterovirus etc)
Partially treated
TB
Cryptococcus
Syphylis
Mallignancy / parasites / autoimmune |
|
|
Term
Gullian BArre Syndrome
Presentation
Investigation
Management |
|
Definition
-Post infectious demylenating polyneuropathy
-Ascending flacid paralysis
-Cranial nerve involvvement in 50%
-Autonomic dysfunction
Ix:High CSF protein without WCC.
Respiratory function tests
Rx:
-Respiratory support as required (Avoid sux for intubation)
-Haemodynamic support sometimes required (autonomic dysfunction)
Plasmaphoresis /plasmaexchange / IG therapy
-Paraesthesias in limbs
Often limb pain |
|
|
Term
BTS spontaneous PTX management guidelines
-Small primary
-Large primary
-Very small secondary
-Small secondary
-Large secondary |
|
Definition
-Small primary (not breathless < 2cm @ hilum)
Observation, OPD f/u 1-2 weeks.
-Large primary / Breathless
NEedle aspiration, repeat CXR, ICC if failed
-Very small secondary (asymptomatic, < 1cm) admit and observe, O2 unless risk of toxicity
1-2cm and not breathless - aspirate, small bore icc if not improved
Large (>2cm or breathless)
-small bore ICC
(8-12 Fr) |
|
|
Term
|
Definition
On presentation
Age >55
WCC > 1600
Glucose>10
LDH>350
AST>250
@ 48 HR
BAse defecit>4
HCT drop>10%
Urea rise> 5
Ca2+<2
PAO2 <60
Fluid sequestration> 6L
0-2 =1% mortality
>7 100%mortality. |
|
|
Term
|
Definition
On presentation
Age >55
WCC > 1600
Glucose>10
LDH>350
AST>250
@ 48 HR
BAse defecit>4
HCT drop>10%
Urea rise> 5
Ca2+<2
PAO2 <60
Fluid sequestration> 6L
0-2 =1% mortality
>7 100%mortality. |
|
|
Term
Asthma
-Severity
-Management |
|
Definition
| Severity |
Signs of Severity |
Management |
| Mild |
Normal mental state
Subtle or no increased work of breathing accessory muscle use/recession.
Able to talk normally
FEVandPEF>75% predicted
|
Salbutamol by MDI/spacer (dose) - once and review after 20 mins. Ensure device / technique appropriate.
Good response - discharge on B2-agonist as needed.
Poor response - treat as moderate.
Oral prednisolone (1 mg/kg daily for 1-3 days) if episode has persisted over several days.
Provide written advice on what to do if symptoms worsen. Consider overall control and family's knowledge. Arrange follow-up as appropriate.
(discharge pack) |
| Moderate |
Normal mental state
Some increased work of breathing accessory muscle use/recession
Tachycardia
Some limitation of ability to talk
FEV/PEF 50-75% predicted
|
Give O2 if O2 saturation is < 92%. Need for O2 should be reassessed.
Salbutamol by MDI/spacer - 1 dose (drug doses) every 20 minutes for 1 hour ; review 10-20 min after 3rd dose to decide on timing of next dose.
Oral prednisolone (1 mg/kg daily for 3 days) |
| Severe |
Agitated/distressed
Moderate-marked increased work of breathing accessory muscle use/recession.
Tachycardia
Marked limitation of ability to talk
Note: wheeze is a poor predictor of severity. |
Oxygen
Salbutamol by MDI/spacer - 1 dose (drug dose) every 20 minutes for 1 hour ; review on-going requirements 10-20 min after 3rd dose. If improving reduce frequency, if no change continue 20 minutely, if deteriorating at any stage treat as critical. If no improvement with salbutamol alone, consider intravenous treatments (see below)
Ipratropium (drug dose) by MDI/spacer
Oral prednisolone (1 mg/kg daily); if vomiting give i.v. methylprednisolone (1 mg/kg daily);
Involve senior staff.
Arrange admission after initial assessment. |
| Critical |
Confused/drowsy
Maximal work of breathing accessory muscle use/recession
Exhaustion
Marked tachycardia
Unable to talk
SILENT CHEST, wheeze may be absent if there is poor air entry. |
Involve senior staff.
Oxygen
Continuous nebulised salbutamol (use 2 x 5mg/2.5L nebules undiluted) - see below re toxicity.
