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PLAB 1 August 2024 > Emergency Medicine > Flashcards

Emergency Medicine Flashcards

1
Q

Definition of Acute dystonia?

A

It’s a movement disorder characterized by involuntary painful muscle contractions and abnormal postures that involves the face, neck and trunk.
Torticolis (head rotated in an odd angle).

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2
Q

Causes of a acute dystonia?

A

Medications, namely:

•Antipsychotics:
-Haloperidol
-Chlorpromazine
-Risperidone

•Antiemetics:
- Metoclopramide

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3
Q

Time onset for acute dystonia?

A

Quick onset after initiation of the medication to 5 days after the initiation of the causative medication.

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4
Q

Treatment of acute dystonia?

A

First line:
-Procyclidine (IV or IM it’s anticholinergic)

2nd line:
-Diazepam IV (benzodiazepine)

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5
Q

What is the management of acute exacerbation of COPD?

A

1.Brochodilators
- Salbutamol (B2 agonist) nebulized 5mg
- (Consider) Nebulized ipratropium bromide 0.5mg (anticholinergic).

2.Corticosteroids
- Prednisolone 30 mg STAT (continue 30mg PO/day for 1-2 weeks)
OR
- Hydrocortisone 100mg IV;

3.Aminophylline
- In cases refractory to the treatment with bronchodilators;

4.Antibiotics if:
- Purulent sputum;
- Fever;
- ↑CPR;
- Signs of pneumonia.

5.O2 therapy
- Initiate with venturi mask with FiO2 of 24-28%;
- The goal is SPO2 in between 88-92%;
- SPO2 <80% will lead to anaerobic metabolism and metabolic acidosis;
- SPO2 >92% will lead to retention of CO2 and respiratory acidosis (inhibition of respiratory drive; the respiratory drive is “driven” by CO₂).
➜ In a patient with COPD, they become desensitised to higher levels of CO2 in the blood, and so they need a higher level of CO2 to generate enough respiratory drive to breathe properly.

6.NIV use when:
- ↓PH (<7.35) + ↑PCO2 (which will lead to resp. acidosis) in spite of adequate O2 therapy offering;

7.Invasive ventilation if:
- Failure of NIV: ↓↓PH (<7.26) + ↑↑PCO2 in spite of NIV;
- Contraindications of NIV: resp. arrest; ↓consciousness level; High aspiration risk.

8.Scenarios
- ↓PH + ↑PCO2 ➜ NIV or Invasive (depends of the case);
- Normal PH + ↑PCO2 ➜ Venturi mask
- Normal PH + Normal/↓PCO2 +↓PO2 (hypoxemia) ➜ Titrate O2 to achieve target 88-92%.

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6
Q

Define Anaphylaxis.

A

It’s an acute allergic reaction, with rapid onset of symptoms that can lead to death.

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7
Q

What are the causes of Anaphylaxis?

A
  • Food
  • Insects bites/venom
  • Medications
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8
Q

Symptoms of anaphylaxis?

A

Skin
• Erythema
• Pruritus
• Urticaria
• Angiodema

Oral
• Lips, tongue and uvula oedema.

Respiratory
• Oedema of pharynx, epiglottis and larynx;
•Dyspnoea;
•Chest thightness;
•Cough;
• Wheeze
• Congestion, rhinorrhoea, sneezing.

Cardiovascular
- Hypotension/Shock due to peripheral vasodilation and increased vascular permeability leading to leakage of plasma from the circulation.
- Dizziness
- Syncope
- Tachycardia

Ocular
- Periorbital oedema.

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9
Q

Anaphylaxis management?

A

1- ABCD
2- Epinephrine IM (middle 3rd of the anterolateral thigh)

• <6 years: 150mcg IM (0,15 ml 1 in 1000)
• 6-12 years: 300 mcg IM (0,3ml 1 in 1000)
• >12 years: 500 mcg IM (0,5ml 1 in 1000)
• Chlorphneramine should be given after Epi.

3- High flow O2
4- (If) Hypotension: IV fluids.

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10
Q

Arterial blood gases

Is the patient hypoxic?

A
  • PAO2 = 80-100 mmHg / 10.7-13.3 kPa
  • Type 1 respiratory failure: ↓PO2 + Normal/low PCO2
  • Type 2 respiratory failure: ↓PO2 + ↑PCO2
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11
Q

Acid-base balance

Is the patient acidotic or alkalotic?

A
  • PH <7.35: Acidosis
  • PH >7.45: Alkalosis
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12
Q

Acid-base balance

PH↓ + ↑PCO2

Whats’s the cause of this acid-base disorder?

A

Respiratory acidosis
* CO2 makes the blood acidotic ➜ Patient retains CO2 acutely;

HCO3 = 24-30 mmol/L
* It is produced by the kidneys to act as a buffer to neutralize the acid in order to maintain normal levels of PH;
* It is a slow process, it takes time so:
1. Acute resp. acidosis: normal HCO3 (it cannot be produced fast enough to compensate for the ↑ of CO2);
2. Chronic resp. acidosis: ↑HCO3 is indicative of a chronic retention of CO2 (e.g.: COPD).

  • In an acute episode of COPD, the patient cannot compensate fast enough so it becomes acidotic even though it has an elevated levels of HCO3.
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13
Q

Whats’s the cause of this acid-base disorder?

↑PH + ↓PCO2

A

Respiratory alkalosis
* An increase in RR will get rid of CO2.
1. Hyperventilation: ↑PH ↓PCO2 ↑PO2
2. Pulmonary embolism: ↑PH ↓PCO2 ↓PO2 (hypoxemia)

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14
Q

Whats’s the cause of this acid-base disorder?

↓PH + ↓HCO3

A

Metabolic Acidosis
* ↑Lactate : -Raised in anaerobic metabolism, indicative of tissue hypoxia.
* ↑Ketones: -Diabetic ketoacidosis
* ↑H+ ions : - Renal failure; - Type 1 renal tubular acidosis; - Rhambomyolysis;
* ↓HCO3: -Diarrhoea; - Renal failure; -Type 2 renal tubular acidosis.

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15
Q

Whats’s the cause of this acid-base disorder?

↑PH + ↑HCO3

A

Metabolic alkalosis
* There’s loss of H+ ions due to:
* Vomiting: stomach produces hydrochloric acid ➜ loss of H+ ions;
* Kidneys loss of H+ ions by the kidneys can be due to: ↑Aldosterone ➜ will lead to excretion of H+ ions.

