Quick Fire Flashcards
Brief screening UL exam:
Rock, paper, scissors, OK = median, radial, ulnar and ant IO nerve Ax
Median = LOAF + flexors
Radial = wrist extensors
Ulna = abductors
Ant IO = thumb flex at IP
NEXUS:
This pt presenting with neck pain requires a structured assessment to determine if imaging is indicated.
NO NSAID = neurological symptoms/signs, spinal tenderness, ALOC, intoxication, distracting injury
Ant TMJ dislocation:
Reduction techniques:
1) Traditional - thumb of both hands on molars, down/posterior force. risks: sedation + bite
2) Extra-oral - thumb on coranoid process of one mandible applying posterior pressure, other side gives jaw thrust
3) Syringe - roll syringe between molars. no sedation, new method from 2014
Tube rule in paeds:
2 x ETT: NGT, OGT and IDC
3 x ETT: depth
4 x ETT: ICC size
Absolute CI for thrombolysis:
ABCDEFG:
AVM/aneurysm, BP >185, CNS Trauma, diathesis (plt <100, INR >1.7), endocarditis/endocrinopathy, former hx of ICH, glucose >20
Easy corrected Na+:
3 mmol/L added for every 10 of glucose >5
Features of GBS:
LMN signs: hypotonia, hyporeflexia, motor weakness in ascending pattern, equivocal Babinski, sensation normal
Procedural sedation steps:
Prep: as per ACEM policy - department ok, resus bay, 2 doctors, 1+ nurse, monitoring - full external incl ET CO2, equipment for procedure + sedation drugs, IV access
Patient: CHECK right limb, right patient, CONSENT/explanation, reassurance, fasting status, allergy check
Perform procedure
Post-sedation care: monitoring duration, discharge plan, return precautions
Discuss your procedural sedation options - what must you consider:
General considerations: efficacy, safety, duration, rapidity of onset, child/patient cooperation, parental choice, expectations, resources, equipment available, staff training, time, ED space
Options: LA infiltration, N20/02, IV opiates, procedural sedation, regional, OT/anaesthetic
Snakes summary:
T-snakes (taipan, tiger): everything can happen B-snakes (brown, black): no paralysis - VICC = brown, myotox/AC = black Just paralysed = death adder Just myotox = sea snake
Dose of prilocaine in Bier’s block:
Prilocaine 0.5% 2.5 ml/kg (= 0.5 ml/kg, usual adult dose 200 mg or 40 mls)
Thrombolysis or ECR criteria:
Large ischaemic penumbra on CT,
NIHSS >20
M. Rankin
PTx exam findings:
Tachycardia, hypotension, hypoxia, tachypnoea
SOB/cyanosis, JVD, reduced unilateral chest expansion, reduced breath sounds
Hyperresonant lung
AAA exam findings:
Tachycardia, hypotension, ALOC
Palpable mass with pulse, flank/umbi bruising (Grey Turners/Cullens/Fox
DKA priorities:
1) Calculate + correct dehydration
2) Correct acidosis/ketosis
3) Prevent complications
4) Identify and treat the cause
Agitated patient tube plan:
Priorities are:
- gain control of the situation
- optimise intubation conditions
Preparation: PPE, security present, restraints
DSI - ketamine or PPF + BVM/NIV - to facilitate adequate pre-oxygenation (intubation reserve)
Reposition after sedation
Stuff/drugs: anticipate hypotension if sick + loss of adrenergic surge
Plan: VL with mac-blade tube over bougie, VL with hyperangulated blade, LMA, CICO front of neck
High dose sedation post-RSI
Seek/treat cause
Paeds standard induction drugs
Ketamine 1-2 mg/kg + Roc 1.5 mg/kg
Neonate tube drugs:
Fentanyl 2-5 mcg/kg IV (over 1/60) + sux 2 mg/kg IV
Atropine 10-20 mcg/kg
Neurosurgical intubation modifications:
Priorities are:
- to prevent reflex sympathetic intubation response
- to prevent secondary injury by using neuroprotective measures
Preparation/position: keep at 30-45 degrees, ETCO2 via BVM 35-40
Drugs: mannitol/hypertonic saline peri-intubation
- pre-treat with fentanyl 2 mcg/kg
- reduce induction agent dose based on degree of ALOC/haemodynamically neutral
- short acting paralytic so rapid re-assessment of neurology
Plan: VL, mac blade + tube over bougie, VL hyperangulated, LMA, CICO scalpel/finger/bougie
Post: neuroprotective measures (ETCO2 35-40, sats 95-98%, minimum PEEP, SBP 120-140)
- deep sedation
Obese (+/- OSA) intubation modifications:
Anatomically +/- physiologically difficult airway, decreased safe apnoea time
Preparation: NIV, seated position with ramp on the bed ear to sternal notch, reverse TRENDELENBURG
- ELM and CICO/neck person allocated
Stuff: may require DSI to tolerate NIV, ketamine as per IBW titrated
Plan: A - VL with hyperangulated blade/stylet in tube, VL with mac blade, LMA + 2xNPA, front of neck
Post-intubation: position at 30 degrees, higher PEEP, sats aim 88-92%, consider permissive hypercapnoea
Anatomically difficult face - face/neck trauma/Ludwigs intubation plan:
Issues:
- primary survey completed - immediate life threats dealt with
- anatomically difficult due to loss of normal anatomy/obstructed views
Preparation: may need to clear airway of debris/loose teeth, double suction setup
Position: c-spine precautions,
Stuff: front of neck access scrubbed
Drugs: haemodynamically neutral/neuroprotective ? associated head injury
- fentanyl, ketamine, roc
Plan modifications: VL rather than DL, plan C (LMA/NPA)/airway manoeuvres may not be possible, BVM subcut emphysema making surgical airway harder
Post-intubation: closely monitor tube position, consider alternative to tube tie
Cardiovascular intubation (STEMI with hypotension, dissection):
Priorities are:
- haemodynamically neutral intubation - prevent hypoxic/hypotensive arrest
- difficult physiologic airway
Preparation/position: anticipate dysrhythmias (VT/VF) - have pads on/amiodarone/adrenaline drawn up
- NIV for pre-oxygenation if in APO
Drugs: commence NA/A infusion prior to induction
- modified dose induction 0.5 mg/kg ketamine
- high dose paralytic 1.2 mg/kg rocuronium
Plan: VL, mac blade + tube over bougie, VL hyperangulated, LMA, CICO scalpel/finger/bougie
Post: direct disposition to cath lab or OT
Initial BIPAP settings in asthma:
PEEP 3-5, iPAP 7-15 (adjust to RR <25), high inspiratory flow rate, low I:E - 1:5
Push dose adrenaline in kids:
1 mcg/kg, max 50 mcg
Femoral splints:
Indications: mid-shaft femoral #
Contraindications: #/dislocation of the knee, ankle injuries
Benefits: reduces haemorrhage, pain control and transfer is easier
Types: Donway (old fashioned metal frame), Thomas and CT-7
Domestic violence resources:
000 - police, any emergency department/GP clinic, safe steps, Berry street, social work, 1800 RESPECT
Domestic violence questions:
SAFE: Do you feel safe at home?
ABUSE: In your relationship(s), have you ever been HITS - hurt, insulted, threatened, screamed/sexually abused?
FRIENDS: Are your friends aware of this?
EMERGENCY PLAN: Do you have a safe place to go, resources, access to those resources?
-
KIDS: Are there any children at risk?
