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OSCE 2022 > Quick Fire > Flashcards

Quick Fire Flashcards

1
Q

Brief screening UL exam:

A

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

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2
Q

NEXUS:

A

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

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3
Q

Ant TMJ dislocation:

A

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

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4
Q

Tube rule in paeds:

A

2 x ETT: NGT, OGT and IDC
3 x ETT: depth
4 x ETT: ICC size

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5
Q

Absolute CI for thrombolysis:

A

ABCDEFG:
AVM/aneurysm, BP >185, CNS Trauma, diathesis (plt <100, INR >1.7), endocarditis/endocrinopathy, former hx of ICH, glucose >20

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6
Q

Easy corrected Na+:

A

3 mmol/L added for every 10 of glucose >5

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7
Q

Features of GBS:

A

LMN signs: hypotonia, hyporeflexia, motor weakness in ascending pattern, equivocal Babinski, sensation normal

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8
Q

Procedural sedation steps:

A

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

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9
Q

Discuss your procedural sedation options - what must you consider:

A

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

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10
Q

Snakes summary:

A 
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
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11
Q

Dose of prilocaine in Bier’s block:

A

Prilocaine 0.5% 2.5 ml/kg (= 0.5 ml/kg, usual adult dose 200 mg or 40 mls)

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12
Q

Thrombolysis or ECR criteria:

A

Large ischaemic penumbra on CT,
NIHSS >20
M. Rankin

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13
Q

PTx exam findings:

A

Tachycardia, hypotension, hypoxia, tachypnoea
SOB/cyanosis, JVD, reduced unilateral chest expansion, reduced breath sounds
Hyperresonant lung

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14
Q

AAA exam findings:

A

Tachycardia, hypotension, ALOC

Palpable mass with pulse, flank/umbi bruising (Grey Turners/Cullens/Fox

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15
Q

DKA priorities:

A

1) Calculate + correct dehydration
2) Correct acidosis/ketosis
3) Prevent complications
4) Identify and treat the cause

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16
Q

Agitated patient tube plan:

A

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

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17
Q

Paeds standard induction drugs

A

Ketamine 1-2 mg/kg + Roc 1.5 mg/kg

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18
Q

Neonate tube drugs:

A

Fentanyl 2-5 mcg/kg IV (over 1/60) + sux 2 mg/kg IV

Atropine 10-20 mcg/kg

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19
Q

Neurosurgical intubation modifications:

A

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

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20
Q

Obese (+/- OSA) intubation modifications:

A

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

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21
Q

Anatomically difficult face - face/neck trauma/Ludwigs intubation plan:

A

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

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22
Q

Cardiovascular intubation (STEMI with hypotension, dissection):

A

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

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23
Q

Initial BIPAP settings in asthma:

A

PEEP 3-5, iPAP 7-15 (adjust to RR <25), high inspiratory flow rate, low I:E - 1:5

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24
Q

Push dose adrenaline in kids:

A

1 mcg/kg, max 50 mcg

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25
Q

Femoral splints:

A

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

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26
Q

Domestic violence resources:

A

000 - police, any emergency department/GP clinic, safe steps, Berry street, social work, 1800 RESPECT

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27
Q

Domestic violence questions:

A

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?

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28
Q

Tumour lysis syndrome:

A

HyperK/urea/PO4, reduced calcium/renal function

IVT 1-2 ml/kg/hr, rasburicase, dialysis

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29
Q

VT storm:

A

Esmolol 500 mcg/kg bolus (40 mg) + 50 mcg/kg/hr infusion

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30
Q

Tamponade exam findings:

A

Tachycardia, hypotension, hypoxia, pulsus paradoxus, JVD, muffled heart sounds, displaced apex beat, pericardial rub

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31
Q

Dissection exam features:

A

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

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32
Q

Initial BIPAP settings in asthma:

A

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

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33
Q

Paeds jet insufflation

A

<8 years
14G cannula
ENK oxygen flow modulator to give breaths

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34
Q

Shoulder dystocia:

A

McRoberts: knee-chest position
Mod-suprapubic pressure
Rubin/reverse wood screw - trying to manipulate anterior shoulder
Posterior shoulder delivery +/- # that clavicle

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35
Q

San Fran syncope rule:

A 
CCF
HCT <30%
ECG changes
SOB
Age >65
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36
Q

Acute stroke assessment key points:

A

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

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37
Q

Cavernous sinus CNs:

A

V (ophthal/maxillary), III, IV and VI

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38
Q

Orbital apex syndrome:

A

II/III/IV/VI + V1

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39
Q

UL myotomes:

A 
C4: shoulder elevation
C5: shoulder abduction
C6: elbow flexion/wrist extension
C7: elbow extension/wrist flexion 
C8: finger flexion
T1: finger abduction
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40
Q

LL myotomes:

A 
L1/L2: hip flexion
L3: knee extension
L4: ankle dorsiflexion
L5: great toe extension
S1: ankle plantar flexion, hip extension 
S2: knee flexion
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41
Q

DVT exam findings:

A

Tenderness, pitting oedema, swelling, unilateral. Calf size >3 cm with contralateral.
Erythema, warmth, dilated veins, palpable cord, tender veins
Phlegmasia alba/rubra

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42
Q

HHS management goals:

A 
Correct volume deficit/dehydration
Provide insulin 0.05 units/kg/hr 
Replace electrolytes - prevent complications
Seek/treat precipitating cause
Prevent complications
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43
Q

Hip dislocation:

A

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

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44
Q

HINTS exam spiel:

A

Suspect stroke if head impulse is negative, fast paced alternating/bidirectional nystagmus
If eyes refixate during cover test of skew

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45
Q

Cranial nerve IV palsy:

A

Trochlear nerve
Head tilted away
Cannot look down/laterally across
- hypertrophia and extorsion

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46
Q

UL reflexes

A

Supinator/biceps: C5/6

Triceps: C7/8

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47
Q

Systemic fluorosis cardiac arrest:

A

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

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48
Q

Facial vs trigeminal nerve

A

Facial nerve = 7 = muscles of facial expression

Trigeminal = 5 = muscles of mastication and facial sensation

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49
Q

Severe trauma intro:

A

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.

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50
Q

Capacity:

A

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

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51
Q

APGAR:

A 
Appearance
Pulse rate
Grimace
Activity 
Respirations/effort
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52
Q

Rhabdo management:

A 
Maintain UO >1-2 ml/kg/hr
Urinary alkalinise 1 mmol/kg 
Urinary pH >6
Mannitol/frusemide
Renal physicians
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53
Q

Neonate vital signs

A

Usual and
BSL
WEIGHT
TEMPERATURE

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54
Q

What is the first thing done when baby is delivered in ED?

A

Check for twin

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55
Q

Borders of the triangle of safety:

A

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

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56
Q

ICC insertion:

A

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

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57
Q

MTP goals:

A

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

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58
Q

MTP initial request:

A

4 units pRBC, 2 units FFP

Cryo if fibrinogen <1 g/L
Consider 1 adult dose platelets
TXA

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59
Q

Indications for bicarb in NaCB overdose:

A

Seizures, arrhythmias, prolonged QRS, hypotension, at the time of induction

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60
Q

Lower limb weakness differential:

A

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

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61
Q

Dix-Hallpike manouvre:

A 
\+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
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62
Q

Extubation criteria in ED:

A

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

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63
Q

HOCM vs AS

A

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

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64
Q

Type of forceps used in ICC and scissors with lat canthotomy:

A

ICC: Kellys forceps

Lat canthotomy: iris scissors

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65
Q

PGE-1 infusion:

A

0.01-0.5 mcg/kg/min, limit oxygen/IVT

Consider adrenal insufficiency

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66
Q

Rhinne and Weber tests:

