Questions from Pastest Flashcards
What is Bladder Exstrophy?
Congenital abnormality where the bladder is open and exposed on the outside. It is associated with adenocarcinoma of the bladder
By what mechanism does hydrofluoric acid cause electrolyte imbalance in burns patients?
Two mechanisms:
i) Hydrogen ions cause the inital skin damage (Because it is an acid)
ii) Fluoride - permeates the skin and binds calcium
Hypocalcaemia - is associated with cardiac arrhythmias (prolonged QT interval), muscle rigidity/cramps and hypertonicity
Diagnostic tests in acromegaly?
Best is Oral glucose tolerance test with GH:
GH is suppressed to <2 in normal people but often rises in people with acromegaly
IGF1 is more sensitive than GH and more reliable
Prolactin can be raised in 30% of patients
Innervation of the GI tract?
Parasympatehtic
Grossly - the vagus nerve supplies the GI tract up to the distal transverse colon. The rest of the GI tract i.e. splenic flexure onwards is innervated by pelvic splanchnic nerves.
Ganglia:
Coeliac - Lower oesophagus and stomach
Superior mesenteric -Duodenum–> jejenum, Caecum, Proximal ascending colon
Inferior mesenteric - Distal Transverse colon –> Sigmoid colon
There is lots of overlap between these
What is Gardner’s Syndrome?
1 MAJOR
and
9 other features
FAP (APC mutation. APC is a tumour suppressor gene)
+
Desmoid tumours,
Epidermal Cysts,
Lipomas,
Multiple Osteomas,
Small Intestinal Malign., Thyroid Malign, Pancreatic Malign. Biliary hepatoblastoma.
Connective Tissue Diseases
Three anatomical narrowings or the ureter
Ureteropelvic junction
Ureteric crossing over iliac vessels
Ureterovesicular junction
Genetic associations of:
Melanoma
Basell Cell Carcinoma
Melanoma: CDKN2A, BRCA1, CDK4
BCC: Gorlin Syndrome, PTCH2, Rombo syndrome, bazex-dupre-christol syndrome,
How many days after inadequate calorific intake should TPN/Enteral adjuncts be used?
7 Days
Where is:
Foregut/Midgut Junction
Midgut/Hindgut Junction
Foregut/Midgut junction - Major Duodenal Papillae. This is where common bile duct and pancreatic duct empty into duodenum
Foregut/Midgut Junction - Distal third of Transverse colon
Where does:
Papillary thyroid carcinoma metastasise too?
Follicular thyroid carcinoma metastaise too?
Papillary thyroid carcinoma - Cervical Lymph Nodes
Follicular thyroid carcinoma - Lung and bone
Which nerves are in close relation to the superior thyroid artery?
External laryngeal nerve - branch of the superior laryngeal nerve
Gold standard diagnosis for urethral injury
Retrograde Urethrography
Features of peutz jeghers
Autosomal Dominant Condition (Chr 19)
Small Bowel Hamartomas
Pigmentation of - skin, buccal mucosa, hands and genitalia
Small Risk of pancreatic, breast, lung, ovarian and endometrial malignancies
How does finasteride work
5 alpha reductase inhibitor
5 alpha reductause usually converts testosterone to dihydrotestosterone
Describe course of recurrent laryngeal nerve.
left:
Branches off of the vagus nerve as the vagus nerve traverses anteriorly over the aortic arch. It ascends posteriorly behind the ligamentam arteriosum + arch where it is in close relation to the inferior thyroid artery. It travels in a groove between the trachea (anterior) and the oesophagus (posterior).
right:
Branches off of the vagus nerve as the vagus nerve traverses anteriorly over the right subclavian artery. It ascends near the inferior thyroid artery. It travels in a groove between the trachea (anterior) and the oesophagus (posterior).
When to give n acetylcysteine?
Delayed presentation > 8 hours after ingestion
If serum paracetomal level is over the line
Staggered overdose
What are the hand muscles supplied by the median nerve?
LOAF
Lateral two lumbricals
Opponens pollicis
Abductor Pollicis brevis
Flexor Pollicis brevis
What is secreted by the gastric:
Chief Cells
Parietal Cells
Foveolar cells
Chief Cells - Pepsinogen (inactive enzyme that is activated once secreted. Breaks down protein into amino acids.
