Part B 04 Flashcards
Clinical test prior to ABG/ART line
Name and procedure
Allen’s test Occlude both radial and ulnar artery’s Make fist open hand - white Remove occlusion ulnar artery <6s = good collateral circ
Ventilation in HI
PCO2 aim for
Normally vs deteriorating
PCO2 = 4.7
Deteriorating patient
<4.3kPa
Radial nerve block
Process
Wrist dorsiflexion Lidocaine Radial/dorsal wrist ~ 3cm prox to radial styloid Aim medially toward radial artery
ASA classification
1: healthy
2: mild systemic ds
3: severe systemic ds
4: severe systemic ds that is constant threat to life
5: moribund pt not expected to survive w/o operation
6: brain dead: organ donation
BiPAP
Stands for
Bilevel positive airway pressure
BiPAP
Types
Timed cycled
or flow cycled
BiPAP
Name of 2 different pressures
IPAP: inspiratory positive airway pressure
EPAP: expiratory positive airway pressure
CPAP equivalent to which pressure of BiPAP
EPAP
CPAP/EPAP
Assists breathing how?
Inspiration
- recruits alveoli -> increase gas exchange
Expiration
- stents alveoli open -> increases functional residual capacity -> increases gas exchange
IPAP
Assists breathing how?
Higher IPAP pressure
- recruits alveoli as per CPAP
- decreases work of breathing , fatigue, myocardial O2 demand
- increases tidal volume -> washes out CO2
Pressure support =
IPAP-EPAP
Starting pressure for NIV
CPAP - 5cm H20
Starting pressure for NIV
BiPAP
10/5cm H2O
Increasing NIV pressure
How much
Increase 2cm every 5 min until response
Max NIV pressure
15-20cm H2O
C.I. to NIV
Resp arrest Cardiac arrest Nil consent Uncooperative pt Unable to tolerate Facial trauma/burns Reduced GCS Untreated pneumothorax Basal skull # Intractable vomiting Untrained staff
Knee ligament injury mechanism ACL PCL MCL LCL
ACL - pivoting PCL - dashboard injury - blow to tibia w’ flexed knee MCL - blow to lat knee (Valgus stress) LCL - blow to med knee (Varus stress)
Mechanism of injury
ACL
Pivoting
Mechanism of injury
PCL
Dashboard injury
Blow to tibia with flexed knee
Mechanism of injury
MCL
Blow to lateral knee
Valgus stress
Mechanism of injury
LCL
Blow to medial knee
Varus stress
Unhappy triad
ACL
MCL
Medial meniscus
Emergency thoracotomy indication
Penetrating injury
- witnessed cardiac arrest
- unresponsive hypotension
Blunt injury
- chest drain >1500ml
- unresponsive hypotension
Massive haemothorax
Defined
> 1/3 blood vol in chest
> 1500ml blood
APLS
Anaphylaxis
Range of adrenaline dose
150-500mcg IM
APLS
Anaphylaxis
Range of chlorphenamine dose
2.5-20mg IM
APLS
Anaphylaxis
Range of hydrocortisone dose
25-200mg
APLS
Non shockable rhythm
Adrenaline dose
10mcg/kg adrenaline
IV/IO
Posterior shoulder dislocation
X-RAY signs
Light bulb sign
Absence ext rotation
Trough line sign
Rim line sign
Trough line sign
Post dislocation
- vertical dense line in medial humeral head
Rim line sign
Widened glenohumeral joint
>6mm
HI and GCS<13 in ED
Imaging
CT head and neck
Commonest hip pain
< 10yo
Transient synovitis
Septic arthritis
Perthes
Congenital hip dysplasia
Tetanus prone wound requiring
Ig
Puncture Wound >6h Dirty wound Significant devitalised tissue Avulsion Open # Gunshot Crush injury Burns
Ulnar neuritis
Sx
Paraesthesia/numb little finger
Hand weakness
Ulnar neuritis
Most common cause
Cubital tunnel syndrome
Ulnar neuritis
Ix
Nerve conduction study
Ulnar neuritis
Tx
Surgical decompression
Cubital tunnel
Location
Medial epicondyle
Under osbournes ligament
Fight bite abx
Co amoxiclav
Or
doxy and metronidazole
Peri anal haematoma
Pathology
Rupture of small vein
> small collection of blood
> firm clot w/i 1h
Peri anal haematoma
Tx
Needle aspiration blood w/i 1h
Spontaneously resolves w/i days
Or
I+D if too painful
Scoring system for
Acute appendicitis
Alvorado score
SIGN guideline
Lower GI bleed
Admit for early endoscopy if:
>60yo Haemodynamic instability Evidence of gross rectal bleed Aspirin/NSAID Significant comorbidity
AAA
RF
Age Male Smoking HTN PVD fHx Connective tissue ds
Commonest cause LBO
Malignancy
Tripod #
Includes
Lat orbit
Zygoma
Maxilla
Tripod #
Aka
zygomaticomaxillary complex
Tripod #
Tx
Severe angulation or comminuted = ORIF
Otherwise conservative
Mandible #
Location
30% condyle
25% angle
25% body
15% mental
Mandible #
Complications
Osteomyelitis
Paraesthesia
Malocclusion
malocclusion
Define
malocclusion is a misalignment or incorrect relation between the teeth of the two dental arches when they approach each other as the jaws close.