A

Conductive hearing loss: abnormal Rhinne in affected ear, Weber localises to affected ear
Sensorineural: Rhine normal in both ears, unaffected ear localises Weber

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67
Q

Differentiating different causes of peripheral vertigo on exam:

A

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

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68
Q

Resus question phrases:

A

Assemble/allocate team roles
Clear plan and ensure everyone understands plan
Closed-loop communications

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69
Q

Barries to leaving in DV:

A

Legal
Financial
Housing
Psychological

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70
Q

Joint exam basics:

A

Look, feel, move, NV exam, special tests
Compare to contralateral side
Examine joint above/below

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71
Q

Joint exam feel components

A 
Bony prominences
Muscles/soft tissues
Heat/cold
Tenderness
Creptius
Fluctuance

Compare to contralateral side

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72
Q

Joint exam - look component:

A 
Limb position at rest
Differences
Swelling
Deformity
Skin changes: pallor, rash, wounds, bruising, erythema
Scars
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73
Q

Lateral medullary syndrome:

A

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

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74
Q

Acute visual loss:

A

Painful: corneal injury, trauma, migraine, endophalmitis, uveitis, GCA

Painless: CRVO/CRAO, stroke, retinal haemorrhage/detachment, vitreous haemorrhage, optic neuritis

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75
Q

Pneumothorax equipment:

A

Aspirate: 16-18G cannula

Small chest tube: 8-14F

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76
Q

PTx study called:

A

Brown/Ball NEJM

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77
Q

Anterior cord syndrome:

A

Flexion injury, AAA, dissection

Loss of motor/pain/temp bilaterally below lesion
Proprioception/vibration intact

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78
Q

Brown-Sequard:

A

Ipsilateral motor/vibration

Contralateral pain/temp

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79
Q

Central cord syndrome:

A

Upper > lower, distal > proximal, motor > sensory (but both variable), some bladder/bowel dysfunction

Causes: hyperextension, spinal canal stenosis, cancer, OA

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80
Q

HEADSS model:

A

Home, education, activities/alcohol/associates, diet/drugs, sexuality/self-esteem, safety/suicide/school

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81
Q

All paeds questions:

A

BSL, weight, parental support, keep warm

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82
Q

Orlowski scale:

A

<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
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83
Q

SAD PERSONS:

A

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
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84
Q

Ethanol treatment in toxic alcohol ingestion:

A

8 ml/kg bolus of 10% then 1-2 ml/kg/hr of 10%

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85
Q

Delta gap teaching:

A

Ratio to help determine if the metabolic acidosis is due to loss of bicarb or due to extra added acids (L TKR)

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86
Q

Three bullying phrases:

A

‘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’

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87
Q

LP site:

A

Cord terminates at L2, L3/4 at iliac crest level midline

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88
Q

3 chambers ICC:

A

Collection
Under water seal
Suction

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89
Q

IO sites and considerations:

A

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)

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90
Q

Paeds weights

A

(Age + 4) x 2

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91
Q

Cuffed and uncuffed ETT size:

A

Uncuffed: age/4 + 4
Cuffed: 0.5 smaller

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92
Q

Missed diagnosis proforma:

A

Complaint management
Clinical governance: case review, resource issues
Risk management: document, facts
Staff support: advise team, educate, M&M

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93
Q

Traumatic arrest modifiers:

A

At the same time:

  • stop bleeding
  • replace circulating volume
  • open airway/assist ventilation
  • collar
  • decompress chest bilaterally +/- thoracotomy if tamponade

Then conventional ALS/CPR

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94
Q

CPR statement:

A

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

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95
Q

4Ts in PPH:

A

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

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96
Q

Cerebellar speech:

A

Jerky, explosive, loud

Irregularly spaced syllables

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97
Q

Haematemesis medical management:

A 
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
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98
Q

Causes of post-tube hypotension:

A

A: anaphylaxis
B: tension pneumo, breath stacking
C: too much induction, tamponade, arrhythmia, hypovolaemia
D: acidosis, electrolytes

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99
Q

Posterior shoulder dislocation:

A

Reverse Cunningham:
Traction, adduction, internal rotation
Elbow up to shoulder and external rotation

Methods: reverse Cunningham, traction/counter traction, DePalma

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100
Q

Thrombolysis in stroke stats:

A

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 ++

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101
Q

Runyon’s criteria:

A

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

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102
Q

Post-intubation hypoxia:

A

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

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103
Q

Disaster plan:

A

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

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104
Q

Post-intubation hypotension approach:

A

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

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105
Q

Outline your approach questions:

A 
Opening statement
DDx
Establish cause - hx/exam/ix 
Treatment dependent on cause
Disposition
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106
Q

Missed diagnosis/2nd presentation:

A

Near miss
Outcome could have been catastrophic
Identify - patient, clinician, departmental factors
Prevention - QI cycle

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107
Q

QI cycle

A

Plan, do, check, act

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108
Q

Trauma must mentions:

A

Primary/secondary survey, MTP, ? Permissive hypotension, ADT, activate trauma team
Ix the cause for trauma
Sequence of life saving measures

109
Q

Labeling:

A

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

110
Q

Rheumatoid arthritis modifiers:

A

C-spine immobility
Adrenal crisis
Immunosuppressed

111
Q

Patients on steroids:

A

Think adrenal crisis 200 mg IV hydrocortisone

112
Q

Ankle jerk reflex

A

S1/S2

113
Q

LP practicalities:

A

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

114
Q

Knee jerk reflex:

A

L3/L4

115
Q

Stroke Ax:

A

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

116
Q

NAGMA causes:

A 
Endo: steroid deficiency (Addisons)
Renal: loss of bicarb, RTA
GI: loss of bicarb - diarrhoea, high outputs 
Gain Acid: NaCl infusion 
Drugs: acetazolamide, spironolactone
117
Q

Metabolic alkalosis

A

Loss of H+

  • GI: vomiting
  • Renal: diuretics, laxatives

Endo: mineralocorticoid excess: Cushing’s, Bartter’s syndrome

Drugs: diuretics (frusemide), milk-alkali, bicarb infusion

118
Q

Antibiotics neonates:

A

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)

119
Q

Pacing steps:

A

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

120
Q

Thyrotoxicosis management:

A

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

121
Q

Respiratory acidosis causes:

A 
COAD
Airway disorders: asthma/obstruction
Reduced central respi drive: drugs, ICH
Lung insults: trauma, APO/ARDS
Inadequate respiratory muscle use: GBS, toxins (snakes)
122
Q

Respiratory alkalosis causes:

A

Central respiratory increased drive: ICH/head injury, anxiety, pain, salicylates, MDMA

Profound hypoxia: PE/pneumonia, APO, asthma, ARDS

123
Q

HAGMA causes:

A

Lactate
Ketoacids
Uraemic renal failure
Toxicological

124
Q

Tox causes of HAGMA:

A

Cyanide, CO, paracetamol, methanol, ethylene, paraquat, iron, isoniazid, metformin, salicylates

125
Q

Key features of methanol toxicity:

A

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)

126
Q

Key features of ethylene glycol toxicity:

A

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

127
Q

Ethanol antidote:

A

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

128
Q

Fomipazole antidote use:

A

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

129
Q

Order of toxic alcohol blood abnormalities:

A

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

130
Q

Reversal of dabigatran:

A

Idarucizumab 2.5 mg twice, consider dialysis
Less likely to make an impact: PCC and TXA

Direct Thrombin inhibitor (DabigaTran)

131
Q

Reversal of apixaban and rivaroxaban:

A

Factor Xa inhibitors
No antidote yet - major trial with an-dexa-net is coming in late 2022
PCC and TXA may help

132
Q

Low fibrinogen:

A

Replace with PCC

133
Q

What are considerations when you reverse someone’s anticoagulants?

