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Emergency Medicine Flashcards

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1
Q

Local anaesthetic toxicity

A

Symptoms of LA Toxicity:
- Light headedness
- Tongue numbness
- Tinnitus
- Visual disturbance
- Circumoral numbness
- Muscular twitching
Signs of LA Toxicity:
- confusion
- Respiratory arrest/ Bradypnea
- Convulsions
- Hypotension, Bradycardia
- Decresed GCS/ COMA
- Tachycardia if with adrenaline
Rx = intralipid 1-1.5 ml/Kg

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2
Q

Brown-Sequard syndrome?

A

Brown-Sequard syndrome:
Cause-transaction of lateral half of the spinal card by bullet or stab wound.
Ipsilateral upper motor neuron weakness
Ipsilateral loss of vibration, joint position; proprioception senses
Contra lateral loss of pain and temperature, often 1/2 levels below injury

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3
Q

Central Cord Syndrome?

A

Central cord syndrome:
Most often seen in older people due to hyper extension of neck
May not have a fracture on X-rays
Caused by compromise of anterior spinal artery supplying central cord
Motor weakness of the arms in greater than lower limbs
Variable sensory loss, cape like
Upper limb areflexia
Horner’s syndrome- meiosis, loss of forehead sweating, ptosis

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4
Q

Anterior cord syndrome?

A

Anterior Cord Syndrome:
Usually causes by vascular insufficiency(ASA) due to disc herniation or tumor
Bilateral para paresis
Loss of pain & temperature bilaterally
Preserved dorsal column function(proprioception & vibration)

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5
Q

Features of neurogenic shock in spinal injury?

A

Neurogenic Shock features:
- Hypotension due to loss of vascular tone, sympathetic loss
- Bradycardia or lack of appropriate tachycardia
- Flaccid paralysis below level
- priapism, at least initially
- preserved anocutaneous and bulbocavernosus reflexes
- abdominal breathing if loss of diaphragm nerves, phrenic, C3C4C5

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6
Q

Autonomic dysreflexia?

A

Autonomic Dysreflexia:
- occurs after spinal injury when reflexes are returning ie long after
- only seen in paraplegia with injury higher than T6 or tetra plegia
- Some stimulus starts it like: constipation/ bone fracture/ painful stimulus/ blocked urine cath
- features: Sudden severe Hypertension, Headache, flushing, sweating, Mydriasis
- Correct stimulus cause
- Treat HTN with nitrates, Nifedipine

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7
Q

C spine assessment?

A

C spine assessment in trauma:
- Anterior vertebral line
- Anterior spinal Line
- Posterior spinal Line
- Spinous processes line
- Pre dental space < 3 mm
- Anterior to C3 space < 7mm
- Anterior to C7 space < 30 mm

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8
Q

Rule of nine for burn estimation?

A

Rule of nine for estimation of burns:
Head = 9%
Each Arm = 9%
Each Leg = 18% (9 front, 9 back)
Front of trunk = 18%
Back of trunk = 18%
Perineum = 1%

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9
Q

Depth of burns

A

Depth of burn estimation:
First Degree (Superficial):
- Damage to epidermis only
- Red and dry
- Blanch with pressure
- Very painful
- Heals within 10 days, no scarring

Second Degree (Partial thickness)
- Damage to epidermis and dermis
- Blisters and edema
- Painful
- Healing occurs in 14 days
- depigmentation may occur
- May require skin grafting

Third Degree (complete thickness):
- Loss of all layers of skin
- Dark and leathery or waxy white
- Painless, nerves lost
- No blanching
- skin grafting required

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10
Q

Parkland formula for fluids in burns case?

A

Parkland formula for estimation of fluid resuscitation in first 24 Hrs of at least 15% or more burns is as:

Total fluid to give = % Burns x Wt (kg) x 4

Half given = in 8 Hrs
Rest Half given = over 16 Hrs

Example:
Fluid: = 30% x 70 (kg) x 4 = 8400 ml
Give 4200 ml in 8 Hrs i.e. at 525 ml/Hr for 8 Hrs
Then give 4200 in 16 hrs i.e. at 262.5 ml per hr for 16 hrs

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11
Q

Complications of electrical burns?

A

Complications of electrical burns:
*Musculoskeletal = Fractures, dislocations, myonecrosis, compartment syndrome
*Neurological = Convulsions, coma, headache, transient paralysis, peripheral neuropathy
*Metabolic = rhabdomyolysis, renal failure
*Cardiac = arrhythmias, cardiac arrest, myocardial damage
*Ophthalmic = cataracts, Glaucoma

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12
Q

Hydrofluoric acid burns

A

Hydrofluoric acid burns: symptoms, signs, treatment:
Symptoms: burns at site, delayed and prollonged due to deep penetration. Fluoride ions chelates calcium in tissues causing severe hypocalcemia leading to other effects.
Signs: of tetany, arrhythmia’s, tissue necrosis with severe pain, convulsions, CNS depression, myoclonus
Treatment: Opioids for analgesia, copious irrigation for 30 minutes, Local OR iv Calcium Gluconate 10%

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13
Q

What is Muir-Barclay formula for fluid in burns?

A

Muir-Barclay formula gives amount of fluid to be given as one aliquot in burns:
Fluid = 1/2 x % Burns x Wt (kg) = one Aliquot fluid in ml
Example:
1/2 x 20% x 60 = 600 ml over 4, 4, 4, 6, 6, 12 Hours, (every time 600 ml)

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14
Q

Gustilo classification of open fractures

A

Gustilo classification of open fractures:
Type I = open fracture + wound < 1 cm & clean

Type II = open # + wound > 1 cm & no avulsion/flaps or extensive soft tissue damage

Type III-A = High energy trauma responsible but bone is covered

Type III-B = Open # + extensive soft tissue loss, peri osteal stripping and loss of bone

Type III-C. = Open # + arterial injury requiring repair

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15
Q

What are the 6P’s of compartment syndrome?

A

6 P’s of compartment syndrome:
- Pain out of proportion at rest and on passive stretch
- Paraesthesia (late sign)
- Pallor
- Paralysis (late signs)
- Pulse less limb (late sign)
- Poikilothermia
Note - if difference between intra compartmental pressure and diastolic blood pressure is < 30 mm Hg - then fasciotomy is required.

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16
Q

What are various methods for reduction of dislocated shoulder?

A

External Rotation method: Hold arm in adduction and close to patient’s body - flex elbow to 90 degrees - hold wrist of patient and rotate externally while holding arm in adduction, close to body.

Kocher’s Method: flex the elbow to 90 degree and apply downward traction on humerus - EXTERNALLY rotate the shoulder to bring the head of humerus forward - Pull the elbow across the patient’s body adducting the shoulder and then internally rotate the arm.
# Milch Method: With the patient supine - arm is externally rotated - then abducted over the patient’s head while maintaining external rotation - gentle force can be applied over head of humerus by operators thumb in axilla
#Stimpson’s Method: Patient prone on trolley - with affected arm hanging off the bed - Apply a weight to the wrist to provide slow traction. - Gravity will reduce dislocation (posterior one)
# Cunningham method: Patient sitting with clinician sitting opposite to him - Rest the patient hand off the affected arm on the clinician’s shoulder - clinician rests one of their arm in patient anti-cubital fossa - gently massages shoulder area and patient is encouraged to pull their shoulder blades together thus moving their scapula out of way and thus aiding reduction.

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17
Q

Monteggia fracture dislocation

A

Monteggia fracture dislocation:
Fracture of shaft of ulna with dislocation of radial head. A line through radial shaft should normally pass through capitellum and is disturbed in monteggia type ie doesnt pass throught capitellum. - needs ORIF.

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18
Q

Galeazzi fracture dislocation

A

Galeazzi fracture dislocation:
fracture of shaft of radius with distal dislocation of radio-ulnar joint - needs ORIF.

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19
Q

Colle’s fracture

A

Colle’s fracture:
distal radius bone fracture with dorsal angulation of distal piece. Happens when fall on out-stretched hand (FOOSH)- can be reduced in ER under hematoma block or Bier’s block.

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20
Q

Smith’s fracture

A

Smith’s fracture:
fracture of distal end of radius (as in colle’s) but with volar displacement - needs ORIF.

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21
Q

Jefferson Fracture of C1

A

Most common vertebral fracture of C1
Usual mechanism is axial loading which occurs when a large load falls vertically on head or patient lands on top of his head in a neutral position
Involves disruption of both anterior and posterior rings of C1 with lateral displacement of lateral masses. both seen in open mouth view of C1C2

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22
Q

Barton’s Fracture

A

Barton’s fracture:
intra-articular fracture involving only the distal radius. Fractured piece of radius tends to displace in volar direction and is unstable - needs ORIF

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23
Q

Lunate and perilunate dislocations?

A

Lunate and Peri-Lunate dislocations = Distal radius, lunate and capitate articulate with each other and all lie in straight line in lateral wrist xrays.

Lunate Dislocation:
- Lunate dislocates anteriorly
- concavity of lunate is empty on lateral view
- radius & capitate remain in straight line lateral view
- Lunate appears triagular on AP view
- Can leads to AVN, Median injury, complex pain syndrome

Peri-Lunate dislocation:
- whole carpus except lunate is displaced posteriorly
- radius and lunate remain in straight line
- hand is very swollen
- Scaphoid is usually fractured as well
- concavity of Lunate is empty

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24
Q

Bennet’s fracture dislocation

A

Bennet’s fracture dislocation:
results typically from a fall onto thumb or from a blow onto closed fist around thumb - fracture through base of first ie thumb metacarpal with radial pull due to Abductor Pollicis Longus muscle.

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25
Q

Garden classification of neck of femur fracture

A

Garden classification of femur neck fracture:

Garden I: trabeculae angulated, but inferior cortex intact, no displacement

Garden II: trabeculae in line but a fracture line visible from superior to inferior cortex, no displacement

Garden III: obvious complete fracture line with slight displacement and/or rotation of femoral head

Garden IV: Gross, often complete displacement of femoral head

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26
Q

Ottawa knee rules and ankle rules

A

Ottawa knee rules:
Do knee radiographs only if any of following is present
- age 55 yrs or older
- isolated patella tenderness
- Tenderness of head of fibula
- inability to bear weight immediately and in ED

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27
Q

Monoarthritis differentials

A

Differentials to consider for monoarthritis:
- Septic arthritis
- Haemarthrosis
- Crystal Synovitis: Gout, Pseudogout, Calcific,
- Osteoarthritis
- Reactive: with urethritis, Conjunctivitis, Skin rash, Enthesopathy
- Neuropathic - Charcot’s
- Synovial: pigmented villonodular synovitis,
- Enteropathic: with SLE, Sarcoidosis, IE, foreign body (thorn)
- Monoarticular presentation of RA/Psoriasis, Ankylosis, etc

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28
Q

Polyarthritis causes

A

Causes of polyarthritis:
- Rheumatoid arthritis
- Ankylosing spondylitis
- Psoriatic arthritis
- Reactive arthritis
- Rheumatic fever
- Gonococcal arthritis
- Viral Arthritis
- Gout

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29
Q

Causes of septic Arthritis: SHANGS

A

SHANGS - mnemonic for septic Jts
Staphylococcal aureus
Haemophillus - 6 to 24 month olds
Aerobic Gram negative rods
Pseudomonas, Enterobacter
Neisseria gonorrhea
Group B streptococci
Streptococcus viridans or pneumoniae

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30
Q

Causes of Hyperuricemia

A
  1. Increased Urate production:
    - Myeloproliferative disorders
    - High purines: beer, meat
    - Cytotoxic drugs - chemo
    - Trauma, Exercise, Alcholism
  2. Decreased urate excretion:
    - Idopathic
    - Enzyme defect: Lesch-Nyhan syndrome
    - Renal Failure
    - Drugs: Diuretics, Low dose ASA
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31
Q

Risk factor for PseudoGout development?

