EMCC Flashcards
SVC obstruction presentation
SOB • Chest pain • Cough • Face/ arm swelling • Head fullness/ headache • Dizziness • Nausea • Stridor • Blurred vision • Syncope • Convulsions • Coma
On exam
• Oedema of the head, neck, arms • Distended neck veins
• Plethora
• Cyanosis
• Distended subcutaneous vessels • Engorged conjunctiva
• Pemberton’s sign +
SVC ob treatment
Treatment
Head elevation
High flow oxygen
Dexamethasone 16mg/24 hours
Radiotherapy/ chemotherapy for the underlying cancer
Balloon venoplasty and SVC stenting provide rapid relief of the symptoms
Definition of shock:
Acute circulatory failure with inadequate or inappropriately distributed tissue perfusion resulting in generalized cellular hypoxia
Causes of shock
Cardiogenic:
LV failure (SV)
MI (SV, HR) Valvular path (SV) Arrythmias (SV, HR
Obstructive (SV):
Tamponade Tension
PE
Hypovolaemic (SV):
Haemorrhage D&V
Burns
Third spacing
Identifying Shock
Clinical Signs & Bedside Investigations
Early signs (Non-progressive):
Tachypnoea, Tachycardia, Oliguria, Increased CRT, Cool/Warm Peripheries
Later Signs (Progressive):
Hypotension (pulse pressure), Confusion, Worsening of Above
Final Signs (Irreversible):
End organ damage – Chest Pain, Unconscious/Stroke, Anuria, Abdo Pain
Bedside Investigations:
VBG: lactic acidosis. Bloods: FBC, LFTs, Renal, Clotting, Trop, G&S. BM. ECG. CXR Echo – CVP, RV pressure, LV function, RWA, Tamponade
Shock management
Management
A-E Assessment
A – 15l NRB, Airway Manouvres/Adjuncts, Anaesthetics (Adrenaline)
B – ABG, CXR, (T2 Intercostal Midclavicular) (Nebulisers)
C – IV access, Bloods (Cultures), Fluids (250-500mls), ECG, Catheter,
ECHO, (Antibiotics)(Steroids/Antihistamines)(Blood)(Furosemide) D – BM (glucose), AVPU/GCS, Temperature. Pupils
E – Urticaria, Purpuric Rash, Blood (1 on floor & 4 more), Spinal Injury
SEPTIC ARTHRITIS causes and RF
Usually staphylococcus aureus
• Gram negative infection more common in
elderly/immunosuppressed
• Infection by direct injury or blood-borne infection from skin/elsewhere
• Risk factors: prosthetic joints, pre-existing joint disease, recent intra-articular steroid injection, diabetes mellitus
Clinical Features of Septic Arthritis
Hot, painful, swollen, red joint; develops acutely
• Fever, evidence of infection elsewhere
• Articular signs muted in elderly, immunosuppressed, rheumatoid arthritis
• 20% cases involve >1 joint
• Prosthetic infection may be early (<3 months) or late/delayed
(>3 months)
• Early: inflammation/discharge from wound, joint effusions, loss
of function, pain
• Late: pain/mechanical dysfunction
Investigations for Septic Arthritis
Investigations for Septic Arthritis
• FBC, ESR, CRP, cultures
• Joint aspiration and synovial fluid analysis (required in any acute monoarthritis)
• Appearance and WCC
• Gramstainandculture
• Polarisedlightmicroscopy(forcrystals)
• Swab urethra, cervix, anorectum if considering gonococcal infection
Management of Septic Arthritis
Management of Septic Arthritis
• Initially (pending sensitivities): flucloxacillin 1-2g 6h IV + fusidic acid 500mg 8h PO (+ gentamycin in immunosuppressed)
• 2 antibiotics for 6 weeks (first 2 weeks IV), then 1 antibiotic for further 6 weeks
• Joint drainage (needle aspiration, arthroscopy, open drainage); refer prosthetics to orthopaedics
• Immobilise joint in acute stage, mobilise early to avoid contractures
• NSAIDs for pain relief
• Septic arthritis DDX
Differentials • Septic arthritis • Gout • Pseudogout • Osteoarthritis • Rheumatoid arthritis
Sepsis Six ?