A

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

134
Q

Warfarin reversal:

A

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)

135
Q

TPA reversal:

A

Most improtant:
TXA 1 gram IV
10 units cryoprecipitate (to replace fibrinogen)

Additionally:
2 units FFP
If plt borderline - transfuse

136
Q

Indications for digoxin immune Fab:

A

Dysrhythmias (with hypotension) OR VT or runs of VEs
K >6 + evidence of toxicity
[Dig] >15 nmol/L + toxicity

137
Q

Treatment of hypocalcaemia:

A

20-40 mls of calcium gluconate IV over 5-15 minutes

138
Q

Treatment of CCB toxicity:

A

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)

139
Q

Systemic fluorosis treatment:

A

Hypocalcaemia - 30 mls of calcium gluconate bolus IV over 5 mins
Hypomagnesaemia - 10 mls of MgSO4
Hyperkalaemia - aggressive management

140
Q

Risk of systemic fluorosis:

A

> 5% BSA + any HF concentration

50% HF + >1% BSA

141
Q

Dermal HF exposure management:

A

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

142
Q

CAGE questions:

A

Cut down
Angry/annoyed
Guilty
Eye opener

143
Q

Agitated patient history:

A

Med hx, psych hx, AOD/medications, social

Delusions, hallucinations, suicidal and homocidal

144
Q

Post-Bier’s or fracture reduction care

A

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

145
Q

Bier’s minimum and maximum times:

A

Cuff inflation time ~20 mins min, max 60 mins after LA administration

146
Q

Access block questions - key terminology to remember:

A

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

147
Q

Measles

A
148
Q

Cannabinoid hyperemesis:

A

Droperidol IV 1.25 mg
Dexamethasone 8 mg IV
Capsacin cream periumbilically
Hot showers

? Ondansetron

149
Q

Treatment of hypernatraemia:

A

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

150
Q

Use of osmolality in hypernatraemia:

A

Urine > serum: urine is not concentrating, central/nephrogenic DI, renal disease, diuretics

Urine < serum: intact urine concentrating ability, GIT/skin loss, excess intake

151
Q

Colles fracture

A

Radial and DORSAL angulation of the distal fragment

152
Q

Causes of hypernatraemia:

A

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

153
Q

Debrief:

A 
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

154
Q

Measles:

A

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

155
Q

PPH management:

A 
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
156
Q

ED management of third stage of labour:

A 
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
157
Q

Asthma exam goals:

A

Confirm asthma diagnosis
Determine severity
Exclude precipitants that require specific Rx - pneumonia, anaphylaxis

158
Q

Asthma severity:

A

Prior ETT/ICU
Poor treatment adherence
Poor control with interval symptoms
Past hx of anaphylaxis as well

159
Q

MSE

A

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

160
Q

Glaucoma drugs:

A 
Acetazolamide 500 mg IV/oral
Opioids for analgesia
Pilocarpine 2% q5min for 1 hour
Timolol 0.5% Q30 min
Latanaprost 1 drop
Definitive care
161
Q

HOCM murmur:

A

Louder with Valsalva, softer with squat

162
Q

CCB overdose:

A

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

163
Q

Lipid emulsion:

A

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

164
Q

Dabigatran reversal:

A 
Dialysis
Idarcizumab 2.5 mg x 2 doses - titrate to improvement in PT
PCC + factor 7a
TXA
Haematology consult
165
Q

DAMA:

A

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

166
Q

Inferior STEMI management considerations:

A

ECG STE III > II, STE V1
Manage hypotension - fluid bolus, no nitrates/b-blockers, peripheral inotropes
Anticipate conduction disturbances
Usual STEMI stuff

167
Q

Intubation of the patient heading to cath lab:

A

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

168
Q

General comments about STEMI:

A

Territory specific considerations - APO in anterior, heart block in inferior
General management + disposition of AMI patient
Optimisation of patient prior to RSI
Anticipate complications

169
Q

Bier’s block LA

A

Prilocaine 0.5% 3 mg/kg

2.5 mg/kg may be easier - translates to 0.5 ml/kg

170
Q

Management of recurrent VT/VF in STEMI:

A

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

171
Q

5th MT fracture:

A

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

172
Q

Febrile convulsion stats:

A

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

173
Q

Neonatal sepsis stats:

A

Sepsis <48 hours - untreated 1/3-4 mortality

Sepsis <28 days - 1/10 mortality if left untreated

174
Q

Neonatal sepsis antibiotics:

A

Benzylpenicillin 60 mg/kg + cefotaxmine 50 mg/kg

> 2 months then flucloxacillin 50 mg/kg + cefotaxime 50/ceftriaxone 100 mg/kg

175
Q

Trifascicular and bifascicular blocks:

A

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

176
Q

Anterior shoulder dislocation:

A

To reduce: flex + externally rotate +/- abduction

Types: Stimson, Cunningham, Spaso, scapular manipulation, Fares and Milch

177
Q

ACLS drugs:

A

Non-shockable: 1 mg adrenaline stat, Q2 nd loop

SHockable: 1 mg after second shock, 300 mg amiodarone after 3 shocks

178
Q

4Hs and 4Ts

A
179
Q

LEMON:

A

= difficult ETT

Look externally
Evaluate 3-2-2
Mallampati score
Obstruction - big tongue, known OSA
Neck mobility poor
180
Q

MOAN

A

= difficult BVM
Moan for santa

Mask seal - ie beard
Obesity/obstruction
Age >55
No teeth

181
Q

Difficult front of neck access considerations:

A

SHORT - surgery, haematoma, obesity, radiation, tumour

182
Q

Post-ROSC management:

A 
Re-evaluate ABCDE
12 lead
Treat cause
Aims - oxygen >94%, normal CO2, normal pH, normal BSL, normal haemodynamics 
TTM

Disposition: ICU/CCU/cath lab

183
Q

COACHED:

A 
Continue compressions
Oxygen away
All else clear
Charging defib
Hands off
ECHO/evaluate rhythm
Defibrillate 150-200 J biphasic AP pads or disarm
184
Q

CPR characteristics:

A 
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
185
Q

When can you do three stacked shocks?

A

If can be given within 20 seconds
Witnessed, monitored setting
Defib is immediately available
Time to rhythm recognition + charging is short

186
Q

What drugs can be given in sympathomimetic toxidrome?

A

Phentolamine, benzos, GTN

187
Q

Newborn ALS:

A

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

188
Q

BRUE:

A 
<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

189
Q

DDx of BRUE

A

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

190
Q

BRUE history:

A

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

191
Q

Management of BRUE:

A

History/exam
Period of observation
Social situation evaluation
Investigations: ECG, NPA, BSL, ? FBE/UEC

? D/c or admit for obs + follow-up planning

192
Q

FI block considerations:

A

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

193
Q

FI block landmarks:

A

Pubic tubercle to ASIS line
Injection point 1-2 cm below the lateral 1/3
Palpate artery medial to this
Confirm location using USS

194
Q

FI block drug details:

A
  1. 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

195
Q

Teaching procedures topics to consider:

A

Recap landmarks
Discuss use of USS
Why choose a specific site
How to minimise the risk of complications

196
Q

Kids weights:

A

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

197
Q

Meaning of the delta ratio:

A

Ratio of extra acids as opposed to bicarb loss

Smaller = bicarb loss 
Higher = extra acids - respiratory/L TKR

DKA = 1

198
Q

Low delta ratio means what?