Parietal Cells - Intrinsic Factor (Needed for vitamin b12 absorption in the terminal ileum). Gastric Acid.
Foveolar Cells - Mucous Production
Surgeries for rectal tumours.
If mass is <5 cm from the anal verge –> Abdomino-perineal resection:
- Anus removed, rectum and partial sigmoidectomy. End stoma left and plastics input for a gluteal flap.
low anterior resection if >5 cm from the anal verge
- this is a function sparing procedure. as much rectum that can be spared is spared. affected portion and part of sigmoid removed. Colo-anal/rectal anastamosis performed.
Transanal endoscopic mucosal resection
- Superficial rectal polyps or small neoplasms.
Describe the MEN conditions
Multiple Endocrine Neoplasia (Autosomal Dominant Disorder)
I - Pituitary, Pancreatit, Parathyroid
IIA- Medullary Thyroid Carcinoma, Phaechromocytoma, Parathyroid
IIB- Marfanoid Features, Mucosal Neuromas, Medullary Thyroid Carcinoma, Phaechromocytoma, Parathyroid
Radiographic Description of fibroadenoma?
Common location
Peak incidence
Radiographically - Ovoid smooth solid mass w/ low level internal echoes
Commonly - upper outer quadrant
Peak incidence - 20s to 30s
Describe Gel and Coombs Classification
Type I - Immediate. Mast Cell Degranulation –> Anaphylaxis, rash.
Type II - Need sensitisation. IgG and IgM. –> Autoimmunity, Haemolytic anaemia, Drug reactions
Type III - Soluble antigen/antibody complxes –> complement cascades. –> Nephritis, Faermer’s lung disease etc.
Type IV - T Cell mediated . Delayes presentation between 24 hour - 72 hours. E.g Contact Dermatitis
Stages of haemorrhagic shock?
I - <15% Loss/ <750 ml
II - 15-30% Loss/ <1500 ml. RR- 20-30. UO 20-30 ml/h
III - 30-40% loss/ <2000ml. Tachycardia 120-140. RR 30-40. UO 5-15 ml/h
IV - >2000ml. Tachycardia >140. RR >35. UO extremely low
Abdominal Aortic Aneurysm Screening age?
65 year old men - once off
Phaeochromocytoma
Aetiology
Symptoms
Treatment Principles
Aetiology:
- Tumour arising from chromaffin cells of the adrenal medulla. Secrete catecholamines.
Symptoms:
- Adrenergic - Sweating, hypertension, tachycardia, increased metabolic rate
Treatment Principles:
alpha block - prevents hypertensive crisis
beta block- heart rate control
- adrenalectomy.
Hepatocellular Carcinoma:
Aetiology
Causes
Treatment
Aetiology
Malignant tumours of hepatocytes. Express AFP.
Causes
Hepatitis B,C
Cirrhosis (Alcoholic, PBC, PSC, Haemochromatosis)
Aflatoxins
Treatment
Annually to Bi-Annually surveillance of at risk patients with US+AFP
Resection, targetted ablation, chemotherapy, radiotherapy.
Grades of splenic injury
I - Either laceration <1cm or subcapsular haematoma <10% of surface area
II - Either laceration 1-3 cm or subcapsular haematoma 10% -50% surface area
III - Either laceration >3cm or subcapsular haematoma >50% surface area
IV - Segmental or hilar vascular injury or 25% devascularisation of spleen
V - Shattered spleen/ Hilar Injury with complete devascularisation
Sequential Organ Failure Assessment
What is it ?
Criteria
Sequential Organ Failure Assessment
Used to identify people at high risk of mortality from sepsis
RR > 20 breaths per minute
BP <100 mmHg
GCS <15
Types of Diabetes Insipidus
Diabetes Insipidus - this is where there is either a lack/reduced responsiveness to ADH
Central DI - Caused by lack of secretion of ADH (Vasopressin) from the posterior pituitary
Nephrogenic DI - Lack of response from the kidneys to ADH. Usually stimulates aquaporin 2 channels to become upregulated.
Drugs associated with development of C Difficile
Pathophysiology of C Difficile
Commonly antibiotics but also chemotherapeutic agents
Antibiotics: (Remember 4 Cs)
Cephalosporins
Co- Amoxiclav
Clindamycin
Ciprofloxacin
Pathophysiology:
Two toxins.
Enterotoxin - A
Cytotoxin - B
Salivary Gland Stones
Glands commonly affected?
