High yield RV Flashcards
Management acute glaucoma
Pilocarpine 2% Q5min for 1 hr. Increase outflow.
Timolol 0.5% 1 drop ever 30-60 min. Redcues production and increases outflow.
Latanoprost 0.05% daily. Increases outflow.
Acetazolamide 500 mg. Decreased production
Causes of painless red eye
Diffuse
- Lids: blepharitis, ecrtropion, eyelid lesion
- Conjuctivitis
Localised Pterygium Corneal Foreign body Ocular trauma Subconjunctival haemorrhage
Causes of painful red eye
Corneal: HSV, bacterial/acantomoebal ulcer, keratitis, foreign body
Lid: chalazion, blepharitis, herpes zoster
Conjunctival: viral/allergic/bacterial conjunctivits
Acute angle closure glaucoma
Scleritis - vascular / connective tissue
Anterior uveitis / iritis, hypoyon, hyphaema
Causes of sudden loss of vision
Transient - amaurosis fugax
Vaso-occlusive: CRVO, CRAO
Optic nerve - optic neuritics, GCA
Retinal detachment
Dental block for lower mandible
Inferior alveolar nerve block - approach over contralteral canine, insert in pterygotemporal depression, advance 20-25 mm - contact with ramus of mandible, withdraw 2 mm, aspirate, inject 2 mls lignocaine
Antibiotic therapy in retropharyngeal abscess
Amoxycillin & clavulanate 1g/200 mg IV Q6 H OR cephazolin 50mg/kg and metronidazole 12.5mg/kg IV BD
Hard signs of penetrating neck trauma and implication
Require immediate surgical or endovascular intervention
rapidly expanding/pulsatile haematoma
Massive haemoptysis Air bubbling Vascular bruit or thrill Stridor/hoarseness or airway compromise Cerebral ischaemia Severe haemorrhage, Shock not responding to fluids, Decreased or absent radial pulse \+/- massive subcutaneous emphysema
Zones of the neck and investigation of penetrating trauma
1 - clavicles/sternal notch to cricoid cartilage
2 - cricoid cartilage to angle of mandible
3 - angle of mandible to base of skull
Zone 1 - CTA, bronchoscopy, oesophagoscopy
Zone 2 - OT if stable and vascular injury, consider imaging prior
Zone 3 - CTA +/- others
Grading of liver injury and implication
Grade III - subcapsular haematoma > 50%, rupture of haematoma, intraparenchymal haematoma > 10 cm or laceration > 3 cm deep
Grade V - venous injury
Grade VI - avulsion
OT if grade III +
Grade of splenic injury and implication
Grade III - subcapsular haematoma > 50%, rupture of haematoma, intraparenchymal haematoma >5 cm or laceration > 3 cm deep
IV - segmental / hilar vessels
V - shattered, devascularised
OT if grade III/IV+
General approach to psychatric patients
General Approach - SACCIT Safety Assessment Confirm provision diagnosis Consultation Immediate treatment Transfer of care
Suicide risk assessment
SADPERSONS Sex - male Age - > 45 or < 19 Depression Previous attempt Ethanol / drug abuse Rationality (loss of) - schizophrenia, psychosis Spouse (absence of) Organised plan No support Sickness (illness)
0-2 discharge & FU
3-4 +/- admission
5-6 admission
>= 7 involuntary if needed
Indications for hospitalisation in eating disorder
HR < 50, postural HR increase > 30 bpm BP < 90/60, systolic postural drop >= 20 mmHg K < 3 T < 36 / 35.5 Dehydration Na < 130 PO4 < 0.5 Long QTc > 450 msec Failure of outpatient treatment
HIV PEP
unknown source: recommended if MSM or high prevalence country with anal or vaginal intercourse, 2 drug regimen
HIV positive source and detectable or unknown viral load: vaginal or anal intercourse give PEP, 3 drug regimen
Regimen
Lamivudine 300 mg PO daily for 4 weeks
Tenofovir 300 mg PO daily for 4 weeks
+/- Dolutegravir 50 mg PO daily for 4 weeks
Diagnosis of thyroid storm
Clinical
- Temperature > 37.5
- Tachycardia out of proportion to fever
- Altered mental status
Treatment of thyrotoxicosis
Propylthiouracil 1200 mg PO/NG
4mg IV dexamethasone TDS
6mg PO lugols iodine (after 1 hr)
80 mg Propranolol, IV esmolol 500mcg/kg/min then 50-100 mcg/kg/min
Supportive care
- hyperthermia –> external cooling
- electrolyte disturbance
- DC cardioversion for arrhythmias
- plasmapheresis / dialysis / haemoperfusion
Pathophysiology, causes and electrolyte disturbance in addison’s disease
Adrenal failure
Causes:
1- autoimmune, infection, haemorrhage, infarction, congenital, malignancy.
