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.
HF management
Pharmacological management
ACE-inhibitor and beta-blocker (these improve mortality)
Consider angiotensin receptor blocker (ARB) if intolerant to ACE inhibitors
Consider hydralazine and a nitrate intolerant to ACE-I and ARB.
Loop diuretics such as furosemide or bumetanide improve symptoms (but NOT mortality)
If symptoms persist and NYHA Class 3 or 4 consider:
Aldosterone antagonists such as spironolactone or eplerenone. These drugs also improve mortality.
Hydralazine and a nitrate for Afro-Caribbean patients
Ivabradine if in sinus rhythm and impaired ejection fraction
Angiotensin receptor blocker
Digoxin - useful in those with AF. This worsens mortality but improves morbidity.
Management of narrow complex tachycardias
Patients should be assessed using the ABCDE approach.
If the patient shows adverse features (shock, syncope, heart failure, or myocardial ischaemia), emergency synchronised direct current (DC) cardioversion is indicated.
In haemodynamically stable patients management differs according to whether there is a broad (QRS duration >120 ms) or narrow (QRS duration <120 ms) QRS complex.
In regular narrow complex tachycardias (SVTs) the first step is to trial vagal manoeuvres (carotid sinus massage or Valsalva manoeuvre).
If vagal manoeuvres fail, adenosine should be administered (initially as a 6 mg intravenous bolus, and if this fails 12 mg followed by a further 12 mg is trialled).
In irregular narrow complex tachycardias the most likely diagnosis is atrial fibrillation.
Atrial fibrillation with onset <48 hours is typically managed with rhythm control (LMWH followed by flecainide if there is no structural heart disease, or amiodarone if there is structural heart disease).
Atrial fibrillation with onset >48 hours is typically managed with rate control (i.e. metoprolol or bisoprolol or verapamil, or digoxin if there are signs of heart failure) and anticoagulation.
ECG features of VF
QRS complexes are polymorphic and irregular
VF management
Management is according to the Advanced Life Support guidelines:
The initial priorities will be as for the Basic Life Support: ensure the airway is patent, check for signs of life (pulse and breathing), and commence CPR.
Ventricular fibrillation is a shockable rhythm: the next step is to administer defibrillation (unsynchronised cardioversion using a 200 J biphasic shock).
Chest compressions should then be resumed.
1 mg adrenaline (10 ml 1:10 000) plus 300 mg amiodarone should be administered after the 3rd shock. Adrenaline should subsequently be administered every 3-5 mins (after every alternate shock).
CG features of Ventricular tachycardia (VT)
Tachycardia (>100 beats per minute), plus
Absent P waves, plus
Monomorphic regular broad QRS complexes (>120 ms).
Management of pulseless Ventricular tachycardia (VT)
f there is no pulse the patient should be managed according to the Advanced Life Support algorithm:
VT is a shockable rhythm so a 200 J bi-phasic (unsynchronised) shock should be administered.
CPR should be resumed for 2 minutes before re-checking the rhythm.
Intravenous adrenaline (1 mg of 10 ml 1:10 000 solution) and amiodarone (300 mg) should be administered after delivery of the 3rd shock.
Adrenaline should be administered every 3-5 minutes thereafter (after every alternate shock).
Management of TdP
Management of TdP in haemodynamically unstable patients
If the patient displays adverse features (shock, syncope, myocardial ischaemia, or heart failure) emergency synchronised direct current shock should be administered, followed by intravenous amiodarone.
Management of TdP in haemodynamically stable patients
In haemodynamically stable patients, initial management is with intravenous magnesium sulphate (2 g over 10 minutes).
Offending drugs such as drugs that prolong the QT interval should be stopped and electrolyte abnormalities (particularly hypokalaemia and hypomagnesaemia) should be corrected.
Isoprenaline infusion and temporary or permanent pacing may be considered. These may be used in patients with recurrent TdP despite initial therapy with magnesium sulphate.
Management of WPW
Radiofrequency ablation of the accessory pathway Drug treatment (such as amiodarone or sotalol) to avoid further tachyarrhthmias. These are contraindicate din structural heart disease. Surgical (open heart) ablation - rarely done and only used in complex case
Risk factors for aortic dissection
Hypertension
Connective tissue disease e.g. Marfan’s syndrome
Valvular heart disease
Cocaine/amphetamine use
Clinical features of AAA
Usually presents in men over the age of 50
Sudden onset ‘tearing’ chest pain or interscapular pain radiating to the back.
It can also present with (depending on how far the dissection extends):
Bowel/limb ischaemia
Renal failure
Syncope
Clinical signs on examination
Radio-radial delay
Radio-femoral delay
Blood pressure differential between arms
AAA investigation
CT angiogram is used to diagnose dissection but other investigations can suggest the diagnosis and/or its complications:
ECG - May show ischaemia in specific territories if dissection extends into coronary arteries.
Echocardiogram - May demonstrate pericardial effusion and aortic valve involvement.
Chest x-ray - May show a widened mediastinum
Bloods:
Troponin may be raised
D-dimer may be positive
Digoxin is a commonly used medication for patients in AF who are also in heart failure or are hypotensive.
Mechanism of action
It inhibits the sodium potassium adenosine triphosphatase ([Na+/K+ ATPase) ion pump in the myocardium and also has parasympathetic effects on the AV node. It is therefore negatively chronotropic and positively ionotropic (i.e. slows heart rate but increases contractility).
Digoxin effects on ECG
Downsloping ST depression T-wave changes (inversion) Biphasic/flattened and shortened QT interval Slight PR interval prolongation Prominent U-waves
Digoxin
Mechanism of action
It inhibits the sodium potassium adenosine triphosphatase ([Na+/K+ ATPase) ion pump in the myocardium and also has parasympathetic effects on the AV node. It is therefore negatively chronotropic and positively ionotropic (i.e. slows heart rate but increases contractility).
Digoxin effects on ECG
Downsloping ST depression T-wave changes (inversion) Biphasic/flattened and shortened QT interval Slight PR interval prolongation Prominent U-waves
Brugada syndrome
e condition is usually diagnosed by characteristic ECG changes and at least one clinical criterion. Examples include:
VF or polymorphic VT Family history of sudden cardiac death under the age of 45 Syncope, ECG signs in the family Inducible VT Nocturnal agonal breathing
many causes of a raised troponin:
Myocardial infarction Pericarditis Myocarditis Arrythmias Defibrillation Acute heart failure Pulmonary embolus Type A aortic dissection Chronic kidney disease Prolonged strenuous exercise Sepsis
Management of STEMI
Targeted oxygen therapy (aiming for sats >94%)
Loading dose of PO aspirin 300mg
Note that some hospital protocols will also call for a loading dose of a second anti-platelet agent such as clopidogrel (300mg) or ticagrelor (180mg)
Sublingual GTN spray - for symptom relief
IV morphine/diamorphine - in addition this causes vasodilation reducing preload on the heart
Primary percutaneous coronary intervention (PPCI) for those who:
Present within 12 hours of onset of pain AND
Are <2 hours since first medical contact
Management of NSTEMI
Targeted oxygen therapy (aiming for sats >94%)
Loading dose of PO aspirin 300mg
Patients should have their 6 month mortality score (often the GRACE score) calculated as early as possible - all those who are anything other than lowest risk should also be given PO clopidogrel 300mg
Sublingual GTN spray - for symptom relief
IV morphine/diamorphine - in addition this causes vasodilation reducing preload on the heart
Start antithrombin therapy such as treatment dose low molecular weight heparin or fondaparinux
Patients with high 6 month risk of mortality should be offered an angiogram within 96 hours of symptom onset.