Submandibular > Parotid
Define the TNM classification system for breast
T - refers to the primary tumour
Tis (In Situ) / T1 - <2cm / T2 2-5cm / T3 >5 cm / T4 spread to adjacent structures
N - refers to nodal involvement
N0 - None, N1 - Mobile axillary nodes, N2 - Fixed axillary nodes, N3 - Other surrounding node groups
M - refers to metastasis
M0 - None
M1 - involving other organ
HIV Testing - when are the following tested for
p24 antigen
antibody
ELISA
p24 (viral core protein) - 4 weeks post-exposure
Antibody - 6 weeks - 3 months post exposure
ELISA - 6 months post exposure
Gynaecomastia:
Causes
Liver Cirrhosis (increased aromatase enzyme activity —> more androgens converting to oestrogens)
Drugs - Anti-psychotics, Digoxin, Cimetidine, Ketoconazole, Oestrogens, Anti-testosterones (finasteride), Spironolactone
Sex Development Disorders - hypogonadism, kinefelter’s syndrome,
Questions regarding portal vein
What two veins form the portal vein?
Where does the portal vein lie in relation to other portal triad structures?
What is the hepatoduodenal ligament?
At what level is the portal vein formed?
Relation to pancreas?
Branches?
What two veins form the portal vein?
Splenic Vein + Superior Mesenteric Vein
Where does the portal vein lie in relation to other portal triad structures?
It lies posterior to the other two structures - hepatic artery proper and common bile duct
What is the hepatoduodenal ligament?
Double layer of periotneum formed from the free edge of lesser omentum enclosing the portal triad
At what level is the portal vein formed?
Transpyloric plane - L1
Relation to pancreas?
Runs posterior to neck of pancreas
Branches?
2 - Left (II-IV) and Right (Anterior branch - V + VIII, Posterior branch - VI + VII)
What is the cardiac index?
Cardiac output
________________________________
Body surface area
Usually between 2.5-4.0 L/min. It is useful in determining the cardiac function in view of different sizes of patients.
Which type of genetic targets are these?
sis
erb B-2
ras
myc
bcl-2
sis - Platelet-derived growth factor activator
erb B-2 - Growth factor receptor oncogene
ras - Signal transducer
myc - transcription factor
bcl-2 - prorammed cell death regulator
Suture Types:
Polypropylene (Prolene)
Silk
Nylon
Polyester
Polydioxanone Sulphate (PDS)
Polygalactin 910 (Vicryl)
Polyglycolic Acid (Dexon)
Polyglyconate (Monocryl)
Polypropylene (Prolene) - Non Absorbable
Silk - Non Absorbable
Nylon - Nonabsorbable
Polyester - Nonabsorbable
Polydioxanone Sulphate (PDS) - Absorbable
Polygalactin 910 (Vicryl) - Absorbable
Polyglycolic Acid (Dexon) - Monofilament Absorbable Suture
Polyglyconate (Monocryl) - Absorbable Suture
Describe venous drainage of the GI Tract
Portal Vein - Formed from SMV and Splenic Vein at L1
Inferior mesenteric vein drains into splenic vein near confluence of portal vein.
Which bacterial infection has pus containing sulphur granules
Actinomycosis
Gram Positive Anaerobic Bacterial infection
Commoner in diabetics + Immunosuppressed
Causes Granulomatous and Suppurative Inflammation
What values correlate with cyanosis?
Thought that >2.0 g/dL of deoxyhaemoglobin/methaemoglobin reliably produce cyanosis
Macroscopic + Microscopic + Extra-intestinal features Findings of:
Crohn’s
Ulcerative Colitis
Crohn’s
Macroscopic - cobblestoning, aphthous ulcers, rose thorn ulcers, abscesses, stricures and fistulae
Microscopic - Transmural inflammation + granuloma
Extra-intestinal - peri-anal, mouth ulcers, erythema nodosum, arthritis, spondloarthropathies, uveitis, episcleritis, Pyoderma Gangrenosum
Ulcerative Colitis
Macroscopic - Psuedopolyps, Friable mucosa, Featureless colon, Reduced haustrae, short colon, toxic megacolon
Microscopic - submucosal, mucosal inflammation, crypt abscess
Extra-intestinal - PSC, arthritis, spondyloarthropathies, uveitis, episcleritis, Pyoderma Gangrenosum
What is the conus elasticus?