Tumour lysis syndrome:
HyperK/urea/PO4, reduced calcium/renal function
IVT 1-2 ml/kg/hr, rasburicase, dialysis
VT storm:
Esmolol 500 mcg/kg bolus (40 mg) + 50 mcg/kg/hr infusion
Tamponade exam findings:
Tachycardia, hypotension, hypoxia, pulsus paradoxus, JVD, muffled heart sounds, displaced apex beat, pericardial rub
Dissection exam features:
Tachy, hypotensive/hypertensive, hypoxia, BP difference >20, R-F delay, neurological signs, Horners, hoarse voice, APO (2 to aortic regurge), effusion (dull percussion), R 2nd ICS murmur - aortic regurge, Becks triad if tamponade, ischaemic limb(s), CVA signs
Initial BIPAP settings in asthma:
PEEP 3-5
iPAP 7-15 - adjust to a RR of <25
High inspiratory flow 80-100 L/min
Low I:E ratio 1:5
Paeds jet insufflation
<8 years
14G cannula
ENK oxygen flow modulator to give breaths
Shoulder dystocia:
McRoberts: knee-chest position
Mod-suprapubic pressure
Rubin/reverse wood screw - trying to manipulate anterior shoulder
Posterior shoulder delivery +/- # that clavicle
San Fran syncope rule:
CCF HCT <30% ECG changes SOB Age >65
Acute stroke assessment key points:
Time critical, cat 2
Check for life threats: ABC
Confirm signs/sx of type of stroke - ACA/MCA/posterior circulation or stroke syndrome
Rule out mimics - ECG/BSL
ID who would benefit from thrombolysis/ECG
ID who has contra-indications for thrombolysis/intervention/surgery/ICU etc
Cavernous sinus CNs:
V (ophthal/maxillary), III, IV and VI
Orbital apex syndrome:
II/III/IV/VI + V1
UL myotomes:
C4: shoulder elevation C5: shoulder abduction C6: elbow flexion/wrist extension C7: elbow extension/wrist flexion C8: finger flexion T1: finger abduction
LL myotomes:
L1/L2: hip flexion L3: knee extension L4: ankle dorsiflexion L5: great toe extension S1: ankle plantar flexion, hip extension S2: knee flexion
DVT exam findings:
Tenderness, pitting oedema, swelling, unilateral. Calf size >3 cm with contralateral.
Erythema, warmth, dilated veins, palpable cord, tender veins
Phlegmasia alba/rubra
HHS management goals:
Correct volume deficit/dehydration Provide insulin 0.05 units/kg/hr Replace electrolytes - prevent complications Seek/treat precipitating cause Prevent complications
Hip dislocation:
90% posterior
Allis - pull external rotation (stand on bed)
Stimson - prone, leg dangles
Whistler - fulcrum patients knee - like Captain Morgan but using clinicians arm not knee
Captain Morgan - clinicians knee on bed, use knee as fulcrum, ext rotation
Bigelow manouvre
HINTS exam spiel:
Suspect stroke if head impulse is negative, fast paced alternating/bidirectional nystagmus
If eyes refixate during cover test of skew
Cranial nerve IV palsy:
Trochlear nerve
Head tilted away
Cannot look down/laterally across
- hypertrophia and extorsion
UL reflexes
Supinator/biceps: C5/6
Triceps: C7/8
Systemic fluorosis cardiac arrest:
10% calcium gluconate 50 mls (0.5 ml/kg)
8.4% sodium bicarb 1 mg/kg
MgSO4 - arrest 0.1-0.2 mmol/k then infusion
Facial vs trigeminal nerve
Facial nerve = 7 = muscles of facial expression
Trigeminal = 5 = muscles of mastication and facial sensation
Severe trauma intro:
This is an unstable patient with —— injuries. My priorities are to keep the patient safe, control any injuries, prevent secondary injuries.
I take a team based approach, activate a trauma code to reduce morbidity and mortality.
Capacity:
Patient needs to understand specific information, they need to be able to process and weigh up the information and then communicate that decision.
Understands
Retains/rationalises
Make a decision
Communicate that decision
APGAR:
Appearance Pulse rate Grimace Activity Respirations/effort
Rhabdo management:
Maintain UO >1-2 ml/kg/hr Urinary alkalinise 1 mmol/kg Urinary pH >6 Mannitol/frusemide Renal physicians
Neonate vital signs
Usual and
BSL
WEIGHT
TEMPERATURE
What is the first thing done when baby is delivered in ED?
Check for twin
Borders of the triangle of safety:
Lateral border of lat dorsi, lateral border of pec major
Apex is the axilla
Base is the 5th ICS
Go slightly anterior to the mid-axillary line
ICC insertion:
Asepsis, skin prep
Horizontal incision above/parallel to the rib (3 cm)
Blunt dissection with forceps (skin, subcut tissue, IC muscle, parietal pleura)
Hissing = breach of pleura
Finger sweep
Load ICC onto curved forceps and place into chest cavity
Before feeding turn forceps superiorly to aim for superior chest
Connect to ICC
- check for draining
- bubbles
Secure it
MTP goals:
Optimise: oxygenation, cardiac output, tissue perfusion, metabolic state
Aim for: temp >35, pH >7.2, BE 1.1, plt >50 (HI >100), PT/APTT <1.5xN, INR <1.5, fibrinogen >1
MTP initial request:
4 units pRBC, 2 units FFP
Cryo if fibrinogen <1 g/L
Consider 1 adult dose platelets
TXA
Indications for bicarb in NaCB overdose:
Seizures, arrhythmias, prolonged QRS, hypotension, at the time of induction
Lower limb weakness differential:
UPPER MOTOR NEURONE
CNS: bilateral frontal lobe pathology (ie midline mass, strokes)
Spine: vascular, acute epidural abscess, OM, vertebral collapse, TV myelitis, neoplasm, ALS, B12/TB/dural AVF, MS
LOWER MOTOR NEURONE
Nerve roots: = CAUDA EQUINA or conus medullaris, malignancy like lymphoma, TB, sarcoid, compressive from vertebrae
Nerves: GBS (classic = ascending, rare = paraperetic), CMT disease
NMJ: snake toxicity, MG
Muscles: myositis (statins)
Systemic: hypothyroid, Addisons, paraneoplastic, botulism
Dix-Hallpike manouvre:
\+VE in BPPV Seated position, turn head 30-45 degrees Focus on a stable point Lie patient supine Horizontal OR rotational nystagmus - delayed by 20-40 s, fatiguable - AFFECTED EAR IS THE EAR ON THE BED
Extubation criteria in ED:
A: protecting airway/coughing well
B: spont ventilation, RR >14, good sats, fiO2 <0.3
C: stable HD
D: follows commands, strong head lift off bed
E: resolving condition
Process: check vent settings compatible, suction, remove air cuff, ETT out with expiration, suction, high flow oxygen, reassess
HOCM vs AS
Both ejection systolic murmur loudest at the aortic area (2nd IC space on the R of sternum)
Valsalva - HOCM louder (reduced pre-load), AS softer
Squat - HOCM soft (increased pre-load), AS louder
Type of forceps used in ICC and scissors with lat canthotomy:
ICC: Kellys forceps
Lat canthotomy: iris scissors
PGE-1 infusion:
0.01-0.5 mcg/kg/min, limit oxygen/IVT
Consider adrenal insufficiency
Rhinne and Weber tests:
Conductive hearing loss: abnormal Rhinne in affected ear, Weber localises to affected ear
Sensorineural: Rhine normal in both ears, unaffected ear localises Weber
Differentiating different causes of peripheral vertigo on exam:
BPPV = Dix Hallpike
Meniere’s or labyrinthitis = senorineural hearing loss, Rhinne normal, Weber localises to affected ear