2ndry - pituitary failure, exogenous steroid supression
Hypoglycaemia, hyponatraemia, hyperkalaemia.
Dose of dextrose in hypoglycaemia
2-5 mls/kg IV 10% dextrose (adult 125-250 ml)
Diagnosis of DIC
Raised D-dimer
Raised PT
Low platelets
Low fibrinogen
Causes of DIC
HOTMISS Hepatic failure Obstetric: amniotic fluid embolism, eclampsia, FDIU Trauma Malignancy: prostate, leukaemia Immune: transfusion, anaphylaxis Sepsis: gram neg, viral haemorrhagic Shock, snake bite
Low risk chest pain
Age < 40 Symptom free Normal ECG and biomarkers No high / intermediate features Aytpical nature of symptoms
High risk chest pain & management
> 10% risk MI / death
ECG persisttent or dynamic ST depression or new TWI, or transient ST elevation in 2 leads, or Wellens syndrome
Elevated troponin
Cardiac failure, MR or haemodynamic instability
Repetitive or prolonged ongoing chest pain / discomfort
Sustained VT
Syncope
Diaphoresis
LVEF < 40%
Prior MI, PCI or CABGS
admit to monitored bed, consider perfusion imaging, PCI within 2 / 24 hr 72 hrs depending on specific symptoms.
STEMI mimics
Pericarditis Benign early repolarisation LVH (MI if ST/R ratio > 0.25) LV aneurysm LBBB +/- AMI
Indications for reperfusion therapy in ACS
STEMI
ST elevation in 2 contiguous leads or new LBBB, >1mm in limb leads >2 mm in precordial leads
Other
High risk ACS without STEMI (wellen’s T waves with STE aVR)
Cardiogenic shock of ischaemic origin
Cardiac arrest with ROSC
Haemodynamically significant ventricular arrhythmias resistant to treatment
Failure of ST elevation to improve by 50% within 90 min of thrombolysis
Ongoing pain uncontrolled by standard therapies without STEMI criteria
Indications for PCI rather than thrombolysis
< 1 hr & <60 min to PCI
1-3 hrs sx & <90 min to PCI
3-12 hrs sx & < 2 hrs to PCI
>12 hrs and haemodynamically unstable
Contraindications to thrombolysis
Aortic dissection New neurological signs Significant head / facial trauma 3 months Previous ICH Previous Ischaemic stroke < 3 months Known intracranial AVM Malignant intracranial neoplasm Acute pericarditis Active bleeding
Relative Anticoagulation Non-compressible vascular puncture HTN, DBP > 110 Surgery < 3 weeks, CNS surgery < 2 months GIT / urinary bleeding in prev 4 weeks Malignancy Pregnancy
Criteria for diagnosis of VT
Absence of RBBB / LBBB morphology Extreme axis Very broad (>160 msec) AV dissociation Capture beats Fusion beats Positive or negative concordance in chest leads
Brugada criteria - if yes to any = VT
absence of RS complex in all precordial leads
R to S interval > 100 msec in 1 precordial lead
AV dissociation
Morphology criteria for VT present in V1/2 and V6
Dominant R wave in V1 - RBBB like: smooth R, RSr’, qR
Dominant S wave in V1 - LBBB like: josephsons sign in S wave
Causes of long QTc
Drugs: amiodarone, sotalol, azithromycin, antipsychotics, phenothiazines (haloperidol)
Electrolytes - hypokalaemia, hypoMg, hypocalcaemia
Hypothermia
Ischaemia - AMI
Raised ICP
Congenital long QT
Diagnosis / management of hypertensive emergency
BP > 180/120 with end organ dysfunction
Brain - enecphalopathy, CVA
CVS - APO, ACS, aortic dissection
Targets
- ICH: SBP < 180 (possibly 140 if anticoagulated)
- CVA 10-15% reduction if > 180 / 105
- Aortic dissection: HR 60-80, SBP 100-120
- Encephalopathy 10-15% reduction, or DBP 100
DDx hyperthermia and mental status changes
Heat stroke - environmental exposure NMS - muscle rigidity Serotonin toxicity - clonus Malignant hyperthermia - drug exposure, masseter spasm Sepsis Thyroid storm Stimulant toxicity
Radiation syndrome
> 2 gy: Haematopoietic syndrome - pancytopaenia
10-15 gy: GIT syndrome
15-30 gy: vascular syndrome
30 gy: cerebral syndrome
Toxidrome and management of chironex fleckeri poisoning
Severe pain, immediate, whip like. Cardiac toxicity - hyper/hypotension, arrhythmias, VT.