↑Aldosterone can be due to:
- Conn’s syndrome (1ry aldosteronism);
- Liver cirrhosis;
- Heart failure;
- Use of loops/thiazide diuretics.

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16
Q

Acid-base balance

Base excess

A

BE=±2
* BE >+2 = Metabolic alkalosis OR Compensated resp. acidosis
* BE < -2= Metabolic acidosis OR compensated resp alkalosis

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17
Q

In ADULTS

What is the management of acute exacerbation of Asthma in adults?

A
  1. Initial immediate treatment
    * O2 administration if SPO2<92% (goal is SPO2= 94-98%)
    * Bronchodilators: -Salbutamol nebulized 5mg OR Terbutaline nebulized 10mg
    * Corticosteroids: - Prednisolone 40-50mg PO OR Hydrocortisone 100mg IV

2.If life threatening features present :
* O2 administration;
* Nebulized salbutamol: -5 mg every 15 min OR 10mg continuous nebulization; - Add Ipratopium bromide 0.5mg to the salbutamol nebulizations.
* MgSO4 IV 1.2-2g (single dose) over 20 min.
* If symptoms are refractory to the treatment: - Salbutamol IV or Aminophylline IV.

3.If improvement of symptoms in 15-30min:
* Salbutamol nebulizations every 4h;
* Prednisolone 40-50mg PO for 5-7 days.

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18
Q

ATLS: Blood loss / Hypovolemia

Describe the 4 different classes

A
  1. Class 1:
    * Blood loss: <750ml / <15%
    * HR: 60-100 bpm

2.Class 2:
* Blood loss: 750 - 1500ml / 15 - 30%
* HR: 101-120 bpm

3.Class 3:
* Blood loss: 1500 - 2000ml / 30 - 40%
* HR: 120 - 140 bpm

4.Class 4:
* Blood loss: >2000ml / >40%
* HR: >140 bpm

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19
Q

BURNS

ATLS formula for fluid requirements?

A

2ml x TBSA% x Weight in Kg

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20
Q

BURNS

Parkland formula for fluid requirements?

A

4ml x TBSA% x Weight in Kg

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21
Q

BURNS

After calculating the fluid requirements, how to administer the fluids?

A
  • Hartmamnn’s solution used
  • 1/2 of the total fluid requirements to be administered in the first 8h (from the time of burn injury and not arrival to the hospital);
  • 2nd 1/2 of the total fluid requirements to be administered over the next 16h.

Calculate the fluid requirements using the ATLS or Parkland formulas.

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22
Q

BURNS

Describe the Wallace Rule of 9’s

Percentage of burned area

A
  • Head and neck (front & back) : 9% (4.5% each side);
  • Upper limbs (front & back each): 9% each (total 18% for both limbs);
  • Thorax and Abdomen (front): 18%
  • Thorax and Abdomen (back): 18%
  • Lower limbs (front & back each): 9% each (total 18% for both limbs);
  • Perineum: 1%
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23
Q

BURNS

When to administer the fluids

Burn percentage to start fluids

A
  • Children: 10% of TBSA burned.
  • Adults: 15% of TBSA burned.
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24
Q

BURNS

When to refer to burns facilities?

A
  1. Children: >2% TBSA burned;
    Adults: >3% TBSA burned;

2.Burns involving these areas:
- Face
- Hands
- Feet
- Genitalia
- Perineum
- Major joints

3.All deep dermal and full thickness burns;
4.All electrical and chemical burns;
5.All inhalation burns;
6.All non-accidental injury burns;
7.All burns not healed within 2 weeks.

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25
Q

BURNS

What is the management of full thickness circumfential burns affecting a limb or the torso?

A

Escharotomy
1. Limbs: full thickness circumfential burns can cause compartment syndrome ➜ urgent escharotomy.
2. Torso: full thickness circumfential burns can impede respiration.

Compartment syndrome: severe pain + paraesthesia + ↓ or absent pulses.

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26
Q

What are the causes of Carbon monoxide poisoning?

A
  • Car exhausts
  • Fire
  • Faulty gas heaters
  • Paint remover (stripper)
  • Industrial solvent.
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27
Q

What is the mechanism of action of Carbon monoxide poisoning?

A
  • It bonds to haemoglobin forming carboxyhaemoglobin (COHg).
  • It reduces the capacity of the blood to carry oxygen.
  • Oxygen delivery to the tissues will be decreased resulting in tissue hypoxia.
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28
Q

What are the symptoms of Carbon monoxide poisoning?

A
  • Headache
  • Nausea and vomiting
  • Vertigo
  • Confusion

► Severe toxicity
- Pink skin and mucosae (cherry skin)
- Hyperventilation
- Arrhythmias
- Fever
- Coma
- Death

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29
Q

What is the management of Carbon monoxide poisoning?

A
  • Clear the airway;
  • Give 100% O2:
    1. If patient is conscious put a tight fitted mask with O2 reservoir;
    2. If patient is unconscious intubate and ventilate in IPPV on 100% O2.

➨ The elimination half-life of CO is:
- 4h in breathing air;
- 1h on 100% O2
- 23 min on O2 at 3 atmosphere pressure.

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30
Q

What is the investigation / test in CO poisoning?

A

Sphectophotometry

It’s the COHgB levels in blood.

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31
Q

In CO poisoning, when to consider hyperbaric O2 treatment?

A

Controversial type of treatment
* >20% of COHb levels;
* Pregnacy
* Myocardial ischaemia
* Neurological signs other than headache.

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32
Q

Intoxications

What are the symptoms of Paracetamol poisoning?

A

Initial sypmtoms
* Nausea
* Vomiting
* Pallor

After 24h
* ↑ levels of hepatic enzymes;

After 48h
* Jaundice
* RUQ pain
* Hepatomegaly

Other symptoms
* Hypoglycaemia
* Hypotension
* Encephalopathy
* Coagulopathy
* Coma

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33
Q

Intoxications

Patients at ↑ risk of hepatotoxicity

In a scenario of paracetamol poisoning

A

Taking drugs that ↑ liver enzymes levels
- Rimfamphicin
- Phenytoin
- Carbamazepine
- Chronic alcohol abuse
- St. John’s Wort (flower that is used in the treatment of depression)

Malnourished patients
- HIV
- Hepatitis C
- Anorexia
- Bulimia
- Cystic fibrosis
- Alcoholism

People who haven’t eaten in a few days.