Nebulised ipratropium 250 mcg 3 times in 1st hr only, (20 minutely, added to salbutamol).
Methylprednisolone 1 mg/kg i.v. 6-hourly.
Aminophylline If deteriorating or child is very sick. Loading dose: 10 mg/kg i.v. (maximum dose 500 mg) over 60 min. If currently taking oral theophylline, do not give i.v. aminophylline - take serum level.
Unless markedly improved, following loading dose give continuous infusion (usually in ICU), or 6 hourly dosing (usually in ward). Drug doses
Magnesium sulphate 50% (500 mg/mL)
Dilute to 200 mg/mL (by adding 1.5mls of sodium chloride 0.9% to each 1ml of Mg Sulphate) for intravenous administration
- 50 mg/kg over 20 mins,
- Then 30 mg/kg/hour by infusion.
In ICU patients - aim to keep serum Mg between 1.5 and 2.5mmol/L.
May also consider i.v. salbutamol. Limited evidence for benefit.
5 mcg/kg/min for one hour as a load, followed by 1-2 mcg/kg/min.
Beware salbutamol toxicity: tachycardia, tachypnoea, metabolic acidosis. Can occur with both IV and inhaled therapy. Lactate commonly high. Consider stopping/reducing salbutamol as a trial if you think this may be the problem.
Aminophylline, magnesium and salbutamol must be given via separate IV lines.
Intensive care admission for respiratory support (facemask CPAP, BiPAP, or intubation/IPPV) may be needed.
|
|
|
|
Term
HHNS
-Diagnostic criteria
-Specific MAnagement
-Supportive care/ monitoring |
|
Definition
Dx:
-Serum Osm >320
-pH >7.3 HCO3>15
-Minimal Ketonaemia
Rx:
N/S Bolus for shock (+/- ionotropes)
Specific
-Insulin infusion tritrated to osmolarity
0.05 u/kg/hr - aim for <3mosm / L / hr reduction in osm
-Replace water defecit slowly over 2-3 days with 0.45 N/S (<1 mmol / L /Hr reduction in corrected Na if hypernatremic)
-Seek and treat precipitant (eg sepsis)
Supportive
-LMWH for thromboembolism prophylaxis
-Monitor HD, LOC, Electrolytes, glucose, osmolarity ( initially hourly) U/O. |
|
|
Term
Environmental Hypothermia
Define severity
Management - modifications to ALS |
|
Definition
Mild 32-35
Mod 28-32
Severe<28
Management (ALS)
Prolonged CPR apppropriate (reports of good neurological outcome)
Continue until T>32
Cautious handling
For arrest:
-CPR 30:2
-Up to 3 shocks if shackable rythm + T<30
then withhold until T>30
-Withhold drugs until T>30, Double dosing intervilles untilT > 35
Warming
-Passive: dry, warm room, insulation
-Peripheral Active- Radient heating, forced air warmer
-Central Active: Warmed IVT 40d, Warmed humidified 02, Body cavity lavage, RRT ,Echmo
Supportive / Monitoring
Core temph |
|
|
Term
Orbital and periorbital Cellulitis
-PAthogens
-Examination
-investigation
-Management
-Complications |
|
Definition
-ORbital: (usually from paranasal sinus --> more common iin adolescents and older)
Strep pneumoniae, Staph Aureus,strep pyogenes Haemophillus in unimmunised.
Periorbital- Usuallu Staph Aureusor Strep pyogenes from superficial scratch / impetigo etc.
Examination features suggestive of orbitalcellulitis
-Toxic
-Proptosis
-Painfull limited eye movement
-Visual impairment
Investigation:
NEed CT or MRI for orbital cellulitis (exclude abscess)
Management:
-Mild periorbital cellulitis = PO fluclox.
-Orbital Cellulitis or severe periorbital Cellulitis
-50mg/kg ceftriaxone OD+ 50mg/kgfluclox QID.
Complications:
-Orbital compartment syndrome / Optic nerve compression / blindness.
-Intracranial extension / meningitis / abscess.
-Cavernous sinus thrombosis
-Endopthalmitis |
|
|
Term
Haemolytic Anaemia
-Features on blood film
-DDx |
|
Definition
-Usually normocytic, may be macrocytic due to reticulocytes.
-Unconjugated hyperbilirubinemia
-Elevated Reticulocytes.
