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1
Q

Risks associated with adverse transfusion reactions

A 
TACO 1:100
Delayed haemolytic reaction 1:1,000
TRALI 1:5,000
Acute haemolytic reaction, 1:12,000
Anaphylaxis 1:20,000
Bacterial Sepsis 1:40,000
Blood born infection Hep B, 1:600,000 and Hep C / HIV < 1 in 10 million 
Transfusion associated GVHD - rare 
--> risk of any above causing mortality, > 1:million
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2
Q

Lights criteria for pleural effusion

A 
Transudate: 
- pleural:serum protein <= 0.5 
- pleural:serum LDH <= 0.6
- pleural LDH <= 2/3 ULN serum LDH 
Causes: hypoalbuminaemia (cirrhosis, nephrotic), constrictive pericarditis, CCF 
Exudate: 
- pleural: serum protein > 0.5 
- pleural:serum LDH > 0.6 
- Pleural LDH > 2/3 ULN serum LDH 
Causes: Autoimmune, oesophageal rupture, infection (TB, parapneumonic, fungal, empyema), malignancy, pancreatitis, post-CABG, PE.
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3
Q

Causes of pleural transudate

A

hypoalbuminaemia (cirrhosis, nephrotic)
constrictive pericarditis
CCF

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4
Q

Causes of pleural exudate

A 
Autoimmune
oesophageal rupture
Infection (TB, parapneumonic, fungal, empyema)
malignancy
pancreatitis
post-CABG
PE
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5
Q

canadian head CT rules

A

Applies to: trauma, GCS > 13, age >= 16, no anticoagulation/bleeding disorder

If high risk features

  • GCS < 15 2 hrs after injury
  • Suspected open or depressed skull fracture
  • Signs of BOS fracture
  • Vomiting >= 2 episodes
  • age >= 65 yrs

Medium risk:

  • amnesia prior to impact >= 30 min
  • Dangerous mechanism (peds car, occupant ejected, fall > 3 ft/5 stairs).
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6
Q

Signs of posterior MI on ECG

A 
V1-V3 
- horizontal ST depression
- broad / tall R waves, > 30 msec 
- upright T waves 
- dominant R wave, R/S ratio > 1 in V2 
ST elevation and q waves on V7-9, > 0.5 mm
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7
Q

Signs of RV infarction on ECG

A 
In inferior STEMI 
ST elevation in V1 
ST elevation III > II 
ST elevation in V1 + depression V2 
ST baseline in V1 and marked depression V2 
ST elevation in V3-V6R (V4R)
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8
Q

Reversal of anticoagulation with DOACs

A

Rivaroxaban and apixaban

  • 3 or 4 factor PCC
  • TXA
  • Andexanet, 400-800 mg IV bolus then infusion

Dabigatran
- Idarucizumab , human fab fragment - SAS, 5g IV

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9
Q

Warfarin reversal guidelines

A

Not bleeding

  • INR 4.5-10, observe, or vit K 1-2 mg if high risk
  • INR > 10, 3-5 mg vitamin K IV/PO and if high risk then add PCC 15-30 units/kg

Bleeding
Critical: Vit K 5-10 mg IV, PCC 50 units/kg and FFP 150-300 mls (for VII), or FFP 15 mls/kg if no PCC
Clinically significant: Vit K 5-10 mg IV, PCC 35-50 units/kg
Minor and INR > 4.5 or high risk: vit K 1-2 mg

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10
Q

Massive transfusion definition

A

> 70 mls/kg (1 blood volume) in 24 hrs, or > 50% in 4 hrs.

Child: > 40mls/kg in 24 hrs (50% BV)

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11
Q

Targets in massive transfusion

A 
Temp > 35 
PH > 7.2 
iCa > 1.1 
Platelets > 50 
APTT < 1.5
INR <= 1.5 
Fibrinogen > 1
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12
Q

Australian snakes and envenoming syndromes

A

Black snakes - aches - myotoxic
Brown - ground (bleed onto) - coagulopathy
Death adder - breath (resp failure due to weakness) - neurotoxic

Taipan - lie (down) pan ( bleeding into) - neurotoxic and coagulopathy

Tiger - evil - all!

