Advice/EPIC Flashcards
Mental health
CDD (capacity, drugs, dependants) Capacity: weigh Risk: - green/amber/red Nursing 1:1? Frisked? Sharps/drugs Dependents Cause for concern form Drugs/alcohol MSE: psychosis/manic Section
Calls for help
ED Consultant Major haemorrhage; code red Trauma Adult cardiac arrest MET/ Cardiac, Peri arrest Obstetric emergency Paediatric emergency Neonatal emergency Security (A+V)
Fast bleep
Intensive care
Anaesthetic
TIA
CT head -> Aspirin 300mg High risk factors: ABCD2 >4 Crescendo TIA (>1/week) On anticoagulant In AF?
TLoC
Reasons to admit
During exertion or supine
Family history <40
>65 w/o prodrome
Abnormal ECG
Heart murmur
Heart failure New SOB (?PE) Abdominal pain (?AAA)
?Seizure
Signs
Eyes open Snoring/grunting Foaming/biting Blue Synchronous limb movement Partial seizure Lateral tongue bite
Signs NEAD
Pseudo seizure
Fluctuating course Closed eyes Asynchronous movements Pelvic thrust Side to side head/body movement Ictal crying Absence postictal confusion
?aortic dissection
Pulse deficit
Bilat BP
Focal neurology
ECG
CXR
ECG ?HOCM
Dagger Q waves
(Deep and narrow)
- lateral and inferior
+- signs LVH
ECG ?LV hypertrophy
R wave lead I
+
S wave lead III
>25mm
Or R wave in aVF>20mm
Investigations to check
BED, obs, scan
- Blood and VBG
(Blood glucose)
- ECG +/- monitor
- Urine + bHCG
Sedation
Overnight Qs
Department safe Time critical? Comorbidities Starved? Reflux? Airway
Cardiac arrest Qs
Pre alert
Time onset/ duration arrest Bystander CPR Initial rhythm Treatment Cause of arrest? AMP QT
Paeds GCS
V1-5
V5: coos babbles
V4: irritable cry, confused
V3: cry in response to pain, inappropriate words
V2: moans in response to pain, incomprehensible words/sounds
V1: no response
Paeds GCS
M to 1-6
M6: purposeful movement (Obey command) M5: withdraw to touch (Localise pain) M4: withdraw to pain M3: abnormal flexion M2: abnormal extension M1: no response
Acute liver injury
Dx and Mx
ALT>500 PT>17 ?paracetamol OD IVF and lansoprazole -> Medical referral
?Encepahlopathic
-> IV Abx +/- ICU
Encephalopathy
Grade
1: abnormal behaviour
2: disorientated, drowsy, flap
3: confused, incoherent, drowsy
4: comatose
Fracture description
Open/closed Neurovascular status Stable/unstable Displaced/angulated/shortened Comminuted
Spinal shock
Vs
Neurogenic shock
Spinal concussion
- transient loss of function
Sign of tamponade/ effusion
on ECG
Electrical alternans
Low voltage criteria
Self discharging patient
Attempt to persuade
- concerns, risks, plan in ED
- safety net
Capacity? Mental health?
Self discharge papers
Document
Against medical advice
Does person have capacity?
- Is there impairment/ disturbance of brain or mind?
- Does that impairment make them unable to make a specific decision
Test
- understanding, weigh, retain, communicate
Personality disorder
Depression
And capacity
BPD: fluctuating capacity
Emotional dysregulation
Depression:
Pathological lack of care about ones own interests
Manifestation of the disorder
How long to observe anaphylaxis after treatment? (2021 RCUK guideline)
2h if:
- 1 dose adrenaline
- has autoninjector
6h if:
- 2 doses adrenaline
- previous biphasic
12h if
- >2 adrenaline
- continuing allergen release
- unsafe
65 year old with abdo pain
Ix
?AAA : USS ECG Bloods, VBG, amylase CXR CT abdo Surgical review
?orbital cellulitis
Signs
Proptosis
Opthalmoplegia
Pain on eye movement RAPD Orbital pain Conjunctival chemosis Purulent nasal discharge
Escalation problems in ED
- Demand exceeding capacity
- Exit block
- Support process breakdown
Handover
ABCDE
Areas and acuity - resus, corridor Beds - medics, surg, ortho Colleagues - sickness Deaths, disasters, deserters Equipment, events - blood gas
Night huddle
Introductions Number in Dept, wait TBS Area (resus) Acuity (Unwell patients) Specialty take lists - theatre planned? Beds - flow Colleagues - fully staffed? Disasters; Resus/Trauma call overnight - roles
Eye pH
7.2
Equal bilat
Asymptomatic Electrical injuries
Ix and plan
ECG
Urine dip; myoglobin
U+E, CK
Home if normal
Diameter of abdominal aorta
2-3cm
Syncopal episode
Consider unusual causes;
PE
AAA
dissection
High risk groups
Paeds Pregnant Elderly abdo/back pain Atraumatic CP Elderly trauma Syncope Immunosuppressed