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34
Q

Intoxications

In a scenario of paracetamol poisoning, when to discharge home?

A

Ingestion of <150mg/Kg (child or adult), with no hepatic risk factors.

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35
Q

Intoxications

In paracetamol poisoning, when to admit to the hospital?

A
  • Patients presenting within 8h of ingestion of >150mg/Kg (24 tablets/12g) ;
  • Unknown amount ingested.
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36
Q

Intoxications

In paracetamol poisoning, when to measure paracetamol plasma concentration levels?

A

≥ 4h post ingestion of >150mg/Kg of paracetamol.

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37
Q

Intoxications

In paracetamol poisoning, when to administer activated charcoal?

A

If the patient presents in <1h post ingestion of >150mg/Kg of paracetamol.

1g/Kg, máx 50g

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38
Q

Intoxications

When to administer N-acetylcysteine?

In paracetamol poisoning

A
  • If after 4h post ingestion, the plasma concentration of paracetamol is above the appropriate line (100mg/L);
  • If 15h post consumption, the plasma paracetamol levels are above 15mg/L;
  • If time of consumption is unknown, regardless of plasma concentration of paracetamol;
  • If the patient presents late (>8h) post ingestion of >150mg/Kg of paracetamol;
  • If there was a staggered overdose (not all the pills were not taken within 1h. e.g.: Consumption of 6g, 12 tablets of paracetamol everyday for 6 days. This is an overdose!)
  • Jaundiced;
  • Comatose.
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39
Q

What are the Kings’s College criteria for Liver transplant?

In paracetamol poisoning

A

Arterial PH <7.3 after 24h of ingestion

OR ALL of the following:
1. Prothrombin time > 100s (normal 11 - 13.5s)
2. Creatinine >300mmol/l
3. Grade 3 or 4 encephalophaty

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40
Q

What is the time of onset of TCA (Tricyclic antidepressants) Intoxication?

A

Rapidly time of onset, sometimes within 1h of ingestion.

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41
Q

What are the symptoms of TCA Intoxication?

A

Dryness
- Dry mouth
- Dry flushed skin
- Urinary retention

Eyes
- Dilated pupils
- Blurred vision

ECG + cardiovascular
- Sinus tachycardia
- Arrhytmias
- Hypotension

Neurological
- Agitation
- Drowsiness
- ↓ level of counsciness
- Seizures
- Severe sedation
- Coma

Acid-base disorder
- Metabolic acidosis

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42
Q

What are the ECG changes found on TCA intoxication?

A
  • Sinus tachycardia
  • Widening of the QRS complex >100ms (as toxicity worsens)
  • Prolongation of the QT interval (as toxicity worsens)
  • Widening of the PR segment (as toxicity worsens)
  • Broad complex tachycardia
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43
Q

What is the Acid-base disorder found on TCA intoxication?

A
  • Metabolic acidosis
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44
Q

What is the management for TCA intoxication?

A
  • ABC
  • Cardiac monitoring looking for widening of the QRS complex;
  • IV bicarbonate in suspected or confirmed TCA poisoning with a QRS>100ms

➜ 250ml NaCl 0.9% bolus + Sodium bicarbonate 50ml -100 ml (50mmol) of 8.4% SLOWLY IV injection
➜ Sodium bicarbonate will correct ECG changes and arrhytmia

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45
Q

Bicarbonate in TCA intoxication management?

A

IV bicarbonate in suspected or confirmed TCA poisoning with a QRS>100ms
➜ 250ml NaCl 0.9% bolus + Sodium bicarbonate 50ml -100 ml (50mmol) of 8.4% SLOWLY IV injection

➜ Sodium bicarbonate will correct ECG changes and arrhytmias

  • Aim for PH of 7.5-7.55
  • Plasma protein binding of tricyclic antidepressants tend to bind in a more alkaline ph environment, which will lead in ↓ amount availability of the active unbound drug.
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46
Q

What are the symptoms of salicylate intoxication?

A

GI tract
- Nausea
- Vomiting

**Hearing** - Tinnitus - Vertigo - Deafness / Impaired hearing

Respiratory
- Hyperventilation

Neuro
- ↓ GCS
- Seizures

Cardiovascular
- Hypotension
- Heart block

Metabolic
- Mixed acidosis: Initially respiratory alkalosis due to stimulation of the central respiratory centre (hence the hyperventilation) ➜ Later metabolic acidosis
- Hypokalemia

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47
Q

What are the symptoms of opioid overdose

A
  • ↓RR / respiratory depression;
  • Miotic pupils;
  • ↓ counscious level
  • Constipation;
  • Bradycardia;
  • Hypotension
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48
Q

What is the antidote drug for opioid overdose?

A

Naloxone
* 0.8mg IV
* Fast onset (2 min to begin action)
* Short duration: - Can be given 2-3 times; -Need to be careful with intoxication using certain opioids with longer duration of action than Naloxone; -Naloxone will finish its effect whiles the opioid has not, which will prompt the intoxication symptoms to re-start.
- Naloxone has a shorter half life compared to Methadone.

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49
Q

What are the symptoms of opioid withdrawal?

A
  • Increased body secretion:
    • Sweating;
    • Tearing;
    • Runny nose;
    • Diarrhoea.
  • Pain:
    • Muscle aches;
    • Joints (arthralgia);
    • Abdominal pain;
  • Others:
    • Dilated pupils
    • Agitation
    • Insomnia
    • Anxiety

✾ Think of heroin as a girlfriend that has left you:
- You cry a lot: Watery eyes, runny nose, sweating
- You can’t sleep: Insomnia
- You miss her: Agitation, anxiety

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50
Q

What is the time onset for opioid withdrawal symptoms?

A
  • Withdrawal symptoms begins 12h after last use;
  • It peaks in between 24-48h;
  • May last up to weeks.
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51
Q

Describe the step by step management of opioid overdose

A
  1. ABCD;
  2. Clear the airway;
  3. Administer O2 using bag and mask ventilation;
  4. Naloxone IV;
  5. Consider intubation (after bag & mask).
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52
Q

What are the drugs used to treat opioid withdrawal?

A
  1. Detoxification: Methadone or Buprenorphine.
  2. Relapse prevention: Naltrexone.
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53
Q

What are the symptoms of benzodiazepines overdose?

A
  • Respiratory depression;
  • Sedation;
  • Anteretrogade amnesia.
  • Acid-base disorder: Respiratory acidosis
    • Resp. depression ➜ apnea ➜ accumulation of CO2 ➜ RA
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54
Q

What is the antidote drug for benzodiazepines overdose?