Conus elasticus is a yellow tissue that forms from the lateral part of cricothyroid membrane.
It has a free edge which forms the vocal ligament.
Connects the Cricoid, Thyroid and arytenoid cartilage
What does antithrombin III do?
What drugs effect it?
Antithrombin III - inactivates coagulation enzmes fXa, fIX, fII, fVII, fXI, DXII
Heparin speeds up this process
What is the epiploic foramen?
Boundaries
Foramen of winslow (epiploid, omental)
Communication between the greater and lesser sac of abdomen.
Borders:
Anterior - Hepatoduodenal ligament( Containing the biliary triad - CBD, Hepatic ARtery, hepatic portal vein)
Posterior - Peritoneum covering IVC - Just Left is the arota
Superior - Peritoneum covering caduate lobe of liver
Inferior - Peritoneum covering duodenum and hepatic artery
Left Lateral - Gastrosplenal and splenorenal ligament
Mechanism of Warfarin Necrosis
Protein C and Factor VII inhibition is greater than the others in the initial period following warfarin initiation ——>
This makes a pro thrombotic state. Skin necrosis is caused
Particularly in young, large women
Causes of low anion gap
Anion Gap=
Cations (K+ + Na+) - Anions (cl- - HCO3-)
High anion gap is caused by bicarb buffering (reduction in anion) —> therefore seems like more cations than anions
Normal anion gap - loss of bicarb through GI, renal loss, renal dysfunction (renal tubular acidosis)
Low anion gap = Caused by an apparent increase in anions.
Usually low albumin states ( where Chloride ions and Bicarb ions are retained to compensate for the negatively charged albumin loss)
Other causes of low anion gap = Hypergammaglobunimaemia (MM) Hypergcalcaemia hypermagnesaemia, lithium toxicity, hyperviscositiy, halide/bromide intoxication
Relation to the lung hila?
Phrenic Nerve
Vagal Nerves
Recurrent laryngeal Nerve
Aorta
Azygos Vein
Phrenic Nerve - Anteriorly to the hila
Vagal Nerves - Posteriorly to the hila
Recurrent laryngeal Nerve - Superior
Aorta - Posterior to left main bronchus
Azygos Vein - Posterior to right main bronches and travels anteriorly to join SVC
Signs of Lidocaine Toxicity
Max dose w/ w/o adrenaline
Max Dose: With adrenaline - 7 mg/kg . Without adrenaline 3mg/kg
Signs of toxicity:
Perioral Paraesthesia
Hypotension
Convulsions
Dizziness
Cardiac Arrhythmias
Collapse
Nutritional Requirements:
Sodium
Potassium
Calories
Protein/Fat/Glucose
Sodium - 1-2 mmol/kg/day
Potassium - 1mmol/kg/day
Calories - 25-30 kcal/kg/day
Protein/Fat/Glucose - 20:30:50
Gallstone Ileus Management
Emergency laparotamy
- Gallstone needs to be passed through into the large bowel to prevent furhter obstruction –> perferation. It can also be extracted via enterotomy.
- Fistula between the gall bladder and duodenum (Cholecystoduodenal Fistula) does not require surgical closure.
Polyhydramnios + Intestinal Obstruction
Duodenal Atresia - Congenital abscence of duodenal lumen
Nasal Anatomy
What drains into the inferior meatus (2)
What drains into the middle meatus (5)
What drains into the superior meatus (2)
Where is the olfactory epithelium
Inferior meatus - Nasolacrimal Duct (Rostral), Auditory Canal (caudal)
Middle meatus - Maxillary Sinus, Anterior ethmoidal air cells( Semilunar hiatus), Frontal sinus (semilunar hiatus) Ethmoidal Bullae, Middle ethmoidal cells,
Superior Meatus - Posterior ethmoidal air cells, sphenoidal sinus
Olfactory epithelium lines the superior aspect of the superior nasal meatus - cribiform plate
Where do small cell lung cancers usually effect?
2 Common Paraneoplastic Syndromes
Radiographically?
Main or lobar bronchi
SIADH, PTHrp (related protein),
Can also cause cerebellar syndromes - anti-yo antibodies, myaesthenia gravis, optic neuritis
Radiographically - Perihilar mass
If nodes are involved then the mediastinum can be widened
Do the left or the right papillary muscles play a part in conduction system of heart?