Things to consider as EPIC
Patients
Incoming
Department
Staff
General aspects procedure
Consent Equipment Position Aseptic; field/gloves/apron Clean
USS Doppler colours
Red
= blood moving toward probe
Red artery
Blue
= moving away from probe
Blue vein
Rhabdomyolsis defined by
Raise in CK 5x baseline
Contraindication
Propofol
Soy or egg allergy
Nasty rash
Check
Mucosal membranes
?Steven Johnson’s syndrome
?TEN
Eczema ?herpeticum
Gentamicin dosing
3-5mg/kg
Based on ideal body weight
3mg if over 65
Max 80mg OD if on dialysis
Rotator cuff injuries
Tests
Empty can - supraspinatus Ext rotation - infraspinatus Lift off test (small of back) - subscapularis No test teres minor
Teenager social Qs
HEADSSS Home Education Activities Drugs Sex Safety Suicide
Pericarditis findings
Pleuritic CP Worse on lying flat Better on sitting forward Friction rub ECG change Troponin
Inferior ST elevation and back pain
Consider
Dissection
Flap covering R coronary Ostia
Drugs causing dystonia
Dopamine antagonists Antipsychotics Metoclopramide Antiepileptics Amphetamines Antihistamines
Volar plate injury
Hyperextension fingers
Avulsion at PIPJ
Tx buddy strap + F/U
Mallet finger
Axial load or flx on finger
Unable to extend finger
Avulsion DIPJ
Tx mallet splint + F/U
Bennett fracture
Forced abduction thumb Fracture at base of 1st MTC Tx Reduce and thumb spica POP Refer to on call Ortho
Maisonneuve fracture
Tailor shift
+/- # medial malleolus
+ proximal fibular #
Taylor shift but no fracture
Maisonneuve fracture
Proximal fib fracture
Talofibular disruption
Deltoid ligament disruption
+- medial malleoulus #
Hyperemesis gravidum
Prolonged N+V
Dehydration
Electrolyte disturbance
>5% pre-pregnancy weight loss
Consider admission if continued weight loss and ketonuria despite oral anti emetics
PID
Sx
Lower abdominal pain (Usually bilat) \+\- deep dyspareunia \+\- abnormal PV discharge \+/- abnormal bleeding
Contraindication to
Beta blocker
Asthma
sBP<90
Severe HF
Phaeochromocytoma
Obstetric cholestasis
~1% Prolonged pruritis (Esp night including palms/soles) Absence of rash Abnormal LFT/bile acid
Comp:
Prematurity, intrauterine death
Lidocaine
10ml of 1% =mg
100mg
Max 3mg/kg
Causes of high anion gap acidosis
LTKR Lactate Toxins Ketones Renal
CATMUDPILES
Calculate anion gap
Na+K - HCO3+ Cl
Raised >30
Borderline 20-29
Causes normal anion gap acidosis
ABCD Addisons Bicarbonate loss (GI/renal) Chloride excess Diuretics
Horners syndrome and pain
Partial ptosis
Miosis
Anhydrosis
Pain in neck; cervical artery dissection
Pain in chest/arm; pancoasts tumour
Tripod fracture
Facial
Inferior orbital rim
Lateral orbital rim
Zygomatic arch
Adequate c spine XR
Junction C7/T1
Central slip injury
Test
Elsons test
Flx 90 deg then ext
Should extend with floppy distal phalanx
Skiers thumb
Ruptured ulnar collateral ligament
Often associated avulsion fracture base of proximal phalanx of thumb
Volume of anaesthetic in digital nerve block
2-3ml per side/injection
ST elevation in aVR
> 1mm
with recipricol changes in lateral leads
Left coronary occlusion
tachy and new low voltage ECG
Pericardial effusion until proven otherwise
Causes of Low voltage ECG
Conduction:
Effusion; Pericardial/ pleural
Fat
Air (COPD, PNX)
Low power
- cardiomyopathy
Locked knee Dx and Ddx
Unable to extend knee same as good side Ddx Meniscal tear ACL injury Loose body
Test ulnar collateral ligament of thumb
(Skiers thumb)
Fix MTC
Radial deviation of MCPJ
In extended and flexed position
Should be less than 15deg movement
Angles of Louis
5cm below sternal notch
Gives you 2nd intercostal space
Complications shoulder dislocation
Axillary nerve
Hill Sachs (top hill)
Bankart lesion (bank bottom)
Sub talar dislocation XR findings
Talus not aligned with navicular
AF management options
Unstable
Stable
- rhythm control (within 48h onset)
- rate control
LV vs RV strain ECG T waves
LV strain = TWI laterally
RV strain = TWI v1-3 and S1Q3T3
Post reduction TMJ dislocation
Soft diet 48h
Avoid wide mouth opening 2weeks
Support moth with hand during yawning
Consider Barton bandage if unable to comply or understand
HIV PEP
Within 72h
4 weeks of drugs
Test at 3months
Kawasaki diagnosis
CRASH and burn
Conjunctivitis
Rash
Adenopathy