A

Flumazenil

  • 200mcg over 15 sec ➜ then 100mcg at 60 sec intervals if needed.
  • Usual dose range: 300–600mcg IV over 3–6min (up to 1mg; 2mg if on ICU).
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55
Q

What are the symptoms of benzodiazepines withdrawal?

A
  • Panic attacks
  • Agitation
  • Insomnia
  • Anxiety
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56
Q

What is the time onset for benzodiazepines withdrawal symptoms?

A
  • Begins at 1-4 days after cessation of the medicine
  • Peaks at 2 weeks
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57
Q

What are the drugs used to treat benzodiazepines withdrawal?

A
  • Diazepam (slowly reduce the dose);
  • Propanolol.
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58
Q

What are the symptoms of cocaine overdose?

A

Unopposed 𝝰-adrenergic vasoconstriction
► ↑HR
► ↑BP
► ↑RR
► Myocardial infarction (coronary vasoconstriction)
► Intracranial haemorrhage
► Mydriasis
► Perforated nasal septum
► Hyperthermia and sweating
► Metabolic acidosis

Think of the symptoms as an association with vasoconstriction.

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59
Q

What are the drugs used to treat cocaine overdose?

A
  1. Benzodiazepines: for treatment of cardiovascular symptoms.
  2. Phentolamine: for management of refractory hypertension.
    * 5 - 15mg IV (every 5-15min)
  3. Nitroglycerine or Nitroprusside as an alternative to phentolamine.

B-blockers are not recommended due to coronary vasoconstriction seen in coke overdose

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60
Q

What is the time onset for cocaine withdrawal symptoms?

A
  • Begins within hours of last dose;
  • Peaks in few days.
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61
Q

What are the symptoms of benzodiazepines withdrawal?

A
  • Depression
  • Restlessness
  • Insomnia
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62
Q

What are the drugs used to treat cocaine withdrawal?

A
  • Propanolol
  • Diazepam
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63
Q

What are the symptoms of LSD overdose?

A
  • Colours become more vivid;
  • Smelling colours;
  • Seeing sounds.
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64
Q

What are the symptoms of ecstasy overdose?

A
  • Seeing spots/flashing/floating colour;
  • Tachycardia
  • ↑ BP
  • ↑RR
  • Uncontrolled body movements
  • Trismus
  • Hyperthermia
  • Rhambdomyolisis
  • Insomnia
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65
Q

What is the time onset for alcohol withdrawal symptoms?

A
  • Within 24;
    -May last a few weeks.
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66
Q

What are the symptoms of alcohol withdrawal?

A
  • Tremors
  • Anxiety
  • Sweating
  • Nausea & vomiting
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67
Q

What is the time onset of Delirium tremens?

A

➜Begins at 24-72h

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68
Q

What are the symptoms of delirium tremens?

A

Alcohol withdrawal symptoms + altered mental status + auditory & visual hallucinations

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69
Q

Management of alcohol withdrawal?

A
  1. First line in uncomplicated withdrawal:
    • Chlordiazepoxide (a BZD)
      - If complicated with seizures:
    • Lorazepam
  2. Second line:
    - Diazepam.
  3. Prevention of Wernicke’s encephalopathy:
    - IV Pabrinex (Thiamine / vitamin B1).
  4. Deterrent / abstinence:
    - Disulfiram.
  5. Cravings reduction:
    - Acamprosate.
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70
Q

Management of delirium tremens?

A

First line:
- Lorazepam;

Second line:
- Diazepam.

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71
Q

What is Wernicke’s encephalopathy?

A

A disorder due to thiamine / vitamin B1 deficiency characterised by:

  • Nystagmus / ophtalmoplegia
  • Ataxia
  • Confusion
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72
Q

What is the treatment for Wernicke’s encephalopathy?

A
  • Thiamine IV
  • Thiamine should be given first before Glucose (so that when glucose is given, it will be utilised to form ATP and prevent cell death in the brain).
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73
Q

Define the Wernicke’s- Korsakoff Syndrome.

A

It’s a syndrome that develops upon improper treatment of Wernicke’s syndrome.

It’s characterized by:

  1. The Wernicke’s triad;
  2. Amnesia;
  3. Confabulation (making up stories).
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74
Q

Describe superficial epidermal burns.

A
  • Red;
  • Painful;
  • Do not blister.

Former 1st degree burns.

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75
Q

Describe partial thickness burns

A

It’s divided into:
* Superficial dermal: Blisters.
* Deep dermal: Shiny, intact sensation.

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76
Q

Describe full thickness burns.

A
  • White / Brown / Black;
  • No blisters;
  • No pain.
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77
Q

Define cardiac tamponade.

A

It is a critical condition, in which there’s fast development of pericardial effusion that compresses the heart.

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78
Q

What is the triad of symptoms in cardiac tamponade?

A

Beck’s triad
1. ↑ JVP / Distended neck veins;
2. Muffled hear sounds;
3. Hypotension.

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79
Q

What is the investigation done in cardiac tamponade?

A

Echocardiography.

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80
Q

What is the initial management / treatment in cardiac tamponade?

A

Intravenous fluids.

Patients usually present with shock (hypotension).

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81
Q

What is the most appropiate management / treatment in cardiac tamponade?

A

Pericardiocentesis.

82
Q

What is the most appropriate management for a patient presenting with cardiac arrest due to cardiac tamponade secondary to penetrating trauma?

A

Immediate thoracotomy.

83
Q

Describe the step by step management of clinical suspicion of PE.

A

Wells score >4:
1. PE likely;
2. Anticoagulation (awaiting CTPA)
3. Order immediate CTPA (computer tomography pulmonary angiogram);
4. Allergy to contrast media / renal impairment ➔ V/Q scan instead of CTPA.

Wells score <4:
1. PE unlikely;
2. Order D-dimers;
3. If D-dimers positive ➔ CTPA (immediate).
4. If negative think of alternate diagnosis.

► In the eventuality of a delay in doing CTPA ➜ Theraupetic anticoagulation until CTPA is done.

84
Q

Define compartment syndrome.

A

↑ in pressure in a closed anatomical space (due to trauma), that results in insuficient blood flow to the muscles and nerves causing ischemia.

85
Q

What are the symptoms of compartment syndrome?