3 in
IV fluid balance
IV antibiotics
Oxygen
3 out
Urine output
Blood cultures and septic screen
Latate
Always escalate
Factors associated with poor prognosis in SCZ
Factors associated with poor prognosis strong family history gradual onset low IQ prodromal phase of social withdrawal lack of obvious precipitant
indications for beta blockers
ndications
angina
post-myocardial infarction
heart failure: beta-blockers were previously avoided in heart failure but there is now strong evidence that certain beta-blockers improve both symptoms and mortality
arrhythmias: beta-blockers have now replaced digoxin as the rate-control drug of choice in atrial fibrillation
hypertension: the role of beta-blockers has diminished in recent years due to a lack of evidence in terms of reducing stroke and myocardial infarction.
thyrotoxicosis
migraine prophylaxis
anxiety
Side effects of Beta blockers
Side-effects bronchospasm cold peripheries fatigue sleep disturbances, including nightmares erectile dysfunction recused hypoglymic awareness
organophosphate poisoning features
(mnemonic = SLUD) Salivation Lacrimation Urination Defecation/diarrhoea cardiovascular: hypotension, bradycardia also: small pupils, muscle fasciculation
organophosphate poisoning management
Management
atropine
the role of pralidoxime is still unclear - meta-analyses to date have failed to show any clear benefit
Budd-Chiari syndrome traid
udden onset abdominal pain, ascites, and tender hepatomegaly
+ hepatic vein thrombosis
Budd-Chiari syndrome Causes
Causes polycythaemia rubra vera thrombophilia: activated protein C resistance, antithrombin III deficiency, protein C & S deficiencies pregnancy oral contraceptive pill
classification of NPDR
Mild NPDR
1 or more microaneurysm
Moderate NPDR microaneurysms blot haemorrhages hard exudates cotton wool spots, venous beading/looping and intraretinal microvascular abnormalities (IRMA) less severe than in severe NPDR
Severe NPDR
blot haemorrhages and microaneurysms in 4 quadrants
venous beading in at least 2 quadrants
IRMA in at least 1 quadrant
Tear drop cells on blood film
associated with thalassaemia, megaloblastic anaemia and myelofibrosis.
head injury - Fluctuating confusion/consciousness?
- subdural haematoma
Extradural (epidural) haematoma presentation
features of raised intracranial pressure
some patients may exhibit a lucid interval
Subdural haematoma presentation
Risk factors include old age, alcoholism and anticoagulation.
Slower onset of symptoms than a epidural haematoma. There may be fluctuating confusion/consciousness
Inguinal hernia presetation
If inguinoscrotal swelling; cannot ‘get above it’ on examination
Cough impulse may be present
May be reducible
Acute epididymo-orchitis presentation
Often history of dysuria and urethral discharge
Swelling may be tender and eased by elevating testis
Most cases due to Chlamydia
Infections with other gram negative organisms may be associated with underlying structural abnormality
Epidiymal cysts presentation
Single or multiple cysts
May contain clear or opalescent fluid (spermatoceles)
Usually occur over 40 years of age
Painless
Lie above and behind testis
It is usually possible to ‘get above the lump’ on examination
Hydrocele presentation
Non painful, soft fluctuant swelling
Often possible to ‘get above it’ on examination
Usually contain clear fluid
Will often transilluminate
May be presenting feature of testicular cancer in young men
Varicocele presentation
Varicosities of the pampiniform plexus
Typically occur on left (because testicular vein drains into renal vein)
May be presenting feature of renal cell carcinoma
Affected testis may be smaller and bilateral varicoceles may affect fertility
bag of worms
muscle relaxant of choice for rapid sequence induction for intubation
Suxamethonium
cardiac tamponade = Becks Triad:
Hypotension
Muffled heart sounds
Raised JVP
prevent vasospasm in aneurysmal subarachnoid haemorrhages
Nimodipine
Ruptured anterior cruciate ligament
Sport injury
Mechanism: high twisting force applied to a bent knee
Typically presents with: loud crack, pain and RAPID joint swelling (haemoarthrosis)
Poor healing
Management: intense physiotherapy or surgery
positive posterior drawer test
PCL damage
.= tibia displaces posteriorly on application of a force.