Vinegar / sea water. Antivenom Indications: unconsious, hypotension/arrhythmia, hypoventilation, neurological symptoms or severe pain. 3 vials if life threatening. Adjunct magnesium sulfate.
Toxidrome and management or irukandji syndrome
Sodium channel effects and catecholamine release
Impending doom, severe pain, agitation.
Vingear / sea water
High dose IV analgesia
magnesium
Antihypertensive - GTN
Travel related non-specific illness
Malaria, dengue Enteric fever - salmonella typhi Hepatitis Viral haemorrhagic fevers TB
Influenza, pneumonia Sepsis HIV Meningococcal Measles
Causes of long QT
Antiarrhythmics - sotalol
Antipsychotics - amisulpride, ziprazidone
Methadone
Citalopram/escitalopram
Antibiotics - fluroquinolones, macrolides
Ondansetron
antifungal - fluconazole
Other causes
electrolyte - hypomagnesaemia, hypocalcaemia, hypokalaemia (pseudo-long)
Heart disease - cardiomyopathy, heart failure, MI, CHB
Congenital
Hypothyroidism
SAH
Indications for multi-dose charcoal
Carbamazepine Dapsone Phenobarbitone Quinine Theophylline
Indications for whole bowel irrigation
Iron > 60 mg/kg SR potassium > 2.5 mmol/kg Arsenic / lead & symptoatmic SR verapamil / diltiazem Body packer
Toxicological Indications for haemodialysis
Carbamazepine Sodium valproate Phenobarbitone Toxic alcohols Metformin Lithium Potassium Salicylate Theophylline
Management of calcium channel blocker overdose
R: > 10 tablets R: IVT, Atropine for bradycardia then adrenaline, Calcium gluconate 10% 30 mls, infusion of adrenaline for hypotension. intubation for shock. HIET. echo - cardiogenic vs vasoplegic D: Charcoal, whole bowel irrigation. ECMO
Management of B-blocker overdose
bradycardia - atropine, adrenaline, pacing
hypotension - IV fluid, adrenaline, HIET, IAPB/ECMO
Management of sodium channel blocker poisoning
soidum bicarbonate 1-2 mEq/kg , Q2-5 min to improve BP and narrow QRS. Slow IV push (2-5 min). End point is pH 7.5-7.55
Intubation, hyperventilation. Target pH 7.5
NGT for charcoal 50g
Seizures - benzodiazepines 5-10mg IV
Hypotension: fluid, noradrenaline
Arrhythmia - soidum bicarbonate, lignocaine if pH > 7.5
Hypertonic saline 3% 3 mls/kg IV
Acute and chronic lithium poisoning clinical features
Acute - GIT; N/V/D, abdo pain.
- supportive, avoid dehydration / hyponatraemia
Chronic - CNS: hyperreflexia, agitation, weakness, ataxia. hypertonia, coma, seizures.
- cease lithium, replace volume, airway protection, haemodialysis (serum li > 2.5)
Risk assessment and treatment in iron overdose
> 60 mg/kg systemic toxicity
120 mg/kg potentially lethal
Fluid replacement.
Decontamination: endoscopy, Whole bowel irrigation
Desferroxamine: increases excretion. 15 mg/kg for 4 hrs.
Management of toxic alcohol poisoning
Intubation, with Na bicarb prior
Hyperventilate due to acidosis
IV benzodiazepines for seizures.
Mx hypoglycaemia, hyperklaemia, hypomag.
Reduce metabolism: ethanol 8 mls/kg 10% ethanol IV and then 1-2 mls/kg/hr.
Haemodialysis
Management of eclampsia
Airway support, oxygen. Left lateral position.
Stop seizure: benzodiazepine, midazloam (0.15mg/kg IM or IV up to 10mg)
Prevent further seizure: Magnesium sulfate
4g in 100 mls over 15 min and Infusion 2g/hr, target 2-3.5 mmol/L
Treat hypertension: labetolol and hydralazine, target SBP reduction 20-30 mmHg and disastolic by 10-15, to BP < 160/90 where possible.
- Labetolol 20mg IV Q10 min, infusion 20-60 mg/hr
- Hydralazine 5mg-10mg IV and infusion 5mg/hr
Urgent Delivery