A
  • Intense pain (that does not match the extense of the injury) despite analgesia;
  • Pain on passive movement;
  • Sensory deficit;
  • Pulse is present (arterial pulse > compartment pressure) ➨ lack of pulse is late finding.
86
Q

Investigation of choice for compartment syndrome?

A

Intracompartment pressure device.

87
Q

What is the treatment in compartment syndrome?

A

Emergency fasciotomy.

88
Q

In compartment syndrome

What condition can develop after fasciotomy?

A

Reperfusion injury:
* When the ischaemic tissue starts being perfused (after fasciotomy), it releases myoglobin into the circulation.
* Myoglobin will cause AKI.

How to prevente it?
* Adequate hydration;
* Alkanisation of urine;
* In severe cases ➔ dialysis.

89
Q

What are the risk factors for PE?

A
  • Surgery;
  • Pregnacy (postnatal period included);
  • Lower limb injury;
  • Immobility;
  • Malignancy;
  • Previous VTE (venous thromboembolism).
90
Q

What is the gold standard / most appropriate diagnostic method for PE?

A

CTPA.

Computed tomography pulmonary angiogram.

91
Q

What is the initial investigation method for PE?

A

X-ray.

To rule out other causes of dyspnoea.

92
Q

In pulmonary embolism

Describe the anticoagulation management.

A

Haemodinamically stable:
1. First line:
- Apixaban or Rivaroxaban;
2. Second line:
- LMWH for 5 days, followed by Dabigatran or edoxaban;
OR
- LMWH + Warfarin.

Haemodinamically unstable:
1. Unfractioned heparin;
2. Consider thrombolysis.

Treatment doses and not the prophylathic doses.

93
Q

Describe the pain in costochondritis.

A
  • Usually in patients >40 yo;
  • Sharp pain that is aggravated by movement, inspiration, sneezing, coughing;
  • Sides of sternum tender.
94
Q

Treatment for costochondritis?

A

NSAIDS

95
Q

How is CPR in adults performed?

A
  1. 30 chest compressions;
  2. Two rescue breaths;
  3. Continue with 30:2.
96
Q

How is CPR in children performed?

A
  1. Five rescue breaths;
  2. 15 chest compressions;
  3. Continue with 15:2.
97
Q

How to administer breaths in infants during CPR?

A
  • With your mouth, cover / seal the infant’s nose and mouth before administering a breath.
  • If the above is not possible, cover / seal the mouth or nose with your mouth, while closing the other with your hand before administering a breath.
98
Q

How to administer breaths in >1 YO during CPR?

A

Seal / cover the child’s mouth with yours before administering a breath over 1 sec.

99
Q

How to administer chest compressions in infants during CPR?

A

➨ Chest compressions are started after rescuing breaths (if there’s no sign of life) at a rate of 100 bpm.
➨ The sternum should be compressed by at least 1/3rd of it’s depht.

  1. Encircling techique: Place both thumbs over the lower half of the sternum for compression (the rest of the hand will encircle the lateral thorax and the back).
  2. Two-finger technique: Place the tips of the index and middle finger on the lower sternum and compress.
100
Q

How to administer chest compressions in >1 YO children during CPR?

A

➨ Chest compressions are started after rescuing breaths (if there’s no sign of life), at a rate of 100 bpm.
➨ The sternum should be compressed by at least 1/3rd of it’s depht.

  1. Start compressions with the heel of one hand placed on the lower sternum.
  2. In a large children use 2 hands, as you would in an adult.
101
Q

CPR

Name the pulseless shockable rhythms.

A
  1. Ventricular fibrillation;
  2. Ventricular tachycardia (pulseless).
102
Q

CPR

Name the pulseless non-shockable rhythms.

A
  1. Asystole;
  2. Pulseless electrical activity.
103
Q

CPR in Advanced Life Support

Describe the step by step management in ALS.

A

► Adult patient is unresponsive with absent / abormal breathing

  1. Give CPR 30:2;
  2. Assess rhythm:

➔ Pulseless shockable rhythms:
* Shock;
* Assess rhythm every 2 min;
* Administer adrenaline every 3-5 min;
* After 3 shocks give Amiodarone.

➔ Non-shockable rhythms:
* Continue chest compressions;
* Assess rhythm every 2 min;
* Administer adrenaline as soon as IV line is inserted and continue every 3-5 min;

104
Q

GCS: eyes assesment

A

4 pts - Eyes opes spontaneously;
3 pts - Eyes open in response to voice commands;
2 pts - Eyes open in response to pain stimulus;
1 pt - No response.

105
Q

GCS: verbal assesment

A

5 pts - Oriented;
4 pts - Confused;
3pts - Inappropriate words;
2 pts - Incomprehensible sounds
1 pt - No response.

106
Q

GCS: motor assesment

A

6 pts - Obeys command;
5 pts - Localizes pain;
4 pts - Withdraws from pain;
3 pts - (abnormal) Flexion in response to pain;
2 pts - (abnormal) Extension in response to pain;
1 pt - No response.

107
Q

Pupillary response to light

Unilateral dilated pupil

Name the causes.

A

► Unilateral space occupying lesion:
* Haematoma;
* Tumors;
* Abscess.

108
Q

Pupillary response to light

Bilateral constricted pupils

Name the causes.

A
  • Cerebrovascular accident affecting the brainstem;
  • Opioid overdose.
109
Q

Pupillary response to light

Bilateral dilated pupils

Name the causes.

A
  • TCA overdose
  • Stimulants
110
Q

When can you indicate a CT scan within 1h in adults after a head injury?

A
  • GCS <13 on arrival to the hospital;
  • 2h after the 1st evaluation a GCS of <15 ;
  • Suspected open or depressed skull fracture;
  • Any sign of basal skull fracture;
  • Post-traumatic seizure;
  • Focal neurologic deficit;
  • More than 1 episode of vomiting.

If any of the above present.

111
Q

When can you indicate a CT scan within 8h in adults after a head injury that present with loss of consciousness & amnesia?

A
  • ≥ 65YO;
  • Patient on anticouagulation;
  • History of bleeding or clotting disorder;
  • Dangerous mechanism of injury;
  • > 30 min retrograde amnesia

If any of the above present.

112
Q

When can you indicate a CT scan within 1h in children after a head injury?

A
  • On arrival to the hospital, GCS<15 if < 1 YO ;
  • On arrival to the hospital, the GCS is < 14 if > 1 YO;
  • 2h after the head trauma a GCS of <15 ;
  • Post-traumatic seizure;
  • Suspected open or depressed skull fracture or tense fontanelle;
  • Signs of basal skull fracture;

If any of the above present.