most common cause of osteomyelitis
Staphylococcus aureus
Dermatomyositis features
an inflammatory disorder causing symmetrical, proximal muscle weakness and characteristic skin lesions
may be idiopathic or associated with connective tissue disorders or underlying malignancy (typically ovarian, breast and lung cancer, found in 20-25% - more if patient older). Screening for an underlying malignancy is usually performed following a diagnosis of dermatomyositis
polymyositis is a variant of the disease where skin manifestations are not prominent
risk factor for pseudogout
Risk factors haemochromatosis hyperparathyroidism acromegaly low magnesium, low phosphate Wilson's disease
causes of type 2 respiratory failure
Increased airways resistance – COPD/asthma
Reduced breathing effort – drug effects (e.g. opiates)/brain stem lesion/extreme obesity
A decrease in the area of the lung available for gas exchange – chronic bronchitis
Neuromuscular problems – Guillain-Barré syndrome/motor neuron disease
Deformity – ankylosing spondylitis/flail chest
Respiratory alkalosis causes
Anxiety – panic attack
Pain – causing increased respiratory rate
Hypoxia – often seen in ascent to altitude
Pulmonary embolism
Pneumothorax
Iatrogenic (excessive mechanical ventilation)
Metabolic alkalosis causes
vomitting
diarrhoea
Renal tubular acidosis blood work results
hyperchloraemic, normal anion gap metabolic acidosis
structure that is compromised in a scaphoid fracture
dorsal carpal branch of the radial artery
Carcinoid syndrome can affect the right side of the heart. what?
valvular effects are tricuspid insufficiency and pulmonary stenosis
Gingival hyperplasia drugs
phenytoin, ciclosporin, calcium channel blockers and AML
Waterlow score
used to identify patients at risk of pressure sores
fibromuscular dysplasia
female patients who develop AKI after initiation of an ACE inhibitor,
Features
hypertension
chronic kidney disease or more acute renal failure e.g. secondary to ACE-inhibitor initiation
‘flash’ pulmonary oedema
Assessment of the severity of an upper GI bleed
Blatchford score
Mesenteric ischaemia traid
triad of CVD, high lactate and soft but tender abdomen
RF for bowel ischaemia
Common predisposing factors
increasing age
atrial fibrillation - particularly for mesenteric ischaemia
other causes of emboli: endocarditis, malignancy
cardiovascular disease risk factors: smoking, hypertension, diabetes
cocaine: ischaemic colitis is sometimes seen in young patients following cocaine use
Undisplaced intracapsular fracture
Internal fixation (especially if young)
Undisplaced intracapsular fracture
Hemiarthroplasty
Displaced intracapsular fracture
total hip arthroplasty (healthy)
Hemiarthroplasty in immobile or over 70
Extracapsular fracture (non special type)
Dynamic hip screw
Extracapsular fracture (reverse oblique, transverse or sub trochanteric)
morbidities affect management Usually intramedullary device
dabigatran antidote (anticoagulant)
Idarucizumab
Toxic multinodular goitre - treatment
radioactive iodine is the treatment of choice
Adverse effects of amiodarone use
thyroid dysfunction: both hypothyroidism and hyper-thyroidism corneal deposits pulmonary fibrosis/pneumonitis liver fibrosis/hepatitis peripheral neuropathy, myopathy photosensitivity 'slate-grey' appearance thrombophlebitis and injection site reactions bradycardia lengths QT interval
Important drug interactions of amiodarone include:
decreased metabolism of warfarin, therefore increased INR
increased digoxin levels
Calcium channel blocker examples
amlodipine
nifedipine
diltiazem
verapamil
Avoid in HF
Verapamil shouldn’t be used with atenolol
ACE inhibitor examples
ramipril
caoripril
imidapril
Beta blocker examples
bispronalol
atenolol
metoprolol
Hypertension treatment under 55
under 55
1st line -ACE inhibitor
2nd ACE inhibitor + Calcium channel blocker or thiazide diuretic
3rd ACE inhibitor + Calcium channel blocker + thiazide diuretic
4th
K+ > 4.5mmol/l - add an alpha- or beta-blocker
K+ below 4.5mmol/l- low-dose aldosterone antagonist (spironolactone)
Hypertension treatment over 55 or AC
1st line -Calcium channel blocker
2nd ACE inhibitor + Calcium channel blocker or thiazide diuretic