Vest neuronitis = more or less constant BPPV, post-viral inflammatory
Ramsay-Hunt syndrome = Bell’s palsy
Otitis media = ear infection on exam p
Resus question phrases:
Assemble/allocate team roles
Clear plan and ensure everyone understands plan
Closed-loop communications
Barries to leaving in DV:
Legal
Financial
Housing
Psychological
Joint exam basics:
Look, feel, move, NV exam, special tests
Compare to contralateral side
Examine joint above/below
Joint exam feel components
Bony prominences Muscles/soft tissues Heat/cold Tenderness Creptius Fluctuance
Compare to contralateral side
Joint exam - look component:
Limb position at rest Differences Swelling Deformity Skin changes: pallor, rash, wounds, bruising, erythema Scars
Lateral medullary syndrome:
Wallenberg syndrome; PICA
5, 9 and 10 cerebellar sympathetic chain
Contralateral: pain/temp to body
Ipsilateral: pain/temp to face, Horners, ataxia, facial sensation/taste/gag reflex, vertigo, ANS disturbance, diplopia, nystagmus, dysphagia
Acute visual loss:
Painful: corneal injury, trauma, migraine, endophalmitis, uveitis, GCA
Painless: CRVO/CRAO, stroke, retinal haemorrhage/detachment, vitreous haemorrhage, optic neuritis
Pneumothorax equipment:
Aspirate: 16-18G cannula
Small chest tube: 8-14F
PTx study called:
Brown/Ball NEJM
Anterior cord syndrome:
Flexion injury, AAA, dissection
Loss of motor/pain/temp bilaterally below lesion
Proprioception/vibration intact
Brown-Sequard:
Ipsilateral motor/vibration
Contralateral pain/temp
Central cord syndrome:
Upper > lower, distal > proximal, motor > sensory (but both variable), some bladder/bowel dysfunction
Causes: hyperextension, spinal canal stenosis, cancer, OA
HEADSS model:
Home, education, activities/alcohol/associates, diet/drugs, sexuality/self-esteem, safety/suicide/school
All paeds questions:
BSL, weight, parental support, keep warm
Orlowski scale:
<3 years, submersion >5 mins, CPR delayed >10 mins, coma on ED arrival, pH <7.10 on ED arrival
- 1-2 = 90% good recovery
- > 3 = 5% good recovery
SAD PERSONS:
Supports
Age <19/>45
Depression/hopelessness
Prior attempts Excessive drugs/alcohol Rational thinking loss Separated/divorce/widow Organised plan/serious attempt No social supports Stated future intent
Ethanol treatment in toxic alcohol ingestion:
8 ml/kg bolus of 10% then 1-2 ml/kg/hr of 10%
Delta gap teaching:
Ratio to help determine if the metabolic acidosis is due to loss of bicarb or due to extra added acids (L TKR)
Three bullying phrases:
‘This is not how you would want to be treated’
‘This is not the standard we expect’
‘This is not good practice for you or your patients’
LP site:
Cord terminates at L2, L3/4 at iliac crest level midline
3 chambers ICC:
Collection
Under water seal
Suction
IO sites and considerations:
Considerations: age of patient, trauma, failed prior attempts, skin breaks (ie infection), distance from heart, patient habitus, flows required (humerus 5x greater than tibia)
Sites: 2 fingers under patella and 1 cm medial (tib tuberosity), medial tibia at ankle (flat bone, 2 fingers above, 1 cm lateral to medial malleolus), humerus (1 cm prox to surgical NOH), sternum (special equipment)
Paeds weights
(Age + 4) x 2
Cuffed and uncuffed ETT size:
Uncuffed: age/4 + 4
Cuffed: 0.5 smaller
Missed diagnosis proforma:
Complaint management
Clinical governance: case review, resource issues
Risk management: document, facts
Staff support: advise team, educate, M&M
Traumatic arrest modifiers:
At the same time:
- stop bleeding
- replace circulating volume
- open airway/assist ventilation
- collar
- decompress chest bilaterally +/- thoracotomy if tamponade
Then conventional ALS/CPR
CPR statement:
Mid-chest, rate of 100-120, 1/3 the depth of the AP chest diameter
Ratio of 30:2 (or 15:2/3:1), minimise interruptions
Allow full recoil between compressions
Changing operators every 2 minutes
4Ts in PPH:
This is primary PPH, an obstetric emergency - call for help
Tone - check for twin, synto 10 units IV + infusion, miso 1 gram PR, ergometrine 500 mcg IV, IDC and fundal massage
Tissue - pressure ++, OT
Thrombin - MTP, reverse coagulopathy, TEG, calcium/pH/temp, pRBC 1:1:1, aim fibrinogen >1 - cryo, TXA, consider DIC
Trauma - sutures, direct pressure
Cerebellar speech:
Jerky, explosive, loud
Irregularly spaced syllables
Haematemesis medical management:
Vitamin K FFP 4 units Prothrombin x 25-50 units/kg Plt 1 bag Pantoprazole 80 mg Octreotide 50 mcg IV Terlipressin 1 mg Ceftriaxone 1 gram IV thiamine 300 mg
Causes of post-tube hypotension:
A: anaphylaxis
B: tension pneumo, breath stacking
C: too much induction, tamponade, arrhythmia, hypovolaemia
D: acidosis, electrolytes
Posterior shoulder dislocation:
Reverse Cunningham:
Traction, adduction, internal rotation
Elbow up to shoulder and external rotation
Methods: reverse Cunningham, traction/counter traction, DePalma
Thrombolysis in stroke stats:
1/10 will get function back, 1/14 complete.
1/100 will die of ICH, 1/42 will have an ICH
If do nothing, 1/10 will improve ++
Runyon’s criteria:
Ascitic fluid has >250 PMNs
If - total protein high, glucose low, LDH > upper limit of normal
Then it is secondary rather than spontaneous bacterial peritonitis
Other signs: polymicrobial, peritonism, free air on USS/CXR, failure to respond to Rx
SBP is 20 x more common
Post-intubation hypoxia:
DOPES:
Displaced/dislodged tube & Drugs (anaphylaxis), Obstructed tube, Patient factors: TPTx/Bronchospasm/APO/PE/collapse, Equipment failure, Stacked breaths
Disconnect, BVM 1.0, tube position, connections, other obs, auscultate, suction
Disaster plan:
Opening statement: overwhelm staff, resources and duration
Mention specifics for the type of disaster
Mention COVID
Declare
Meat of the answer: consider the following - space, capacity, staff, equipment, PPE, drugs
Summary
Post-intubation hypotension approach:
Confirm BP, other obs, ECG, rhythm
A: allergy/anaphylaxis
B: ventilator - disconnect, hand bag, ? TPTx, bronchospasm, breath stacking
C: drugs - doses/allergies
Examine patient - rash, air entry
Ix - CXR, echo, ECG, VBG
Treat - fluid bolus, antidysrhythmics, pressors, steroids, adrenaline
Dispo - ICU
Outline your approach questions:
Opening statement DDx Establish cause - hx/exam/ix Treatment dependent on cause Disposition
Missed diagnosis/2nd presentation:
Near miss
Outcome could have been catastrophic
Identify - patient, clinician, departmental factors
Prevention - QI cycle
QI cycle
Plan, do, check, act
Trauma must mentions:
Primary/secondary survey, MTP, ? Permissive hypotension, ADT, activate trauma team
Ix the cause for trauma
Sequence of life saving measures
Labeling:
Name it: this is a _______ emergency or _______ is of concern to me,
Why is this a problem? Because patients like this _______________.
