Part B 02 Flashcards
Define sepsis
Life threatening organ dys
Due to host response
To infx
Septic shock
Definition
Circulatory or metabolic ab which increases mortality
- vasopressors MAP>65
- lactate >2
Despite adequate fluid resus
qSOFA
sBP<100
RR>22
GCS<15
> 2 = poor outcome
Fluid bolus in sepsis
Volume
30ml/kg
Ventilator settings
Tidal Vol
6-8ml/kg
Ventilator settings
Rate
10-15
Ventilator settings
Fi O2
0.21-1.00
Ventilator settings
PEEP
0-20cmH2O
Ventilator settings
Inspiratory flow rate
40-60L/min
Ventilator settings
I:E ratio
<1:1
Ideal body weight
male
Female
Male
Height cm - 100
Female
Height cm - 110
Median nerve block
Process
Between palmaris longus and flexor Carpi radialis Or 1cm medial flexor carpi radialis 2.5cm from wrist crease 0.5cm deep 5-10ml 1% lidocaine
Decreasing ETCO2
Causes
Cardiopulmonary arrest PE Hypotension Massive blood loss Cardiopulmonary bypass
% people with no palmaris longus
15%
Numbness lateral thigh
Dx
Meralgia paresthetica
Meralgia paresthetica
Pathology
Lateral femoral cutaneous nerve
Often due to increase weight, pressure from belt
Also DM, trauma
Ottawa ankle rules
Pain in malleolar region +
- tender distal 6cm posterior edge (lat/medial)
- inability to weight bear immediately and in ED
Ottawa foot rules
Pain in mid foot +
- tender base 5th metatarsal
- tender navicular
- Inability to weight bear immediately and in ED
Exclusion to Ottawa rules
Pregnancy
HI or intoxicated
(+ unable to follow test)
Children <6
CI to knee joint aspiration
Cellulitis
Coagulopathy
Joint prosthesis
Knee joint aspiration
Process
Clean, drape, lidocaine Approach med/lat/superior/inferior 1cm from patella Direct needle posterior to patella toward joint space Aspirate +/- milk joint space
Knee aspirate
Send for
Cell count
Culture and sens
Gram stain
Crystal analysis
APLS
Shock strength
4J/kg
APLS
Adrenaline dose
10mcg/kg
APLS
Amiodarone dose
5mg/kg
APLS
fluid bolus volume
20ml/kg
N saline
Paeds
CT head criteria
w/i 1 hour for any of these
Suspected NAI Post traumatic seizure Initial GCS<14 or <15 (<1yr) At 2h post injury GCS <15 ?depressed/basal skull # Tense fontanelle Focal neuro deficit (<1yr) with >5cm injury to head
Manipulate colles’ # if
> 10• posterior tilt (lat view)
Displaced ulnar styloid
Ulnar angulation distal fragment
Visual deformity (not swelling)
Entonox
Time to act
Time to wear off
Time to act - 30s
Time to wear off - 60s
Suxamethonium
Type drug
Onset time and length of action
Depolarising NM blocker
30s to onset
3-5 mins action
CI to suxamethonium
Malignant hyperthermia
Hyperkalaemia
Severe burns
Severe muscle trauma
Suxamethonium dose
~1mg/kg
Causes of
Rising ETCO2
Hypoventilation
High temp (increased metabolism)
Pain
Sharkfin or sawtooth
Capnography
Indicates
Bronchospasm or
Airway obstruction
Drugs for conscious sedation
Opioids or Benzos
Curare cleft
Notch in ETCO2
Due to spontaneous breathing
NM block wearing off
Mallampati score
1: soft palate, uvula, Fauces, pillars
2: as above, no pillars
3: s palate, Base uvula
4: hard palate only
Path external jugular vein
Inferior from ear lobe to mid clavicle
Ulnar nerve block
Process
Needle under flexor carpi ulnaris Distal to styloid process Advance 5-10mm 3-5ml lidocaine 1% Further 2-3ml at ulnar aspect of wrists for dorsal branch
Atracurium
Type drug
Non depolarising
Cf sux
Atracurium
Intubating dose
V
Maintenance dose
Intubating dose 0.3-0.6mg/kg V Maintenance dose : 1/3 above 0.1-0.2mg/kg
Cause of
Horners syndrome
Disruption of sympathetic chain
90% sialoliths
Found in
Whartons duct
Submandibular gland
Scoring system
Sore throats
FeverPAIN Facet over last 24h Purulence Attended in <3d Inflamed tonsil No cough/coryza
When to give abx
For sore throat
FeverPAIN
0-1 nil abx
2-3 delayed script
>4 abx
Tx strep throat
Phenoxy…
or
Clarith
10d
BRUE
Stands for
Brief resolved unexplained incident