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13
Q

DDx LAD

A 
LVH
LBBB
LAFB 
Pacing 
Old inferior MI 
WPW
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14
Q

DDx RAD

A 
LPFB 
RVH 
Lateral MI 
Lung disease - pulmonary HTN, acute PE 
VT 
Hyperkalaemia 
Sodium channel blockade
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15
Q

Parkland formular for fluid replacement in burns

A

4 mls x weight (kg) x % TBSA burnt
1/2 in first 8 hrs
remainder in next 16 hrs

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16
Q

PPM problems

A

Failure to pace - lead displacement, insulation break or lead fracture

Failure to capture - electrolytes, drugs, ischaemia, scar tissue, new BBB

Failure to sense - regular pacing despite native rhythm, lead displacement/fracture/insulation break, not sensitie enough

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17
Q

Commencement settings for temporary pacing wire

A

Rate 60-80
Output at 2, decrease until loss of capture, then increase to lowest capture x2 + 1
Sensitivity of 1-2 mV, can test
Asynchronous

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18
Q

Dialysable toxins

A 
Carbamazepine 
Lithium 
Metformin 
Theophylline 
Toxic alcohols 
Sodium valproate 
Salicylate
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19
Q

Indications for multi-dose activated charcoal

A 
Carbamazepine 
Colchicine 
Dapsone 
Phenobarbitone 
Quinine 
Theophylline
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20
Q

Indications for whole bowel irrigation

A 
Iron overdose > 60 mg/kg 
SR KCl ingestion > 2.5 mmol/kg 
SR verapamil / diltiazem ingestion 
Symptomatic arsenic ingestion, lead 
Body packer
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21
Q

Calculation of osmolar gap and causes

A

Measured osmolality (normal 270-290) - calculated osmolarity
normal -4 to + 10
= 1.86xNa + urea + glucose in mmol/L

causes: lithium, calcium, alcohols, proteins (AAs)

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22
Q

Indications for prolonged resuscitation

A

Young person with persistent VF (electrical storm)
Hypothermia
Asthma
Toxicological
Thrombolytic for suspected PE
Pregnancy prior to resuscitative hysterotomy

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23
Q

Indications for cessation of CPR

A

ROSC
Pre-existing chronic illness preventing meaningful recovery
Acute illness incompatible with life
No response at 20 min of effective resus - no ROSC, shockable rhythm or reversible causes

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24
Q

Predictors of difficult intubation

A 
Look externally 
Evaluate 3/3/2 mouth opening, thyromental, thyrohyoid
Mallampati
Obstruction / obesity 
Neck mobility
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25
Q

Predictors of difficult BVM

A 
Mask seal compromise 
Obstruction / obesity 
Aged 
No teeth 
Stiffness - asthma / COPD / pulmonary oedema / pregnancy
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26
Q

Expected rate of cooling with various techniques in hyperthermia

A

Ice packs 0.05 deg / min
Immersion in ice bath 0.2 deg / min
Evaporative spraying 0. 3 deg / min
Peritoneal lavage 0.5 deg / min

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27
Q

Expected rate of warming with various techniques in hypothermia

A

Forced air warmer 1.5-2 deg / hr
Warmed IV fluids (40 deg) ant humidified O2 1-2 deg/hr
Pleural lavage (40 deg) ?5 deg/hr
Cardiac bypass 7.5 deg/hr

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28
Q

Indicators of unsalvagable patient with hypothermia

A 
K >10 
Core temp < 6-7 deg 
Core temp < 15 with no circulation for 2 hrs 
PH < 6.5 
Intracardiac thrombus on echo 
Severe coagulopathy
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29
Q

Prognostic factors in drowning

A

Patient factors: age < 3, elderly, trauma, comorbidities (epilepsy)
Submersion factors: unwitnessed, > 10 min, cold/fresh water
Rescue factors: No resus in 10 min, early EMS
Resus response: resp effort < 15-30 min, no response to 30 min resus, ROSC prior to ED arrival
Arrival to ED: pH < 7.1, fixed dilated pupils, coma on arrival (<20% good outcome), no signs of life on arrival

30
Q

Glaucoma manaement

A

Acetazolamide 500mg IV
Pilocarpine 2%, 1 drop Q5 min for 15 min then 30 min (pupil constriction)
Timoptol 0.5%, 1 drop Q30-60 min (decreased production aqueous)
Latanoprost 0.005% 1 drop (increaes outflow and decreases IOP)

Laser iridotomy . iridoplasty.