A

HYPERCHLORAEMIC NAGMA - ie iatrogenic normal saline

199
Q

Acute glaucoma management:

A 
Acetazolamide 500 mg IV/oral (not in AKI/allergy)
IOP Q30 mins
Pilocarpine 2% drops
Timolol 1 drop 
Pred 1% drops
? Mannitol
Analgesia/antiemetics
200
Q

Babinski’s reflex:

A

L5/S1/S2

201
Q

Neonate HR <60

A

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

202
Q

OT vs CT in trauma:

A

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

203
Q

Exploring what went wrong in error:

A 
Department (ie very busy)
Technique (ie lack of training)
Doctor (ie tired)
Equipment (ie USS broken)
Patient (ie difficult anatomy)
204
Q

Error statements to consider:

A

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?

205
Q

PEP:

A

Truvada + dolutegravir

Confidential, quiet room, support person, information sheets, contraception/condoms

206
Q

When would you not perform painful touch and coordination in neuro examination?

A

Coordination is only for cerebellar disease

Sharp touch would be only for spinothalamic tract involvement

207
Q

Neck injury examination:

A

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

208
Q

Difference between cauda equina and conus medullaris:

A

Cauda equina: only LMN

Conus medullaris: typically T12/L1, mixed UMN + LMN

209
Q

Central cord syndrome:

A

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
210
Q

Brown-Sequard:

A

Contralateral pain/temperature loss

Ipsilateral motor/sensory function, proprioception/touch/vibration sense

211
Q

Anterior cord syndrome:

A

Near complete paralysis below level of lesion
Loss of pain/temp below lesion
Autonomic dysfunction

Intact posterior columns: proprioception and vibration are normal

212
Q

Mnemonic for spinal cord tract locations:

A

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!

213
Q

Cauda equina:

A

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

214
Q

Neonatal jaundice approach:

A

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

215
Q

Brugada types

A

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

216
Q

HOCM features:

A

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

217
Q

LVH criteria:

A

S-wave in V1 + R-wave in V5 or V6 >35 mm

218
Q

Management of Bell’s Palsy:

A

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

219
Q

Nursemaids elbow reduction:

A

Supination technique - firmly hyper-supinate + extend arm fully, then flex at elbow

Hyperpronation - firmly pronate and then flex at elbow

220
Q

SIADH definition

A

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)

221
Q

Eclampsia management:

A 
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
222
Q

Calcium gluconate dose in CCB overdose kids:

A

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

223
Q

Cultural competency:

A

Attitudes, skills and knowledge

224
Q

Posterior hip dislocation relocation techniques:

A

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

225
Q

Posterior hip dislocation complications:

A

Reduce within 6 hours
AVN
50% have acetabular or femur fracture
Sciatic nerve injury in 10%

226
Q

Lower limb neurovascular assessment:

A

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

227
Q

Wellens syndrome

A
228
Q

Diplopia eye cranial nerve assessment:

A 
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)
229
Q

Electrical storm management:

A

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

230
Q

STEMI:

A

CORRECT ELECTROLYTES

231
Q

STEMI thrombolysis:

A

50 mg IV bolus of tenecteplase

- > 60 kg patient

232
Q

Biochemical changes with sodium valproate:

A

Hypernatraemia, high lactate/ammonia, LOW calcium, low glucose, HAGMA

233
Q

EDACS

A

Age, Gender
Known CAD or 3+ RFs
Diaphoresis
Pain radiation - arm/shoulder/neck/jaw

Negative points: pleuritic pain, reproducible pain

234
Q

Blood product refusal:

A

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

235
Q

Dangerous mechanism c-spine:

A 
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

236
Q

Key elements of hx and exam in cspine injury:

A

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

237
Q

AF causes:

A

Ischaemia, valvular heart disease, thyroid, alcohol, PE, pre-excitation, electrolytes, drugs (sympathomimetics), acute infections, pre-excitation syndromes, cardiomyopathies, endocrinopathies

238
Q

AF vs flutter:

A

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

239
Q

CHADSVASC-2 and HASBLED

A 
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)