3rd ACE inhibitor + Calcium channel blocker + thiazide diuretic
(ACE I in diabetes)
angina treatment
1. lifestyle 2 . medication - GTN, 3. beta blocker or CBB first line 4. antiplate (apsirn 75mg) ACEi if has diabetes
Angiotensin-receptor blockers
candesartan
Losartan
use with ACEi aren’t tolerated
hypertension with low potassium
onn’s, Cushing’s, renal artery stenosis and Liddle’s. The first step in this case should be further simple investigations. Quantifying the renin and angiotensin levels will help to distinguish the cause here, before going on to more specialised tests.
In an obese individual with symptoms and LP findings indicative of idiopathic intracranial hypertension, best initial management
weight loss
there after
diuretics e.g. acetazolamide
topiramate is also used, and has the added benefit of causing weight loss in most patients
repeated lumbar puncture
surgery: optic nerve sheath decompression and fenestration may be needed to prevent damage to the optic nerve. A lumboperitoneal or ventriculoperitoneal shunt may also be performed to reduce intracranial pressure
thiazide diuretic
Chlorothiazide (Diuril) Chlorthalidone. Hydrochlorothiazide (Microzide) Indapamide. Metolazone.
contraindicated due to the history of gout,
If new BP >= 180/120 mmHg + retinal haemorrhage or papilloedema
admit for specialist assessment
Stage 1 hypertension
Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg
treat if < 80 years of age AND any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 10% or greater
in 2019, NICE made a further recommendation, suggesting that we should ‘consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 hypertension and an estimated 10-year risk below 10%. ‘. This seems to be due to evidence that QRISK may underestimate the lifetime probability of developing cardiovascular disease
Stage 2 hypertension
Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg
Offer drug treatment regardless of age
back pain red flags
Weight loss
Fevers, night sweats
Age at onset <20 years or > 55 years
Traumatic mechanism of injury
Constant, progressive, unrelated to activity
Sleep disturbance and night pain
Thoracic distribution - commonest site for metastasis
Urinary habit - retention, incontinence, loss of sensation
Faecal incontinence
PMH of malignancy (active or previous)
Evolving neurology - motor +/- sensory
back pain. surgical emergencies
Epidural haematoma - esp post lumbar puncture
Metastatic spinal cord compression
Often joint medical / surgical care as up to 30% are CUP
Myeloma workup
Traumatic injuries
Manage as per ATLS principles
Epidural abscess
Often radiologically aspirated to guide microbiological therapy +/- surgery
L3 nerve root compression
Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
L4 nerve root compression
Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
L5 nerve root compression
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
S1 nerve root compression
Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
Spinal stenosis
Usually gradual onset
Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as ‘aching’, ‘crawling’.
Relieved by sitting down, leaning forwards and crouching down
Clinical examination is often normal
Requires MRI to confirm diagnosis
Peripheral arterial disease
Pain on walking, relieved by rest
Absent or weak foot pulses and other signs of limb ischaemia
Past history may include smoking and other vascular diseases
Charcot’s cholangitis triad:
fever, jaundice and right upper quadrant pain
classically linked to ascending cholangitis.
ascending cholangitis. management
Management
intravenous antibiotics
endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction
Acute pancreatitis: causes
GET SMASHED
Gallstones
Ethanol
Trauma
Steroids
Mumps (other viruses include Coxsackie B)
Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
Scorpion venom
Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
ERCP
Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)
investigation for small bowel obstruction
CT abdo is the definitive diagnostic
Perforated peptic ulcer
Sudden onset of pain (usually epigastric).