31
Q

Pregnancy failure

A

Mean sac diameter > 25 mm with no foetal pole

Visible foetal pole, CRL > 7mm with no FHR

32
Q

BHCG at which gestational sac should be visible

A

1500 units/L

33
Q

Hard signs of penetrating neck trauma

A 
Bubbling from wound 
stridor / hoarse voice 
Massive haemoptysis 
Rapidly expanding / pulsatile haematoma 
vascular bruit / thrill 
Cerebral ischaemia 
Severe haemorrhage / unresponsive shock
34
Q

Pleural fluid findings, to determine exudate

A

Pleural fluid protein: serum > 0.5
Pleural fluid LDH: serum > 0.6
Pleural fluid LDH > 2/3 ULN of serum LDH

35
Q

Management of HR / BP in aortic dissection

A

IV esmolol 500 mcg/kg over 1 min, then 50 mcg/kg over 4 min, then infusion of 50-200 mcg/kg/min, aim HR 60-80
IV GTN 10 mcg/min increase every 3-5 min, 5-50 mcg/min to SBP 100-120

36
Q

Differentiating causes of hypovolaemic hyponatraemia

A

Urinary sodium

  • low < 20 mmol/L. pre-renal - sweating, vomiting, SBO, third space, burns
  • high > 20 mmol/L. renal - RTA, renal failure, addisons, thiazide diuretic, osmotic diuresis
37
Q

Differentiating causes of euvolaemic hyponatraemia

A

Urinary vs serum osmolarity
Low urine osmolarity. water overload, psychogenic polydipsia, potomania.
High urine osmolarity. SIADH. lung mass, CNS infection/mass, medications.

38
Q

Differentiating causes of hypervolaemic hypernatraemia

A

Urine sodium

  • Low < 20 mmol: CCF, Liver failure, hepatorenal syndrome
  • High > 20 mmol: diuretic, renal failure, steroids
39
Q

4 elements of competence

A
  • understand information
  • remember information
  • utilise information (weigh up)
  • communicate a choice
40
Q

Serotonin syndrome

A
  • Spontaneous clonus
  • Inducible / occular clonus AND temp > 38 AND agitation/diaphresosi/hypertonia
  • Tremor AND hyperreflexia
41
Q

indications for RRT

A

Oliguria (< 200 mls/12 hrs) or Anuria
Serum urea > 35 mmol/L
Serum Cr > 400 mmol/L
Serum K+ > 6.5 or rapidly rising
Serum sodium < 100 mmol/L or > 160 mmol/L
Pulmonary oedema not responding to diuretics
Severe metabolic acidosis, pH < 7.1
Uraemic syndrome (asterisks, psychosis, myoclonus, seizures, pericarditis)
Overdose with dialysable toxin

42
Q

Dialysable toxins

A 
Phenobarbitol
Lithium
Acidosis
Salicylates
Metformin
Alcohols
Theophylline
Valproic Acid
43
Q

Multi dose activated charcoal

A 
Aminophylline / theophylline
Barbiturates
Carbamazepine / concretion forming drugs (salicylates)
Dapsone
Quinine
44
Q

Risk assessment in TCA poisoning

A

< 5mg/kg minimal symptoms
5-10 mg drowsiness, mild anticholinergic effects
> 10 mg/kg potenital for major toxicity
> 30 mg/kg severe toxicity, pH dependent cardiotoxicity and coma > 24 hrs

QRS > 100 msec predicts seizures
QRS > 160 msec predicts VT

45
Q

Features of Haemolytic Uraemic Syndrome & management

A

Preceeding Diarrhoea or respiratory infection.
Microangiopathic haemolytic anaemia, thrombocytopaenia and acute kidney injury.