240
Q

AF rate control vs rhythm control:

A

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

241
Q

Delta ratio:

A

[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)

242
Q

Corrected Na:

A

Na + (BSL - 5 / 3)

243
Q

Three shoulder exam tests:

A 
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

244
Q

Shoulder pain examination:

A

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

245
Q

End of life drugs:

A

Subcut:
Morphine/midaz 2.5 mg Q2H PRN
Metoclopramide 10 mg Q8H PRN
Glycopyrralate 200 mcg Q2H PRN

246
Q

End of life ancillary supports:

A

Pastoral care, social work, private room, prioritise admission, medical/carers certificates, refreshements, contact/ability to escalate

247
Q

Why is the patient not improving on NIV?

A

Patient factors: hypoventilation, PTx, pneumonia, oversedation, CNS pathology
Equipment factors: leak, inappropriate pressures, I:E ratio inappropriate

248
Q

Settings that can be adjusted on NIV machine:

A 
FIO2
PEEP = EPAP
Psupport = difference between IPAP and EPAP
I:E ratio
Trigger sensitivity
249
Q

Power

A

0: paralysis, 1: flicker, 2: move without gravity, 3: against gravity, 4: slight resistance, 5: normal

250
Q

Reflexes:

A

0 = absent, +1 = hyporeflexia, +2 = normal, +4 = hyperreflexia

251
Q

Lower limb screening neuro test:

A

Up on toes (S1)
Up on heels (L4/5)
Squat to stand (L3/4)

252
Q

Preparation points:

A

People
Area
Equipment
Drugs

253
Q

GI bleeding drugs:

A 
Terlipressin 2 mg
Octreotide 50 mcg + infusion
Pantoprazole 80 mg + 8 mg/hr
Ceftriaxone 1 gram IV
Treat encephalopathy - lactulose, thiamine
254
Q

Blakemore tube insertion:

A

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)

255
Q

Causes of hyperkalaemia:

A

Increased intake: potassium supps
Decreased excretion: renal failure, drugs (K+ sparing diuretics), Addison’s
Redistribution: acidosis, rhabdo, haemolysis, drugs such as sux

256
Q

ECG changes with K+

A

> 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

257
Q

Hyperkalaemia management:

A

Membrane stabilisation: calcium gluconate 10% 30 mls
Redistribution of K+: insulin, salbutamol, bicarb
Elimination: resonium, dialysis

258
Q

Liver unit criteria:

A 
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
259
Q

Paeds lung protective ventilation:

A 
SIMV
PEEP 8-10
TV 5-6 ml/kg 
RR 25
FiO2 1.0
260
Q

Dabigatran reversal:

A

Idarucizumab 2.5 g x 2 doses
TXA 30 mg/kg
Prothrombin-X 50 iu/kg IV

261
Q

Elderly fall from ladder, head strike, anticoagulants - priorities:

A

ABCs + primary survey - seek and treat associated life-threatening injuries
Neuroprotection - prevent secondary injury
Reversal of anticoagulation
Stabilisation to get patient to CT + transfer

262
Q

Knee exam:

A

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
263
Q

TOX =

A

BSL, ECG, paracetamol level

264
Q

Which toxic alcohol leads to hypocalcaemia:

A

Ethylene glycol

Also - calcium crystals

Methanol - high lactate + basal ganglia haemorrhages

265
Q

Patient out drinking, not waking up appropriately:

A

Think brain injury AND OTHER PROBLEMS like hyponatraemia, hypoglycaemia

266
Q

Disaster planning:

A

Hospital plan: hospital mx, other departments, specialist help
ED plan: staff, decanting, areas, equipment
Other: admin, ongoing disaster planning

267
Q

Foot drop key features:

A

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.

268
Q

Conus medullaris vs cauda equina

A

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

269
Q

Benefits of thrombolysis:

A

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)

OSCE 2022 (4 decks)

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