Intervention required - simultaneously resuscitate and assess
- seek and treat cause
Rheumatoid arthritis modifiers:
C-spine immobility
Adrenal crisis
Immunosuppressed
Patients on steroids:
Think adrenal crisis 200 mg IV hydrocortisone
Ankle jerk reflex
S1/S2
LP practicalities:
Pencil-point needle, bevel long axis of spine
LA/asepsis
Introducer into the interspace in umbi direction on midline
When in interspinous ligament insert spinal needle, withdraw stylet
Stabilise, manometer, w/draw CSF
Knee jerk reflex:
L3/L4
Stroke Ax:
FABS/ROSIER scores
Hx - LOC/seizures - make ischaemic stroke less likely
Exam -
1) visual fields
2) mm facial expression
3) arms up/palms up 10 s - pronator drift
4) legs up 5 s each
5) name objects - watch, pen
6) repeat sentence - they heard him speak on the radio last night
NAGMA causes:
Endo: steroid deficiency (Addisons) Renal: loss of bicarb, RTA GI: loss of bicarb - diarrhoea, high outputs Gain Acid: NaCl infusion Drugs: acetazolamide, spironolactone
Metabolic alkalosis
Loss of H+
- GI: vomiting
- Renal: diuretics, laxatives
Endo: mineralocorticoid excess: Cushing’s, Bartter’s syndrome
Drugs: diuretics (frusemide), milk-alkali, bicarb infusion
Antibiotics neonates:
Benpen 60 mg/kg and cefotaxime 50 mg/kg - dosing dependent on age UP TO 2 months
> 2 mo: fluclox 50 mg/kg + ceftriaxone 100 mg/kg (or cefotaxime 50 mg/kg)
Pacing steps:
Consent, comfort INCLUDING ONGOING COMFORT
Pads/ecg leads
Turn on defib/pacer
Demand + synch mode
Rate 60-80, 0 mA and then increase with 10 mA every 10 s until electrical capture on monitor
Check for mechanical capture at radial pulse
If still low BP —> increase HR
Definitive care: TV pacing
Thyrotoxicosis management:
Propranolol 1 mg/min (max 10 mg) - aim HR <100
PTU 1 gram o/NGT/PR
1 hour later - lugols 10 drops
Hydrocortisone 100 mg IV
Respiratory acidosis causes:
COAD Airway disorders: asthma/obstruction Reduced central respi drive: drugs, ICH Lung insults: trauma, APO/ARDS Inadequate respiratory muscle use: GBS, toxins (snakes)
Respiratory alkalosis causes:
Central respiratory increased drive: ICH/head injury, anxiety, pain, salicylates, MDMA
Profound hypoxia: PE/pneumonia, APO, asthma, ARDS
HAGMA causes:
Lactate
Ketoacids
Uraemic renal failure
Toxicological
Tox causes of HAGMA:
Cyanide, CO, paracetamol, methanol, ethylene, paraquat, iron, isoniazid, metformin, salicylates
Key features of methanol toxicity:
Snowstorm vision —> blindness
Basal ganglia haemorrhage —> Parkinsonism
Lactic acidosis (artificially high lactate)
Windshield wiper fluid
Give folate, urinary alkalinisation, HD (coma, acidosis, ARF, HD instability, serum concentration >50 mg/dL)
Key features of ethylene glycol toxicity:
Fluorescent urine
Calcium oxalate crystals
Hypocalcaemia - 30 ml of CaCl IV aiming for Ca2+ >1.5
Wide QRS/prolonged QT
Rx: thiamine, pyridoxine, haemodialysis (persistent acidosis, serum concentration >50 mg/dL, coma, HD instability, ARF
Ethanol antidote:
Loading: 8 ml/kg of 10% ethanol (or 4 x 30 ml vodka)
Maintenance: 1-2 ml/kg/hr of 10% (or 30 ml vodka per hour)
—> 10% solution = 100 mls 100% ethanol + 900 ml of 5% glucose
HYPOGLYCAEMIA IN CHILDREN!!!!
Aim for serum concentration of 0.1-0.15 g/dL
Increase dosing when HD is commenced
Fomipazole antidote use:
Preferred in: kids, pregnancy (cat C…. Risk/benefit), liver disease, disulfiram, difficult to measure serum [ETOH]
Loading dose 15 mg/kg IV + 10 mg/kg Q12H for 4 doses
- increase in haemodialysis
Order of toxic alcohol blood abnormalities:
Initially raised osmolar gap —> as toxic alcohol is broken down then the HAGMA + associated comes
So if presenting >3-4 hours post-ingestion and bloods are normal (ie both osmolar gap and HAGMA) then ? Either between the hockey sticks OR no toxic ingestion has occurred
Reversal of dabigatran:
Idarucizumab 2.5 mg twice, consider dialysis
Less likely to make an impact: PCC and TXA
Direct Thrombin inhibitor (DabigaTran)
Reversal of apixaban and rivaroxaban:
Factor Xa inhibitors
No antidote yet - major trial with an-dexa-net is coming in late 2022
PCC and TXA may help
Low fibrinogen:
Replace with PCC
What are considerations when you reverse someone’s anticoagulants?
1) How coagulopathic is the patient?
2) How ill is the patient? Ie how important is reversal?
3) Why was the patient anticoagulated?