113
Q

Criteria to indicate a CT scan within 1h in children after a head injury with ≥ 2 of it present?

A
  • Loss of consciousness > 5 min;
  • Abnormal drownsiness;
  • Amnesia > 5 min;
  • ≥ 3 episodes of vomiting;
  • High speed RTA;
  • Fall from a height >3m.

2 or more of the above to do the CT.

114
Q

What are the signs of basal/basilar skull fracture?

A
  • Racoon / panda eyes (bilateral periorbital bruising);
  • Batle’s sign (retroauricular / mastoid process bruising without direct trauma);
  • Haemotympanum or bleeding from the auditory meatus;
  • CSF rhinorrhea or othorrhea.
115
Q

What is the bone affected in basal/basilar skull fracture?

A

Temporal bone

116
Q

CT scan of epidural (extradural) haematoma?

A

An expanding lemon.

117
Q

CT scan of subdural haematoma?

A

Banana.

118
Q

Describe what is Flail chest

A

It is when multiple ribs (>3) are broken due to trauma, causing paradoxical respiration (chest in during inspiration, and out during expiration).

119
Q

Describe the presentation of Flail chest

A
  • RTA;
  • Chest pain;
  • Dyspnoea.
120
Q

What is the management of Flail chest?

A
  • High flow O2;
  • Analgesia (3 steps analgesia, intercostal block / T4 thoracic epidural);
  • If fatigue of breathing: Intubation + Positive pressure ventilation
121
Q

What are the 3 features of DKA (diabetic ketoacidosis)?

A
  1. Hyperglycaemia;
  2. Acidosis;
  3. Ketonaemia.
122
Q

What are the (most common) causes of DKA?

A
  • Infections;
  • Missed insulin doses;
  • Cardiovascular disease’s (MI, cerebral stroke).
123
Q

What are the symptoms of DKA?

A
  • Polyuria, polydipsia, vomiting, dehydration;
  • Abdominal pain;
  • Kussmaul respiration;
  • Acetone smelling breath;
  • Altered mental status —> Coma.
124
Q

How is the diagnosis of DKA made?

A

All of the following must be present

  • Capillary glucose > 11 mmol/L or known DM.
  • Capillary ketones > 3mmol/L or urinary ketones > ++.
  • Arterial blood gas PH< 7.3 and/or HCO3 < 15.
125
Q

What is the initial management of DKA?

A

Hydration / fluid replacement with NaCl 0.9%.

126
Q

After the initial management with saline, what is the follow up management of DKA?

A

After appropriate saline infusion

  • Correct potassium (if needed) with KCl 40mmol/L
  • Insulin therapy (if given early, before the IV fluids, can cause cerebral oedema);
  • When plasma glucose reaches 14, add dextrose 10% alongside the saline infusions and consider reducing the IV insulin.
127
Q

What glucose value is considered hypoglycaemia?

A

4 mmol/L.

128
Q

What are the causes of hypoglycaemia?

A
  • Anti-diabetic medications.
  • Binging of alcohol;
  • Post gastric surgery.
129
Q

Symptoms of hypoglycaemia?

A
  • Sweating
  • Anxiety
  • Hunger
  • Tremors
  • Dizziness
  • Palpitations
  • Confusion
  • Seizures
  • Coma
130
Q

What is the management of hypoglycaemia?

A

Conscious patient
- Carbohydrated snack
- Glucose gel.

Unconscious patient
- 1mg glucagon IM (if outside the hospital);
- Glucose IV:
Glucose 20% 75ml IV (10-15 min);
Glucose 10% 50ml IV, every 2 min until patient is conscious or 250 ml has been given.
Glucose 50% 25-50ml (in large vein followed by saline flush, hypertonic solution that can damage veins).

131
Q

What are the contraindications for the use of Glucagon?

A
  • Alcohol intoxication
  • Chronic alcoholism
  • Liver failure
  • Hypoglycaemia due to sulfonylurea drugs
132
Q

When to suspect foreign body aspiration in toddlers?

A

Story of a child playing with a toy, followed by a cough, wheeze, stridor (acute respiratory symptoms).

133
Q

What is the management in a unstable toddler with suspected or confirmed foreign body aspiration?

Unconscious & basic life support already done.

A

Laryngoscopy.

134
Q

What is the management in a stable toddler with suspected or confirmed foreign body aspiration?

No cyanosis, mild wheezing, child relatively well.

A
  1. X-ray;
  2. Bronchoscopy (even if normal x-ray).
135
Q

Define haemothorax.

A

Blood accumulation in lung pleural cavity. Usualy caused by RTA or stab injury.

136
Q

What are the symptoms of haemothorax?

A
  • Hypotension
  • Tachycardia
  • Dullness on percussion
  • Chest x-ray: homogenous opacity on the lower lung field.
137
Q

What is the initial management of haemothorax?

A
  1. Oxygen;
  2. Insertion of 2 large venous cannulae and request blood.
138
Q

What is the definitive management of haemothorax?

A
  • Chest drain insertion;
  • Surgery (rarely done).
139
Q

Define pneumothorax.

A

It is air accumulation in the pleural cavity that results in lung collapse on the affected side.

140
Q

What are the symptoms of pneumothorax?

A
  • Sudden onset of chest pain;
  • Dyspnoea;
  • Hyperressonance on the affected side.
141
Q

What is the classification of pneumothorax?

A
  1. Based on the cause
    * Primary / Spontaneous: No identifiable cause;
    * Secondary: idenfiable cause such as COPD/Asthma.
  2. Based on the nature
    * Closed: the volume of air doesn’t change in the pleural cavity;
    * Open: Communicates with the athmosphere;
    * Tension: volume of air int pleural cavity expands.
142
Q

What is the management of primary / spontaneous pneumothorax?

A
  • Erect chest x-ray, to confirm the diagnosis;
  • ≤ 2cm: O2 & conservative management.
  • > 2cm or distressed patient: Needle aspiration;
143
Q

What is the management of secondary pneumothorax?

A
  • < 1cm: O2 & conservative management.
  • 1-2 cm: Needle aspiration.
  • > 2cm: Chest drain.
144
Q

What are the symptoms of tension pneumothorax?

A
  • Acute respiratory distress;
  • Hypotension;
  • Tracheal deviation from the pneumothorax side;
  • ↓ air entry on the affected side;
  • ↑ JVP.
145
Q

What is the management of tension pneumothorax?