A

Pseudogout that is precipitation of calcium pyrophorphate in joints is seen with:
- Hyper-para-thyroidism
- Haemochromoatosis
- Hypo-thyroidism
- Hypo-magnesemia
- Hypo-phosphatemia
- Acromegaly
- Diabetes mellitus
- Any long standing arthritis-RA, AS, OA

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32
Q

Sero-negative Arthritis

A

Sero-negative Arthritis conditions: (REAP-U)
- Reactive arthritis
- Enteropathic arthritis
- Ankylosing spondylitis
- Psoriatic arthritis
- Undifferentiated spondyloarthropathy

Common Features:
= HLA B27 positivity
= Axial spine, SA Jt involvement
= Tendon insertion enthesitis
= RA factor negatives

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33
Q

Features of ankylosing spondylitis?

A

Ankylosing spondylitis:
Presentation in low back pain in MEN 15-30 year old,
- bamboo spine-fused spine with kyphosis - Q mark posture
- Restrictive Pulmonary disease
- Restricted neck movements, difficult intubation
- Uveitis
- Lung fibrosis
- Aortitis
- Plantar fascitis
- achilles tendonitis

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34
Q

Features of reactive arthritis (Reiter’s syndrome)

A

Reactive Arthritis (reiter’s):
Urethritis: dysuria, frequency, urgency, urethral discharge, circinate balanitis
Arthritis: asymmentric & arthralgia, Jt swelling of knees, ankle, feet
Conjunctivitis+Uveitis: redness, pain, irritation, watering, photophobia
Keratoderma blenorrhagicum: small hard nodules on palm, soles
Mouth Ulcers:
Cardiac: AR, Myocarditis

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35
Q

Rheumatoid Arthritis featurres

A

**Features of RA: **
- 70% RA factor positive
- MCP and PIP joint inflammation, ulnar deviation, volar subluxation at MCP jts
- Boutonnier & swan nek deformity finger and Z thumbs
- Degeneration of transnverse ligament of odointoid peg - more subluxation risk
- Subcut rheumatoid nodules, mostly elbows
- nail fold infarcts
- livedo reticularis
- Pulmonary fibrosis and plerisy
- pericarditis, endocarditis
- Anemia, spleenomegaly, scleritis

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36
Q

Cauda Equina Syndrome

A

Features of cauda equina are according to nerve roots compressed, L1-L5 & S1-S5:
L1:- Groin sensation loss
L2:- Sensation to medial prox thigh, Hip flexion
L3:- Distal thigh, knee, knee Jerk
L4:- medial lower Leg, Knee jerk, Ankle Dorsiflex
L5:- Lateral low Leg, Great Toe, Great Toe Ext
S1:- Lat foot, Little toe, Ankle jerk, Plantar fkex
S2:- Sensation to Posterior thigh
Bladder disturbance: S2S3S4
Bowel disturbance: S2S3S4

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37
Q

Anatomical Snuff Box

A

**Borders of Anatomical snuff Box:
** Ulnar side - EPL tendon
Radial side - APB, APL tendons
Proximally - Radial styloid process
Distally - Base of thumb metacarpal
Floor - scaphoid and trapezium
Contents - radial artery

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38
Q

Intrinsic Muscles of Hand

A

**Intrinsic Hand muscles:
**- Interossei - 4 dorsal + 3 palmar (ulnar n) - flex MCP and extends IP joints, Palmar adducts, Dorsal ABducts (PAD DAB)
- Lumbricals - 4, flexes MCP, extends IP, 1+2 by median nerve, rest ulnar nerve
- Thenar muscles: APB, FPB, OP, adductor pollicis (first 3 by median, AddP by ulnar)
- Hypothenar muscles: Abd digiti minimi, FDMinimi, OPDminimi, all by Ular nerve

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39
Q

Carpal Tunnel anatomy

A

**Carpal Tunnel anatomy:
**Flexor retinaculum runs from -
Ulnar side - Pisiform, hamate
Radial side - Scaphoid, Trapezium
Contents -nine tendons + median nerve
FDP - 4 tendons
FDS - 4 tendons
Flexor pollicis longus - 1 tendon
Superficial to CT & Flexor retinaculum is Guyon’s canal containing Ulnar nerve & artery.

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40
Q

Median Nerve Injury

A

Median Nerve injury
at Thumb: Loss of sensation on radial 3& 1/2 fingers (thenar eminence sensations preserved as palmar cutaneous branch doesnot pass through Carpal tunnel)
Weakness of thenar muscles and loss of flexion at MCP + PIP + DIP joints - ape Hand (except at little finger)
in the Forerarm:
Hand of benediction,1, 2, 3 fingers do not flex
Weakness of wrist flexion+ pronation
Loss of flexion@ PIP jts of radial 4 fingers
Loss of Flexion @ DIP jts of radial 4 fingers

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41
Q

Kanavel’s Signs

Signs of finger tendon sheath infection

A

Kanavel’s Signs:
1. Tenderness along course of flexor tendon
2. symmetrical edema of the finger
3. Pain on passive extension of finger
4. Flexed resting posture of finger
Tendon sheath of thumb & little fingers of continuous with radial & ulnar bursa & infections can go to carpal tunnel.

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42
Q

Accidental digital injection of adrenaline

A

Managing accidental digital injection of adrenaline:
- Insert finger in warm water
- apply Topical or IV GTN
- local infiltration of pentolamineC(Alfa blocker)

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43
Q

Medical Cause of acute Abdomen

A

Medical Causes of Acute Abdomen:
Cardio-respiratory:
- Inferior STEMI
- Pericarditis
- Lower Lobe Pneumonia
- Pulmonary embolism
Metabolic:
- DKA
- Addison’s crisis
- Acute intermittent porphyria
- Hyperlipidemia
- Familial mediterranean fever
Drug Induced:
- opioid withdrawal
- Lead poisoning
Haematological:
- Sickle cell crisis
- Acute leukemia
CNS conditions:
- herpes zoster
- Nerve Root compression

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44
Q

What is Charcot’s triad?

A

Charcot’s Triad: Obstruction of the CBD leads to biliary stasis & a predisposition to the bacterial infection ascending from duodenal ampulla. Classic presentation of ascending cholangitis is charcot’s triad and is:
- Fever
- Jaundice
- RUQ Pain abdomen
Note - approx 10% of GB stones are radio-opaque.

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45
Q

Courvoisier’s Law?

A

Courvoisier’s Law states that - in the presence of jaundice, if gallbladder is palpable, the cause if UNLIKELY to be a GB stone. Suspect pancreatic carcinoma.

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46
Q

Causes of Acute Pancreatitis - GET SMASHED

A

GET SMASHED - causes of pancreatitis
G - Gallstones
E - Ethanol consumption
T - Trauma to abdomen
S - Steroids
M - Mumps + CMV, EBV
A - Autoimmune
S - Scorpion venom, rare
H - Hyperlipid,Hypocalcemia,High Temp
E - ERCP procedure side effect
D - Drugs - Azathioprine, Statins, Estrogens, Thiazides, Valproate
I - Idiopathic
P - Pregnancy

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47
Q

Glasgow scoring for acute Pancreatitis

A

Glasgow scoring for acute pancreatitis to predict severity of disease:
Age - > 55 YRS
WBC - > 15 K
Glucose - > 10 mmols
Urea - > 16 mmols
PaO2 - < 8 kPa
Corrected Calcium - < 2 mmols
Albumin - < 32 Gms/Lit
LDH Levels - > 600 Units/L
AST/ ALT - > 100 Units/Lit

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48
Q

Complication of Acute Pancreatitis

A

Complication of Acute Pancreatitis:
1. Local complications:
- Pancreatic necrosis/ abscess
- pancreatic pseudocyst
- Ascites
- Biliary obstruction
- Portal vein thrombosis
- paralytic ileus
- GI Haemorrhage
2. Systemic complications:
- ARDS
- Hyperglycemia
- Hypocalcemia
- Acute Kidney injury, DIC
- Sepsis, Multi-organ failure, Death

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49
Q

Alvorado score for Appendicitis

A

Alvorado score: appendicitis: MANTRELL
M = Migration of pain to RIF
A = Anorexia
N = nausea, vomiting
T = tender RIF
R = Rebound tenderness , 2 points
E = Elevated Temp >37.3
L = Leucocytosis
L = Left shift Leucocytosis
5/6 - maybe, 7/8 - probable, 9/10 - likley

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50
Q

Causes of small bowel obstruction

A

Causes of small bowel obstruction: > 3 cm diameter in AXR centrally
- Adhesions
- Hernias
- Crohn’s disease
- Gallstone ileus
- Tumor
- intussusception
- Foreign boodies

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51
Q

Causes of Large bowel obstruction

A

Causes of Large bowel obstruction:
- Volvulus: Sigmoid or Caecal
- Hernia’s
- Adhesions
- inflammatory bowel disease
- Tumor
- Fecal impaction
- Diverticulitis
> 5 cm diameter in AXR peripherally

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52
Q

Causes of functional bowel obstruction

A

Causes of Functional Bowel Obstruction
- Hypokalemia
- Hyponatremia
- Hypomagnesemia
- Intestinal Ischaemia
- Intra-abdominal infection
- Trauma
- Pseudo-Obstruction - TCA’s use

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53
Q

AAA suspect, work up

A

AAA features:
- pulsatile mass in abdomen, central
- Left renal colic + hematuria like
- Sudden Hypotension, PEA
- Absent one or both femoral pulses
- Retro peritoneal haemorrhage
Aorta diameter at various levels:
- at diaphragm: 2.5 cm
- at Renal artery: 2 cm
- At bifurcation level - 1.5 to 2 cm
- Iliac arteries just distal - origin 1.5 cm
CT Aortic diameter > 3 cm is aneurysm

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54
Q

Aortic dissection types

A

Classification of aortic dissection:
1. Stanford System:
Type A - involvement of ascending aorta and aortic arch
Type B - descending aorta involvement distal to the origin of left subclavian artery
2. DeBakey System:
Type I: - dissection originates in ascending aorta and spread to whole aorta
Type II: - Originates & confined to ascending aorta/ arch
Type III: - involves only descending aorta

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55
Q

Risk factors for Aortic dissection

A

Risk factor for aortic dissection:
- Hypertension
- Connective tissue diseases- EDS, Marfan’s
- Bicuspid aortic valve
- Coarctation of aorta
- Cocaine abuse
- Giant cell arteritis
- Iatrogenic CAG, CABG

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56
Q

Suspect Aortic dissection

A

Suspect aortic dissection if:
- tearing interscapular, chest pain
- unequal pulses
- Pulsus paradoxus + Distended neck veins + Quiet heart sounds tamponade
- AR murmur
- More than 20 mmHg BP diff between arms
- New neuro signs due to cord ischemia
- complication signs

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57
Q

Radiological signs of Aortic dissection

A

Radiological signs of Aortic dissection
- widened mediastinum
- Loss of aortic knuckle
- Pleural cap
- Pleural effusion
- Right sided deviation of trachea
- Right sided NGT deviation
- Left mainstem bronchus pushed inferiorly
- Calcium sign - separation of calcified aortic walls
- Globular heart s/o hemopericardium
- aortic wall thickening > 15 mm
- ECG may show STEMI/ nonSTEMI/ LVH
- Trans-esophageal ECHO confirms
-

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58
Q

Pre-renal & renal causes of Hematuria

A

Pre-renal causes of hematuria:
- sickle cell disease
- Leukemia
- Anticoagulation
- Exercise induced
- Infective endocarditis
Renal causes of Hematuria:
- Glomerulonephritis
- Malignancy
- renal trauma
- Calculus
- Polycystic disease
- Pyelonephritis
- Ruptured AAA

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59
Q

Other causes of Hematuria: Ureteric-Bladder-Urethral?