4) Pharmacology specifics ie are they on aspirin as well
Warfarin reversal:
10 mg IV vitamin K (6 hrs to start working)
3-factor PCC - 50 units/kg
FFP x 4 units (3-factor is missing factor VII)
TPA reversal:
Most improtant:
TXA 1 gram IV
10 units cryoprecipitate (to replace fibrinogen)
Additionally:
2 units FFP
If plt borderline - transfuse
Indications for digoxin immune Fab:
Dysrhythmias (with hypotension) OR VT or runs of VEs
K >6 + evidence of toxicity
[Dig] >15 nmol/L + toxicity
Treatment of hypocalcaemia:
20-40 mls of calcium gluconate IV over 5-15 minutes
Treatment of CCB toxicity:
Give 30 mls of calcium gluconate IV over 5-15 mins
Rpt Q20 mins
Then calcium gluconate 10 mls (= 1 gram) in 100 mls fluid at 0.5 g/hr (50 mls per hr)
Systemic fluorosis treatment:
Hypocalcaemia - 30 mls of calcium gluconate bolus IV over 5 mins
Hypomagnesaemia - 10 mls of MgSO4
Hyperkalaemia - aggressive management
Risk of systemic fluorosis:
> 5% BSA + any HF concentration
50% HF + >1% BSA
Dermal HF exposure management:
1) Ca2+ gluconate gel - 10mls of 10% ca gluconate + 30 mls of lubricating gel)
- place it in a latex glove if hand exposure
2) Subcut infiltration - 10% ca gluconate/0.5 ml of skin
3) Regional Bier’s block - 20 min cuff inflation time, 10 mls of 10% gluconate + 40 mls of 0.9% saline
4) Intra-arterial - 10 mls of 10% in 40 mls of 0.9% saline over 4 hours
CAGE questions:
Cut down
Angry/annoyed
Guilty
Eye opener
Agitated patient history:
Med hx, psych hx, AOD/medications, social
Delusions, hallucinations, suicidal and homocidal
Post-Bier’s or fracture reduction care
Reassess neurovascular status
Plaster care, sling/elevate, oral analgesia
Return advice - pain ++, finger colour change, altered sensation
Social work for ADLs
Assess reason for fall - ? ECG ? Others
Ensure no other injuries that need treatment
Follow-up with orthopaedics
Bier’s minimum and maximum times:
Cuff inflation time ~20 mins min, max 60 mins after LA administration
Access block questions - key terminology to remember:
Over capacity with high acuity
ICU patients are staff/resource intensive and distract from incoming workload - send to ICU asap
Urgent Rx for those with potential life threats/risk of deterioration
Timing of the day - ward rounds, handovers, engaging the medical executive
Measles
Cannabinoid hyperemesis:
Droperidol IV 1.25 mg
Dexamethasone 8 mg IV
Capsacin cream periumbilically
Hot showers
? Ondansetron
Treatment of hypernatraemia:
Mild: manage underlying causes
Mod: manage underlying cause, monitor UO, UEC Q2H
Aim to lower 0.5 mmol/L/hr
0.9% saline +/- 5% glucose - give maintenance + ongoing losses + replace deficit
Use of osmolality in hypernatraemia:
Urine > serum: urine is not concentrating, central/nephrogenic DI, renal disease, diuretics
Urine < serum: intact urine concentrating ability, GIT/skin loss, excess intake
Colles fracture
Radial and DORSAL angulation of the distal fragment
Causes of hypernatraemia:
Water deficit:
Commonly: GI loss (diarrhoea), skin loss (burns/sweating), renal loss (ATN), cannot get water/milk
Others: DI, increased sweating, hypothalamic dysfunction
Na excess: less common
Increased ingestion, bicarb/hypertonic saline administration
Increased aldosterone: Conn’s, CCF/nephrotic/steroids
Debrief:
Safe space Hot vs cold Summary of case What went well Improvements Summarise key learnings Points to action - ie risk notification Staff wellbeing + follow-up
Benefits of debrief: reflect, support, ID deficiencies, safe, blame-free
Measles:
History: viral illness, 10 day incubation, 2-4 day prodrome: fever, conjunctivits, coryza, cough
Hx of exposure, travel diarrhoea, vomiting
Hx of complications: earache, laryngitis, pneumonia, encephalitis, optic neuritis
Immunosuppression, pmhx, meds, allergies, socila
Exam: maculopapular rash starting behind ears, fever, obs consistent with viral illness, rhinorrhoea, conjunctivitis, Koplik spots on buccal mucosa, look for complications: otitis media, crackles/focal lung findings, jaundice
Infectious: 5 days before, 4 days after rash onset
At risk persons: immunocompromised, pregnant, ATSI, kids <5 years, undervaccinated, unvaccinated
Management: treat for complications, confirm diagnosis, notify public health/GP, contact tracing, isolate
Treat the upset clinician: check vaccination status, console, show concern for wellbeing, explore other causes for missed diagnosis, teaching opportunity
PPH management:
Check for twin Syntocinon 10 units IM x2 +/- 40 units in 500 mls over 2 hours Ergometrine 0.25 mg + ondansetron Misoprostil 1 mg PR Cabroprost 250-500 mcg IV Massage IDC TXA 1 gram Sutures Packing
ED management of third stage of labour:
Call for help Team lead Antenatal brief hx Check for twin Controlled cord traction Synto 10 units IM/IV IV access Uterine fundal massage Check placenta for completeness
Asthma exam goals:
Confirm asthma diagnosis
Determine severity
Exclude precipitants that require specific Rx - pneumonia, anaphylaxis
Asthma severity:
Prior ETT/ICU
Poor treatment adherence
Poor control with interval symptoms
Past hx of anaphylaxis as well
MSE
BOAT-PIS
Behaviour/appearance Orientation/cognition Affect/mood Talk/speech, thought form/content Perceptions - hallucinations, delusions Insight + judgement Safety risk
MINIMUM: suicidality, homocidality, hallucinations, delusions
Glaucoma drugs:
Acetazolamide 500 mg IV/oral Opioids for analgesia Pilocarpine 2% q5min for 1 hour Timolol 0.5% Q30 min Latanaprost 1 drop Definitive care
HOCM murmur:
Louder with Valsalva, softer with squat
CCB overdose:
Atropine 0.5-1.5 mg IV + external pacing unlikely to work
IVT 1-2 L
CaCl 10% 10 ml over 10 mins; gluconate 10% 30 ml
Adrenaline/NA - based on early echo findings
HIET
- bolus: 1 unit/kg IV actrapid + 50 mls of 50%
- infusion: 1-5 units/kg/hr + 10-50% glucose titrating to a BSL 5.5-11, K+ 3-3.5
Lipid emulsion:
Intralipid 20% 1.5 ml/kg IV bolus repeated Q5min to a max of 8 doses
Adverse: ECMO/dialysis filter crashes, interference with labs, pancreatitis, acute lung injury, fat embolism syndrome
Dabigatran reversal:
Dialysis Idarcizumab 2.5 mg x 2 doses - titrate to improvement in PT PCC + factor 7a TXA Haematology consult
DAMA:
Assessment of competence: decision-making capacity (does patient understand, can they synthesis, do they formulate risks/benefits and can they repeat consequences back to you)
Explore why patient wants to leave
Involve others - family, inpatient team
Safety nets - written, GP, others
Document - diagnosis, treatment recommendations, reasons for refusal, discussion of alternatives
Inferior STEMI management considerations:
ECG STE III > II, STE V1
Manage hypotension - fluid bolus, no nitrates/b-blockers, peripheral inotropes
Anticipate conduction disturbances
Usual STEMI stuff
Intubation of the patient heading to cath lab:
1) Pre-oxygenation - NIV 100% or BVM, PEEP, non-apnoeic oxygenation and apnoeic oxygenation
2) Circulatory support: (nor)adrenaline 5-10 mcg/min uptitrate to a SBP of >95, modified dose induction drugs, anticipate recurrent VT/VF - amiodarone loading prior, correct hypoK/Mg, draw up lignocaine
3) Expedites PCI
4) Pacing pads on
5) Prioritise transport equipement/monitoring/anaesthetics
General comments about STEMI:
Territory specific considerations - APO in anterior, heart block in inferior
General management + disposition of AMI patient
Optimisation of patient prior to RSI
Anticipate complications
Bier’s block LA
Prilocaine 0.5% 3 mg/kg
2.5 mg/kg may be easier - translates to 0.5 ml/kg
Management of recurrent VT/VF in STEMI:
Electrolyte optimisation - DO A VBG
- KCl 10 mmol over 30 mins, aim for K+ of 4.5-5
- MgSO4 10 mmol over 30 mins, aim for Mg >1
Amiodarone 300 mg loading or lignocaine 1.5 mg/kg IV
Prioritise PCI
5th MT fracture:
Most proximal = pseudo-Jones, non-union uncommon (hard soled shoe)
Jones - involves the 4-5th articulation zone, high rate of non-union - up to 30%
- IM screw for athletes
- short-leg cast for 8 weeks for all others
Zone 3 fracture also short-leg cast
Febrile convulsion stats:
3% of healthy kids have febrile convulsions
50% of kids <1 years will have another; 30% of kids <2 years
No RF for epilepsy - 1% have or will develop it - same as general population
Neonatal sepsis stats:
Sepsis <48 hours - untreated 1/3-4 mortality
Sepsis <28 days - 1/10 mortality if left untreated
Neonatal sepsis antibiotics:
Benzylpenicillin 60 mg/kg + cefotaxmine 50 mg/kg
> 2 months then flucloxacillin 50 mg/kg + cefotaxime 50/ceftriaxone 100 mg/kg
Trifascicular and bifascicular blocks:
3rd degree AV block + RBBB + LAFB
3rd degree AV block + RBBB + LPFB
Bi: RBBB + LAD (LAFB) or RAD (LPFB) WITH either 1st/2nd degree HB
Anterior shoulder dislocation:
To reduce: flex + externally rotate +/- abduction
Types: Stimson, Cunningham, Spaso, scapular manipulation, Fares and Milch
ACLS drugs:
Non-shockable: 1 mg adrenaline stat, Q2 nd loop
SHockable: 1 mg after second shock, 300 mg amiodarone after 3 shocks
4Hs and 4Ts
LEMON:
= difficult ETT
Look externally Evaluate 3-2-2 Mallampati score Obstruction - big tongue, known OSA Neck mobility poor
MOAN
= difficult BVM
Moan for santa
Mask seal - ie beard
Obesity/obstruction
Age >55
No teeth
Difficult front of neck access considerations:
SHORT - surgery, haematoma, obesity, radiation, tumour
Post-ROSC management:
Re-evaluate ABCDE 12 lead Treat cause Aims - oxygen >94%, normal CO2, normal pH, normal BSL, normal haemodynamics TTM
Disposition: ICU/CCU/cath lab
COACHED:
Continue compressions Oxygen away All else clear Charging defib Hands off ECHO/evaluate rhythm Defibrillate 150-200 J biphasic AP pads or disarm
CPR characteristics:
Rate 100-120 bpm Ratio 30:2 (15:2, 3:1) Allow complete chest recoil ET CO2 aim for 10-20 Lower third sternal border 1/3 the AP diameter of the chest Minimising interruptions
When can you do three stacked shocks?