Right
They communicate with the moderator band (originating from the interventricular septum)
Anencephaly and Spina bifida
Dates and neuropre
Anencephaly - failure of cranial neuropore closure by day 25
Spina Bifida - failure of caudal neuropore closure by day 27
Breast reconstruction
Types
Complications
Types: i) Cosmesis ii) Free tissue iii) Flap
Types of Flap:
- TDAP -Lat Dorsi, Thoracodorsal perforator artery
TRAM - Transverse rectus abdominus myocutaneous
DIEP - Deep inferior eipigastric artery perforator
IGAP - inferior gluteal artery perforator
TUG - Transverse upper gracilis
Complications:
Scarring, haematoma, seroma, Abdominal wall hernias
Flap Necrosis - Usually effects outer areas. Can be due to insufficient arterial supply or impaired outflow (congestion/ thrombosis - venouss)
Cosmesis - Flap necrosis, infection, rippling, capsular contracture, leak, rupture
Nerves: Roots and Actions
Pudendal
Obturator
Post-Ganglionic Parasympathetic
Genitofemoral
Ilioinguinal
Pudendal - S2 - S4 nerve roots from sacral plexus. Perineum, Pelvic Floor and external anal sphincter
Obturator - L2-L4 ventral rami of lumbar plexus. Adductor Magnus, longus and brevis. Gracilis. Obturator Externus. Cutaneous- middle part of medial thigh
Post-ganglionic parasympathetic- Pelvic spanchnic nerves. Involuntary supply of internal anal sphincter. Relaxes in response to pressure
Genitofemoral nerve- L1-L2. Divides into respective genital + femoral nerves in men. Supplies - creamscertic and dartos nerve. Sensory innervaton to tunica vaginalis, spermatic fascia and upper part of scrotum
Ilioinguinal nerve - L1. Sensory supply to genitalia (root of penis, scrotum. labia majora, mons pubis).
Why is peritoneal insufflation difficult in terms of anaesthtics for people with lung pathology?
It causes splinting of the diaphragm and reduces lung movements:
This leads to reduced lung compliance needing higher airway pressures to achieve adequate oxygenation
Brachial Plexus
3:1:0:3:5:5
3 Branches from roots : LSD
Long thoracic nerve, Nerve to subclavius, Doral Scapular nerve
1 from trunk:
Suprascapular Nerve
0 From divisions
3 from lateral cord: LML
Lateral Pectoral nerve
Musculocutaneous Nerve
Lateral Root of median Nerve
5 from medial cord: Miss Mary Makes Me Unhappy
Medial pectoral nerve, medial cutaneous nerve of forearm, medial cutaneous nerve of arm, medial root of median nerve, ulnar nerve
5 from posterior cord: 2STAR
2 Subscapular nerves (upper and lower)
Thoracodorsal nerve
Axillary Nerve
Radial Nerve
GI manifestations of thermal injury
Paralytic ileus – Gastric dilatation
Curling’s Ulcers
Decreased Gastric Acid Production
Splanchnic vasoconstriction
Hepatic blood flow numbers
Supply from the portal vein ?%
hepatic artery ?%
normal portal vein pressure
Portal vein - 75%
Hepatic Artery - 25%
Portal venous pressure - 5-7 mmHg
Duke Staging + 5 year survival
Stage A - Confined to mucosa 90-95% 5 year Survival
Stage B - Muscularis Propria
B1 - Grown into propria 75% - 80% 5 year survival
B2 - Through propria into serosa 60% 5 year survival
Stage C - Lymph Node Involvement
C1 - 1-4 regional lymph nodes 25-30%
C2 - >4 regional lymph nodes
Stage D - Distant metastases <1%
Complications of FNA of lung
Pneumothorax: 17-26% (Increased risk with COPD/bullous lung disease, increase depth of lesion, small lesion size)
Haemothorax, Pneuonia, Empyema, Pulmonary Haemorrhage< Tumour Seeding, Cardiac Tamponage, Air Embolus, Need to re-bioopsy
Features of Fat Embolus Syndrome
4 Major
7 Minor
Gurd and Wilson Criteria
Major: Petechiae in vest like distribution, Hypoxaemia, CNS depression, Pulmonary Oedema
Minor: Tachycardia, Pyrexia, Retinal Emboli, Fat in urine, Fat in sputum, Increased ESR, Haematocrit/Platelet Drop
Facial Nerve Anatomy
Branches
Exiot foramen
Relations to other structures
Major Functions
Two Zulus Buggered My Cat
- Temporalis, Zygomatic, Buccinator, Mandibular, Cervical
Facial Nerve - exits through stylomastoid foramen
Major Functions:
- Controls facial expression
- Taste to anterior two thirds of th tongue
- Pre ganglionic Parasympathetic Fibers to several head and neck ganglia
Nerve Supply to digastric muscle
Anterior - Supplied by the nerev to mylohyoid ( Sub branch of V3)
Posterior - Supplied by digastric branch of facial nerve
Pathophysiology of neurogenic shock
Loss of sympathetic innervation —> Reduced Sympathetic innervation and Vasomotor tone .