Strawberry tongue
Hands and feet
Fever (>39) over 5 days
Zygomaticomaxillary injury advice
Avoid nose blowing
Do not occlude nose when sneezing
Malar region numbness due to
Inferior orbital nerve injury
Wernickes
Vs
Korsakoffs
Thiamine deficiency (acute vs chronic)
Wernickes
- triad; ataxia, confusion, opthalmoplegia
- reversible
Vs
Korsakoffs
- memory loss and confabulation
- irreversible
Clinical frailty score
1: very fit
2: no active disease Sx
3: managing well
4: vulnerable; Sx limit activities
5; mildly frail; help with some ADLs
6; moderately frail; help with dADLs and pADLs
7; severely frail; completely dependent for pADLs
8; very severely frail; completely dependent
9; terminally ill
Sudden onset sensorineural hearing loss Tx
Prednisolone 40mg OD, 1 week
PPI if indicated
Bell’s palsy Tx
Presnisolone 60mg OD 10 days
+|- Aciclovir 200mg OD
Eye taping
Manchester mandibular fracture rule ruled out if;
All negative
Malocclusion
Trismus
Pain with mouth closed
Broken teeth
Step deformity
Signs Ludwig’s angina
Trismus (reduced mouth opening)
Woody submandibular region
Tender submandibular region
Inability to protrude tongue
Tongue displaced superior and anterior
Upper airway signs of concern
Stridor
Trismus (limited opening)
Drooling
Change in voice
Tripoding
Resp distress
Limited neck movement
Biphasic T wave
Do not exist
Terminal portion determines if
Positive or negative
TWI normal variants
Isolated inversion (not in contigous leads)
aVR, V1
V2, III, aVL
Juvenile Twaves = TWI V1-3
RF for cerebral venous thrombosis
Third trimester
Recent oral contraceptive (oestrogen)
Coagulopathy
Recent sinusitis
Pregnancy drugs to avoid
Trimethoprim
tetracyclines
NSAIDS
Operates at birth
Sodium valproate
Ondanesetron under 12weeks
Headache in pregnancy consider
Cerebral vein thrombosis
Pre eclampsia
Consider neutropaenic sepsis and Dx
Chemotherapy last 6 weeks
Haematological malignancy
Stem cell transplant
Myelodysplastic syndrome
Dx
Neutrophil less than 0.5 and sepsis
Achilles tendon rupture signs
Palpate tender, step deformity
Active movement reduced
Simmons test
Feet hang over edge, squeeze calf, no movement shows tendon rupture
Normal anion gap
8-16 when not including K
10-20 when including K
Phaechromocytoma Tx
Alpha blockade
- phenoxybenzamine or phentolamine
Then b blockade
- propranolol
Lemierre syndrome
Thrombophlebitis of internal jugular vein
Secondary to oropharyngeal infection
Usually young people
Can lead to cerebral vein thrombosis and metastatic infection
Hereditary angioedema treatment
C1 esterase inhibitor
(Icatibant acetate)
FFP
SVCO Tx
? Intubation
IV steroids
IV furosemide
Endovascular stenting
Radiotherapy, chemotherapy
?surgical resection
Retinal artery occlusion. Tx
Ocular massage 10 sec on 5 off
Increase blood oxygen content 15L
Dilate retinal arteries; GTN
Reduce intra ocular pressure:
- acetazolamide and mannitol
Irreversible damage after 4h
Orthostatic hypotension Dx
30mmHg drop sBP if hypertensive
20mmHg drop sBP if normotensive
10mmHg drop dBP
Facial structures at risk of injury in facial lacerations
Parotid gland and duct
Lacrimal gland and duct
Facial nerve
DVLA medical reasons to stop driving (class1)
Ask if have class 2 licence
Arrhythmia: stop until diagnosis and controlled for 4 weeks
Seizure; 6m seizure free
LOC; undiagnosed LOC: 4w or 6m depending on low high risk and if treatment started
TIA; 1m
Menieres; until Sx controlled
Psychosis and mania; 3m
Schizophrenia; 3m if stable
Sleep apnea: until symptoms controlled
Test for rhinorrhea
Beta 2 transferrin
Carbon monoxide questions
COMA
Co-occupants similar Sx?
Outdoors better?
Maintenance; boilers and cooking appliances?
Alarm; CO functioning?
Indicators for liver transplant in paracetamol OD
pH <7.30 after 2 days
INR>6.5
Creatinine >300
Hepatic encephalopathy (grade 3/4)
Increasing INR on day 3 or 4
Consent from child
Gillick competent child or over 16
Parental consent
Court order
ECG in collapse - check
W - Wolff Parkinson White
O - Obstructed AV pathway
B - Bifascicular block
B - Brugada
L - LV Hypertrophy (consider AS, HOCM)
E - Epsilon wave
R - Repolarisation abnormality
Pseudo hyponatraemia
Normal or high serum osmolality
Due to high BG, high lipid or para protein