Those at high risk should be offered early angiography (within 96 hours of symptoms onset)
ALL patients post-MI patients should be started on the following four drugs:
ALL patients post-MI patients should be started on the following four drugs:
Aspirin 75mg OM
Beta blocker (normally bisoprolol)
ACE-inhibitor (normally ramipril)
High dose statin (e.g. Atorvastatin 80mg ON)
Causes of pan-systolic murmurs
Mitral regurgitation - loudest at the apex, radiating to the axilla and loudest in expiration
Tricuspid regurgitation - heard loudest at the lower left sternal edge, in inspiration
Ventricular septal defect
Differentials of ejection systolic murmurs
Aortic Stenosis Aortic Sclerosis Flow murmur (anaemia, pregnancy, thyrotoxicosis) Hypertrophic obstructive cardiomyopathy Pulmonary stenosis
Aortic stensosis diagnosis
Echocardiography is the primary test for the diagnosis and evaluation of severity in aortic stenosis (AS).
Indications for intervention in aortic stenosis
Indications for intervention
Intervention in aortic stenosis is indicated in the following patients:
All patients with symptomatic aortic stenosis
Asymptomatic patients with a left ventricular ejection fraction (LVEF) < 50%
Asymptomatic patients with an LVEF > 50% who are physically active, and who have symptoms or a fall in blood pressure during exercise testing
Asymptomatic patients with an LVEF > 50% who have the following risk factors
Aortic valve peak velocity > 5.5 m/s^2
Severe calcification and peak velocity progression >= 0.3 m/s^2
Markedly elevated BNP levels without other explanation
Severe pulmonary hypertension (pulmonary artery systolic pressure > 60mmHg)
AS management
Management
Choices of intervention are transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR).
TAVI is favoured with patients with severe comorbidities, previous heart surgery, frailty, restricted mobility, and those older than 75 years of age.
SAVR is favoured for patients who are low risk and less than 75 years of age.
Management of MR
Treat concurrent complications:
AF - rate control and anticoagulation
Thromboembolism - anticoagulation
Heart failure - Diuretics, ACE-Inhibitors, beta-blockers
The definitive management for symptomatic MR is surgery - there are two main options:
Mitral valve repair (mitral valvuloplasty) - this is preferable as is preserves all components of the native valve and avoids use of prostheses.
Mitral valve replacement - offers the choice between a mechanical valve (lifelong anticoagulation but long-lasting), and a bioprosthetic valve (limited durability but no need for anticoagulation)
ECG features of right heart strain
Sinus tachycardia (most common) Right ventricular strain pattern (ST depression and T wave inversion in right ventricle and inferior leads) RBBB Right axis deviation P pulmonale S1Q3T3 Atrial arrhythmias
AR finding on exam
Examination findings
Peripheral findings:
“Waterhammer” pulse (Corrigan’s pulse)
De Musset’s sign - bobbing of the head in synchrony with the beating of the heart
Quincke’s sign - Pulsation of the nail beds
Traube’s sign - “Pistol shot” like bruit heard on auscultation of the femoral pulse
Müller’s sign - Pulsation or bobbing of the uvula
Widened pulse pressure (low diastolic pressure) is usually present
Auscultation findings
Early diastolic murmur
Heard best in the aortic area whilst the patient is leant forward and on exhalation
Soft S1 and occasionally an ejection flow murmur
AR diagnoses
Investigations
Echocardiogram is the definitive investigation for aortic regurgitation (AR).
Cardiac MRI is indicated in patients with moderate to severe AR, with suboptimal or inconclusive Echocardiogram findings.
Invasive cardiac catheterisation and angiography can finally be used when noninvasive tests are inconclusive, and can give detailed information on severity of the AR, aortic valve movement, determination of left ventricular size, function and pressures, and dimensions of the aortic root.
New-onset atrial fibrillation presenting within 48 hours
stable
low molecular weight heparin anticoagulation followed by either electrical direct current cardioversion or pharmacological cardioversion.
New-onset atrial fibrillation presenting over 48 hours
stable
chemical cardioversion (using intravenous amiodarone). An alternative is with electrical direct current cardioversion.
second degree heart block motbitz type 1 (wenback)
progressive lengthening of the PR interval which results in a P wave that fails to conduct a QRS.
reversible conduction block at the AV node
mobitz type II heart block
he PR interval is constant and there may no pattern or fixed ratios such as 2:1 or 3:1 block.
distal block in the His-Purkinje system and many patients have pre-existing left bundle branch block/ bifascicular block.
Management of Mobitz Type I
It is generally asymptomatic and does not require any specific management as the risk of high AV block/ complete heart block is low. If symptoms do arise, ECG monitoring may be required, exclude precipitating drugs and if bradycardic may require atropine.
Management of Mobitz Type II
Management of Mobitz Type II
Definitive management is with a permanent pacemaker as these patients are at risk of risk of complete heart block and becoming haemodynamically unstabl
Cardiac resynchronisation therapy
improves the synchronisation of ventricular and atrial contraction, and is helpful in patients with symptomatic heart failure despite optimum medical therapy, left ventricular ejection fraction (< 35%), and are in sinus rhythm with a prolonged QRS (> 130ms).
right coronary artery leads ECG
Inferior
II, III, aVF
Proximal LAD leads. ECG
V1-2 septal
V3-4
Anterior LAD
V5-6
Distal LAD/ LCx/ RCa apex
reinfarct blood test
CK-MB
Guedel’s stages of anaesthesia
Stage I (stage of analgesia or disorientation):
From beginning of induction of general anaesthesia to loss of consciousness
• Stage II (stage of excitement or delirium):
From loss of consciousness to onset of automatic breathing
Eyelash reflexes disappear but other reflexes remain intact and coughing and vomiting may occur; respiration can be irregular with breath holding
• Stage III (stage of surgical anaesthesia):
From onset of automatic respiration to respiratory paralysis It is divided into four planes:
• Plane I – From onset of automatic respiration to cessation of eyeball movements Eyelid reflex is lost, swallowing reflex disappears
• Plane II - From cessation of eyeball movements to beginning of paralysis of intercostal muscles. Laryngeal reflex is lost although inflammation of the upper respiratory tract increases reflex irritability, secretion of tears increases (useful sign
17
of light anaesthesia), respiration is automatic and regular, movement and deep
breathing as a response to skin stimulation disappears
• Plane III - From beginning to completion of intercostal muscle paralysis.