A

Ureteric causes of Hematuria:
- Calculus,
- Carcinoma
- Schistosomiasis
Bladder Causes of Hematuria:
- UB, Prostate malignancy
- BPH
- Calculus, UTI, Trauma
Urethral causes of hematuria:
- Malignancy
- Calculus
- Foreign body

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60
Q

Coloured Urine, no blood

A

Colored Urine without blood
- Myoglobin
- Porphyria
- Beetroot
- Rifampicin
- Doxorubicin

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61
Q

Hematuria in children

A

Hematuria in children
- UTI
- Trauma
- Glomerulonephritis
- Wilm’s tumor
- Bleeding diasthesis
- Urinary tract stones
- Exercise
- Foreign bodies
- Factitious

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62
Q

Renal stones

A

Renal stones:
- calcium oxalate 80% - HyperPTH, Oxaluria, RTA
- Calcium Phosphate, - High PTH, RTA
- Mg-NH3-Phosphate - Proteus UTI
- Uric acid stones in Gout
- Cystine stones

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63
Q

Causes of priapism

A

Causes of Priapism:
- Iatrogenic - papaverine, Alprostadil intracavernosal injections
- Blood disorders: SCD, Myeloma, Leukemia
- Pelvic Trauma
- Spinal cord injury
- Bladder/ prostate malignancy
- Cocaine
- Idiopathic 40%
- Drugs: Chlorpromazine, Fluoxetine, Heparin used in dialysis
Rx - Ice packs, Hydration, Oral pseudoephedrine, Oral Terbutaline, Phenylephrine inj in penis, Embolization or surgical ligation of ruptured artery

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64
Q

LMN Facial Palsy

A

LMN Facial palsy causes:
- Bell’s palsy (idiopathic, viral)
- Pontine tumors
- Acoustic neuromas at CP angle
- Ramsay-Hunt syndrome, Zoster of 7,8
- Trauma, # of base of skull
- Middle ear infections, cholesteatoma
- Sarcoidosis
- Parotid Gland tumors

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65
Q

Medications that can induced vertigo

A

Medicine Classs = Examples
Analgesics = codeine

Antibiotics = aminoglycosides, macrolides, minocycline, nitrofurantoin, sulfamethoxazole

Anticonvulsants = levetiracetam, phenytoin, pregabalin

Anti-inflammatories = celecoxib, parecoxib, naproxen, prednisone

Antimalarials = mefloquine, quinine, hydroxychloroquine

Antivirals = oseltamivir, raltegravir

Anti-Parkinson’s drugs = lisuride

Cardiovascular drugs = nifedipine, furosemide, indapamide, prazosin, terazosin, glyceryl trinitrate, isosorbide mononitrate, sotalol, timolol

Gastroenterology drugs = omeprazole, lansoprazole, sucralfate

Rheumatology drugs = zolendronic acid, alendronate

Phosphodiesterase type-5 inhibitors: sildenafil, vardenafil

Other medicines = lithium, haloperidol, benzodiazepines, desmopressin, melatonin

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66
Q

Causes of vertigo

A

Peripheral vertigo:
- BPPV
- Vestibular neuritis
- Acute Labrynthitis
- Cholesteatoma
- Otitis media
- Menier’s disease

Central Vertigo:
- Stroke, TIA
- Acoustic neuroma
- CP Angle tumors

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67
Q

Dix-Hallpike Manoeuvre

A

Dix Hallpike Manoeuvre:
Step 1 - Sit patient upright and ask to turn head to right side 45 degrees - examiner on right side to patient holding patient’s head
Step 2 - Quickly place patient in supine position with head extended down the edge of bed by 20 degrees
Step 3 - Ask patient to fix vision on your nose - observe 30 seconds for nystagmus
Step 4 - Sit the patient up and bring head to neutral position and observes eyes for 30 seconds
Repeat Test on other side same way
BPPV + if = nystagmus when affected ear is down (like right sided ear down with nystagmus means right BPPV)

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68
Q

Epley Manoeuvre

A

Epley Manoeuvre:
= Tilt your head to whichever side is causing vertigo.
= Have you quickly lie flat on your back with your head slightly off the edge of the examination table in the same position. (Your vertigo symptoms may worsen during this portion of the procedure.)
= Gradually move your head to the opposite side.
Rotate the rest of your body so it’s in alignment with your head.
= Ask you to remain on your side for a few moments.
= Sit you upright.

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69
Q

Head Impulse test

A

Head Impulse test for assessment of vestibular system:
01 - sit face to face in front of patient
02 - ask patient to fix eyes On your nose
03 - hold patient head & move side to side while he keeps eyes fixed onto you
04 - any deviation of eyes laterally along with head movements and then return to examiner’s nose = positive test = indicates vestibular dysfunction

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70
Q

Acute angle closure Glaucoma

A

Features of Glaucoma, Acute angle:
- History of blurred vision
- Haloes around lights due to corneal edema
- Headache and eye pain
- Nausea, Vomiting
- Decreased visual acuity
- Mid dilated fixed pupil
- Hazy edematous cornea
- Circumferential erythema, ciliary
- Raised IOP

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71
Q

Iritis, Anterior Uveitis,

A

Iritis, Anterior uveitis
Uveal tract comprises posterior choroid layer and anteriorly ciliary body + iris.
- iritis is common with Ankylosing spondylitis, UC, sarcoidosis
- also with trauma, surgery, keratitis
- HLA B27 association
- photophobia, consensual also
- painful eye
- accommodation increase pain
- slit will show cell in AC

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72
Q

Scleritis, Episcleritis

A

Outer Sclera has 3 layers - episclera, Tenon’s capsule and conjunctiva.
Scleritis:
- deep episcleral plexus inflammation
- blueish sclera
- pain deep within
- painful eye movements
- pain on digital palpation
- reduced VA
- can perforate

Episcleritis:
- inflamed episcleral plexus
- irritation rather than pain
- localised
- less serious than scleritis
Self limiting

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73
Q

Orbital cellulitis

A

Orbital cellulitis - inflammation and infection behind orbital septum means involves orbit itself, commonest cause is streptococcus pneumoniae
- painful eye movements
- ophthalmoplegia
- red desaturation due to neuritis
- loss of vision
- Proptosis
- chemists
- conjunctival Edema
Complications-
- systemic spread
- cavernous sinus thrombosis
- central retinal artery occlusion
- secondary glaucoma
- optic neuritis
- meningitis
- endophthalmitis
- osteomyelitis
- Death

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74
Q

Peri-Orbital cellulitis

A

Peri-Orbital cellulitis,
Involves eye lids & soft tissues anterior to orbital septum, less severe
Follows URTI, trauma to lids
- eyes features absent as mentioned in orbital cellulitis

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75
Q

CRAO versus CRVO

A

CRAO - arterial
- pale retina with cherry spot at fovea
- Relative afferent pupillary defect
- Rebreather CO2 to dilate retinal artery
- sublingual GTN to dilate RetinalArt
- massage globe to dislodge emboli
- Timolol drops to reduce pressure
- IV diamox to reduce eye pressure

CRVO - venous:
- sunset stormy fundus
- dilated tortuous fundus veins
- RAPD
- risk factors reduction- HTN, chronic glaucoma, Polycythemia,

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76
Q

Temporal arteritis

A

Temporal arteritis:
- vasculitis
- temporal headaches
- scalp tenderness, temporal
- Jaw clarification during chewing
- red vision desaturation
- RAPD
- Unilateral blindness
- pale swollen optic disc
- PMR- malaise, myalgia in shoulders & thighs, weight loss, proximal muscle weakness (difficulty in getting up from chairs)

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77
Q

Amaurosis fugax

A

Amaurosis fugax - is a temporary vision loss, usually 5-20 minutes, due to temporary arterial obstruction which can be due to:
- emboli, stroke
- atheromatous disease
- acute angle closure glaucoma
- raised ICT
- hypercoagulability

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78
Q

Le forte facial fracture classification

A

Classification of facial fractures

Le forte 1 = involves tooth bearing portion of the maxilla. There may be associated split in hard palate, hematoma of the soft palate and malocclusion

Le forte 2 = involves maxilla, nasal bone & medial orbit. Floating maxilla and possible airway obstruction.

Le forte 3 = involves maxilla, zygoma, nasal bones, ethmoid and base of skull.

Nasoethmoidal fractures results in splaying of the nasal complex and a saddle shape nose deformity. These will be significant pre orbital bruising & may be associated with supra orbital or supracochlear hypoesthesia

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79
Q

Contraindications to LP include:

A

Contraindications to LP include:

raised intracranial pressure
coagulation abnormalities
suspicion of spinal epidural abscess
infection at the LP site
uncontrolled convulsions
————————

The spinal cord ends at L3 in newborns, so the lumbar puncture should be performed at the top of the iliac crest, L3/4 or L4/5 intervertebral space. Usually, the L2/3 and L3/4 levels are preferred for LP in adults

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80
Q

Tripod fractures of face
Orbital fracture signs

A

Tripod fracture of face involves 3 sutures:
= Zygomatico-temporal
= Zygomatico-frontal
= infra Orbital foramen

Signs of orbital fracture due to direct trauma:
Tear Drop Sign - tissue herniating from orbit into maxillary sinus roof seen in xrays as tear drop
Eye Brow Sign - air around superior orbit due to maxillary sinus fracture noted in xrays around at at eye brow areas

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81
Q

Zones of neck for injury assessment

A

Zones of neck and structures at risk:
Zone 01 = clavicle to cricoid cartilage, structures at risk are: subclavian vessels, brachocephalic vessels, CCA, Aortic arch, Jugular veins, trachea, C spine, Lung apices, Spinal cord and nerve roots

Zone 02 = Cricoid to angle of jaw = structures at risk are: Carotid arteries, vertebral arteries, Jugular veins, pharynx, larynx, trachea, esophagus, C spine, Spinal cord

Zone 03 = from angle of mandible to skull base = structures at risk are = salivary, parotid glands, esophagus, trachea, vertebral bodies, carotid arteries, jugular veins, cranial nerves 9-12