Often preceding history of upper abdominal pain.
Soon develop generalised abdominal pain.
On examination may have clinical evidence of peritonitis.
Causes of hydronephrosis include:
Unilateral: PACT Pelvic-ureteric obstruction (congenital or acquired) Aberrant renal vessels Calculi Tumours of renal pelvis
Bilateral: SUPER Stenosis of the urethra Urethral valve Prostatic enlargement Extensive bladder tumour Retro-peritoneal fibrosis
hydronephrosis management
Management
Remove the obstruction and drainage of urine
Acute upper urinary tract obstruction: nephrostomy tube
Chronic upper urinary tract obstruction: ureteric stent or a pyeloplasty
Paracetamol overdose - high risk if
chronic alcohol, HIV, anorexia or P450 inducers
Extra-renal manifestations of polycystic kidney disease
Extra-renal manifestations
liver cysts (70% - the commonest extra-renal manifestation): may cause hepatomegaly
berry aneurysms (8%): rupture can cause subarachnoid haemorrhage
cardiovascular system: mitral valve prolapse, mitral/tricuspid incompetence, aortic root dilation, aortic dissection
cysts in other organs: pancreas, spleen; very rarely: thyroid, oesophagus, ovary
Type 1 RTA (distal)
inability to generate acid urine (secrete H+) in distal tubule
causes hypokalaemia
complications include nephrocalcinosis and renal stones
causes include idiopathic, rheumatoid arthritis, SLE, Sjogren’s, amphotericin B toxicity, analgesic nephropathy
Type 2 RTA (proximal)
decreased HCO3- reabsorption in proximal tubule
causes hypokalaemia
complications include osteomalacia
causes include idiopathic, as part of Fanconi syndrome, Wilson’s disease, cystinosis, outdated tetracyclines, carbonic anhydrase inhibitors (acetazolamide, topiramate)
Type 4 RTA (hyperkalaemic)
reduction in aldosterone leads in turn to a reduction in proximal tubular ammonium excretion
causes hyperkalaemia
causes include hypoaldosteronism, diabetes
Management of orthostatic hypotension (ESC 2018):
education and lifestyle measures such as adequate hydration and salt intake
discontinuation of vasoactive drugs e.g. nitrates, antihypertensives, neuroleptic agents or dopaminergic drugs
if symptoms persist, consider compression garments, fludrocortisone, midodrine, counter-pressure manoeuvres, and head-up tilt sleeping
Nutrition options in surgical patients
Oral intake
Easiest option
May be supplemented by calorie rich dietary supplements
May contra indicated following certain procedures
Nutrition options in surgical patients
Naso gastric feeding
Usually administered via fine bore naso gastric feeding tube
Complications relate to aspiration of feed or misplaced tube
May be safe to use in patients with impaired swallow
Often contra indicated following head injury due to risks associated with tube insertion
Nutrition options in surgical patients
Naso jejunal feeding
Avoids problems of feed pooling in stomach (and risk of aspiration)
Insertion of feeding tube more technically complicated (easiest if done intra operatively)
Safe to use following oesophagogastric surgery
Nutrition options in surgical patients Feeding jejunostomy
Surgically sited feeding tube
May be used for long term feeding
Low risk of aspiration and thus safe for long term feeding following upper GI surgery
Main risks are those of tube displacement and peritubal leakage immediately following insertion, which carries a risk of peritonitis
Percutaneous endoscopic gastrostomy
Combined endoscopic and percutaneous tube insertion
May not be technically possible in those patients who cannot undergo successful endoscopy
Risks include aspiration and leakage at the insertion site
Acute Respiratory Distress Syndrome (ARDS)
dyspnoea and hypoxaemia, which progress to acute respiratory failure.
Common causes are pneumonia, sepsis, aspiration, and severe trauma.