Dialysis for AKI.
Antihypertensives.
Transfuse for anaemia. No platelet transfusion.
Avoid antibiotics (increases toxin release)

46
Q

Thrombotic Thrombocytopaenic Purpura - features & treatment

A 
Microangiopathic haemolytic anaemia 
THrombocytopaenia 
Neurological abnormality 
Fever
Renal abnormality

Treatment with steroid, anti-platelet, immunosuppression & plasma exchange

47
Q

Treatment of severe / critical asthma (paediatric)

A

Continuous nebulised salbutamol
Nebulised iptratropium Q20 min 3 doses
Methyprednisolone 1mg/kg
Magnesium sulfate 0.2 mmol/kg over 20 min (to 8mmol)
Aminophylline 10mg/kg IV to 500 mg over 60 min
Adrenaline 10 mg/kg IM
Invasive respiratory support

48
Q

Brugada algorithm

A

Presence of any = VT

Absence of RS complex in all precordial leads?
RS interval > 100 msec in 1 precordial lead?
AV dissociation?
Morphology criteria for VT present in precordial leads V1/2 and V6?
- RBBB: V1/2 tall L rabbit ear in V1/2, smooth R, or qR
- LBBB: V1/2 - dominant S wave, josephsons sign (notching of S),

49
Q

Athrocentesis findings in Infective, inflammatory and on-inflammatory causes of arthritis

A

Infective: WCC >50,000 / microL, >85% polymophs, turbid, positive gram stain. Bacterial arthritis.

Inflammatory: WCC 2,000-50,000 / microL, >50% polymorphs, crystals (urate, calcium pyrophosphate). Gout, pseudogout, reactive arthritis

Non-inflammatory: WCC 200-2,000. Variable polymorphs. Microscopy unremarkable.

50
Q

Indications for digoxin immune fab fragment

A

Acute

  • arrest
  • arrhythmia
  • > 10 mg adult / > 4 mg child
  • serum level > 15 nmol / L
  • K+ > 5.5

Chronic - clinical features (CNS, CVS, GIT) and elevated level

51
Q

Describe the clinical findings in central cord syndrome, and usual mechanism

A

Hyperextension injury
Motor: UL > LL, Distal > proximal
Sensory: variable, but usually loss of pain/temp in UL
Sphincters: variable, urinary retention common

52
Q

Describe the mechanism and clinical findings in anterior cord syndrome

A

Vascular insufficiency or anterior compression (hyperflexion, bony fragments) of anterior spinal artery.
Motor: Loss / weakness below affected level
Sensory: loss pain/temperature (preserved prop/vib)
Sphincters: variable

53
Q

Outline approach to patient complaint

A

SAIN RICE
Support
Acknowledge complaint, apologise for experience
Investigation of what occured - staff, records
Notify / report / document - units, legal, executive, MDO
Respond - in writing, meet with complainant
Implement - systems to prevent recurrence
Communicate / educate - events via network
Evaluate - response

54
Q

Elements of open disclosure

A 
Acknowledgement of adverse event 
Expression of regret, sincere 
Factual explanation of what happened 
Information about further treatment 
Potential consequences for patient 
Steps taken to manage / prevent recurrence
55
Q

Indications for charcoal administration in paracetamol overdose

A
  1. < 2 hrs in cooperative adult
  2. < 4 hrs if IR and > 30 g
  3. < 4 hrs with SR ingestion
56
Q

Outline approach to staggered ingestion of paracetamol

A

Assume at earliest time
Commence NAC < 8 hrs if APAP available, otherwise commence empirically
If < 2 hrs from the last ingestion, repeat APAP at 2 hrs

57
Q

Thresholds for supratherapeutic paracetamol ingestions

A

> 200 mg/kg or 10 g in 24 hrs,
500 mg/kg or 30 g massive ingestion
300 mg/kg or 12 g in 48 hrs
theapeutic dose / day for > 48 hrs and symptoms