Diaphragmatic respiration persists but there is progressive intercostal paralysis, pupils dilated and light reflex is abolished. This was the desired plane for surgery when muscle relaxants were not used
• Plane IV - from complete intercostal paralysis to diaphragmatic paralysis (apnoea)
Recovery discharge
Be fully conscious - responding to voice or light touch
• Be able to maintain a clear airway and have a normal cough reflex
• Have a satisfactory respiration rate and oxygen saturations
• Be cardiovascularly stable with a normal (or back to preoperative) pulse and blood pressure
• Have pain and emesis adequately controlled, with suitable analgesic and anti-emetic
regimens charted
• Have oxygen and fluid therapy appropriately prescribed where required
‘Shock State’
- Tachycardia
- Vasoconstric&on
- ↓ Cardiac output
- Narrow pulse pressure 3. ↓ Mean arterial pressure 3. ↓ Blood flow
alpha and beta receptors
α1 - vasoconstriction, mydriasis
! α2 - cardiac muscle relaxation, platelet activation !
β1 - ↑ heart rate and ↑ contractility
! β2 - smooth muscle relaxation, bronchodilation
Ephedrine
β1 agonist - ↑ heart rate and contractility
! Acts indirectly by increasing release of endogenous
NA
! May be ineffective in presence of β-blockers !
Treats ↓BP associated with ↓HR
! Dose = 3-9mg IV bolus
Atropine
Inhibits parasympathetic transmission via vagus nerve ! Anticholinergic ! Treats bradycardia due to: - anaesthetic agents - heart block - prior treatment with β-blockers - hypoxia - vagal stimulus e.g. peritoneal or anal stimulation, pneumoperitoneum ! Dose = 300-600mcg IV bolus
Metaraminol
! α1 agonist - ↑SVR ∴ ↑ BP ! Acts directly on the receptor ! Treats ↓BP associated with ↑HR ! Induces a reflex bradycardia (baroreceptor reflex) mediated by carotid sinus ! Dose = 0.5mg IV bolus
Normal anion gap acidosis causes
ACCIRUED
acid load, chronic renal failure, carbonic anhydrase inhibitors, renal tubular acidosis [RTA], ureteroenterostomy, expansion/extra-alimentation, diarrhea
Raised anion gap acidosis causes
MUDPILES:
Methanol; uremia; diabetic ketoacidosis (DKA); paraldehyde, phenformin; iron, isoniazid; lactic (ie, carbon monoxide [CO], cyanide
Right sided heart failure signs and symptoms
cor pulmonale in the case of isolated RHF of pulmonary origin
Symptoms of fluid retention and increased CVP
Jugular venous distention: visible swelling of the jugular veins due to an increase in CVP and venous congestion
Kussmaul sign
Hepatosplenomegaly: may result in cardiac cirrhosis and ascites
Left sided heart failure signs and symptoms
divided into systolic (heart doesn’t pump out blood ) or diastolic (doesn’t fill fully)
Dyspnea , orthopnea
Pulmonary edema
Paroxysmal nocturnal dyspnea
Nocturnal bouts of coughing and acute shortness of breath
Caused by reabsorption of peripheral edema at night → increased venous return
Find crackles Laterally displaced apical heart beat (precordial palpation beyond the midclavicular line)
Coolness and palor of lower extremities
acisites investigations
consider imaging and sodium (may have hyppnaterium due to dilution)
Ultrasound-guided diagnostic paracentesis
Indications: first diagnosed ascites, worsening ascites or suspected complication
Ascitic fluid analysis
Ascisties management
General measures
Treatment of the underlying disease (e.g., using anticoagulation in case of a thrombosis or tuberculostatics in case of a tubercular peritonitis)
Sodium restriction
Regular weight control
Water restriction or avoiding overhydration
Spironolactone in PORTAL hypertensive ascites
drainage if tense ascites (therapeutic abdominal paracentesis)
large-volume paracentesis for the treatment of ascites requires albumin ‘cover’.
paracentesis induced circulatory dysfunction can occur due to large volume paracentesis (> 5 litres)
ascites - portal hypertension (ie SAAG > 11g/L) (high saag)
Cirrhosis Alcoholic hepatitis Cardiac ascites Mixed ascites Massive liver metastases Fulminant hepatic failure Budd-Chiari syndrome Portal vein thrombosis Veno-occlusive disease Myxoedema Fatty liver of pregnancy
ascites SAAG <11g/L (normal / low saag)
Peritoneal carcinomatosis Tuberculous peritonitis Pancreatic ascites Bowel obstruction Biliary ascites Postoperative lymphatic leak Serositis in connective tissue diseases
Large-volume paracentesis in ascites
Evidence suggests this reduces paracentesis-induced circulatory dysfunction and mortality
clinical features of hepatitis
Clinical Features
Malaise and fatigue Nausea and vomiting Right upper quadrant pain diarrhoea (may have pale stools and dark urine) Jaundice Hepatomegaly Splenomegaly and lymphadenopathy Liver failure: characterized by hepatic encephalopathy, jaundice, ascites and abnormal clotting.
Hepatitis A
Flu-like symptoms followed by jaundice, pale stools (in some), dark urine and abdominal pain.
Incubation period of 2-6 weeks
Complete recovery can take up to 6 months.
test for IgM and IgG antibodies to HAV.
Supportive management
Hepatitis B Virus type
jaundice, fever, malaise, and darkening of urine and lightening of stool. Some develop fulminant liver failure with decompensation (ascites, encephalopathy etc.). Risk of developing chronic disease is low (<5%).
HBsAg is detected 3-5 weeks after infection. If present for >6 months, this defines carrier status (5-10% of infections).
Antibodies to HBsAg (anti-HBs) indicate previous vaccination
Antibodies to hep B core antigen (anti-HBc) indicate past infection.
Only adults who are HBsAg-positive, have compensated liver disease, are pregnant or of young age may be referred for treatment
Peginterferon alfa-2a is the first line, with tenofovir and entecavir as second-line alternatives.
Hep C management
Symptomatic treatment in the early stages of the disease
Drug therapy should be considered for all patients and depends on the genotype of the virus. Nucleoside analogs are generally preferred e.g. Sofosbuvir and often lead to undetectable viral loads
Antivirals of proven benefit in basically every patient irrespective of the amount of cirrhosis and fibrosis
Manage any underlying cirrhosis
Autoimmune hepatitis
may present with signs of chronic liver disease
acute hepatitis: fever, jaundice etc (only 25% present in this way)
amenorrhoea (common)
ANA/SMA/LKM1 antibodies, raised IgG levels
liver biopsy: inflammation extending beyond limiting plate ‘piecemeal necrosis’, bridging necrosis
Management
steroids, other immunosuppressants e.g. azathioprine
liver transplantation
Achilles Tendonitis
Posterior ankle pain
Pain on palpation of the Achilles tendon
Swelling and thickening of the Achilles tendon
Treatment is conservative, with rest and analgesia (non-steroidal anti-inflammatory drugs are most useful)
Baker’s cyst
extension of the knee synovium that develops between the medial head of gastrocnemius and the semi-membranous muscle.
essential to rule out a venous thrombosis in rupture
In children - Consider referral:
To a paediatric orthopaedic surgeon, if symptomatic or the cyst is very large.