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82
Q

Features of PID

A

Features of PID:
- Lower abd pain and tenderness, usually bilateral
- Fever > 38c
- abnormal vaginal discharge
- cervical motion tenderness on bimanual exam
- Deep dyspareunia
- abnormal vaginal bleeding, intermenstrual, post-coital
- Adnexal mass and tenderness
- Fitz-Hugh-Curtis syndrome: peri hepatitis in PID, RUQ pain
Rx -
1. Oflox 400 BD + Flagyl 400 BD x 14 days
2. IM Ceftriaxone 500 mg then Flagyl + Doxy x 14 days

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83
Q

Emergency contraception

A

Emergency contraception options:
1. Oral - Levonorgestrel and Ulipristal
Levonorgestrel - 1.5 mg upto 72 hrs
Ulipristal - 30 mg upto 120 Hrs
Contraindications:
- severe Liver disease
- Porphyria, Migraine, Pregnancy, Malabsorption
2. Cu-IUCD - upto 5 days (120 Hrs) - 98% effective - risk of uterine perforation, PID, Ectopics, etc

84
Q

Types of Miscarriages

A

Types of Miscarriages - Loss of pregnancy prior to 24 weeks.
1. Threatened Miscarriage - PV bleeding but cervical Os closed.
2. Inevitable Miscarriage - PV bleeding with open cervical Os
3. Incomplete Miscarriage - PV Bleed but not all products passed
4. Missed Miscarriage - silent loss of pregnancy and directly noted in Ultrasound only
5. Miscarriage with infection
6. Complete Miscarriage

85
Q

Gestational Tropoblastic Disease

A

Gestational trophoblastic disease - occasionally fertilized ovum may form abnormal ovum instead of fetus and has two forms:
1. Hydatidiform mole - bening
2. Choriocarcinoma, malignant
- excessive beta HCG causes hyperemesis gravidarum
- PV bleeding by 12-16 weeks
- passage of frog spawn like PV tissue
- USG: snowstorm appearance

86
Q

Placenta praevia

A

Placenta praevia - complete placenta in lower segment of the uterus, if it covers cervical os its called complete otherwise incomplete. Risks of having PP are:
- Maternal age > 35 yrs
- Multiparity history
- Previous PP
- Twin pregnancy
- Uterine abnormalities
Presentation- Bright red painless per vaginal bleeding in 3rd trimester + Labour.
Vasa praevia - rare condition in which fetal blood vessels grown within the membranes and over the internal opening(os_) AND HAS RISK OF FETAL BLEEDING WHEN THE MEMBRANES RUPTURE.

87
Q

Kleihauer Test

A

The KB test is the standard method of quantitating fetal–maternal hemorrhage (FMH). It takes advantage of the differential resistance of fetal hemoglobin to acid. A standard blood smear is prepared from the mother’s blood and exposed to an acid bath. This removes adult hemoglobin, but not fetal hemoglobin, from the red blood cells. Subsequent staining, using Shepard’s method, makes fetal cells (containing fetal hemoglobin) appear rose-pink in color, while adult red blood cells are only seen as “ghosts”. 2,000 cells are counted under the microscope and a percentage of fetal to maternal cells is calculated.

In those with positive tests, follow up testing at a postpartum check should be done to rule out the possibility of a false positive. This could be caused by a hemoglobinopathy in the mother which causes persistent elevation of fetal hemoglobin, e.g. sickle cell trait.

88
Q

Cervical Shock

A

Cervical Shock - is a shock condition in which products of conception during miscarriage gets stuck at cervical Opening - causing intense vagal stimulation leading to bradycardia, hypotension and lower abdomen pain. They need removal of products from internal O S.

89
Q

Rule of 2 of Lumbar Plexus

A

Rule of 2 of Lumbar plexus
2 roots one supplies 1 action and next 2 other opposite action.
At Hip Joint:
Flexion by L2L3 - Iliopsoas muscle
Extension by L4L5 - Glutes & Hamstrings
———————————-
At Knee Joint:
Extension: by L3L4 - Quadriceps
Flexion: by L5S1 - Hamstrings
———————————
At Ankle Joint:
Flexion by L4L5 - Dorsiflexion, Posteriaris tibialis extensor
Extension: S1S2 - Plantar flexion, Calf muscles

90
Q

Hyperemesis gravidarum

A

Complications of Hyperemesis gravidarum:
- Hyponatremia, AKI
- Wernicke’s Encephalopathy, thiamine
- Mallory weis tear of esophagus
- Central pontine myelinolysis
- B12, B6 deficiency
- Foetal intra uterine growth retardation
- Venous thromboembolism
- Hypochloremic metabolic acidosis

91
Q

Pre-Eclampsia, Eclampsia

A

Pre-Eclampsia: triad of
- Hypertension > 140/90
- Proteinuria
- Leg edema, non specific
Eclampsia - add convulsions to above
Clinical features:
= Malaise
= Head ache, blurred vision
= RUQ & epigastric pain (Liver edema)
= Occipital Lobe Blindness
= Clonus, Hyperreflexia
= convulsions due to cerebral edema

92
Q

Anti D immunoglobulin guidance

A

Anti D, when to give: indications
when mother is RhD negative blood grp
= close trauma to tummy
= Antepartum bleeding
= IUD
= INVASIVE PRE NATAL diagnostic tests
= Ectopic pregnancy
= Spontaneous miscarriage
= Threatened miscarriage
=Therapeutic termination of pregnancy
= External cephalic versions
How much to give:
500 IU at 28 and 34 weeks of gestation
250 IU prophylactic if< 20 wks gestation
500 IU prophylactic if > 20 wks

93
Q

Postpartum Haemorrhage

A

Primary Postpartum Hemorrhage:
within 24 Hrs of delivery, minor 500-1000 ml, major if > 1000 ml
= Uterine atony
= Retained placenta
= Genital tract trauma, cut
= DIC
———————-
Secondary PPH, 24 hrs to 12 weeks
= Retained products
= Intra-uterine infection
= Genital tract trauma
= Trophoblastic disease
= DIC
————————–
General Risk factors:
- Placental abruption, praevia
- Placenta accreta, adherant
- Multipara
- Pre-eclampsia
- Past PPH
- Haemophillia
- Anti-coagulant use

94
Q

Arrhythmia - AVNRT

A

AVNRT -AV nodal re-entry tachycardia
- accessory re-entery circuit within AV node
- In typical AVNRT, retrograde P waves occur early, so we either don’t see them (buried in QRS) or partially see them (pseudo R’ wave at terminal portion of QRS complex)
no short pr or delta waves like WPW
MORE COMMON THAN AVRT

95
Q

Arrhythmia - AVRT

A

AVRT - AV re-entry tachycardia (not nodal) - accessory ciruit is not within AV node - narrow qrs
a form of paroxysmal supraventricular tachycardia that occurs in patients with accessory pathways, usually due to formation of a re-entry circuit between the AV node and accessory pathway
Can be
= Orthodromic AVRT: Anterograde conduction through AV node
= Antidromic AVRT: Retrograde conduction through AV node
In both forms, the features of pre-excitation are lost

96
Q

Orthodromic AVRT

A

Orthodromic AVRT: anterograde
ECG features of AVRT with orthodromic conduction:
= Rate usually 200-300 bpm
= Retrograde P waves are usually visible, with a long RP interval
= QRS < 120ms unless pre-existing bundle branch block, or rate-related aberrant conduction
= QRS alternans: phasic variation in QRS amplitude associated with AVNT and AVRT, distinguished from electrical alternans by a normal QRS amplitude
= Rate-related ischaemia is common

Orthodromic AVRT, or just AVNRT?
This rhythm can appear very similar to AVNRT, but the RP interval can assist us to differentiate:
In typical AVNRT, retrograde P waves occur early, so we either don’t see them (buried in QRS) or partially see them (pseudo R’ wave at terminal portion of QRS complex)
In AVRT, retrograde P waves occur later, with a long RP interval > 70 msec

Treatment of orthodromic AVRT
As always, patients that are unstable due to this rhythm require urgent DC cardioversion
The anterograde portion of conduction is typically the “weak link” of the re-entry circuit.

Management options in the stable patient therefore target slowing conduction through the AV node
A stepwise approach similar to AVNRT can be employed, beginning with vagal manoeuvres followed by adenosine and/or verapamil
Note that with administration of any AV nodal blocking drug, there is a very small but significant risk of inducing AF. If verapamil is used, patients should be observed for at least 4 hours to ensure AF does not develop as a consequence of AV nodal blockade

97
Q

Antidromic AVRT - resembles VTach

A

Antidromic AVRT
Antidromic AVRT is rare, and makes up only 5% of tachyarrhythmias in patients with WPW. As the name suggests, it involves anterograde conduction via the AP. Retrograde conduction is usually via the AV node, but can also be via another AP. The abnormal direction of ventricular depolarisation results in a broad complex tachycardia, which can be easily mistaken for VT.

ECG features of AVRT with antidromic conduction:
Rate usually 200-300 bpm
Wide QRS complexes due to abnormal ventricular depolarisation via AP

Treatment of antidromic AVRT
This rhythm can be difficult to distinguish from VT, and if there is any doubt, we should presume a diagnosis of VT and treat accordingly
In stable patients, drug therapy should be targeted at the AP
Procainamide (class I) would be our first line antiarrhythmic. Ibutilide (class III) and amiodarone are second-line options, but their effectiveness is less established
DC cardioversion may still be required if drug therapy fails

98
Q

The re-entry circuit involves the AV node — why can’t we use AV nodal blocking agents?

A

The re-entry circuit involves the AV node — why can’t we use AV nodal blocking agents?
Antidromic AVRT is often associated with a rapidly conducting anterograde AP
AV blockade through adenosine may interrupt this re-entry circuit, but as stated above, with administration of any AV nodal blocking agent there is a small risk of inducing AF
If this occurs it will likely precipitate cardiac arrest due to rapid conduction via the AP
As such, in a stable patient drug therapy should be targeted at the AP

99
Q

WPW Syndrome

A

WPW Syndrome refers to the presence of a congenital accessory pathway (AP) and episodes of tachyarrhythmias. The term is often used interchangeablely with pre-excitation syndrome. First described in 1930 by Louis Wolff, John Parkinson and Paul Dudley White
Incidence is 0.1 – 3.0 per 1000
Associated with a small risk of sudden cardiac death.
———————————-
ECG features:
- PR interval < 120ms
- Delta wave: slurring slow rise of initial portion of the QRS
- QRS prolongation > 110ms
- Discordant ST-segment and T-wave changes (i.e. in the opposite direction to the major component of the QRS complex)
- Pseudo-infarction pattern in up to 70% of patients — due to negatively deflected delta waves in inferior/anterior leads (“pseudo-Q waves”), or prominent R waves in V1-3 (mimicking posterior infarction)
APs can be left-sided or right-sided, and ECG features will vary depending on this:

Left-sided AP: produces a positive delta wave in all precordial leads, with R/S > 1 in V1. Sometimes referred to as a type A WPW pattern
Right-sided AP: produces a negative delta wave in leads V1 and V2. Sometimes referred to as a type B WPW pattern

100
Q

Lown–Ganong–Levine syndrome

A

Lown–Ganong–Levine syndrome
- short PR with pre-excitation due to AV accessory pathway
- normal QRS that is no delta wave

101
Q

Sick Sinus syndrome

A

Sick Sinus Syndrome - also called as Tachy-brady syndrome: due to ischemia, fibrosis or degeneration of SA node.
= Sinus pauses of> 2 seconds or sinus arrest.
= Junctional or other escape rhythms like AFib might occure causing tachy
needs pacemaker

102
Q

Second Degree Heart Block

A

Second Degree Heart Block:
Mobitz Type I(wenkebach) = progressive prolongation of PR interval in ECG followed by a dropped beat
Mobitz Type II = no progressive prolongation but dropped beat suddenly, more dangerous,
- 2:1, 3:1 or irregular pattern
- needs pacemaker

103
Q

Brugada syndrome

A

Brugada syndrome -
= autosomal dominant condition with mutations in SCN5A gene (cardiac sodium channel gene).
= 80% developd VT or VF
—————————————–
#Type 1 = Coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave. This is the only ECG abnormality that is potentially diagnostic. It is often referred to as Brugada sign.
= This ECG abnormality must be associated with one of the following clinical criteria to make the diagnosis:
= Documented ventricular fibrillation (VF) or polymorphic ventricular tachycardia (VT).
= Family history of sudden cardiac = death at <45 years old .
= Coved-type ECGs in family members.
= Inducibility of VT with programmed electrical stimulation .
= Syncope.
= Nocturnal agonal respiration.
——————————
#Type 2 = Brugada Type 2 has >2mm of saddleback shaped ST elevation.
———————————
# Type 3 = Brugada type 3: can be the morphology of either type 1 or type 2, but with <2mm of ST segment elevation.
The only proven therapy is an implantable cardioverter – defibrillator (ICD).