58
Q

Indications for NAC in SR paracetamol overdose

A

> 200 mg/kg or 10 g or clinical suspicion
- start NAC. 2 levels 4 hrs apart.
- if > 30 g, double second bag
- if double nomogram, double second bag
< 200mg/kg or 10g.
- 2 concentrations 4 hrs apart, and start NAC if either over nomogram line.
- if intentional, just start, and stop if 2 below threshold

59
Q

Standard NAC infusion for paracetamol overdose

A

NAC 200 mg/kg oer 4 hrs

NAC 100 mg/kg over 16 hrs

60
Q

Digoxin toxicity clinical features (Hx/Ex/Ix)

A

Cardiac

  • Atrial tachycardia
  • High grade AVB
  • Automaticity (VEB)
  • regularised AF, bidirectional VT

Neurological

  • yellow vision, haloes
  • confusion, delirium

GIT

  • N&V
  • diarrhoea
61
Q

Causes of complete heart block

A 
AV node blocking drugs
Hyperkalaemia 
Inferior MI 
Infiltrative (Sarcoid, amyloid)
Inflammatory (Rheumatic fever, myocarditis)
Autoimmune (SLE)
Cardiac surgery (MVR)
62
Q

Scarbosa criteria (modified)

A

Concordant ST depression > 1 mm in V1-3
Concordant ST elevation > 1 mm in any lead
Excessively discordant STE in any lead (>25% of s wave)

63
Q

Criteria for low risk BRUE

A 
No concerning features on history / exam 
AND 
- > 60 days old 
- born > 32 weeks and CGA > 45 weeks 
- no CPR by HCP 
- first event 
- < 1 min
64
Q

Radiation exposure and syndrome

A

> 2 gy: haemotoietic syndrome. pancytopaenia by 3 weeks.

10-15: GIT syndrome. D&V, bloody diarrhoea. associated with radiation pneumonitis, renal failure, liver injury.

15-30: Vascular syndrome. cerebral oedema and vascular collapse.

> 30 Gy: Cerebral syndrome, N&V&D. CVS collapse. death within 48 hrs.

65
Q

Calculation of digoxin fab dose

A

serum digoxin (ng/ml) x weight (kg) / 100 = number of ampoules

66
Q

Information to recieve when notified of major incident

A 
Major incident declared? 
Exact location 
Type of incident 
Hazards 
Access
Number of casualties 
Emergency services present / needed?
67
Q

Preparation for major disaster

A 
Space 
People 
Equipment 
Drugs 
Other notifications - director / CEO / media / Secuirty 
Post-disaster care
68
Q

Outline disaster triage

A 
SIEVE - on site, to treatment post 
Black - not breathing with open airway 
Red - high/low RR or CRT > 2 sec 
Yellow - normal RR and CRT, not ambulant 
Green - ambulant

SORT - on site, treatment to hospital
1-4 points per observation HR, RR and GCS
Red / Yellow / Green / Black

In ED: ATS

1: Airway / breathing intervention (OT, ICU)
2: shock (OT, angio, ICU)
3: non-ambulant not shocked. Ward +/- delayed OT.
4: treatment required, non-spinal.
5: observation only, ambulant.

69
Q

Indications for resuscitative thoracostomy

A

Stab wound to heart with pericardial tamponade
Penetrating chest trauma with signs of life < 10 min
Possibly blunt trauma with evidence of pericardial tamponade

In ED if no perfusion on arrival, or unresponsive due to shock.

70
Q

Causes of priapism

A 
Medications 
- impotence treatment, intracavernosal PGE
- silendafil
- Antipsychotic, stimulants, lithium, heparin/warfarin, prazocin
Idiopathic 
Sickle cell disease 
Haematological malignancy 
Spinal cord disease
Vasculidities
71
Q

Diagnostic criteria for Rheumatic Fever

A

2 major or 1 major and 2 minor

Major: carditis, chorea, erythema marginatum, subcutaneous nodules or polyarthritis

Minor: Temp > 38, ESR > 30 / CRP > 3, Arthralgia, history of rheumatic fever, long PR

Need to know (5 decks)

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