If can be given within 20 seconds
Witnessed, monitored setting
Defib is immediately available
Time to rhythm recognition + charging is short
What drugs can be given in sympathomimetic toxidrome?
Phentolamine, benzos, GTN
Newborn ALS:
Warm, stimulate, dry
Crying, good tone, good resp effort —> mum
If not, CALL FOR HELP!!! And either: at a rate of 40-60 bpm
- ineffective breaths or respiratory distress —> open airway + CPAP + sats
- if not breathing/barely breathing —> open airway + PPV + sats/HR
—> both with fiO2 .21
Reassess after 30 s
- CPAP or PPV improving - great continue
- CPAP worsening —> PPV
- PPV worsening - open airway, APPLY OXYGEN, intubation/LMA, sats probe on, estimate HR
HR <60 start CPR 3:1, 100% oxygen, intubate, venous access
HR 60-100 hang tight
HR >100 improving
Reassess after 30-60 sec - HR <60 - IV adrenaline 10-30 mcg/kg
BRUE:
<12 months <1 minute duration Sudden onset/offset >1 of cyanosis, pallor, change to breathing, change in tone, ALOC Not explained otherwise
Low risk = >60 days, >32/40 born, no CPR by healthcare professional, first event, lasted <1 min
DDx of BRUE
Airway: obstruction, FB, laryngospasm, infection, congential (ie laryngomalacia)
Cardiac: congenital, vascular ring, arrhythmias, long QT
Abdo: intussuception, strangulated hernia, torsion
Infection: pertussis, sepsis, pneumonia, meningitis
Metabolic: hypoglycaemia, hypocalcaemia, hypokalaemia, inborn errors
NAI
Toxins: accidental/non-accidental
BRUE history:
Description of event: gagging, apnoea, colour, distress, conscious state, tone, movement
Prior to event: feeding, awake/asleep, position, vomiting, sleeping arrangement, objects swallowed, unwell prior
End of event: duration, self-resolved, resus, recovery: rapid/gradual
Other PMHx: similar events, sick contacts, intercurrent illness, meds, family hx, social, relationships
Management of BRUE:
History/exam
Period of observation
Social situation evaluation
Investigations: ECG, NPA, BSL, ? FBE/UEC
? D/c or admit for obs + follow-up planning
FI block considerations:
USS guidance + landmark = less complications, increased success
Ropivacaine 3 mg/kg - less cardiotoxic, longer duration of action
Field block = need volume 30-40 mls at least
If you get resistance - withdrawal of needle, may be within iliacus
Landmark technique - blunt 21/23G needle, to enhance the two pops (fascia lata + fascia iliaca)
Border of the lateral 1/3 and middle 1/3 - ASIS-pubic symphysis
- 1 cm below
FI block landmarks:
Pubic tubercle to ASIS line
Injection point 1-2 cm below the lateral 1/3
Palpate artery medial to this
Confirm location using USS
FI block drug details:
- 75% ropivacaine 10 mls + 10 mls normal saline = 0.375%
- dose 2-3 mg/kg
Across two syringes 40 mls in total
- give 30 mls of 0.375% if <60 kg, 35 mls if >60 kg
Teaching procedures topics to consider:
Recap landmarks
Discuss use of USS
Why choose a specific site
How to minimise the risk of complications
Kids weights:
6 months = 7 kg
1 year = 10 kg
1.5 years = 11 kg
2 years = 12 kg
3 years = 14 kg
5 years = 18 kg
10 years = 35 kg
Meaning of the delta ratio:
Ratio of extra acids as opposed to bicarb loss
Smaller = bicarb loss Higher = extra acids - respiratory/L TKR
DKA = 1
Low delta ratio means what?
HYPERCHLORAEMIC NAGMA - ie iatrogenic normal saline
Acute glaucoma management:
Acetazolamide 500 mg IV/oral (not in AKI/allergy) IOP Q30 mins Pilocarpine 2% drops Timolol 1 drop Pred 1% drops ? Mannitol Analgesia/antiemetics
Babinski’s reflex:
L5/S1/S2
Neonate HR <60
30 sec PPV - PIP 30 and PEEP 5
Then start CPR 3:1, fiO2 .1, intubate, cannulate umbi vein and give IV adrenaline 10-30 mcg/kg
OT vs CT in trauma:
Depends on my team, capabilities, services available
Unstable/cannot keep up with resuscitation then OT
Stable/can organise angiogram - may be appropriate to aide pre-operative planning
Exploring what went wrong in error:
Department (ie very busy) Technique (ie lack of training) Doctor (ie tired) Equipment (ie USS broken) Patient (ie difficult anatomy)
Error statements to consider:
We come to work to do our very best for our patients but sometimes even that is not enough.
Errors happen, we all make them from time to time.
Go home - take this time to rest/reflect
How are things at home?
PEP:
Truvada + dolutegravir
Confidential, quiet room, support person, information sheets, contraception/condoms
When would you not perform painful touch and coordination in neuro examination?