This leads to venous ppooling–> Reduced venous return –> Reduced Pre-Load –> Reduced cardiac output
Clinically - warm peripheries, low BP, widened pulse pressure
Exit foramina of the skull
Cribiform Plate I
Optic Canal II
Superior Orbital Fissure III, IV, V1 (Frontal Nerve, lacrimal, nasociliary) , VI
Inferior Orbital Fissure - V1 (Inferior Division), Parasympathetic Pterygopalatine (from facial nerve), Zygomatic branch (V2)
Foramen Rotundum V2
Foramen Ovale V3
Internal Acoustic Meatus VII, VIII
Jugular Foramen IX, X, XI
Hypoglossal Canal XII
2 Most common sites for breast malignancy
Upper outer quadrant
Central/ Subareolar Region
Classification for Diverticular Perforation
Hinchey I - Paracolic Abscess
Hinchey II - Pelvic Abscess
Hinchey III - Purulent Peritonitis
Hinchey IV - Faecal Peritonitis
What is the:
i) cloaca
ii) sinovaginal bulb
Cloaca
5th - 7th week:
Cloaca divides urogenital sinus(anterior) and anal canal (posterior).
Urogenital Sinus —> Bladder, Urethra, Genital Tubercle
Anal Canal –> Rectum, Anal Canal
Sinovaginal
Formed from urogenital sinus —> Lower part of vagina
Bacterial Flexor Tenosynovitis
Cardinal Signs
Bacterial Cause
Cardinal Signs:
partially flexed posture, fusiform swelling, tenderness across flexor tendon sheath, pain on passive extension.
Bacteria: Staph Aureus
Early –> IV Abx and splinting
Late –> Exploration +/- drainage
What stimulates/ Inhibits Insulin release
Stimulates:
Amplifies:
Inhibits:
Stimulates: Glucose, Mannose, Leucine, Vagal Stimulation, Sulfonylureas
Amplifies: GLP-1, Gastrin inhibitory peptide, Cholecystikinin, Secretin, Gastrin, Beta Adrenergic Stimulation, Arginine.
Inhibits: Hypokalaemia, Somatostatin, Drugs( Dazoxide, Phenytoin, Vinlastine, Colchicine)
Compartment Syndrome
Signs
Compartment Pressures
Signs:
Pain on passive stretch, Absent peripheral pulses, paraesthesia, paralysis
Rhabdomyolysis —> Hyperkalaemia, hyperphosphataemia, High URic Acid Levels, metabolic acidosis
Compartment Pressures
Normally 3-4 mmHg
If >30-35 mmHg —–> fasciotomy
Anal Cancer
Common Type
Treatment
Common Type - Squamous Cell Carcinoma. Above dentate line tumours spread to perirectal and internal iliac lymph nodes.
Below dentate line tumours spread to inguinal and femoral nodes.
Treatment -
Radiotherapy + 5 FU (+/= mitomycin/ cisplatin)
AP Resection —> Only if recurrent or resistant tumours
Relations of hte parotid gland
Anterior - masseter + Mandible
Superior - TMJ + External Auditory Meatus
Inferiorly - Posterior belly of digastric ( CNVII)
Medially- CN IX, X, XI, XII, IJV, ICA, Lateral Pharyngeal
Superficially ( superficial to deep ) - Facial Nerve, Retroauricular Vein, ECA
SIRS Criteria
Two or more of following criteria:
Temp: >38, <35
HR >90 BPM
Tachy pnoea >20 or low PaCO2
WCC <4 / >12
