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VT vs SVT with abberancy
- Epidemiological criteria: age > 35, IHD, structural heart disease. FHx sudden cardiac death.
- Clinically unstable —> DCR
- Features of VT —> treat as VT
- Very broad, QRS > 160 msec
- North west axis
- AV dissociation
- Capture / fusion beats
Brugada Criteria
- absence of RS complex in all precordial leads (concordance)
- RS inverval of > 100 msec in precordial lead
- AV dissociation
- Morphological criteria for VT in V1-2 and V6
— Dominant R in V1 (RBBB) - smooth monophasic R, taller initial R in RSR (taller L rabbit ear). V6 QS complex (no R)
— Dominant S in V1 (LBBB) - R wave > 30-40 msec, notchign S wave (josephson’s sign), RS inverval >60 msec (brugada sign), QS wave in V6
Vereki algorithm.
- Dominant inital R wave in aVR
Indications for thrombolysis in ischaemic stroke
Age > 18 yrs
Consistent clinical syndrome with significant deficit, not rapidly resolving
< 4.5 hrs from onset
Exclusion of stroke mimics (migraine, hypoglycaemia, seizure)
Clinical and CT findings suggestive of ischaemic stroke
Contraindications for thrombolysis in ischaemic stroke
Clinical CI:
- seizure at onset, hypoglycaemia
- improving, or obtunded / severe (NIHSS > 25)
- Septic embolism / dissection
- BP > 180/110
Hx CI
CNS: No ICH, AVM, SOL.
CAP: no trauma, AMI or surgery in last month, or bleeding GI/GU
No blood thinners
No dementia, disseminated cancer or frailty/dependence
Describe central cord syndrome
Hyperextension injury
Motor effects upper limb > lower, distal effects > proximal
Variable sensory involvement
Describe anterior cord syndrome
Flexion injury to spine or vascular insufficiency - anterior spinal artery
Motor loss / weakness below level
Loss pain / temperature (preserved proprioception/vibration)
Hard signs of penetrating neck trauma
Bubbling air Massive haemoptysis Stridor, hoarse voice or airway compromise Rapidly expanding haematoma Vascular bruit / thrill Cerebral ischaemia
.
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DDx acute red eye, painless
Diffuse:
- Lids: blepharitis, ectropion, eye lid lesion
- conjunctivitis
Localised:
- pterygium
- corneal FB
- occular trauma
- subconjunctival haemorrhage
Differential diagnosis painful acute red eye
Orbit: cellulitis
Lids: chalazion, blepharitis, HZV
Diffuse conjunctival: conjunctivitis, dry eyes
Corneal
- HSV, dendritic ulcer
- bacterial ulcer (contacts?)
- Marginal keratitis (bacterial)
- foreign body / corneal abrasion
Acute angle closure glaucoma
Ciliary injection - vascular / connective tissue
Anterior chamber -
- uveitis / iritis
- hypopyon
- hyphaema - trauma, NAI, bleeding disorder
DDx sudden loss of vision
Transient: amaurosis fugax
Vaso-occlusive:
- CRAO
- CRVO
Optic nerve
- optic neuritis
- GCA
Retinal detachment
DDx diplopia
Mono-ocular:
- distorsion of lens/cornea - corrects with pinhole
- retina - not correcting with pinhole
- functional
Binocular
- cranial nerve palsy: III, IV, VI
- impaired globe movement (muscle entrapment)
- Gaze palsy (internuclear - ms), normal ROM independently
- Peripheral vertigo
- neuromuscular - myasthenia
- occipital cortical - CVA, SOL
Describe management of massive transfusion
- What is massive transfusion? 1/2 blood volume 4 hrs (70 mls/kg = TBV adult).
- Stop bleeding. ED & definitive. Tourniquet, pressure. Arrange definitive care.
- Large bore IV access. X-match - crossmatched blood when available.
- Balanced transfusion, 1:1:1 PRBC, FFP to platelets. Then viscoelastography guided.
- Targets for transfusion
- SBP of X
- No haemoglobin target
- Avoid acidosis pH > 7.2, avoid hypothermia temp > 36 (warm blood)
- iCa > 1.1 (give calcium), APTT & INR < 1.5 x normal, plt > 50 (give platelets), Fibrinogen > 1 (give Cryo) - Reverse coagulopathy if present. Specific reversal agent.
- Monitor for complications
- of blood loss: worsening hypotension / clinical condition
- of blood transfusion: fever, TACO
- distraction from other priorities (to OT)
Addisons disease
- causes
- clinical findings
- treatment
Primary adrenal insufficiency - autoimmune - infection (viral, TB, protozoa) - adrenal haemorrhage - malignancy - sarcoid Secondary adrenal insufficiency - drugs - pituitary failure - hypothalamus
Findings
- Fluid resistant hypotension
- hyponatraemia, hyperkalaemia
Clinical / investigation findings in conns and cushings syndrome
Hypertension
Alkalosis
Hypokalaemia
Hypernatraemia / oedema
Clinical and investigation findings in Addisons
Primary adrenal insufficiency
Hypotension Hyponatraemia Hyperkalaemia Acidosis Hypoglycaemia
Causes of addisons disease
Primary adrenal insufficiency
Autoimmune
Infection
haemorrhage (sepsis, anticoagulants)
Malignancy
Causes of adrenal insufficiency
Primary = Addisons
- autoimmune
- infection
- Haemorrhage
- malignancy
Secondary
- Drugs
- pituitary failure
- hypothalamic failure
Findings in congenital adrenal hyperplasia
Different forms. Salt loosing male form, presents 7-14 days with shock - hyponatraemia - hyperkalaemia - hypoglycaemia
Girls - ambiguous genitalia
Boys - non-salt loosing, present 2-4 years with early virilization (androgen excess)
Definition of anaphylaxis
- Acute onset of skin/mucosal features (urticaria, angiooedema) and
- CVS: hypotension, dizziness, OR
- Resp: stridor, hoarse voice, bronchospasm
- GIT, persistent/severe: abdominal pain, vomiting, diarrhoea.
OR - Acute onset of hypotension, bronchospasm or upper airway obstruction where anaphylaxis is considered possible.