Coordination is only for cerebellar disease
Sharp touch would be only for spinothalamic tract involvement
Neck injury examination:
Obs - neurogenic shock
Respiratory - hypoventilation
Midline c-spine assessment with inline mobilisation
Upper limb assessment
Lower limb assessment
Testing both sensation/motor in line with the American spinal injury scale (ASIA scale)
- A: complete, B: incomplete sensory, C: incomplete motor, D: incomplete motor, E: normal
- incomplete spinal injuries - central, anterior, Brown-Sequard, conus medullaris, cauda equina
Bulbarcavernosus reflex - spinal shock
Difference between cauda equina and conus medullaris:
Cauda equina: only LMN
Conus medullaris: typically T12/L1, mixed UMN + LMN
Central cord syndrome:
Most common
Smaller lesions: spinothalamic tract interruption = bilateral pain/temperature loss (cape-like)
Larger lesions: involves corticospinal, ST and dorsal columns
- UMN patern below, LMN at the site of injury
- arms > legs, motor > sensory
Brown-Sequard:
Contralateral pain/temperature loss
Ipsilateral motor/sensory function, proprioception/touch/vibration sense
Anterior cord syndrome:
Near complete paralysis below level of lesion
Loss of pain/temp below lesion
Autonomic dysfunction
Intact posterior columns: proprioception and vibration are normal
Mnemonic for spinal cord tract locations:
GPS (proprioception, vibration) is in the back of fancy new cars
Motor is in the front of fancy new cars
Sensation is in the centre - sensational feeling sitting behind the motor in a new car!
Cauda equina:
Perianal and saddle paraesthesias
Bowel/bladder/sexual dysfunction
Host of other symptoms/signs - variable: low back pain, sciatica, paraesthesias, weakness, change to lower limb reflexes
Neonatal jaundice approach:
Common 60% of term, 80% pre-term babies
We worry about it because it can cause kernicterus - long-term neuro sequelae
Majority is physiological jaundice
Pathological - clues in the history and examination
History: onset, offset, antenatal hx (maternal blood group, infectious serology), bith trauma, instrumental delivery, feeding: breat/formula, weight gain, output (dark urine, pale stools), family hx (thyroid, G6PD)
Exam: general tone, obs, neuro exam, hydration status, plethora, bruising/cephalohaematoma, hepatosplenomegaly, pattern/degree of jaundice
Causes:
1) <24 hours always pathological - sepsis or haemolysis
2) 24 hrs - 14 days: physiological, dehydration, sepsis, haemolysis, breastmilk, bruising/birth trauma
3) >14 days: pathological - sepsis, haemolysis, dehydration, hypothyroidism
Investigations:
- dependent on likely cause
- transcutaneous bilirubin meter
- septic screen
- SBR +/- conjugated/unconjugated - always pathological - neonatal hepatitis, extrahepatic obstruction, metabolic.
Treatment:
1) Treat the cause - ie sepsis, dehydration, surgery
2) Follow-up
Brugada types
Type 1: COVED ONE
Type 2: saddleback (horse + rider) - >2 mm
Type 3: <2 mm
Type 1 diagnostic if ECG changes + documented VF/VT or FHx <45, similar ECG change in family members, VT inducible, syncope, nocturnal agonal resps
Types 2/3 need EP studies
HOCM features:
LVH criteria met (S-wave in V1 + R-wave in V5 or V6 >35 mm)
Dagger-like Q-waves in the lateral and inferior leads
LVH criteria:
S-wave in V1 + R-wave in V5 or V6 >35 mm
Management of Bell’s Palsy:
Eye care: lubricating eye drops 3 times daily, pad eye shut at night
Steroids: 1 mg/kg/day oral if people present within 72 hours
Antivirals: aciclovir if vesicular rash present
Other points: facial weakness worsens within 3 weeks, most recover by 6 weeks, 95% recovered by 12 months, eye care to present scratches, change in hearing and less saliva is also common
Paed/GP review in 3-5 days then PRN - corneal ulceration monitoring
Nursemaids elbow reduction:
Supination technique - firmly hyper-supinate + extend arm fully, then flex at elbow
Hyperpronation - firmly pronate and then flex at elbow
SIADH definition
Hyponatraemia, euvolaemia, urinary Na >20, serum osmolarity <280
No abnormal renal, cardiac, thyroid, adrenal or hepatic function
Not on a diuretic
Causes: drugs (MAOI, SSRI, TCA), CNS infection, respiratory (PPV, pneumonia), malignancy (lung, pancreas, prostate, lymphoma)
Eclampsia management:
Midaz/midaz 0.15 mg/kg IV Keppra 40 mg/kg IV MgSO4 4 grams IV + 2 grams/hr, aim Mg <1.5 Hydralazine 5-10 mg IV Labetalol 20 mg IV x4 doses
Calcium gluconate dose in CCB overdose kids:
Calcium gluconate 0.6 ml/kg (max 30 mls) over 2-3 mins, Q10 minutely + infusion at up to 0.6 ml/kg/hr
Adrenaline 0.1 mcg/kg IV Q2-3 min
Atropine 20 mcg/kg IV
Fluids 10-20 ml/kg
HIET in children: 1 unit/kg actrapid + 2.5 ml/kg 10% glucose
- infusion 1 unit/kg/hr + titrate glucose to a BSL of 4-8 mmol/L
Potassium 0.4 mmol/kg IV over 1-2 hours
Cultural competency:
Attitudes, skills and knowledge
Posterior hip dislocation relocation techniques:
Ellis - stand on bed, pull flexed hip up and rotate
Captain Morgan - leg is fulcrum
Whistler - arm is fulcrum, place your hand on contralaterally bent knee, pull shin down into bed and ext rotate
Rochester
Bigello - ipsilateral knee in elbow and pull
Stimson - over bed edge
All: STABILISE THE PELVIS, traction, flex hip, external rotation, then if fails —> internal rotation
Posterior hip dislocation complications:
Reduce within 6 hours
AVN
50% have acetabular or femur fracture
Sciatic nerve injury in 10%
Lower limb neurovascular assessment:
Common fibular nerve: dorsiflexion, 1st dorsal webspace (deep fibular)
- deep fibular is in the ANTERIOR compartment
Tibial nerve: plantarflexors, sole of foot sensation
- POSTERIOR compartment
Wellens syndrome
Diplopia eye cranial nerve assessment:
CNIII: diplopia in all directions CN IV: worse with downward/inward movements CN VI (6): impaired abduction of eye (lateral rectus, abduction of shoulder is C5/6)
Electrical storm management:
Continue ALS
Double defibrillation - 2 sets of pads (AP and sternum/apex) - fire at same time
Esmolol 40 mg bolus (0.5 mg/kg)
Avoid adrenaline
STEMI:
CORRECT ELECTROLYTES
STEMI thrombolysis:
50 mg IV bolus of tenecteplase
- > 60 kg patient
Biochemical changes with sodium valproate:
Hypernatraemia, high lactate/ammonia, LOW calcium, low glucose, HAGMA
EDACS
Age, Gender
Known CAD or 3+ RFs
Diaphoresis
Pain radiation - arm/shoulder/neck/jaw
Negative points: pleuritic pain, reproducible pain
Blood product refusal:
In paeds: human tissue act 1982 - allows for blood products to be transfused if child is likely to die with out it imminently as long as a second consultant agrees
Involve clinical ethics, legal counsel and director, social work and mental health if required
We will do best to honour wishes but if child likely to die then consultant in charge and may administer against their wishes. Obviously different in adults.