104
Q

Wellens Syndrome

A

Wellens Syndrome is a clinical syndrome characterised by biphasic or deeply inverted T waves in V2-3, plus a history of recent chest pain now resolved. It is highly specific for critical stenosis of the left anterior descending artery (LAD).
The pattern is usually present in the pain free state — it may be obscured during episodes of ischaemic chest pain, when there is “pseudonormalisation” of T waves in V2-3
Wellens syndrome is a key example of why all patients presenting with chest pain must have serial ECGs
Type A – Biphasic, with initial positivity and terminal negativity (25% of cases)
Type B – Deeply and symmetrically inverted (75% of cases)

105
Q

Transient Loss of consciousness

A

TrLOC has 3 main causes:
1. Syncope
2. Epilepsy
3. Psychogenic
————————–
Syncope causes:
= Neurogenic reflex mediated
- Vasovagal
- Carotid Sinus
- Situational - cough, micturition
= Orthostatic Hypotension - Autonomic
= Cardiac causes - Arrhythmias, AS, HOCM, Cardiomyopathy
—————————-
Also see - Sugar, UPT, HCT%, Postural BP, drug list, Injuries

106
Q

Orthostatic Hypotension

A

Primary Autonomic Failure:

= Parkinson’s disease
= Levy body dementia
= Multi system Atrophy
= Pure autonomic failure

= Diabetes mellitus, long standing
= Amyloidosis of chronic diseases
= Uremia
= Spinal cord injury

107
Q

ECG Red flags for LOC

A

ECG red flags in LOC:
- Conduction: RBBB, LBBB, blocks
- QTc > 450 ms or < 350 ms
- Inappropriate persistent Bradycardia
- Ventricular arrhythmia, VPC’s
- Brugada syn. - V1V2V3 concave STE
- Pre-excitation-WPW/LGL - short PR, delta waves
- RVH OR LVH
- Abnormal T wave inversions
- Pathololgical q waves
- Atrial arrhythmia, sustained
- Paced rhythm in ECG

108
Q

Risk scoring-Red flags in LOC

A

Risks-Red flags in LOC:
= ECG abnormalities
= Heart failure: History or with signs
= LOC during exertion/running/exercise
= Family H/o sudden deaths < 40 yrs
= No or unexplained SOB
= A Heart Murmur
= 65 yrs of older without prodromes

109
Q

San Franscisco-CHESS Rule-Syncope

A

San-Franscisco rule for LOC (CHESS)
= Congestive heart failure history
= Hematocrit <30%
= EKG abnormal (EKG changed, or any non-sinus rhythm on EKG or monitoring)
= Shortness of breath symptoms
= Systolic BP <90 mmHg at triage

110
Q

Sudden Cardiac Death

A

Sudden Cardiac Death is within 1 hour of symptoms. It might be due to
1. Structural Heart Diseases or
2. Arrhythmia syndromes

  1. Structural Heart Diseases:
    = IHD associated, reperfusion
    = DCM: Postpartum, Infection, Autoimmune, Alcohol, Thyrotoxicosis, Idiopathic
    = HOCM: Genetic, AS,
    = Valvular Heart disease - Aortic stenosis
    = Congenital HD: TOF, TOGV, AS, Fontan operation, Marfan syndrome, MVP, Hypoplastic heart syndrome,
    Eisenmenger syndrome, Ebstein anomaly
111
Q

Sudden Cardiac Death: Arrhythmias

A

Arrhythmic causes of SCD
Long QT syndromes
= Inherited: Romano-ward and Jervill-Lange-Nelson syndromes
——————————–
Acquired Long QT
= Drug induced (Quinidine, Amiodarone, Sotalol), TCA, Loratadine, Erythromycin, Phenytoin
= Hypo - kalemia/calcemia/magnesemia
= Hypothyroidism
= Hypothermia
= Intracranial haemorrhage: SAH
——————————-
Short QTc< 0.33 + peaked T waves, K channelopathy
—————————-
Brugada Syndrome: V1V2V3 ST coving elevation with downsloping ST + inverted T or RBBB without terminal S waves in lateral leads
——————————–
WPW syndrome - short PR with delta or no delta waves

112
Q

Hypertensive Emergency,
Diastolic Blood pressure > 140mmHg,
Mean BP = 2x DBP +SBP/all divide by 3

A

Hypertensive Emergency: = Look for:
- Urine blood, proteins
- ECG changes of ACS, MI
- Fundus for changes, papilloedema
- Altered Sensorium, Convulsions, GCS
- CXR - congestion, mediastinum
- Blood - Hemolysis, RFT, Troponins
- CT head for Encephalopathy, ICH
————————————
Treat by
- Reduce MAP by 25% in first Hour
- Nitroprusside titrate, cover with foil
- Labetolol, alfa, beta blocker (good in HTN-stroke)
- Nitrate infusion
Monitor: ECG, BP, Urine output, GCS,

113
Q

Hypertensive Emergency,
Diastolic Blood pressure > 140mmHg,
Mean BP = 2x DBP +SBP/all divide by 3

A

HTN Emergency Effects
= Encephalopathy, altered sensorium
= MI, STEMI, Non-STEMI etc
= Renal injury, rising creatinine
= Acute LVF
= Aortic dissection
= Intracranial Hemorrhage
= Eclampsia

114
Q

Causes of Hypertension

A

Causes of Hypertension:
= Essential, idiopathic, primary
= Renal: RA Stenosis( High renin levels)
= Renal: Parenchymal, Polycystic
= Arterial: Coarctation of Aorta, stiffening with loss of elasticity
= Phaemochromocytoma, catecholamines
= Conn’s (Primary Aldosteronism)
= Cushing’s syndrome - Glucocorticoids
= Cocaine, Steroids, OC Pills, Amphetamines, NSAID’s,

115
Q

Infective Endocarditis - Duke’s

A

Infective Endocarditis
Duke’s Diagnostic Criteria
Major Criteria:
= 1. Blood cultures positive
= 2. Blood C/s persistently + for atypical
= 3. Evidence of endocardial involvement
such as 2D-ECHO findings, Abscess, vegetations, new murmur, valve dehiscence
Minor Criteria:
1.Predisposition - IVDU, Heart issues
2. Fever present > 90% cases
3. Vascular: Embolic stroke, Septic PE, Mycotic aneurysms, ICH, conjunctival bleed, Janway Lesions
4. Immunological: Osler nodes, Roth spots, RAF +, Glomerulonephritis
5. Microbiological - + Blood cultures but not major

116
Q

Infect. Endocarditis - Causative Organisms

A

IE Causative Organisms:
- Strep viridian most common
- Staph aureus
- Enterococci
- Strep Bovis
———————
HACEK group if initial blood cultures negative
—————————
Brucella, Fungal, Coxiella Burnetti, Bartonella, Chlamydia (all initial blood c/s negative)

117
Q

Infective Endocarditis - Clinical

A

IE Clinical Presentation
= Fever with new murmur
= Arthropathy - multiple joint pains
= Poor appetite and weight loss
= Immunological: Osler nodes, Roth spots, GN evidence
= Vascular: Janeway lesions, Splinter haemorrhages
= Embolic events: Stroke, PE, Digital infarcts, peripheral skin necrosis, Spleenomegaly

118
Q

Infective Endocarditis- Initial Rx

A

IE - Empiric Antibiotic regimens
Native Valve:
= Augmentin + Gentamicin iv 4-6 weeks
= Vanco + Genta + Cipro for 4-6 wks if penicillin allergic
—————————–
Prosthetic Valve:
= Vanco iv + Genta iv + Rifampicin PO for 6 weeks

119
Q

Pericarditis:
Triad & Causes

A

= Viral infections as EBV, CMV
= Bacterial - TB, Pneumococci
= Uremic pericarditis
= Post MI early near infarct zone
= Dressler syn, 2-14 wks, autoimmune
= Rheumatic Fever
= Malignancy - paraneoplastic
= CTD - SLE, RA, PAN
= Post Cardiac surgery or radiotherapy
= Chest Trauma - Blunt or penetrating
= Drugs: INH, Ciclosporin, Warfarin, Hydralazine
= Idiopathic
——————————
Rx = Admit + Brufen 2 wks + Colchicine may be - some times Steroids for autoimmune, Uremia etc

120
Q

Beck’s Triad of Tamponade

A

Beck’s triage in cardiac tamponade
1. Low Blood pressure
2. Distended neck veins, specially during inspiration known as Kussmaul sign
3. muffled heart sounds
—————————————————–
Other features:
- Pulsus paradoxus, SBP drops >10mmHg on inspiration
- Tachycardia, Tachypnea
- clear lung fields usually
ECG - Alterans in effusion, low voltage tachycardia, non specific changes
CXR - Globular heart, clear Lungs

121
Q

Respiratory Failure

A

Type 1 Resp Failure:
= Hypoxemic, PaO2 < 8 kPa
= failure of oxygenation
= usually due V/Q mismatch
= Pneumonia, ARDS, Asthma, PE, LVF ARDS
———————————-
Type 2 Resp Failure:
= Ventilatory failure with Pco2 >6.5 kPa
= due to Hypoventilation
= COPD, osa, Chest wall deformity, Neuromuscular disorders, Sedatives, Head injury
——————————-

122
Q

Kilopascal, Pascal, PSi

A

kPa = kilopascal (kPa), one thousand times the unit of pressure and stress in the metre-kilogram-second system (the International System of Units [SI]). It was named in honour of the French mathematician-physicist Blaise Pascal (1623–62). 1 kilopascal equals 1,000 pascals. 1 atm is equal to 101.325 kPa or 14.7 psi, which corresponds to atmospheric pressure at mean sea level. The SI unit of pressure is pascal (represented as Pa) which is equal to one newton per square metre (N/m2 or kg m-1s-2). Interestingly, this name was given in 1971. Pounds per square inch (PSI) is the pressure that results when a 1-pound force is applied to a unit area of 1 square inch. It is the measurement of pressure used in the imperial unit system of measurement.
Oxygen Values at sea level: Partial pressure of oxygen (PaO2): 75 to 100 millimeters of mercury (mm Hg), or 10.5 to 13.5 kilopascal (kPa). The partial pressure of carbon dioxide (PCO2) is the measure of carbon dioxide within arterial or venous blood. It often serves as a marker of sufficient alveolar ventilation within the lungs. Generally, under normal physiologic conditions, the value of PCO2 ranges between 35 to 45 mmHg, or 4.7 to 6.0 kPa.