To a paediatric rheumatologist or paediatrician, if an underlying condition (such as inflammatory joint disease) is suspected.
To a paediatric orthopaedic surgeon or paediatrician, if diagnosis is unclear.
If no underlying disease is suspected, and the diagnosis is confirmed on ultrasound scan, reassure the child (and the parents or carers) that primary Baker’s cysts usually resolve without treatment.
If symptoms are troublesome:
Consider simple analgesia (such as paracetamol or ibuprofen) and physiotherapy
Osteosarcoma
Osteosarcoma is the commonest primary bone malignancy and occurs mainly in adolescent males.
It presents with a warm, painful swelling and most commonly at the knee.
X-ray shows periosteal reaction with codman’s triangle and a sunburst appearance.
Ewing’s Sarcoma f
Ewing’s Sarcoma occurs in adolescents and presents as a painful, warm, enlarging mass along long bone diaphysis. The patient will have systemic symptoms such as fever and anaemia, with a raised ESR and WCC.
X-ray shows onion skin periosteal reaction.
Chondrosarcoma
Chondrosarcoma is cartilaginous malignancy at occurs in older patients (>40) with pain and a lump. Many of these arise from previous chondromas that have undergone malignant change. X-ray shows a lytic lesion with ‘fluffy popcorn calcification’.
Carpal tunnel syndrome
MEDIAN NERVE
tingling/pain in the first three digits, worse at night and relieved by shaking/ hanging out the hand at night. There may also be clumsiness in hand movements and decreases sensation in the first three digits.
Management
Carpal tunnel syndrome can be treated through splinting, local steroid injections and treatment of the underlying cause if it is secondary. If these fail, then decompression surgery is used- performed by dividing the tunnel roof (flexor retinaculum).
Colles
fall on an outstretched wrist and leads to a distal radial fracture with dorsal displacement of the distal fragment
Risk of non-union, medial nerve injury
compliocation of hip replacement
Posterior hip dislocations (treat with manual reduction or open reduction if this fails) Surgical site infection Injury to blood vessels/nerves Leg-length discrepancy Fracture
myositis ossificans
heterotopic ossification within large muscles. It can be inherited but typically occurs 2-6 weeks after trauma, with the most common sites being the elbow and the thigh. It can mimic osteal malignancy and can even histologically appear like osteosarcoma, leading to incorrect management.
radiologically ->circumferential calcification with a lucent centre and a radiolucent cleft (string sign) that separates the lesion from the cortex of the adjacent bone.
Intracapsular NOF
ORIF and cancellous screws in grade 1 or 2
grade 3/4
young - ORIF
middle and healhty - total hip
old and co morbid - hemi-arthroplasty
Extra-capsular fractures a
pen repair and internal fixation (ORIF) with dynamic hip screw
Orbital blow
need CT
reatment involves close ophthalmology follow up +/- antibiotics or surgery.
Osteochondritis dissecans
blood supply of bone is interrupted, leading to bone and cartilage detaching from the area and being able to move freely in the joint space. It commonly occurs in young adults at the knee, elbow and ankle.
bone debris in the joint and include: swelling after exercise; joint locking, and decreased range of movement.
Posterior shoulder dislocations
Less common
Ass/w epilepsy, electrocution and trauma.
Radial nerve injuries
high
medial
low
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.
Supra-condylar fractures
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.
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.
ulnar nerve injury
weakness of the intrinsic muscles of the hand and give rise to a ‘claw hand’.
Clinical signs include finger weakness in both abduction and adduction, as well as sensory loss over the fifth digit. Froment’s sign will be positive (flexion of thumb when holding a piece of paper between thumb and second digit; due to weak adductor pollicis). Patients will also be unable to cross their fingers in a ‘good luck’ sign.
The ulnar paradox describes greater clawing in the hand when there is a lesion at the wrist compared to the elbow. This is because higher lesions will cause weakness of flexor digitorum profundus- hence an inability to flex the digits.
Long thoracic nerve damage
winging of scapula
bruising on the left posterior aspect of the thoracic cage
Shoulder flexion and abduction is limited.
suprascapular nerve
inital abduction of shoulder
injury - inability to initiate active abduction
Jobe/empty can = suprspinatus muscle which is innervated by this
Cubital tunnel syndrome
= ULNAR nerve palsy
4th and 5th digit isssues
Osgood-Schlatter’s
think Knee in active kids
1st line = xray (big tib tubule )
infraspintus injury
rep work in rotator cuff injury
maybe difficult to sleep on the right shoulder and finds it difficult to comb his hair using his right hand due to pain.
cluster headache
unilateral headache that is typically worse around the eye.
A bloodshot or teary eye
Vomiting
Severe headache
Management
Treatment of cluster headaches acutely is with 100% oxygen and sumatriptan.
Prophylactic treatment may have some effect, and includes verapamil and steroids.
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.
Contraindications for Starting NIV
Facial burns Vomiting Untreated pneumothorax Severe co-morbidities Haemodynamically unstable Patient refusal
Treatment of trigeminal neuralgia can be medical or surgical.
Medical treatment includes; carbamazepine (first line) phenytoin lamotrigine gabapentin Surgical options include; microvascular decompression treatment of the underlying cause and alcohol injections
Choking in adults
Management of the conscious patient
Encourage the patient to cough
5 back blows with the heal of hand aiming centrally between shoulder blades
5 abdominal thrusts performed from behind the patient, with a fist placed between the umbilicus and xiphisternum, grasping it with the other hand and pulling upwards and inwards sharply
Continue these motions until the obstruction is dislodged, or the patient becomes unconscious
Management of the unconscious patient
If unconscious, call for help and start ABC
Benzodiazepines OD presentation
Lethargy Ataxia Slurred speech Coma Respiratory depression
Beta-blockers OD presentation
Bradycardia
Hypotension
Mild hypoglycaemia
Mild hyperkalaemia
Cyanide OD presentation
Nausea and vomiting - if small doses Rapid loss of consciousness Apnoea Seizures Cardiac arrest
MDMA (ecstasy) OD presentation
Agitation Tachycardia Hyperthermia Acute renal failure Hypo/hypertension Mydriasis
features of life-threatening asthma
PEF <33% SO2 <92% or PO2 <8 Cyanosis Hypotension Exhaustion, altered consciousness Silent chest Tachyarrhythmias
raised PCO2 is an indication of near fatal asthma.