Consider: TXA, recombinant products, discuss non-whole blood options - PCC vs cryoprecipitate
Dangerous mechanism c-spine:
Fall from >5 stairs Axial load MCV >100 km/hr, rollover, ejection Rec vehicles Bike accident
Non-simple rear end: bike, bus, truck, rollover, high speed vehicle, pushed into oncoming traffic
Key elements of hx and exam in cspine injury:
High risk mechanism of injury
History of known factors that predispose to cspine injuries
Peristent neurological symptoms - pain, paraesthesia, weakness
ALOC, traumatic torticollis, using hand to support neck, concerning neurology, cspine tenderness, restricted neck movements, unexplained refractory hypotension/signficant associated other trauma
AF causes:
Ischaemia, valvular heart disease, thyroid, alcohol, PE, pre-excitation, electrolytes, drugs (sympathomimetics), acute infections, pre-excitation syndromes, cardiomyopathies, endocrinopathies
AF vs flutter:
Flutter is one re-entrant pathway; fibrillation is multiple
AFib is usually resulting in poor ventricular filling —> decreased CO, flutter is more coordinated
Both managed by rate or rhythm control
Atrial flutter requires less energy, fibrillation usually 150-200 J
Same risk of embolism and same risk of anticoagulation
? Adenosine to slow and see flutter waves
CHADSVASC-2 and HASBLED
Age Gender CHF history HTN Stroke/TIA/thromboembolism hx Vascular disease hx Diabetes history
HTN, renal disease, liver disease, stroke hx, prior major bleeding, labilie INR, age >65, meds (aspirin etc)
AF rate control vs rhythm control:
Metoprolol 25 mg BD (max 100 mg BD), verapamil or diltiazem 180 mg daily (less preference in heart disease)
Amiodarone 200 mg daily
IV: metoprolol 2.5-10 mg or amiodarone 300 mg over 1-2 hours
Delta ratio:
[AG-12]/[24-bicarb]
<0.4 = hyperchloraemic NAGMA
0.4-0.8 = HAGMA + NAGMA (? Renal failure)
1-2 = pure HAGMA
>2 = meta acidosis + pre-existing reason for elevated HCO3 (ie meta alka or respi acid)
Corrected Na:
Na + (BSL - 5 / 3)
Three shoulder exam tests:
Empty can test (supraspinatus injury, C5 - suprascapular nerve) Winged scapula test (long thoracic n, C6 - serratus anterior) Apprehension test (subluxation, joint stability, labral tears)
Hoffman test - flick DIP of MF and thumb IP contraction —> positive
Shoulder pain examination:
Trauma: #, dislocation, recurrent subluxations, tendinopathies
Atraumatic: septic arthritis, malignancy, osteomyelitis
Referred: chest/abdo/neck/upper limb
Shoulder look, feel, move
Neck
Rest of upper limb
Chest/abdo
End of life drugs:
Subcut:
Morphine/midaz 2.5 mg Q2H PRN
Metoclopramide 10 mg Q8H PRN
Glycopyrralate 200 mcg Q2H PRN
End of life ancillary supports:
Pastoral care, social work, private room, prioritise admission, medical/carers certificates, refreshements, contact/ability to escalate
Why is the patient not improving on NIV?
Patient factors: hypoventilation, PTx, pneumonia, oversedation, CNS pathology
Equipment factors: leak, inappropriate pressures, I:E ratio inappropriate
Settings that can be adjusted on NIV machine:
FIO2 PEEP = EPAP Psupport = difference between IPAP and EPAP I:E ratio Trigger sensitivity
Power
0: paralysis, 1: flicker, 2: move without gravity, 3: against gravity, 4: slight resistance, 5: normal
Reflexes:
0 = absent, +1 = hyporeflexia, +2 = normal, +4 = hyperreflexia
Lower limb screening neuro test:
Up on toes (S1)
Up on heels (L4/5)
Squat to stand (L3/4)
Preparation points:
People
Area
Equipment
Drugs
GI bleeding drugs:
Terlipressin 2 mg Octreotide 50 mcg + infusion Pantoprazole 80 mg + 8 mg/hr Ceftriaxone 1 gram IV Treat encephalopathy - lactulose, thiamine
Blakemore tube insertion:
Patient supine at 45 degrees
Estimate length (nose - xiphoid)
Lubricate
Insert into oesophagus
Insert small amount of air into gastric balloon - CXR - fill up to 250 mls
Pull back against fundus
Fix and attach to rope-pulley system with 1L bag of fluid
Check for ongoing bleeding via port
Does not usually need oesophageal balloon inflation (20-40 mmHg)
Causes of hyperkalaemia:
Increased intake: potassium supps
Decreased excretion: renal failure, drugs (K+ sparing diuretics), Addison’s
Redistribution: acidosis, rhabdo, haemolysis, drugs such as sux
ECG changes with K+
> 5.5 = repolarisation - peaked T waves
6.5 = atrial paralysis - P-wave widens, PR long, P-waves gone
7 = conduction abnormalities - wide QRS, high grade blocks, conduction blocks, slow AF, sine-wave
9 = asystole, VF, PEA
Hyperkalaemia management:
Membrane stabilisation: calcium gluconate 10% 30 mls
Redistribution of K+: insulin, salbutamol, bicarb
Elimination: resonium, dialysis
Liver unit criteria:
Oligouria or acute renal failure INR >3.0 at 48 hours, >4.5 any time BP <80 Hypoglycaemia Severe low plt Encephalopathy Acidosis <7.3
Paeds lung protective ventilation:
SIMV PEEP 8-10 TV 5-6 ml/kg RR 25 FiO2 1.0
Dabigatran reversal:
Idarucizumab 2.5 g x 2 doses
TXA 30 mg/kg
Prothrombin-X 50 iu/kg IV
Elderly fall from ladder, head strike, anticoagulants - priorities:
ABCs + primary survey - seek and treat associated life-threatening injuries
Neuroprotection - prevent secondary injury
Reversal of anticoagulation
Stabilisation to get patient to CT + transfer
Knee exam:
Look/Feel - scars, deformity, effusion + size, palpate bony structures
Move - full ROM active, passive
- crepitus, move patella
Special Tests - ACL (Lachmann), PCL (post drawer), test collaterals, meniscal palpation
Distal neurovascular examination:
- common fibular nerve: dorsiflexors, 1st dorsal webspace (deep fibular)
- tibial nerve: plantarflexors, sole of foot sensation
TOX =
BSL, ECG, paracetamol level
Which toxic alcohol leads to hypocalcaemia:
Ethylene glycol
Also - calcium crystals
Methanol - high lactate + basal ganglia haemorrhages
Patient out drinking, not waking up appropriately:
Think brain injury AND OTHER PROBLEMS like hyponatraemia, hypoglycaemia
Disaster planning:
Hospital plan: hospital mx, other departments, specialist help
ED plan: staff, decanting, areas, equipment
Other: admin, ongoing disaster planning
Foot drop key features:
Weakness of ankle dorsiflexion, toe extension, eversion - either L5 radiculopathy or common peroneal nerve. However if there is INVERSION weakness = L5 radiculopathy.
L5 more extensive sensory loss, 1st dorsal webspace = common peroneal.
Conus medullaris vs cauda equina
CM: sacral nerve roots, CE: L4-5 typically
CM motor of lower limb spared, less pain, only absent reflex would be ankle, saddle/bladder/bowel
Benefits of thrombolysis:
Favourable in >80%
Improves electrical instability, heart blocks, LVEF by 10%, more salvagable tissue
Greatest benefit in 6 hours
Mortality benefit 1:40 *(1:24 in anterior STEMI)