- oxygen and ventilation
- Prone positioning can improve oxygenation in patients with ARDS
Management of acute asthma includes the following;
Rapid assessment High flow oxygen Nebulised salbutamol 2.5-5mg Nebulised ipratropium bromide 500mcg Steroids - IV hydrocortisone 100mg IV magnesium sulphate 1-2g ITU review Intubation and ventilation for life threatening asthma
Surgery - low BP due to fentanyl
give metaraminol (as is an alpha agonist)
Medication overuse headaches
Medication overuse headaches occur in patients who use analgesics such as paracetamol, NSAIDs and weak opiates to manage existing headaches.
Paradoxically, they develop frequent, almost daily headaches which worsen with the frequent use of these drugs.
It is thought to be due to down-regulation of pain receptors, leading to a lack of efficacy of analgesics when they are used.
The most appropriate treatment is to withdraw the offending drugs, and start the patient on an agent such as gabapentin or a tricyclic once the withdrawal period is over.
Risk of aspiration in surgery (ie hernia repair_
rapid sequence induction
Risk factors for pneumothorax include;
Smoking
Family history
Marfan’s syndrome
Male
Lung disease e.g COPD, malignancy, cystic fibrosis
Previous pneumothorax
Treatment of a tension pneumothorax
large bore cannula in the 2nd intercostal space, mid-clavicular line on the same side, and following this a chest drain needs to be inserted.
Cardiac tamponade
Diagnosis can be clinical or with a FAST scan, and urgent treatment with pericardiocentesis or surgery is required.
Peri-operative management for steroids
1.Switch oral steroids to 50-100mg IV hydrocortisone.
If there is associated hypotension then fludrocortisone can be added.
For minor operations oral prednisolone can be restarted immediately post-operatively. If the surgery is major then they may require IV hydrocortisone for up to 72 hours post-op.
Management of status epilepticus is stated in the NICE guidelines (2011) as follows.
Pre-hospital
Rectal diazepam 10-20mg
Buccal midazolam 10mg
In hospital
Intravenous lorazepam 4mg, repeated every 10-20min
Anesthetic review
Status epilepticus
Phenytoin infusion
Consider propofol and thiopentone
Intubation and ventilation
atrophic vaginitis, t
nflammation of the vagina as a result of the mucosa becoming thinner and fragile. This is due to a fall in the level of oestrogen, hence is most common after menopause.
The reduced mucosa leads to vaginal dryness and itching. As the mucosa is more fragile, it is more likely to be damaged such as during sexual intercourse. Hence some women experience dyspareunia and post-coital bleeding. The inflammation can also lead to the production of vaginal discharge.
In regard to differentials, post-menopausal bleeding should be investigated to exclude endometrial cancer. Itching and discharge may be due to genital infections.
Clinical Features of Skull Fracture
Subcutaneous hematoma
CSF rhinorrhea: leakage of CSF from the anterior nares (nostrils)
Subcutaneous hematoma around the orbitae (“raccoon eyes”)
CSF otorrhea: leakage of CSF from the external auditory meatus
Hemotympanum
Subcutaneous hematoma behind the ear (Battle sign)
Subcutaneous emphysema.
Cranial nerve palsies: arise 1–3 days after the trauma
Interventions contraindicated in Head Trauma
Nasopharyngeal airways are contraindicated in these patients as they can cause further damage to the patient.
A head tilt chin lift is contraindicated in trauma patients at risk of a C-spine injury as it can cause further instability and damage.
Classical triad of features
Normal pressure hydrocephalus
lassical triad of features is seen
urinary incontinence
dementia and bradyphrenia
gait abnormality (may be similar to Parkinson’s disease)
Normal pressure hydrocephalus treatment
Management
ventriculoperitoneal shunting
around 10% of patients who have shunts experience significant complications such as seizures, infection and intracerebral haemorrhages
Contraindications to thrombolysis
Contraindications to thrombolysis active internal bleeding recent haemorrhage, trauma or surgery (including dental extraction) coagulation and bleeding disorders intracranial neoplasm stroke < 3 months aortic dissection recent head injury severe hypertension
Subluxation of the radial head
most common upper limb injury in children under the age of 6. This is due to the fact that the distal attachment of the annular ligament covering the radial head is weaker in children at this age group. Signs include elbow pain and limited supination and extension of the elbow. The child usually refuses examination on the affected elbow due to the pain.