Management of Acute Asthma Exacerbation
mmediate management:
Sit-up
100% O2 via non-rebreathe mask (aim for 94-98%)
Nebulised salbutamol (5mg) and ipratropium (0.5mg)
Hydrocortisone 100mg IV or prednisolone 50mg PO
If Life-threatening:
Inform the intensive care team
Mangesium sulphate 2g IV over 20 minutes
Nebulised salbutamol every 15min
Monitoring:
Peak flow measurement every 15-30min pre- and post-Salbutamol
SpO2: keep >92%
Consecutive Arterial blood gas measurements
Definition of Unstable angina
Unstable angina = critical narrowing of coronary artery causing ischaemia
Chest pain at rest or minimal exertion lasting >15 minutes
ECG changes (new ST-depression or T wave inversion)
NO rise in troponin: no myocardial necrosis
NSTEMI = partially occluded coronary artery
Chest pain at rest or minimal exertion lasting >15 minutes
ECG changes (new ST-depression of T wave inversion)
Rise in troponin: myocardial necrosis
Diagnosis of STEMI
To diagnose a STEMI on ECG, there should be new ST-segment elevation in 2 or more contiguous leads. The ST elevation should be ≥2mm in the precordial leads or ≥1mm in the limb leads.
Treatment of STEMI
MMONAC can be used to remember the initial treatment for STEMI. It stands for:
Morphine Metoclopramide Oxygen (if sats <94%) Nitrates (GTN spray) Aspirin 300 mg Clopidogrel 300 mg
mergency management of Chronic Obstructive Pulmonary Disease
Oxygen Therapy
Sit-up
24% O2 via Venturi mask: SpO2 88-92%,
Vary FiO2 and SpO2 target according to Arterial Blood Gas
Nebulised Bronchodilators (Air Driven)
Salbutamol 5mg/4h
Ipratropium 0.5mg/6h
Steroids
Hydrocortisone 200mg IV
Prednisolone 40mg PO for 7-14d
Antibiotics (if evidence of infection)
Management of anaphylaxis involves:
Remove trigger if possible Call for help early ABCDE assessment Administer oxygen and Lie patient flat and raise legs Administer adrenaline (Adult dose is 500 micrograms IM) Administer chlorphenamine and hydrocortisone IV fluid challenge if hypotensive
Clinical features of cardiac tamponade include:
Beck’s triad (raised JVP, hypotension and muffled heart sounds)
Kussmaul’s sign (rise of JVP with inspiration)
Pulsus paradoxus (drop in systolic blood pressure with inspiration)
An ECG may show electrical alternans (alternating height of QRS complexes) and an Echocardiogram is the most useful diagnostic investigation.
Emergency Management of Ethylene Glycol Poisoning
Management
Gastric lavage or NG aspiration if <1 hour since ingestion
Fomepizole (competitive inhibitor of alcohol dehydrogenase) - prevents metabolism of ethylene glycol into toxic metabolites.
Alcohol (ethanol) can be used if Fomepizole is unavailable.
Haemofiltration can be used in severe cases
Primary pneumothoraces are managed as follows:
If the patient is NOT short of breath AND the pneumothorax is <2 cm on a chest x-ray conservative management is sufficient. The patient can be discharged and reviewed in the outpatient department in 2-4 weeks.
If the patient IS short of breath OR the pneumothorax is >2 cm the pneumothorax should be aspirated with a 16-18G cannula under local anaesthetic. If this is successful the patient can be discharged. If this fails an intercostal drain is necessary (and the patient must be admitted).
Secondary pneumothoraces are managed as follows:
If the patient is NOT short of breath AND the pneumothorax is <1 cm on the chest x-ray they do not require further invasive intervention but should be admitted for observation for 24 hours and administered oxygen as required.
If the patient is NOT short of breath and the pneumothorax is 1-2 cm on the chest x-ray aspiration is required. If this is successful the patient can be admitted for 24 hours of observation. If this is unsuccessful and intercostal drain is necessary.
If the patient IS short of breath OR the pneumothorax is >2 cm on the chest x-ray an intercostal drain is necessary (and the patient should be admitted).
Status epilepticus
ABCDE approach
Oxygen
Ensure IV access
Arterial Blood gas
Bloods for glucose, FBC/UE/CRP,Calcium/Phosphate/Magnesium, drug levels if the patient is on anti-epileptic medications
Anaesthetic review to ensure the airway is managed
IV lorazepam 4mg
A second dose of lorazepam should be given if no response
In the absence of IV access, PR diazepam or buccal midazolam can be administered.
If the initial benzodiazepine fails, further anti-convulsants can be used:
Leviteracetam
Phenytoin
Valproate
Management of non-variceal bleeding
Treatment of any upper GI bleed is as follows:
ABCDE assessment
Insert 2 large bore IV cannulae and take bloods for FBC, U+E, LFT, clotting, cross match
IV fluids - fluid challenge if hypotensive
Catheterise
Correct clotting if needed
Urgent endoscopy
main medical treatment option for stable patients with a regular broad complex tachycardia
IV Amiodarone
ascites Management
- reducing dietary sodium
- fluid restriction is sometimes recommended if the sodium is < 125 mmol/L - aldosterone antagonists: e.g. spironolactone
- drainage if tense ascites
- large-volume paracentesis for the treatment of ascites requires albumin ‘cover’. Evidence suggests this reduces paracentesis-induced circulatory dysfunction and mortality
AC joint separation
Injury to the AC joint is relatively common and typically occurs during collision sports such as rugby following a fall on to the shoulder or a FOOSH (falls on outstretched hand).
AC joint injuries are graded I to VI depending on the degree of separation.
Grade I and II injuries are very common and are typically managed conservatively including resting the joint using a sling.
Grade IV, V and VI are rare and require surgical intervention.
The management of grade III injuries is a matter of debate and often depends on individual circumstances.
Brain abbess I and M
Investigations
Assessment of the patient includes imaging with CT scanning
Management
surgery
a craniotomy is performed and the abscess cavity debrided
the abscess may reform because the head is closed following abscess drainage.
IV antibiotics: IV 3rd-generation cephalosporin + metronidazole
intracranial pressure management: e.g. dexamethasone
Patients with hydrocephalus present with symptoms due to raised intracranial pressure, which include:
Headache (typically worse in the morning, when lying down and during valsalva)
Nausea and vomiting
Papilloedema
Coma (in severe cases)
Cerebral toxoplasmosis
accounts for around 50% of cerebral lesions in patients with HIV
constitutional symptoms, headache, confusion, drowsiness
CT: usually single or multiple ring-enhancing lesions, mass effect may be seen
management: pyrimethamine plus sulphadiazine for at least 6 weeks
Internuclear ophthalmoplegia
Overview
a cause of horizontal disconjugate eye movement
due to a lesion in the medial longitudinal fasciculus (MLF)
controls horizontal eye movements by interconnecting the IIIrd, IVth and VIth cranial nuclei
located in the paramedian area of the midbrain and pons
Features
impaired adduction of the eye on the same side as the lesion
horizontal nystagmus of the abducting eye on the contralateral side
Causes
multiple sclerosis
vascular disease
Near-fatal asthma’,
characterised by a raised pC02 and/or requiring mechanical ventilation with raised inflation pressures.