123
Q

Hypoxemia Mechanisms

A
  1. Alveolar Hypoventilation
  2. Ventilation/Perfusion mismatch
  3. Pulmonary diffusion defects
  4. Reduced Oxygen concentration air
124
Q

Alveolar Hypoventilation

A
  1. Alveolar Hypoventilation - Oxygen not reaching alveoli due to:
    = Airway obstruction as in asthma
    = Respiratory depression, poor drive
    = impaired ventilation- hemopneumoTx
    alveolar partial pressure of Oxygen drops and that of CO2 increases from body.
125
Q

Ventilation-Perfusion Mismatch

A
  1. Ventilation/Perfusion mismatch
    V/Q > 1 - ventilation exceeds perfusion so some defect in perfusion as PE, collapsed alveoli,
    V/Q < 1 - Perfusion exceeds ventilation so there is some issue in some area as obstruction/ FB/ Mucus plug etc
    IF more than 30% pulmonary blood goes through regions with V/Q<1 ie no oxygen there - ultimate hypoxemia will result even if other areas get 100% Oxygen.
126
Q

Pulmonary Diffusion defects

A

conditions causing thickening of alveolar membranes such as fibrosing alveolitis. This impairs O2 transfer into the blood. More oxygen administration can correct this.

127
Q

High Anion Gap

A

High AG Metabolic Acidosis > 18
(MUD PILES)
M= Methanol poisoning
U= Uremia
D= DKA
P = Paraldehyde Poisoning
I= Iron/INH
L= Lactic Acid
E= Ethanol/ Ethylene Glycol
S= Salicylates

Other Causes of High AG:
(CAP MARC)
C= CO poisoning
A= Amphetamines
P= Paracetamol Toxicity
M= Metformin
A= Rhabdomyolysis
R = Alcoholic Acidosis
C= Cocaine

128
Q

Normal Anion Gap Metabolic Acidosis

A

Normal AG Metabolic Acidosis
FUSED CARS
Fistula, Uretero-enteric conduit, Saline load, Endocrine (HyperPTH), Diarrhea, Carbonic unhydrase, Ammonium Cl, RTA, Spironolactone

GI Tract Losses of HCO3 :
= Diarrhoea
= Pancreatic fistula
= Small bowel fistula
Renal Loss of HCO3 - RTA type 2
Renal failure
Hypoaldeosteronism (RTA Type 4)
Carbonic anhydrase inhibitor (Diamox)
Extra Chloride intake (NH4Cl, MgCl)

129
Q

Osmolor Gap (High)

A

Osmolality = 2(Na+K) + Urea +Glucose
Osmolar Gap - Measured - Calculated
Normal OG < 10 mosmol/kg
—————————
Caused of High OG:
= Ethanol
= Ethylene glycol
= Methanol
= Mannitol
= Lactic acid
= Acetone
= Formaldehyde
= End Stage Renal Failure
= Paraldehyde

130
Q

High Omolol Gap - ME DIE

A

ME DIE
= Methanol,
= Ethanol,
= Diuretics (such as mannitol and isosorbide),
= Isopropanol, and
= Ethylene glycol can reach millimolar concentrations in plasma, resulting in significant elevations in the osmolar gap.

131
Q

GOLD-MARK

A

High Anion Gap Metabolic Acidosis
G - Glycols
O - Oxoproline
L - L Lactate
D - D Lactate
M - Methanol
A - Aspirin
R - Renal Failure
K - Ketoacidosis

132
Q

Metabolic Alkalosis

A

Causes of Metabolic Alkalosis
1. Loss of Acid:
= GI tract loss: diarrhea, vomiting, NGT
= Renal losses: Excess Aldosterone in Conn’s syndrome - NA-H exchange rises
——————————–
2. Shift of H-ion into cell: Hypokalemia
———————————
3. Alkali Administration:
= HCO3 infusion
= Excess Antacid consumption
= Citrate in massive blood transfusions is converted to HCO3
—————————————-
4. Contraction Alkalosis:
loss of HCO3 rich, Cl rich ECF due to diuretics - Thiazides, Loop
Compensation - by Hypoventilation

133
Q

Respiratory Acidosis, CO2 retention

A

Causes of Respiratory acidosis
= CO2 retention as in COPD
= Hypoventilation
= CNS depression with Hypoventilation
= Acute airway obstruction
= Neuro-muscular disease

134
Q

Respiratory Alkalosis, CO2 washout

A

Causes of Respiratory alkalosis as
= Hyperventilation in normal Lungs
= Stroke, SAH, Meningitis
= Altitude Hyperventilation
= Fever, Pregnancy
= Meds: Salicylates, Aminophylline
= Sepsis
= CO Poisonins
= Hyperthyroidism
= Liver Failure
= Oral HCO3 therapy

135
Q

Alveolar-Arterial Gradient of O2

A

A-a Gradient =
PAO2(alveolar) - PaO2(arterial)
———————
PAO2 = FiO2 X (Pb-Psvp) - PaCO2 / RQ where
PAO2 = Alveolar Oxygen partialpressure
FiO2 = Fraction of inspire O2, 0.21@ air
Pb = atmospheric pressure, 101.3 kpa@ sea level
Psvp = Saturated vapour pressure of O2 (6.3 kpa)
RQ = Respiratory Quotient, 0.8
———————
so PAO2 = FiO2 X 95 - (Paco2/0.8)
——————————
Normal A-a gradient:
< 2 kPa in young adults
2-5 kPa in elderly

136
Q

ABCDE approach to Trauma

A

A - Airway assessment with Cspine protection: assess phonation, note any stridor, correct if any doubt
B - Breathing ie ventilation assessment, spontaneous or not, ventilate if problem
C - circulation ie any major bleeding, stop or tournique if found, fluids to give
D - Disability: GCS assessment, document
E - Expose completely and examine not to miss anything but prevent Hypothermia

137
Q

Heat Exhaustion

A

Body temperature usually < 39 degrees (102.2F)
Intact mental status
Non specific symptoms like: Malaise, Myalgia, Nausea, emesis, Headaches, Lightheadedness
Dehydration signs
Loss of electrolytes

138
Q

Mallampatti classification

A

I - soft palate, fauces and pillar visible
II - soft palate, uvula, fauces visible but not pillars
III - soft palate, base of uvula visible
IV - Hard palate only visible, (uvula not seen)

139
Q

3-3-2 Rule in LEMON assessment

A

3 = FINGER distance between upper and lower incisor teeth, if less means difficult mouth opening for intubation so be ready

3 = finger distance between HYOID bone and CHIN, if less means intubation might be difficult

2 = fingers distance between thyroid notch and floor of mouth, if less means difficult intubation

Any less distance in 3-3-2 rule indicates difficult intubation and be ready with difficult intubation tray, Tracheostomy tray and fiberoptic scopy

140
Q

LEMON assessment

A

Look: externally for thick neck, small mouth, any scars

Evaluate: 3-3-2 rule for various anatomical distances ( 3 fingers between incisors, 3 fingers between hyoid+chin, 2 fingers from thyroid to floor of mouth)

Mallampatti score: 1-4 score

Obstruction features: Epiglottitis, tonsils, abscess, traumatic damage

Neck movement assessment, dont do it if Hard collar in situ due to suspected neck trauma

141
Q

Cold Injury types

A

Frost Nip:
mildest form, Pain, pallor & numbness of affected part, Reversible with rewarming

Frost Bite: Freezing of tissues
1st degree:
Hyperemia, edema without skin necrosis
2nd degree:
blisters, skin necrosis, hyperemia, edema
3rd degree:
Full thickness skin necrosis, Haemorrhagic blisters
4th Degree: Gangrene

Non-Freezing Injury:
due to microvascular endothelial damage
stasis and vascular occlusion Ex - Trench foot

142
Q

Odontoid Process Fracture Types

A

Type I: involves tip of odontoid process

Type II: through base of dens, most common

Type III: at base of dens process and extends laterally into the body of axis

143
Q

Depth of Burn assessment

A

First Degree Burns:
superficial with erythema, blisters and intense pain. Epidermis remains intact, no need IV fluids

Partial Thickness, 2nd Degree Burns:
Painful even with air currents, Red, shiny with blistering, wet appearance, need 14 days to heel, may scar

Full Thickness Burns, 3rd Degree:
Dark, leathery or white,
painless as nerves destroyed
generally dry without blanching
doesnot heel, needs skin replacement

144
Q

Myotomes

A

C5 = Deltoid muscle, arm abduction
C6 = forearm flexion, Biceps
C7 = forearm extension, Triceps
C8 = Flexion of wrist and fingers
T1 = small finger abductors (digiti minimi), abduction and adduction of fingers

L2 = Hip flexors, Iliopsoas
L3L4 = Knee extensors Quadriceps, Patellar reflex
L4L5S1 = Knee flexion: Hamstrings
L5 = Ankle, Big Toe dorsiflexion, tibialis anterior & extensor hallucis longus
S1 = ankle plantar flexors, Soleus, Gastrocnemius

145
Q

Heat Stroke

A

Life threatening condition
Two forms: Classic and Exertional
Hot flushed dry skin
High core temperature > 40 degree (104F)
Dehydration severe
CNS dysfunction ie altered sensorium
Delirium, convulsions, coma
Multiple Oran Dysfuction, DIC sets in

146
Q

Pediatric Trauma Score

A

Weight - >20kg, 10-20 kg, < 10 kg
Airway - Normal, Oral or nasal reqd, Intubation
Systolic BP - > 90 mmHg, 50-90, < 50
Perfusion - Good, Carotids felt, weak centrals
Alertness - Awake, Obtunded, Comatose
Fracture - no #, Single closed, Open multiple
Cutaneous - Non visible, contusion, Tissue loss
injury - Abrasion, Gunshot, Cuts < 7 cm. Stab deep

2 point - 1 point - minus 1 point

147
Q

Pregnancy: Lab Values (Normal)

A

Haematocrit: 32-42%
WBC count: 5-12 k
Arterial PH: 7.40-7.45
Bicarbonate serum - 17-22
PaCO2 - 25-30mmHg, due to raised tidal volume
Fibrinogen: 3.79 gms/Lit in third trimester

148
Q

Haemorrhage Classification: Severity

A

Class I Haemorrhage:
- blood loss upto 750 ml, 15%
- Pulse rate < 100
- Systolic blood pressure - normal
- Pulse pressure - normal or raised
- Respiratory Rate - 14-20
- Urine output > 30 ml per Hour
- Mental Status - slightly anxious
- Initial Fluids to give - Crystalloids