Management
analgesia and passively supination of the elbow joint whilst the elbow is flexed to 90 degrees
Cushings reflex
hypertension and bradycardia
Extradural or subdural haemorrhage?
Extradural = lucid period, usually following major head injury.
Subdural = fluctuating consciousness, often following trivial injury in the elderly or alcoholics
Colles’ fracture
fall on an outstretched wrist and leads to a distal radial fracture with dorsal displacement of the distal fragment. It occurs mostly in older women with osteoporotic bones.
management = manipulation in order to reduce the fracture. If good reduction is not achieved or precise alignment is needed (e.g. in those who use their wrists for work/skills e.g. sportsmen) then open reduction and internal fixation with plates and screws can be performed.
Colles’ fracture complications
Mal/non-union
Sudek’s atrophy/complex regional pain syndrome
Extensor pollicis longus rupture
Median nerve injury
Carpal tunnel syndrome
Frozen shoulder (a result of the mechanism of the fall causing shoulder injury rather than directly due to the fracture).
Medium nerve injury
weak pronation of the forearm, weak flexion and radial deviation of wrist, with thenar atrophy and inability to oppose or flex the thumb
; - sensory distribution includes thumb, radial 2 1/2 fingers, and the corresponding portion of palm.
Monteggia Fracture
proximal third of the ulnar shaft and anterior dislocation of the radial head at the capitellum.
MUGGER
M- ulnar
Galeazzi fractures,
which involve the distal third of the radial shaft and dislocation at the radio-ulnar joint.
Scaphoid fractures present after a fall onto an outstretched hand.
features
The most important clinical sign is pain on palpation of the anatomical snuffbox. There may also be pain whilst telescoping the thumb.
Management
Management involves requesting a scaphoid series of X-rays. If scaphoid fracture is confirmed then the wrist should be placed in the ‘beer glass position’ and casted. If highly suspicious of scaphoid fracture, treatment should commence even if there is no initial radiological evidence of fracture, with repeat X-rays/MRI after 10 days.
Supra-condylar fractures presentation
semi-flexed position, with tenderness and swelling. They are classified as either extension (most common) or flexion type.
Assessing for neurovascular status is the most important aspect of examination. Local structures that may be damaged are the brachial artery, median nerve and radial nerve.
radial nerve. injury
Numbness from the triceps down to the fingers.
Problems extending the wrist or fingers.
Pinching and grasping problems.
Weakness or inability to control muscles from the triceps down to the fingers.
Wrist drop – when the wrist hangs limply and the patient cannot lift it.
Supra-condylar fractures Management
Management
If there is any evidence of vascular damage then the patient should urgently be taken to theatre for reduction and potential on-table angiogram to assess brachial artery patency.
Non-displaced fractures can be managed with a collar and cuff whereas displaced fractures will require manipulation under anaesthesia with Kirschner wire fixation and then a collar and cuff.
Thoracic Outlet Syndrome
Compression of the brachial plexus leads to neurological symptoms (neurogenic thoracic outlet syndrome)
Compression of the subclavian vein leads to swelling and decreased venous return, especially during and after strenuous upper limb exercise (venous thoracic outlet syndrome)
Compression of subclavian artery leads to ischaemic pain and a cold limb - rarest form, approximately 1% of cases (arterial thoracic outlet syndrome)
Ulnar nerve injury
little finger loss of sensation
thumb abduction
travels in the medial aspect the condyle
SCFE presentation
SCFE causes pain and discomfort in the hip joint, especially on movement. Internal rotation and abduction are particularly painful. Pain can also be referred to the knee. There may be a history of precipitating minor trauma.
The pattern of radial nerve injuries will vary depending on where the lesion is located.