LMN facial nerve palsy
Ddx
Bells Ramsey hunt synd Trauma Parotid bland tumour Vestibular schwanomma Middle ear infx Cholesteatoma Sarcoidosis
Traumatic aortic rupture
% RTA deaths
15-20%
Traumatic aortic rupture
Most common location
Incomplete laceration
Next to ligamentum arteriosum
Traumatic aortic rupture
CXR signs
Widened mediastinum
Trachea deviated to Right
De Quervains tenosynovitis
Sx
Thickened and inflamed tendons
Radial side of wrist
De Quervains tenosynovitis
Tendons involved
Extensor pollicis brevis
Abductor pollicis longus
De Quervains tenosynovitis
Test
Finkelsteins test Flx wrist w ulnar deviation And thumb flx across palm Stretches tendons > pain
De Quervains tenosynovitis
Tx
Rest
Thumb splint to immobilise
Barton’s #
Define
Intra articular # distal radius
W’ dislocation of radiocarpal joint
Distal fragment can be displaced dorsal or volar
Barton’s #
Tx
Inherently unstable#
Needs ORIF
Consider SBP if
Any patient with ascites that is deteriorating
Asymptomatic cases have been reported
% patients with ascites that develop SBP per year
30% per year
Tx
SBP
Ceftriaxone or cipro
+
IV albumin (reduces renal failure)
Ascetic tap
Process
- Find flank dullness
- Lateral to rectus abdominis
- 5cm superior and medial to ant superior iliac spine
Arctic tap fluid analysis that suggests SBP
WCC >500 cells/ml Neut>250 Lactate >25mg/dl pH<7.35 Bacteria on gram stain
Prophylactic abx for SBP
Norfloxacin
WPW causes what type of tachyarrhythmia
AVRT
Atrioventricular re-entrant tachycardia
WPW
ECG features
Short PR<120ms
Delta wave
Widened QRS
Types WPW
Type A; features sim RBBB
Tube B; sim LBBB
Drop INR by 1
Decrease warfarin dose by
15%
Types transfusion reaction
Acute haemolytic reaction Febrile transfusion reaction Allergic reaction TRALI ~6h Delayed haemolytic reaction (4-8d) GVHD (1-4w)
Cause of
Acute haemolytic reaction
ABO mismatch error
Cause of
Febrile transfusion reaction
Cytokines in blood
Cause of allergic reaction to blood transfusion
Eg due to anti IgA Ab
Cause of TRALI
Ab in donor blood vs recipient
Theophylline
Type of drug
And risk using
Phosphodiesterase inhibitor
Narrow therapeutic window
Theophylline
OD sx
Headache, N+V
Seizure, low electrolytes
High BG
Cannabinoid hyperemesis syndrome
Time to develop
Average 16 years of chronic use
V rare for cannabinoid toxicity
Cannabinoid hyperemesis syndrome
Improves with
Hot baths
Cannabinoid hyperemesis syndrome
Complications
Cannabinoid hyperemesis acute renal failure
Hypovolaemic
Paracetamol OD
Toxin
And how it accumulates
NAPQI
Hepatotoxic
Glutathione used up allowing NAPQI to damage liver
Paracetamol OD
Amount taken that can cause severe Damage
> 12g
Or
150mg/kg
Paracetamol OD
Time to
- abnormal LFT
- hepatic failure
- abnormal LFT ~18h
- hepatic failure ~48h
Paracetamol OD
Significant ingestion
What dose
> 75mg/kg
Start NAC Tx
If
4h level over Tx line
Or
>8h and significant OD (75mg/kg)
NAC
Effectiveness reduced if over x h since OD
8h since OD
NAC
Tx dose, vol, time
1) 150mg/kg in 200ml over 1h
2) 50mg/kg in 500ml over 4h
3) 100mg/kg in 1L over 16h