Class II Haemorrhage:
- blood loss: upto 750-1500 ml, 15-30%
- Pulse rate < 100-120/min
- Systolic blood pressure - normal
- Pulse pressure - decreased
- Respiratory Rate - 20-30/min
- Urine output: 20-30 ml per Hour
- Mental Status - anxious but not confused
- Initial Fluids to give - Crystalloids

Class III Haemorrhage:
- blood loss: 1500-2000 ml
- Pulse rate: 120-140
- Systolic blood pressure - below 90
- Pulse pressure - decreased
- Respiratory Rate - 30-40
- Urine output: 5-15ml per Hour
- Mental Status - anxious, confused
- Initial Fluids to give - Crystalloids, Blood

Class IV Haemorrhage:
- blood loss > 2000 ml, 40%
- Pulse rate: > 140
- Systolic blood pressure - < 90
- Pulse pressure - decreased
- Respiratory Rate - > 35/min
- Urine output = negligible
- Mental Status - confused
- Initial Fluids to give - Crystalloids, blood

149
Q

Shoulder Dislocation: Atraumatic: AMBRI

A

A - Atraumatic born loose shoulder
M - Multidirectional
B - Bilateral usually
R - Rehabiliation of muscle strengthening
I - Inferior capsular shift: surgery if rahab fails

150
Q

Shoulder Dislocation: Trauma: TUBS

A

T - Traumatic
U - Unilateral
B - Bankard Lesion: Capsule of shoulder is attached to neck of scapula but dettached from glenoid labrum
S - Surgical treatment

151
Q

Rotator Cuff Muscles: SITS

A

SITS:
Supra-spinatus = abduction of shoulder
Infra-spinatus = External rotation@ shoulder
Teres minor = External rotation + Extension
Subscapularis = Internal Rotation

152
Q

Anaphylaxis Management Tips

A

Oxygen,
Epinephrine - 0.5 ml IM 1:1000, repeat @ 5 min
Epipen - 300 mcg if used instead of IM dose
Chlorpheniramine - 10 - 20 mg slow iv
Hydrocortisone - 100-500 mg iv
Salbutamol 5 mg nebulization
IV Fluids: 1000-2000 ml iv prn

Give 50% dose of Salbutamol or Epinephrine if patient is on TCA’s or MAO inhibitors.

INFORM - Committee on Safety of Medicines
Provide - Medical Alert Bracelet
Arrange - possible Desensitisation

153
Q

Septic Arthritis Pearls

A

The case fatality rate of septic arthritis is reported as 11%.
More than one joint is affected in approximately 15% of cases of septic arthritis. [4] [5] Septic polyarthritis is more frequent among patients with rheumatoid arthritis
Apart from septic arthritis, common differential diagnoses of a hot swollen joint to consider include :
- Gout
- Inflammatory arthritis
- Haemarthrosis
- Trauma
- Bursitis / cellulitis.
The Gram stain is positive in only 50% of episodes of septic arthritis.
here is no evidence to support direct inoculation of joint aspirates into blood culture bottles. The specimen is sent fresh to the laboratory for direct agar and broth enrichment culture.
Anticoagulation with warfarin is not an absolute contraindication to needle aspiration if septic arthritis is suspected.
Antibiotics are given intravenously for up to two weeks or until signs improve. They are then changed to oral antibiotics for about four weeks during which time the patient is often discharged with outpatient follow up.
Flucloxacillin has a poor profile in terms of joint space penetration. In practice treatment needs to be given for at least six weeks.

154
Q

Organisms causing Septic arthritis

A

Which organisms cause septic arthritis?
The most common organisms causing septic arthritis are Gram positive cocci: Staphylococcus aureus is the most common type, and streptococci, particularly the beta haemolytic streptococci (for example group A streptococci) are also frequently found.

Over recent years there has been an increasing incidence of MRSA as a cause of septic arthritis, particularly where the patient has acquired the infection in a hospital or nursing home. Community acquired MRSA is increasing in incidence as a cause of septic arthritis, and PVL positive S. aureus has also been isolated.

Gram negative bacteria account for between 10 to 20% of cases of septic arthritis and are more common in older patients and patients who are immunocompromised. Neisseria gonorrhoea is more commonly found in the US than the UK and western Europe, although overall the proportion of cases is low compared to S. aureus. Neisseria meningitidis has also been isolated. Haemophilus influenzae type b is a rare cause of septic arthritis, and in children it has declined as a cause of septic arthritis due to immunisation.

Intravenous drug abusers are especially susceptible to mixed bacterial infections, fungal infections, and unusual organisms.

155
Q

Aortic dissection clues

A
  • Wide mediastinum in CXR
  • Double knuckle aorta
  • aortic wall breadth > 5mm gaping
  • Left pleural effusion
  • tracheal deviation to right
  • difficult to control chest pain
  • new AR murmur
  • absent or unequal radial pulses
  • neurological signs due to carotid or spinal artery involvement
156
Q

Contraindications for Air Travel

A

Contraindications for air travel:
- unstable angina
- severe, decompensated chronic heart failure or symptomatic valvular heart disease
- uncontrolled hypertension or arrhythmia
- CABG or CVA within the last 14 days
- Eisenmenger syndrome

Following acute coronary syndrome:
low risk: within 3 days of event
medium risk: within 10 days of event
high risk or awaiting intervention or treatment: defer air travel until stable

Respiratory Contraindications for air travel:

  • recent hospitalization for acute respiratory illness
  • severe, labile asthma
  • bullous lung disease
  • spontaneous pneumothorax within 7 days or - traumatic pneumothorax within 14 days
  • pleural effusion within 14 days
  • need for high levels of supplemental oxygen
  • major chest surgery within 10 days
  • severe anemia (Hb < 8.4 g/dl)
  • cerebral edema due to tumor
  • < 7 weeks since cranial surgery
  • cardiovascular, gastrointestinal, or pulmonary complications
  • uncomplicated appendectomy or laparoscopic surgery within 5 days
  • major surgery within 14 days
  • colonoscopy or gastrointestinal bleed within 24 hours
  • partial bowl obstruction
  • liver failure, especially if due to cirrhosis or heavy alcohol use
157
Q

Empty Can Test (Rotator Cuff)

A

Tests Supraspinatus tendon function
Abduct shoulder to side, point thumb down as if emptying a can and push up against resistance. Pain at shoulder indicates probable supraspinatus tendon tear or strain

158
Q

External Rotation Test @ shoulder

A

for infra-spinatus and Teres minor function
With elbows at sides and flexed to 90 degrees ie shoulders to side at 90 degrees and elbows at right angle anteriorly - externally rotate at shoulder against resistance - pain indicates infra-spinatus or Teres minor tear.

159
Q

Liff off Test for subscapularis

A

Patient places dorsum of hand on lumbar back and tries to lift it off the back. Cannot do this if subscapularis injured.

160
Q

Hawkin’s impingement, Subacromial

A

Pain at shoulder with internal rotation when the arm is flexed to 90 degrees with the elbow bent to 90 degrees - indicates sub-acromial impingement at shoulder.

161
Q

Drop Arm rotator Cuff test

A

Patient is unable to lower his arm from raised position - indicates large rotator cuff tear

162
Q

Anterior drawer Test: Ankle

A

Examiner pull forward on patient’s heel by pushing from back to front in a relaxed position while stabilizing lower leg with other hand. Excessive ankle movement indicates anterior Talo-fibular ligament injury (ATFL).

163
Q

Inversion Stress Test: Ankle

A

Examiner inverts ankle with one hand while stabilizing lower leg with the other hand. Excessive translation or palpable clunk of talus on tibia suggests Calcaneo-fibular Ligament tear (CFL)

164
Q

Squeeze test: Mid Leg

A

Examiner compresses tibia/ fibula at mif calf - pain at anterior ankle joint below where examiner is squeezing indicates syndesmotic injury.

165
Q

Lachman Test: Knee

A

indicated ACL injury if positive,
with knee in 20 degree of flexion pull tibia against femur bu encircling hand around knee - excessive translation of knee anteriorly suggests ACL tear

166
Q

Anterior Drawer Test: Knee

A

with foot fixed on bed, and knee bent at 90 degrees, pull knee forward against femur - excessive anterior movement of knee forward indicates ACL tear.

167
Q

Vulgus Stress: Knee

A

Knee in 30 degree flexion and again at full extension, medially directed force at knee and laterally directed force at ankle - excessive translation of knee to medial side indicates MCL tear.

168
Q

Varus Stress: Knee

A

Knee in 30 degrees and again in full extension push knee laterally and pull ankle medially -excessive translation of knee indicates Lateral collateral ligament injury.

169
Q

Drug choices for Status Epilepticus

A
  1. Magnesium sulfate: Eclampsia, Malnutrition, Alcoholics
  2. Lorazepam 5-10 mg or
  3. Diazepalm 5-10 mg
  4. Fosphenytoin 15 mg/kg at 150 mg/min or
  5. Phenytoin 15 mg/kg at 50 mg/min
  6. Pabrinex A+B, in 50 ml NS over 30-60min
  7. General anaesthesia, Intubation
170
Q

Causes of Hypoglycemia

A
  • Insulin use or OHA use
  • Alcohol causes direct Hypoglycemia
  • Insulinoma
  • Addison’s disease
  • Pituitary insufficiency
  • Post Gastrectomy
  • Liver failure
  • Malaria
  • Extra pancreatic tumors
  • Suicide attempts using large OHA/Insulin doses
171
Q

Rx of Hypoglycemia

A

If sugar < 3 mmols, take a venous sample
Give Oral Leucozade, Dextrosol or Sugar lumps
Give Biscuit with milk
—————-
Glucagon 1 mg sc/im/iv
Dextrose 50 ml 50% iv then flush with saline
IV Dextrose 10% infusion, keep sugar 7-11 mmol
Octreotide for SFU toxicity

Mannitol or Dexamethasone if cerebral edema suspected due to hypoglycemia but get CT also

172
Q

Foot nerve supply

A
173
Q

Kussmaul’s sign

A
174
Q

Pulsus paradoxus

A
175
Q

4 AT scoring for delirium

A
176
Q

Tumor markers

A
177
Q

Head injury signs

A
178
Q

Capnographic waveform

A
179
Q

Spine trauma & MethylPred

A
180
Q

Choice of anti emetics

A

The most appropriate first-line antiemetic in this patient with severe hypercalcaemia would be haloperidol. It is a dopamine D2 antagonist and useful in opioid-induced nausea and vomiting too. Haloperidol is usually given orally, once or twice a day, to treat chemically or metabolically induced vomiting. This is an off-label indication for haloperidol tablets and an oral solution. Metoclopramide is useful where there is gastric stasis, cyclizine is useful in raised intracranial pressure or motion sickness and ondansetron in the treatment of chemotherapy-induced emesis.

181
Q

Tumor Lysis Syndrome

A

The condition is classified using the Cairo-Bishop (2004) definition. This consists of two categories Laboratory Tumour Lysis syndrome (LTS) and Clinical Tumour Lysis Syndrome (CTLS).