A
  1. High flow O2;
  2. Needle decompression: Insert large bore cannula (14-16G) into the 5th mid-axillary intercostal space;
  3. Chest drain;
  4. X-ray.
146
Q

Causes of hypercalcaemia?

A
  • Primary hyperparathyroidism;
  • Malignacy: Multiple myeloma, Lung carcinoma (produces PTH like molecule);
  • Sarcoidosis;
  • Immobilization.
147
Q

Symptoms of hypercalcaemia?

A
  • Gastro (Moans): Constipations due to ↓ bowel activity;
  • Renal (Stones): Kidney stones & nephrolithiasis due to calcium deposits in kidney. Polyuria & polydipsia due to induction of diabetic insipidus;
  • Neuro & Psych (Groans): Lethargy, confusion and depression;
  • Bone pain (Bones): seen in hyperthyroidism.
148
Q

What is the management of hypercalcaemia?

A
  1. Hydration with (3-4L) of NaCl 0.9% to induce urinary output and excretion of calcium;
  2. Bisphosphonates IV (Zoledronic acid or pamidronate);
  3. In sarcoidosis: steroids;
  4. 2ry hyperparathyroidism: Cinalcet hydrochoride;
  5. Renal failure: hemodialysis;
149
Q

What ECG changes are seen in Hyperkalaemia?

A
  1. Tall tented T waves;
  2. Flattening of the P wave;
  3. Widening of the QRS complex ➜ sinusoidal pattern ➜ asystole.
150
Q

What is the classification of hyperkalaemia based on severity?

A
  • Mild: 5.5-5.9 mmol/L
  • Moderate: 6.0-6.4 mmol/l
  • Severe: ≥6.5 mmol/L
151
Q

What are the causes of hyperkalaemia?

A
  • Potassium sparing diuretics / ACE-inhibitors / ARB’s / Spironolactone;
  • Acute renal failure;
  • Metabolic acidosis;
  • Addison’s
152
Q

What is the management of moderate or severe hyperkalaemia with ECG changes?

A
  1. Stop caustive drugs (if any);
  2. Calcium gluconate (if ECG changes or K>6.5)
  3. Insulin IV & Dextrose.

Other methods:
* Calcium resonium (binds K+ to the gut);
* Salbutamol
* Bicarbonate
* Hyperventilation
* Loop diuretics;
* Dialysis.

153
Q

What is the most initial management of hyperkalaemia with ECG changes?

A

Calcium gluconate.

154
Q

What is the most aproppriate management of hyperkalaemia with ECG changes?

A

Dialysis.

155
Q

What is the management of mild or moderate hyperkalaemia asymptomatic and without ECG changes or signs of AKI?

A
  1. Stop the causative drugs;
  2. Repeat K+ levels in 1-3 days in primary care.
156
Q

What are the causes of hypovolaemic hyponatremia?

A

►Develops when Na+ and water are lost but only water gets replaced
* GIT losses (diarrhoea, vomiting);
* Skin loss (burns, sweating);
* Diuretics (Na & water are lost through renal excretions but only water gets replenished by mouth);
* Addison’s disease (Aldosterone causes renal Na reabsortion and K excretion, when aldosterone is lost, there is Na and water loss and accumulation of K).

157
Q

What are the causes of euvolaemic hyponatremia?

A
  • SIADH
  • Diuretics
  • Psychogenic polydipsia
158
Q

What are the causes of hypervolaemic hyponatremia?

A
  • Excess water;
  • Cirrhosis;
  • Congestive heart failure;
  • Nephrotic syndrome;
  • Renal failure (free water is not excreted).
159
Q

What are the other causes of hyponatraemia?

A
  • Pseudohyponatraemia: In hyperglycaemia, the high glucose amount causes a shift of water without Na from cells and into the vascular space.
  • SSRI;
  • ACEi;
  • Elderly patients (prone to SIADH cause they’re unable to suppress ADH effectively) (investigations necessary only if Na <130)
160
Q

What investigations / lab analysis should be requested in hyponatraemia?

A
  • Urinary sodium (High sodium in urine = hypovolaemia).
  • Volume status of patient
161
Q

What is the management of hyponatraemia?

A
  1. Emergency cases (coma/seizure): IV hypertonic solution 1.8% or 3% NaCl & furosemide;
  2. Hypovolaemic: Normal saline 0.9%
  3. Euvolaemic: Normal saline 0.9% given slowly (1L over 8h); Euvolaemic due to SIAHD: Fluid resctrition / demeclocycline or vaptans if fluid resctritions is inadequate;
  4. Hypervolaemic:Treat the underlying cause.
162
Q

What are the symptoms of panic attacks?

A
  • Numbness or tingling sensation: Hyperventillation ➔↓CO2➔Respiratory alkalosis➔Hypocalcaemia.
  • Palpitations;
  • Chest pain
  • Sweating;
  • Tremors;
  • Difficulty breathing.
163
Q

How long do panic attacks last for?

A

10-20 min.

164
Q

Management of panic attacks?

A
  • Acute: breathing into a bag;
  • Long term: CBT, Antidepressants (SSRI)
165
Q

Define sepsis

A

Life threatening organ dysfunction caused by desregulation of host’s response to infection.

166
Q

What are the red flags in sepsis?

A
  • SBP <90mmHg / a fall of >40 mmHg from the baseline;
  • HR >130 bpm;
  • Lactate >2 mmol/L;
  • SPO2 <91% (<88% in COPD);
  • RR >25 breaths/min;
  • Neuro: unresponsive / responds to voice or pain only;
  • Urine output <0.5ml/Kg/h in ≥ 2h;

If ≥1 red flag present, complete the Sepsis six within 1h.

167
Q

What are the sepsis 6?

A

If ≥1 red flag present, complete the Sepsis six within 1h.

Take 3 & Give 3

Take 3:
* Blood cultures;
* FBC, U&E, clotting, serial lactate;
* Urine output (monitor);

Give 3:
* High flow O2;
* IV fluids;
* IV antibiotics.

168
Q

What is the initial management of sepsis ?

A
  • High flow O2;
  • IV fluids;
  • IV antibiotics.

If all options given then follow ABC protocol according to the symptoms.

169
Q

Define septic shock?

A

Hypotension that is persistent and refractory to fluids administration.

170
Q

Describe qSOFA?