BRUE
Criteria
Brief resolved unexplained incident <12m Last<1m Resolved No clinical explanation Altered level responsiveness
BRUE aka
ALTE
Apparent life threatening event
BRUE
RF
Prematurity <10w Recent anaesthesia Airway obs GORD Previous apneic episode
Paeds
Trauma analgesia
Intranasal diamorphine 0.1mg/kg in 0.2ml H20 IV morphine 0.1mg/kg Oral paracet 20mg/kg Oral ibuprofen 10mg/kg
Paeds
Femoral # immobilisation
Distal:
Padded long leg splint
Proximal
Skin traction (weight 10% body weight)
Coopers sign
Meniscal tear
Pain when changing position even w/I weight bearing
Arthritis usually with weight bearing
MCL attached to
Medial meniscus
Causes of T1 resp failure
PE Atelectasis P edema ARDS High altitude
Cause T2 resp failure
Ex COPD Life threatening asthma OSA Obesity Kyphoscoliosis CF NM disorder
Causes of
Airway obstruction in
Maxillofacial trauma
FB: teeth, vomit Bleeding Swelling airway Mid face # displaces posteriorly Bilat mandible # Trauma larynx/trachea
Thiopental sodium
Type drug
Barbiturate
Non depolarising anaesthetic
Dose
Thiopental sodium
5mg/kg
Thiopental sodium
SE
Hypotension Arrhythmia Myocardial depression Laryngeal spasm Cough Rash
Manoeuvres to aid
Intubation
Position: Neck flex 35’, face ext 15’ Gum elastic bougie BURP Alternate laryngoscope Reduce cricoid pressure
3-3-2 rule
Fingers between
3: incisors
3: hyoid to chin
2: thyroid notch to floor mouth
Factors that cause
Difficult intubation
C spine injury Arthritis c spine Mid face # Mandibular # Limited mouth opening Receding chin Overbite Short/muscular neck
Oxygen requirement calculation
Ventilated patient
(During transfer)
FiO2xMV + ventilator O2
X
2x transfer time
Amount O2 ventilator uses per min
1L O2/min
Bells phenomena
Bell’s palsy
Ask or close eye
Eye rolls up and out
Cannot close eye
Bell’s palsy
Tx
Prednisone
25mg BD for 10d
Subconjunctival haemorrhage
Associated with
HTN
Basal skull #
Blood dyscrasia
Subconjunctival haemorrhage
Time to resolve
Improves w/i 10-14d
Cause of optic nerve lesions
MS Trauma Malignancy Infection Inflx - GCA B12 deficiency
Dendritic eye ulcer
Tx
HSV t1 Aciclovir drops 5x/day for 10d High dose vit c Eye clinic
Mydriatic eye drops
CI
Hx AACG
Mydriatic eye drops
List drugs
Atropine
Phenylephrine
Cyclopentolate
Tropicamide
Causes of
Pathological mydriatic pupil
Holmes Addie
Traumatic iris damage
3rd nerve palsy
Rubeosis iridis
Gout
RF
Medications - diuretics FHx Lifestyle - etoh, bmi Metabolic syndrome Renal ds Trauma/surgery
Indication for joint aspiration
?septic joint ?crystal arthropathy Unexplained arthritis and effusion Check response septic arthritis to Tx Check joint capsule integrity post trauma
Unwell or with surgical abdomen
No time for CT
Tx
Explorative laparotomy
Most common spinal cord infarction
Anterior spinal arteries
Anterior cord syndrome
Anterior cord syndrome
Sx
Loss of motor functions
+ some sensory
Lisfranc injury
Define
Tarsometatarsal # dislocation
Lisfranc injury
Tx
Bacslab POP
Non weight bearing
Ortho referral
Likely ORIF
SAH + 3rd nerve palsy
Indicates
Likely ruptured posterior communicating artery aneurysm
HASBLED
Acronym
HTN (sBP>160) Abnormal liver/renal Stroke hx Bleeding predisposition Labile INR Elderly >65 Drugs (NSAIDS, EtOH)
HASBLED score
Indicates
> 3 indicates high risk bleeding
Consider anticoagulation
Increase review
Q fever
Organism
Coxiella Burnetti
Zoonotic infection
Q fever
Tx
Doxycycline 2w
Q fever
Complications
Atypical pneumonia
HIV seroconversion illness
% who get it
When
40%
1-6w Post exposure
HIV seroconversion illness
Ix
p24 antigen tear
HIV RNA levels
NB: Ab test will be negative
Thyroid storm
Tx
IV fluids Paracetamol Benzodiazepine Steroids for adrenal suppression Abx for infx Propranolol 80mgPO High carbimazole 50mg/day Potassium iodide 200mg IV over 1h (Blocks release thyroid hormones)