Laboratory Tumour Lysis syndrome (LTS) is when any two or more of the following occur within 3 days of receiving chemotherapy:

Serum uric acid level increases by 25% or more
Serum potassium level increases by 25% or more
Serum phosphate level increases by 25% or more
Serum calcium level decreases by 25% or more
This electrolyte imbalance occurs because the cytotoxic agents kill (lyse) the tumour cells, as they die they release cellular contents into the bloodstream which results in raised serum phosphate, potassium and urate and reduced calcium. The serum calcium is lower as a consequence of the raised serum phosphate, calcium binds with phosphate thus leading to a lowering of the serum calcium.

Clinical Tumour Lysis Syndrome (CTLS) develops when there is a significant rise in serum creatinine, cardiac arrhythmia, seizure and death.

Reflection: It is important to consider that each establishment may interpret its results differently and this needs to be considered when analysing the blood values of patients.

182
Q

Biliary presentations

A

Please read the difference between
1. Biliary colic (only RUQ pain with no fever or jaundice)
2. Cholecystitis (RUQ pain with fever but no jaundice), and
3. Cholangitis (RUQ pain with fever and jaundice).

183
Q

Duke’s Criteria for IE

A

Major criteria for Infective endocarditis (IE) encompass:
- Two positive blood cultures yielding a characteristic microbe
- Persistent bacteraemia
- Serological positivity for Coxiella
- Positive echocardiography demonstrating vegetation, abscess, new regurgitation, and dehiscence of prosthetic valves.

The minor criteria for Infective endocarditis (IE) include:
- Predisposing cardiovascular disease
- Pyrexia >38oC
- Immunological events
- Vascular events such as major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial haemorrhage, conjunctival haemorrhages, and Janeway lesions.
- Echocardiographic findings compatible with IE but failing to fulfil a major criterion and microbiological events (positive blood culture but not fulfilling a major criterion) are also considered as minor criteria.

Blood culture-negative IE refers to infectious endocarditis in which no causative microbe can be isolated using conventional blood culture methods.

184
Q

King’s college criteria for Acute Liver injury

A

King’s College Hospital criteria for transplantation in acute liver failure:

Paracetamol

+ pH <7.30 (irrespective of grade of encephalopathy)

+ Prothrombin time >100 seconds and serum creatinine >300 µmol/L if in grade III or IV coma

Non-paracetamol

+ Prothrombin time >100 seconds (irrespective of the grade of encephalopathy) or

+ Any three of the following (irrespective of the grade of encephalopathy):

aetiology: non-A, non-B (indeterminate) hepatitis, halothane hepatitis, idiosyncratic drug reactions
age <10 or >40 years
jaundice to encephalopathy interval >7 days
prothrombin time >50 seconds
serum bilirubin >300 µmol/L

185
Q

Vaccine induced Thrombocytopenia thrombocytopenia

A

thrombocytopaenia associated with headache 2 weeks after receiving the ChAdOx1 nCoV-19 (AstraZeneca) SARS-CoV-2 vaccine, hence a diagnosis of cerebral venous sinus thrombosis due to vaccine-induced thrombocytopaenic thrombosis should be considered and assessed with CT. The diagnosis of VITT can be supported by measuring antibodies to PF-4. Treatment with IV immunoglobulin plus high-dose glucocorticoids can improve the outcome together with anticoagulation with non-heparin-based anticoagulation, such as argatroban or fondaparinux.

The occurrence of VITT is rare and estimated to be 1 in 100,000 exposures and recent studies reveal that this is much lower than the thrombotic risk associated with COVID-19 infection. However, most authorities now avoid the use of the ChAdOx1 nCoV-19 (AstraZeneca) SARS-CoV-2 vaccine in individuals under 50 years.

186
Q

Conditions presenting with HTN Emergency, bP >200/120

A
  • Essential HTN
  • Co-arctation of Aorta
  • Renovascular disease: Atheroma, fibromuscular dysplasoa, acute renal disease
  • Renal Parenchymal disease: Acute GN, Vasculitis, Scleroderma
  • Endocrine: Phaechromocytoma, Cushing’s syndrome, Primary Hyperaldosteronism, Thyrotoxicosis, hyperPTH, Acromegaly, Adrenal cancer
  • Eclampsia, Pre-Eclampsia
  • Vasculitis
  • Autonomic hyperactivity
  • Drugs: Cocaine, MAO inhibitors, Amphetamines, Ciclosporine, Withdrawal of BB or Clonidine
187
Q

Conditions associated with Aortic dissection

A
188
Q

Myasthenia gravis management

A

Management of Myasthenia Gravis:

Mild disease:
- Pyridostigmine (1st line)
- Corticosteroids
- Other immunosuppressants as steroid sparing

Moderate disease:
- Pyridostigmine, Steroids, Azathioprine, MMF, Ciclosporin, Tacrolimus as combinations
- Thymectomy
- plasma exchange
- IV immunoglobulin

Severe MG crisis:
Unable to swallow
Respiratory insufficiency, CO2 retention, dropping FVC, Hypoxic
- ventilation if FVC<15ml/kg (normal>60) negative Inspiratory force 20 cmH2O or less (normal >70)
- IV IG or plasma exchange
- High dose steroids, DVT prophylaxis, ICU care

189
Q

NIV indications in acute hypercapneic respiratory failure

A

In COPD, after trial of bronchodilators and controlled oxygen therapy: start NIV if
- Ph < 7.35
- Pco2 > 6.5
- RR > 23

190
Q

Intraosseus access sites

A
  1. Humerus - lateral surface of proximal humerus, 1 cm above surgical neck, at greater tubercle
  2. Proximal tibia: 2-3 cm below tibial tuberocity
  3. Distal tibia - 3 cm above medial malleolus medial surface
  4. Distal femur - anterolateral surface of distal femur, 3 cm above lateral condyle
191
Q

Allis technique for reduction of posterior Hip dislocation

A

Stand on trolley, sedate the patient
Assistant needs to press down on ASIS of patients pelvis same side of dislocation

Flow the hip & knee both 90 degrees
Grasp patients knee with both hands
Lean back and pull the knee up, pulling the patients hip up - clunk confirms relocation - confirm with X-rays

192
Q

Hip fracture types

A

See picture

193
Q

Ketamine contraindications

A

All are relative
- airway instability/ tracheal pathology
- predisposition to laryngospasm
- predisposition to apnea
- severe CAD/IHD
- CSF obstructive states
- previous psychosis
- Hyperthyroidism
- Globe injury or glaucoma

194
Q

Croup severity score, Westley

A

See picture

195
Q

Risk of asystole in bradycardia

A

Recent asystole:
Mobitz type II block - regular PR with sudden drop beat
Complete heart block with broad QRS
Ventricular pause > 3 seconds

196
Q

Medications for Bradycardia Rx

A

Atropine 500 mcg
Second line drugs:
- Glucagon if BB/CCB overdose suspected
- Digoxin FAB if toxicity features
- IV Aminophylline for bradycardia in inferior STEMI, spinal cord injury, post cardiac transplant
- Infusion of isoprenaline, adrenaline, dopamine
Cardiac pacing - transcutaneous or transvenous

197
Q

Kawasaki disease (vasculitis)

A

Acute febrile illness > 5 days
Conjuntival suffusion, bilateral
Erythematous rash over body
Strawberry tongue
Cervical lymphadenopathy
Oral hyperemia
Lips - fissuring, cracking, swelling, redness
Uncommon:
- neck stiffness due to aseptic meningitis
- anterior uveitis
- facial palsy
- pleural effusion
- pulmonary infiltration
- pericardial effusion, CHF

198
Q

Malignant Hyperthermia

A

Autosomal dominant, 1:30,000 births
Drugs - can trigger it
- Halothane
- Suxamethonium
- Isoflurane
- Desflurane
- Sevoflurane
Master spasm,
High fever (late)
Rhabdomyolysis
Unexplained - tachycardia, rising Pco2, tachypnea, rising need for O2 in patients under anaesthesia

Dantrolene 2.5 mg/kg
Cooling, Hydration,
avoid CCB for arrhythmias
Forced diuresis, NaHCO3, Lasix

199
Q

Neuroleptic malignant syndrome

A

Tetrad of:
1. Altered sensorium
2. muscle rigidity
3. Autonomic instability
4. Hyperthermia
Caused by Dopamine antagonist antipsychotics or their sudden withdrawal

HTN, Tachycardia, Tachypnea, Fever, Diphoresis, Hypersalivation, Stupor, lead-pipe rigidity, normal pupils, rising CK,

Rx - dantrolene, Bromocriptine, Amantadine

200
Q

Serotonin syndrome

A

Due to serotonin agonist agents

Fever, HTN, Tachycardia, Tachypnea, Diphoresis, Hypersalivation, Agitation, Delirium,

Hyper-, reflexia, Rigidity with clonus, Dilated pupils, Hyperperistasis,

Rx - Valium, Cyproheptadine, Stop offending agent, supportive

201
Q

Doses of local anaesthetics

A

Lignocaine:
3 mg /kg without adrenaline
7 mg/kg without adrenaline
Action lasts 1-2 hrs & 2-4 with adrenaline

Prilocaine:
6 mg/kg without adrenaline
9 mg/kg with adrenaline
Action lasts 1-2 & 2-4 hrs
Used in Bier’s block

Bupivacaine:
2 mg/kg
Action lasts 3-12 hrs
Used in fascia iliaca block

202
Q

Hexavalent vaccine (6 in 1)

A

vaccine shot contains -
1. diphtheria,
2. tetanus,
3. whole-cell pertussis [DTwP],
4. hepatitis B and
5. Haemophilus influenzae type b) with
6. inactivated polio vaccine (IPV).

203
Q

Anterior uveitis: signs

A

Ciliary flush
Small fixed irregular pupils (adhesions)
Eye tender to palpation
Talbot sign - pain on convergence(reading)
Slit Lamp- synechiae, Flare, Hypopyon, keratic precipitates
Symptoms- painful red eye, more on reading, blurred vision, watering, photophobia

204
Q

Important pediatric calculations

A

Weight:
Upto 12 months - (0.5 x age) + 4
1-5 yrs - (2 x age) + 8
6-12 years - (3 x age) + 7
————-
ET tube size, internal diameter
: size = age /4 + 4 uncuffed
Size = age/4 + 3.5 cuffed
Infant 6 months = size 4
Infant at 12 months = size 4.5
Neonate < 3 kg = size 3 or 3.5
——-
ET tube length
Age /2 + 12 for oral tube
Age/2 + 15 for nasal tube

205
Q

Radioactivity

A

Amount of ionizing radiation released by a material,
US unit - Curie(Ci)
International Unit - Becquere(Bq)
1 Bq = 2.7 x 10 rest to -11 C

206
Q

2D Echo signs of tamponade

A

The core echocardiographic findings of pericardial tamponade consist of: a pericardial effusion, diastolic right ventricular collapse (high specificity), systolic right atrial collapse (earliest sign), a plethoric inferior vena cava with minimal respiratory variation (high sensitivity), and exaggerated respiratory cycle changes in mitral and tricuspid valve in-flow velocities as a surrogate for pulsus paradoxus.

207
Q

Indications to Sync Shocks

A

Unstable SVT
Unstable AFib
Unstable A flutter
Unstable regular monomorphic tachycardia with pulse

Emergency Medicine (1 decks)

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