A
  • RR ≥22 breaths/min;
  • Altered mentation;
  • SBP ≤ 100mmHg
171
Q

What is the management for upper GIT bleeding secondary to varices?

A
  • Fluid resuscitation;
  • Endoscopy (especially if the patient is unstable) ——> Band ligation;
  • Terlipressin 2mg IV 4/4h
  • If prolonged INR, give Vit K;
  • Platelets transfusion if <50;
  • Prophylactic antibiotics (cipro or cephalosporin);

Omeprazole should be avoided unless known peptic ulcer disease.
PPI’s shouldn’t be given prior to endoscopy diagnosis.

172
Q

How to manage urethral injuries secondary to pelvic fractures / perineal trauma?

A
  • Refer to urology;
  • Do not insert an urinary catheter;
173
Q

ABCDE evaluation

Describe the Airway evaluation.

A
  • Look for signs of airway obstruction:
    •Noisy air entry;
    •Paradoxical chest and abdominal movements;
  • Clear airway:
    •Airway opening manoeuvre;
    •Airway suction;
    •Insertion of nasopharyngeal or oropharyngeal airway;
    •If all fails, tracheal intubation;
  • High concentration O2.
174
Q

ABCDE

Describe the breathing evaluation.

A
  • RR, chest expansion, auscultaste the breathing sounds;
  • If RR inadequate or absent —> Bag-mask ventilation;
  • NIV and intubation can be consider.
175
Q

ABCDE

Describe the cardiovascular evaluation.

A
  • Look for signs of circulation problems (BP, HR, peripheral and central pulses);
  • If hypotension give 500 ml of crystaloids (saline 0.9% or Hartmann’s).
176
Q

ABCDE

Describe the disability evaluation.

A
  • Look for common causes of unconsciousness (hypoxia, cerebral hypoperfusion, low glucose)
  • Check pupils.
177
Q

ABCDE

Describe the exposure evaluation.

A

Expose the patient but do respect their dignity.

178
Q

Describe the presentation of Orbital blowout fractures.

A
  • Associated with fracture of the maxilla (orbital floor);
  • Presents with vertical diploplia due to involvement of inferior rectus muscle;
  • Enophtalmos (sunken eye);
  • Infraorbital anaesthesia.
179
Q

What is the management of Orbital blowout fractures?

A
  • Initial: X-ray or the skull.
  • Most appropriate/definitive/gold standard: CT scan.
  • Surgery.
180
Q

What are the causes of Mallory-Weiss syndrome

A
  • Persistent vomiting / retching —> Oesophageal tear —> Haematemesis;
  • Alcoholism;
  • Bulimia nervosa.
181
Q

What is the investigation in Mallory-Weiss Syndrome?

A

Endoscopy.

182
Q

What is the management of Mallory-Weiss Syndrome?

A
  • ABCDE
  • IV fluids and blood transfusion if needed;
    -Endoscopy immediately after resuscitation.
183
Q

What is the choking management for an infant?

A
  • While seating down, put the infant on your lap on prone position with the head tilting down;
  • Deliver 5 back blows with the heel of the hand, along the spine in between the shoulders blades.
  • Turn the infant supine and deliver 5 chest thrusts (less intense than chest compressions).
184
Q

What is the choking management for a child and adult?

A
  • Deliver 5 back blows;
  • Stand behind the patient and give 5 abdominal thrusts as the patient is leaning forward. Clench one fist and grip the fist with the other hand and pull upwards and inwards sharply.
  • Alternate in between step 1 and 2.
185
Q

What is the choking management for an unconscious patient?

A
  • Lay the patient on the floor;
  • Call ambulance;
  • Start CPR.
186
Q

Describe what is hereditary angioedema.

A

It’s an autosomal dominant hereditary condition, due to C1-esterase inhibitor deficiency.

It can be precipitated by:
- Stress;
- Infection;
- Trauma;
- Surgery.

187
Q

What are the symptoms of hereditary angioedema?

A
  • Lip, mouth and face swelling;
  • Dyspnoea and stridor (laryngeal oedema);
  • Abdominal pain.
188
Q

What is the investigation done in hereditary angioedema?

A
  • Serum C4 level;
  • C1 inhibitor level.
189
Q

Management of hereditary angioedema?

A
  • C1 inhibitor concentrate IV or SC;
  • Bradykinin receptor inhibitor;
  • Kallikrein inhibitor;
  • Severe laryngeal oedema —> intubation and ventilation.
190
Q

What are the symptoms of an acute case of peptic ulcer?

A
  • Epigastric pain;
  • Haematemesis;
  • Melaena.
191
Q

What is the management for an acute case of peptic ulcer?

A
  • Endoscopy
  • Acid suppression (PPI/H2 antagonist);
192
Q

What are the risk factors for peptic ulcer

A
  • NSAID’s
  • Steroids
  • H. pylori infection
193
Q

What are the symptoms of a perforated peptic ulcer?

A
  • Epigastric pain
  • Melaena
  • Rebound tenderness
  • Guarding
  • Abdominal rigidity
194
Q

What is the investigation in perfurated peptic ulcer?

A

Erect X-ray: air under diaphragm.

195
Q

What is the treatment of perforated peptic ulcer?

A

Laparoscopic or laparotomy repair.

196
Q

What is the Serotonin syndrome?

A

Increased levels of serotonin in the synapses due to drug overdose or interaction between MAOI, SSRI and SNRI.

197
Q

What are the symptoms of Serotonin syndrome?

A

Autonomic hyperactivity
- Hypertension
- Tachycardia
- Hyperthermia

Neuromuscular abnormalities
- Tremor
- Ocular clonus
- Hypertonicity

Mental status changes
- Anxiety
- Confusion

198
Q

What is the management of serotonin syndrome?

A
  • Stop the offending drug
  • BZD
  • IV fluids
  • Cyproheptadine
199
Q

Define status epilepticus

A

Single epileptic seizure lasting for > 5 min OR two epileptic seizures with less than 5 min in between them without full recovery in between.

200
Q

What is the management of Status epilepticus?

A
  • ABCDE (including glucose)
  • Lorazepam IV (max 2 doses)
  • Buccal midazolam or rectal diazepam (if no IV) (max 2 doses)

If after 2 doses or 1 dose of bucal MDZ and then later 1 dose of Lorazepam IV

  • Phenytoin IV (1st)
  • Phenorbabital IV (if seizures refractory to phenytoin)
  • Intubation and ICU.

PLAB 1 August 2024 (32 decks)

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