Moderate asthma attack
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm
Severe asthma attack
PEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpm
Life-threatening asthma attack
PEFR < 33% best or predicted Oxygen sats < 92% 'Normal' pC02 (4.6-6.0 kPa) Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma
Acute bronchitis Management
analgesia good fluid intake consider antibiotic therapy if patients: are systemically very unwell have pre-existing co-morbidities have a CRP of 20-100mg/L (offer delayed prescription) or a CRP >100mg/L (offer antibiotics immediately) doxycycline first-line
fiO2 in room air
21 percent
Hepatitis C
features
features such as:
a transient rise in serum aminotransferases / jaundice
fatigue
arthralgia
Hepatitis C investigations
HCV RNA is the investigation of choice to diagnose acute infection
whilst patients will eventually develop anti-HCV antibodies it should be remembered that patients who spontaneously clear the virus will continue to have anti-HCV antibodies
f hepatitis B complications
chronic hepatitis (5-10%). 'Ground-glass' hepatocytes may be seen on light microscopy fulminant liver failure (1%) hepatocellular carcinoma glomerulonephritis polyarteritis nodosa cryoglobulinaemia
Management of hepatitis B
pegylated interferon-alpha used to be the only treatment available. It reduces viral replication in up to 30% of chronic carriers. A better response is predicted by being female, < 50 years old, low HBV DNA levels, non-Asian, HIV negative, high degree of inflammation on liver biopsy
whilst NICE still advocate the use of pegylated interferon firstl-line other antiviral medications are increasingly used with an aim to suppress viral replication (not in a dissimilar way to treating HIV patients)
examples include tenofovir, entecavir and telbivudine (a synthetic thymidine nucleoside analogue)
Hepatitis E
RNA hepevirus
spread by the faecal-oral route
incubation period: 3-8 weeks
common in Central and South-East Asia, North and West Africa, and in Mexico
causes a similar disease to hepatitis A, but carries a significant mortality (about 20%) during pregnancy
does not cause chronic disease or an increased risk of hepatocellular cancer
a vaccine is currently in development, but is not yet in widespread use
Hepatitis A
flu-like prodrome abdominal pain: typically right upper quadrant tender hepatomegaly jaundice cholestatic liver function tests
Ischaemic hepatitis
diffuse hepatic injury resulting from acute hypoperfusion (sometimes known as ‘shock liver’). It is not an inflammatory process. It is diagnosed in the presence of an inciting event (e.g. a cardiac arrest) and marked increases in aminotransferase levels (exceeding 1000 international unit/L or 50 times the upper limit of normal). Often, it will occur in conjunction with acute kidney injury (tubular necrosis) or other end-organ dysfunction.
Features - Autoimmune hepatitis
Features
may present with signs of chronic liver disease
acute hepatitis: fever, jaundice etc (only 25% present in this way)
amenorrhoea (common)
ANA/SMA/LKM1 antibodies, raised IgG levels
liver biopsy: inflammation extending beyond limiting plate ‘piecemeal necrosis’, bridging necrosis
Management
steroids, other immunosuppressants e.g. azathioprine
liver transplantation
Reversible causes of cardiac arrest:
Hs Hypoxia Hypovolaemia Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders Hypothermia
Ts Thrombosis (coronary or pulmonary) Tension pneumothorax Tamponade – cardiac Toxins
a single shock for VF/pulseless VT is followed by -
by 2 minutes of CPR, rather than a series of 3 shocks followed by 1 minute of CPR
if cardiac arrest witnessed in a monitored patient
if the cardiac arrested is witnessed in a monitored patient (e.g. in a coronary care unit) then the 2015 guidelines recommend ‘up to three quick successive (stacked) shocks’, rather than 1 shock followed by CPR
asystole/pulseless-electrical activity:
adrenaline 1mg should be given as soon as possible. Should be treated with 2 minutes of CPR prior to reassessment of the rhythm
Ventricular tachycardia: management
If the patient has adverse signs (systolic BP < 90 mmHg, chest pain, heart failure, syncope) then immediate cardioversion is indicated.
Drug therapy
amiodarone: ideally administered through a central line
lidocaine: use with caution in severe left ventricular impairment
procainamide
Supraventricular tachycardia
Acute management
vagal manoeuvres: e.g. Valsalva manoeuvre, carotid sinus massage
intravenous adenosine 6mg → 12mg → 12mg: contraindicated in asthmatics - verapamil is a preferable option
electrical cardioversion
Choking
Mild airway obstruction
Response to question ‘Are you choking?’
victim speaks and answers yes
Other signs
victim is able to speak, cough, and breathe
f mild airway obstruction
encourage the patient to cough
Choking
Severe airway obstruction
Response to question ‘Are you choking?’
victim unable to speak
victim may respond by nodding
Other signs victim unable to breathe breathing sounds wheezy attempts at coughing are silent victim may be unconscious
If severe airway obstruction and is conscious:
give up to 5 back-blows
if unsuccessful give up to 5 abdominal thrusts
if unsuccessful continue the above cycle
Primary pneumothorax
if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered
otherwise, aspiration should be attempted
if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted
patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men
Secondary pneumothorax
if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.
otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours
Acute respiratory distress syndrome (ARDS)
Causes
Causes infection: sepsis, pneumonia massive blood transfusion trauma smoke inhalation acute pancreatitis cardio-pulmonary bypass
Acute respiratory distress syndrome
Clinical features are typically of an acute onset and severe:
(ARDS)
dyspnoea
elevated respiratory rate
bilateral lung crackles
low oxygen saturations
aspirin 300mg in stroke
orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded
stroke Thrombolysis with alteplase should only be given if
it is administered within 4.5 hours of onset of stroke symptoms (unless as part of a clinical trial)
haemorrhage has been definitively excluded (i.e. Imaging has been performed)
Thrombectomy for acute ischaemic stroke
Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours), to people who have:
acute ischaemic stroke and
confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA)
OR
6 hours and 24 hours
potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
Anterior cerebral artery stroke
Contralateral hemiparesis and sensory loss, lower extremity > upper
Middle cerebral artery
Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia
Posterior cerebral artery
Contralateral homonymous hemianopia with macular sparing
Visual agnosia
Weber’s syndrome (branches of the posterior cerebral artery that supply the midbrain)
Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity
Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome)
Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus
Adhesive capsulitis associated
Associations
diabetes mellitus: up to 20% of diabetics may have an episode of frozen shoulder
Adhesive capsulitis
features
Features typically develop over days
external rotation is affected more than internal rotation or abduction
both active and passive movement are affected
patients typically have a painful freezing phase, an adhesive phase and a recovery phase
bilateral in up to 20% of patients
the episode typically lasts between 6 months and 2 years
Adhesive capsulitis
Management
no single intervention has been shown to improve outcome in the long-term
treatment options include NSAIDs, physiotherapy, oral corticosteroids and intra-articular corticosteroids
Bleomycin adverse effects
Lung fibrosis
Anthracyclines ie doxorubicin) adverse effects
Cardiomyopathy
Methotrexate adverse effects
Myelosuppression, mucositis, liver fibrosis, lung fibrosis
Fluorouracil (5-FU) adverse effects
Myelosuppression, mucositis, dermatitis
Addison’s disease management
hydrocortisone + fludrocortisone
Haemothorax
Most commonly due to laceration of lung, intercostal vessel or internal mammary artery
Haemothoraces large enough to appear on CXR are treated with large bore chest drain
Surgical exploration is warranted if >1500ml blood drained immediately
Pulmonary contusion
Most common potentially lethal chest injury
Arterial blood gases and pulse oximetry important
Early intubation within an hour if significant hypoxia
epidural risks
Risks
It can cause maternal hypotension resulting in foetal and maternal distress.