For very high lesions, the cause is commonly impingement e.g. due to crutches or ‘Saturday night palsy’. Here, there will be wrist drop and triceps weakness
For high lesions, the cause is normally a humeral shaft facture. This will give wrist drop, reduced sensation in the anatomical snuffbox but no triceps weakness
For low lesions, the cause is normally a fracture in the forearm e.g. the head of the radius. This leads to finger drop with no sensory loss.
Tennis elbow also known as lateral epicondylitis.
Features
pain and tenderness localised to the lateral epicondyle
pain worse on wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended
episodes typically last between 6 months and 2 years. Patients tend to have acute pain for 6-12 weeks
Management options advice on avoiding muscle overload simple analgesia steroid injection physiotherapy
Brachial plexus injuries
Erb palsy
Erb palsy
Injury to the upper trunk of the brachial plexus
(C5–C6)
Clinical features
Weakness of muscles in the C5 and C6 myotomes → flexed wrist with an extended forearm and internally rotated and adducted arm (waiter’s tip posture)
Weak biceps brachii, brachialis and brachioradialis
→ impaired flexion and supination of the forearm; absent biceps reflex
Weak infraspinatus → impaired external rotation of the arm
Weak deltoid and supraspinatus → impaired arm abduction
Weak wrist extensors → impaired wrist extension
Asymmetric Moro reflex in infants (absent or impaired on the affected side)
Sensory loss in the C5 and C6 dermatomes (thumb and lateral surface of the forearm and arm
Erb palsy treatment
Treatment
Immobilization in flexion and external rotation with an abduction brace
Physiotherapy
Surgery for severe nerve damage or prolonged cases
Axillary nerve injury
caused via Anterior shoulder dislocation
Fracture of surgical neck of the humerus
Iatrogenic (shoulder reconstruction procedures, rotator cuff surgery, osteosynthesis of humeral fractures)
Compression due to mass in the axilla
(e.g., nodular fasciitis, schwannoma)
Paralysis of the deltoid muscle → impaired arm abduction
Paralysis of the teres minor muscle → impaired external rotation of the arm
Muscle atrophy: flattened deltoid
Inferior gluteal nerve injury - Posterior hip dislocation
Paralysis of gluteus maximus
→ impaired thigh extension
Difficulty standing from a sitting position and climbing stairs
Backward lurching gait (an abnormal gait in which the trunk tilts backwards during the heel strike phase in the limb with the weak hip extensor)
Forward pelvic tilt
Sciatic nerve injury
Paralysis of hamstring muscles → impaired knee flexion
Motor deficits of tibial nerve injury
and common peroneal nerve injury
TIPPED nerve injury
TIPPED = tibial nerve injury
versus peroneal nerve injury: TIP = Tibial → damaged foot Inversion, Plantarflexion; PED = Peroneal → damaged foot, Eversion, Dorsiflexion
Sick sinus syndrome presentation
Dizzy spells Syncope Chest pain Palpitations Angina Low output heart failure Note that sick sinus syndrome describes an intrinsic pathology, and drug causes should be excluded before the diagnosis is made.
Sinus bradycardia
Sinoatrial block
Periods of sinus arrest
Abnormally long pauses after a premature beat
ew York Heart Association Classification of Heart failure
Class I - no limitation in physical activity, and activity does not cause undue fatigue, palpitation or dyspnoea.
Class II - slight limitation of physical activity, and comfort at rest. Ordinary physical activity causes fatigue, palpitation and/or dyspnoea.
Class III - marked limitation in physical activity, but comfort at rest. Minimal physical activity causes fatigue (less than ordinary).
Class IV - inability to carry on any physical activity without discomfort, with symptoms occurring at rest. If any activity takes place, discomfort increases.
HF investigations
If the BNP is raised, the patient should be referred for trans-thoracic echocardiogram.
If BNP>2000ng/L the patient needs an urgent 2 week referral for specialist assessment and an ECHO.
If BNP 400-2000ng/L the patient should get a 6 week referral for specialist assessment and an ECHO.