DDx- 1: RCC abnormalities (membrane eg sperocytosis, Hb eg HbS, enzyme eg G6PD)
2: Extrinsic - a: Autoimmune Haemolysis,(eg incompatible transfusion, Hydrops)
b: MEchanical - eg heart valve, microangiopathic haemolytic anaemias, hypersplenism) |
|
|
Term
|
Definition
Immediately stop ongoing infusion of thrombolytic drug, and stop all antiplatelet and anticoagulant therapies.
Investigate according to site of haemorrhage (e.g. CT brain, CT abdo/pelvis)
Obtain blood tests: FBC, coagulation profile; repeat q2h until bleeding controlled
obtain cross match
reverse fibrinolysis:
— FFP 2 units q6h for 24h
— cryoprecipitate 10 units
— tranexamic acid 1g IV
— ? role of prothrombinex and Factor 7
reverse anti-platelet effects:
— platelets 1 adult bag
— DDAVP 0.3 microg/kg
reverse anti-coagulant effects:
— protamine 1 mg for every 100 U of unfractionated heparin given in the preceding 4 hours
— protamine 1 mg for every 1 mg of enoxaparin (or 100 units of dalteparin) given in the preceding 8 hours
consult appropriate teams e.g. haematology, neurosurgery, cardiology, general surgery
If intracerebral hemorrhage: |
|
|
Term
D-Winter T waves
-Description
-Significance |
|
Definition
-Tall prominent symmetric anterior T waves
-Upsloping ST dep >1mm precordial leads
-No ST elevtion precordial
-0.5-1mm ST elevation aVR
Anterior STEMI eqivalent requiring urgent re-perfusion (LAD lesion) |
|
|
Term
erythema nodosum
-Description
-Causes |
|
Definition
-Hypersensitivity panniculitis, erythematous papules on legs transform into purpura, usually between age 20 and 40
Causes:
-Strep throat
-TB
-Mycoplasma
Drugs
-OCP, sulphonamides, NSAIDS
Pregnancy,sarcoidosis, IBD |
|
|
Term
Synovial fluid analysis
-Non inflammatory, inflammatory, infective |
|
Definition
Noninflammatory - WCC<2000, neut <25%
Inflammatory -WCC 2000-50000, neut>50%
Septic -WCC>50000,neut >75% gram stain oten + (except gonococcus which is only 25 % positive) |
|
|
Term
peritoneal fluid analysis
-Exudate vs transudate
-WCC |
|
Definition
High albumin = exudate, SAAG (serum - ascitic albumin> 1.1mg/Dl)
Or: ascitic/ serum protein >0.5, Ascitic/Serum LDH>0.6, AsciticLDH > 400
WCC: <300/ mcl normal, >300 abnormal.
NEutrophilla >25 % --> SBP (usually 90%, Cirrhosis (50%)
Lymphocytes eg: TB
G+ SBP, G-ve secondary peritonitis |
|
|
Term
|
Definition
-Referral sexual assault team
-MAnage injuries as appropriate
-Psychological support
-Forensic Issues
-STD prophylaxis - Azithromycin 1g PO + Ceftriaxone Benzylpenicillin if high risk.
Hepp B - Vaccine / IGg if not immune
HIV discuss with ID
-Pregnancy prophylaxis (if not preg ) 1.5mg single dose orally. |
|
|
Term
|
Definition
-SPINAL CORD DISEASE
+Malignant compression
+ Disk prolapse
+Transverse Myelitis
+Epidural Abscess
+Ischemia (eg vasculitis / dissection)
+Demyelenation (MS)
-MYOPATHY
+Metabolic (Esp hypokalemia , also hyperkalemia, hypercalcemia, hypermagnesemia) Endocrine eg: Hyperthyroidism)
-Hypokalemic periodic paralysis
-Muscular Dystrophy
-Neuromuscular disorders (eg Myaesthenia gravis)
+NEUROPATHY
-GBS
-Meds / Drugs (eg alcohol)
-DM
-Toxins (eg Tick, botulism)
-Motor Neuron Disease |
|
|
Term
Arthrocentesis
-Microscopy interpretation |
|
Definition
-Infective: WCC>50000, neutrophils >75%
-Inflammatory:WCC 2000-50000, Neutrophils > 50%
-Non inflammatory WCC<2000, Neuts< 25% |
|
|