Additionally, there is risk of dural puncture, resulting in a severe postural headache.
Other risks include epidural haematoma.
Local anaesthetic toxicity
management
Management
Stop administration of local anaesthetic!
ABCDE approach including ECG monitoring
Lipid emulsion (20% intralipid) 1mL/kg every 3 minutes up to a dose of 3mL\kg
Initiate lipid emulsion infusion at a rate of 0.25mL\kg\min
Maximum total dose = 8mL\kg
Rapid Sequence Induction
seven p’s
Preparation
Involves ensuring the environment is optimised, equipment is available and staff are ready
Preoxygenation
Involves the administration of high flow oxygen for 5 minutes prior to the procedure
Pretreatment
May involve administration of opiate analgesia or a fluid bolus to counteract the hypotensive effect of anaesthesia
Paralysis
The administration of the induction agent (e.g. Propofol or Sodium Thiopentone) and paralysing agent (e.g. Suxamethonium or Rocuronium)
Protection and positioning
Cricoid pressure should be applied to protect the airway following paralysis. In line stabilisation may be required in some cases.
Placement and proof
Intubation is performed via laryngoscopy, with proof obtained (direct vision, end-tidal CO2, bilateral auscultation)
Post-intubation management
Taping or tying the endotracheal tube, initiating mechanical ventilation and sedation agents
Glasgow Coma Scale
Scoring Motor Response
6- obeys commands
5 - localises to pain
4 - withdraws to pain
3 - flexor response to pain
2 - extensor response to pain
1 - no response to pain
Scoring Verbal Response
5 - oriented
4 - confused conversation
3 - inappropriate speech
2 - incomprehensible
1 - none
Scoring Eye Opening
4 - spontaneous
3 - open in response to speech
2 - opens to pain
1 - no eye opening
Therefore, the lowest GCS is 3/15.
Achilles tendonitis
Clinical features
Posterior ankle pain
Pain on palpation of the Achilles tendon
Swelling and thickening of the Achilles tendon
Management
Treatment is conservative, with rest and analgesia (non-steroidal anti-inflammatory drugs are most useful)
Approach to assessing for C-Spine injury:
ABCDE approach
Full immobilisation until C-Spine ‘cleared’
Detailed history and examination
Imaging as required
Axillary nerve injury
result of a shoulder injury, particularly anterior dislocation and proximal humeral fractures
weakness of shoulder abduction due to disruption in the motor supple to deltoid and teres minor.
may also be weakness in shoulder flexion, extension and external rotation
There may also be sensory disturbance to the lateral deltoid, around the ‘regimental patch’.
Management is typically conservative, with reconstructive surgery reserved for those who do not respond to non-surgical management.
Symptoms and signs of basal skull injury
Head injury Reduced consciousness Battle's sign = bruising of the mastoid process Raccoon eyes = bruising around the eyes Rhinorrhoea = CSF leaking from the ear Cranial nerve palsy Bleeding from the nose/ears Haemotympanum = blood visible behind the tympanic membrane
Bennet fracture
fracture of the base of the thumb, commonly caused by forced abduction injuries. It is diagnosed via x-ray. Stable fractures are managed with a cast for 3-4 weeks followed by physiotherapy. Unstable fractures require surgery with an open reduction and fixation using screws or k-wires.
Bicep Tendon Tear
Biceps tendon tears are injuries to the biceps muscle that result in the complete or partial severing of the tendon from the bone.
It can be caused by minimal trauma in elderly patients with pre-existing degenerative shoulder disease or secondary to eccentric loading of the muscle.
Osteosarcoma features
Osteosarcoma is the commonest primary bone malignancy and occurs mainly in adolescent males.
It presents with a warm, painful swelling and most commonly at the knee.
X-ray shows periosteal reaction with codman’s triangle and a sunburst appearance.
Ewing’s Sarcoma features
Ewing’s Sarcoma occurs in adolescents and presents as a painful, warm, enlarging mass along long bone diaphysis. The patient will have systemic symptoms such as fever and anaemia, with a raised ESR and WCC.
X-ray shows onion skin periosteal reaction.
boxer’s fracture
fracture of the neck of the 4th or 5th metacarpal.
= transverse fracture
Pain and swelling over the metacarpophalangeal joints of the 4th and 5th fingers.
Indications for Surgery in Boxer’s Fracture
Surgery is required if there is:
Significant rotation or angulation of the affected fingers.
Articular involvement of the fracture
Multiple metacarpal fractures
Open fractures
Calcaneal fractures
. Symptoms include heel pain and inability to weight bear. CT is the gold standard for diagnosis.
Management of a non-displaced fracture is with cast immobilisation and non-weight-bearing for 6-12 weeks.
Cauda Equina Syndrome management
Patient with clinical features suggestive of spinal cord compression or cauda equina syndrome should have an urgent WHOLE spine MRI, with an aim (in appropriate cases) to surgically decompress within 48 hours.
In patients where malignancy is demonstrated on MRI, or in patients where clinical suspicion is high, administration of dexamethasone 16 mg daily in divided doses (with PPI cover) is indicated.
Clavicle fractures management
Treatment of closed uncomplicated clavicle fractures is with initial sling immobilisation for 2 weeks, following by range of motion exercises
Complications of Colles’ include:
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).
Common peroneal nerve injury
Injury causes a ‘foot drop’ due to paralysis of the foot extensors (tibialis anterior, extensor digitorum longus and extensor hallucis longus). Foot inversion may also occur as the common peroneal nerve also innervates the foot evertor muscles.
Complications of hip surgery include:
Anaesthetic complications Infection Loosening of the joint Hip dislocation Leg length disparity Thrombosis Nerve damage
Symptoms and signs of ACL injury
Sudden painful 'popping' sensation with rapid swelling Inability to return to activity Lateral knee and joint line tenderness Lachman test often positive Anterior drawer test may be positive
Symptoms and signs of PCL injury
Mechanism of posterior cruciate ligament injury
Mechanism usually direct blow to proximal tibia when knee flexed
Symptoms and signs of PCL injury
May be asymptomatic, or have posterior or anterior knee pain
Posterior drawer test may be positive
Posterior sag test may be positive
Cubital tunnel syndrome
‘ulnar nerve entrapment’ is compression or irritation of the ulnar nerve as it passes through the cubital tunnel at the elbow. It manifests with pain at medial elbow or forearm and sensory disturbance of the 4th and 5th digits, hypothenar eminence and ulnar side of the dorsum of the hand.
Treatment is with conservative treatment with the use of an elbow splint, with surgical decompression reserved for those with inadequate improvement with splinting, or with symptoms of moderate weakness.
De Quervain’s tenosynovitis
inflammation of the extensor pollicis longus and extensor pollicis brevis tendons at the base of the thumb
Symptoms typically include pain at the base of the thumb, which is exacerbated by abduction of the thumb, gripping and ulnar movement of the wrist.
There may be tenderness of the anatomical snuffbox and weakness of the hand. Splinting and analgesia are the mainstay of treatment, with corticosteroid injections or surgery reserved for those in whom non-surgical treatment has failed.
Myositis ossificans
heterotopic ossification within large muscles.
can be inherited but typically occurs 2-6 weeks after trauma
It can mimic osteal malignancy and can even histologically appear like osteosarcoma, leading to incorrect management.
ganglion cyst
synovial fluid filled swelling that commonly occurs at the wrist. Ganglions may be asymptomatic, or may present with pain.
Treatment is recommended for symptomatic ganglions and is with aspiration or excision of the cyst.
Hamate fractures
typically occur as a result of direct trauma to the base of the thumb and often present weeks after the initial injury. Diagnosis is via plain x-ray, with a ‘carpal tunnel’ view most useful for visualisation of hamate fractures.
Lateral epicondylitis or ‘tennis elbow’
chronic condition presenting with pain at the site of insertion of the forearm extensors at the lateral epicondyle of the humerus.
It typically presents in those over the age of 35 in those who perform repetitive activities involving elbow extension. Symptoms typically resolve with rest.
Lipohaemarthrosis
presence of blood and fat in the joint space. This occurs due to fracture and escape of blood and bone marrow into the joint cavity
. It commonly occurs in fractures of large joints e.g. knee and can be identified on plain x-ray by the presence of a fluid-fat level.
Lisfranc injury
dislocation of the tarsometatarsal joint between the medial cuneiform bone and base of the second metatarsal in the mid foot
Symptoms include midfoot pain and inability to weight bear.
Long thoracic nerve damage
thoracic nerve is derived from the brachial plexus and runs distal to the clavicle, superficial to the first two ribs
innervate serratus anterior muscle.
damage = scapula winging
This nerve can be damaged by repetitive stretching, e.g. in sports requiring overhead activity e.g. basketball, or can be damaged acutely by trauma to the chest or neck.
Treatment is typically conservative, including rest and physiotherapy.
Maisonneuve injury
spiral fracture of the proximal fibula, together with an unstable ankle injury and is typically caused by external rotation and pronation of the foot.
Management is typically surgical and may involve fixation of the ankle injury, and reduction and stabilisation of the proximal fibula fracture.
Medial epicondylitis
Tendinopathy of the wrist flexor tendons which attach to the medial epicondyle of the distal humerus.
. Patients typically report gradual-onset medial elbow pain exacerbated by activity, particularly flexion of the wrist. There may also be weakness of wrist flexion.
Diagnosis is typically clinical, and the condition is usually treated conservatively with rest and guided rehabilitation. Surgical debridement of damaged tissue may be indicated in cases which do not respond to 6 months non-surgical management.
Interpretation of DEXA scans
All women aged over 65 should be assessed and men aged over 75. Younger patients should be assessed if they have risk fractures e.g. a previous fragility fracture of frequent use of oral corticosteroids.
Depending on this score they may be offered a bone density scan of the spine and hip.
A score which shows a 10 year fracture risk of greater than 10% requires further assessment using a bone density scan.
T-scores compare the patient’s bone density with that of a young patient of the same gender. A score of 0 is average. A positive or negative score indicates how many standard deviations away from the mean the patient’s bone density is.
Osteoporosis is diagnosed when patients have a T-score of less than 2.5 standard deviations below the mean. A score of between -1 and -2.5 indicates osteopenia.
Patterns of radial nerve injury
or 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.
Shoulder impingement
One of the most common causes of shoulder pain. Occurs when the tendons of the rotator cuff muscles become compressed between the humeral head and the acromion. Presents with pain and stiffness, particularly when performing overhead activities. Plain x-ray may be useful in evaluating the acromiohumeral joint space. Treatment is usually non-operative, with analgesia and physiotherapy. Subacromial decompression surgery may be indicated if non-operative management fails.
Supracondylar fractures of the humerus
semi-flexed position, with tenderness and swelling.
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.
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)
Causes of Thoracic Outlet Syndrome
Compression between the anterior and middle scalene muscles (most common cause)
Compression by a cervical rib is the (second most common cause). a cervical rib is a normal anatomical variant. It is an extra rib that comes off the 7th cervical vertebra. They are present in almost 0.5% of the population, more often bilateral and more common in females.
Trochanteric bursitis
Symptoms include:
lateral hip pain (worse at night and aggravated by physical activity)
swelling
A positive Trendelenberg (single leg stance) test
ulnar nerve injury
Ulnar nerve lesions will lead to weakness of the intrinsic muscles of the hand and give rise to a ‘claw hand’.
Clinical signs include finger weakness in both abduction and adduction, as well as sensory loss over the fifth digit. Froment’s sign will be positive (flexion of thumb when holding a piece of paper between thumb and second digit; due to weak adductor pollicis). Patients will also be unable to cross their fingers in a ‘good luck’ sign.
shoulder injury -nerve and associated muscle impacted
radial - Brachioradialis
commonest causes of cauda equinina
Lumbar disc herniation
rotator cuff muscles
supraspinatus, infraspinatus, teres minor and subscapularis.
Cozen’s test
Cozen’s test used to diagnose lateral epicondylitis. Lateral epicondylitis is a tendinopathy involving the common origins of the extensor muscles of the forearm. The muscle most commonly involved is the extensor carpi radialis brevis (ECRB).
Pain is on the lateral aspect of the elbow and is worsened by movements that place stress on the tendon of the ERCB such as resisted wrist extension.
Neer’s test would be positive in shoulder impingement.
It is performed with the patient positioning the affected arm in internal rotation. The examiner then passively brings the affected shoulder to full flexion. A positive test is if there is pain. Shoulder impingement is a tendonitis of the rotator cuff muscles as they pass through the subacromial space. When the arm is raised, the subacromial space narrows causing impingement of the tendon and pain to the patient.
management for displaced, intra-capsular fractures in young patients.
Open repair with internal fixation and cancellous screws
proximal scaphoid pole fractures
require surgical fixation
Pain on the radial side of the wrist/tenderness over the radial styloid process ?
Quervain’s tenosynovitis
Olecranon bursitis
Swelling over the posterior aspect of the elbow. There may be associated pain, warmth and erythema. It typically affects middle-aged male patients.
Lumbar spinal stenosis
back pain, neuropathic pain and symptoms mimicking claudication.
Sitting is better than standing and patients may find it easier to walk uphill rather than downhill.
Ventricular tachycardia medications contra?
verapamil is contraindicated - likely to precipitate severe hypotension, ventricular fibrillation or cardiac arrest
Mitral valve prolapse is associated with
polycystic kidney disease
Verapamil and beta-blockers
should never be taken concurrently - possibility of heart block and fatal arrest
