Stuff

Question 1

Lisfranc

Answer 1

Tarsometatarsal joint (TMTJ) complex injury

Question 2

Causes of Lisfranc injuries

Classification

Answer 2

RTA
Fall from height
Field sports like rugby

Classification: Myerson classification

Question 3

TMTJ complex contents

Answer 3

• 5 MTs
• 3 Cuneiforms
• Cuboid

Question 4

Lisfranc ligament
x3

Answer 4

1. Dorsal ligament (weakest)
2. Interosseus ligament (aka Lisfranc ligament; strongest)
3. Plantar ligament

All run obliquely from medial border of 2nd MT to lateral aspect of medial cuneiform

Question 5

Lisfranc injury mechanisms

Answer 5

axial load on plantar-flexed foot then forcibly rotates / bends / compressed

e.g. miss a step downstairs
lands on heel of a plantar flexed foot

Question 6

Pathognomonic sign for Lisfranc

Answer 6

Plantar ecchymosis
(24-48h after)

Question 7

Special tests for Lisfranc

Answer 7

1. Pronation-abduction test
2. TMT squeeze test

Question 8

Fleck sign for Lisfranc injury

Answer 8

Pathognomonic

Avulsion fracture of medial cuneiform or 2nd MT

Question 9

Cx of Lisfranc injuries

Answer 9

Acute
- Vascular compromise
- Nerve injury
- Compartment syndrome

Chronic
- OA
- Chronic midfoot pain

Question 10

Normal Foot XR findings

Answer 10

Normal AP
- medial border of 2nd MT colinear with medial border of middle cuneiform

Normal oblique
- medial border of 4th MT colinear with medial border of cuboid

Question 11

Carpal bones

Answer 11

Trapezium Trapezoid Capitate Hamate
Scaphoid Lunate Triquetral Pisiform

Question 12

Anatomical snuffbox

Answer 12

Medial: EPL
Lateral: EPB, APL
Proximal: Radius styloid
Floor: Scaphoid, Trapezium

Question 13

Jefferson #

Answer 13

anterior and posterior arches of C1

C1 (atlas) burst #

from axial load on back of head or hyperextension of neck

Question 14

Hangman #

Answer 14

both pedicles or pars of C2

forcible hyperextension of neck

Traumatic Spondylolisthesis of C2

Bilateral fracture traversing the pars interarticularis of C2 with an associated traumatic subluxation of C2 on C3

Question 15

Jefferson bit off a hangman’s thumb

Answer 15

• Jefferson #
• Bilateral facet dislocation
• Odontoid #
• Atlanto-axial and Atlanto-occipital dislocation
• Hangman # (hyperextension)
• Teardrop #

Question 16

Central cord syndrome

Answer 16

Hyperextension injuries
Cervical spondylosis
UL > LL neurological deficit
Bladder dysfunction
Variable sensory loss

Question 17

Anterior cord syndrome

Answer 17

Paralysis
Loss of pain / temp
Preserved propioception / vibration / 2-point

Question 18

Posterior cord syndrome
(less common)

Answer 18

Loss of proprioception / vibration
Ataxic gait
Hypotonia
Loss of deep tendon reflexes
Romberg +ve

Question 19

NEXUS criteria full name

Answer 19

National emergency X-radiography utilization study

Question 20

NEXUS criteria
(x5)

Answer 20

1. No focal neurology
2. No midline C-spine tenderness
3. Conscious
4. No intoxication
5. No distracting injury

Question 21

ABCD2 score for TIA

Answer 21

Age >=60

BP >= 140/90

Clinical features of TIA (Unilateral weakness = 2; speech disturbance = 1)

Duration of symptoms (<10 mins = 0; <1h = 1; >- 1h = 2)

DM

Question 22

Dengue fever symptoms

Answer 22

Headache, retro-orbital pain, joint pain
MP rash
Biphasic fever course (saddle back)
Thrombocytopenia
Dengue hemorrhagic fever

WHO 2009 classification
- Dengue without warning signs
- Dengue with warning signs
- Severe dengue

Question 23

Segond fracture

Answer 23

Avulsion # of lateral surface of lateral tibial condyle

Excessive internal rotation + varus stress

ACL tear; also MCL and lateral meniscus injury

Question 24

Arcuate sign

Answer 24

Avulsion fracture of fibular head (at site of insertion of arcuate ligament complex)
asso w/ cruciate ligament injury

Question 25

Reverse Segond #

Answer 25

Avulsion # of medial tibial plateau Valgus stress + External rotation PCL, MCL, Medial meniscus injury

Question 26

Chauffeur's # / Hutchinson #

Answer 26

Oblique # of radial styloid FOOSH, compression of scaphoid against radial styloid

Question 27

Purple glove syndrome

Answer 27

IV Dilantin (Phenytoin) max rate: 50mg/min (Pedi: 1-3mg/kg/min)

Question 28

Tillaux fracture

Answer 28

Intraarticular fractures involving the physis and epiphysis of the distal tibia (antero-lateral) Salter Harris type 3 asso w/ AITFL (anterior inferior tibio-fibular ligament) injuiry occurs when medial aspect of the distal tibial growth plate has started to fuse from abduction-external rotation mechanism anterior tibiofibular ligament avulses the anterolateral corner of the distal tibial epiphysis Vertical fracture through the distal tibial epiphysis (Salter-Harris III) with a horizontal extension through the lateral aspect of the physis. The lack of a metaphyseal fracture component in the coronal plane (evaluated with lateral x-ray or CT) distinguishes a Tillaux fracture from a triplanar fracture.

Question 29

Common medical causes of blindness (x4)

Answer 29

Cataract Glaucoma Age related macular degeneration Diabetic retinopathy

Question 30

Takotsubo cardiomyopathy

Answer 30

aka stress cardiomyopathy, "broken heart syndrome" 1. Transient hypokinesis, dyskinesis, or akinesis of the LV midsegments, with or without apical involvement; the regional wall-motion abnormalities extend beyond a single epicardial vascular distribution, and a stressful trigger is often, but not always, present 2. Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture 3. New ECG abnormalities (either ST-segment elevation and/or T-wave inversion) or modest elevation in the cardiac troponin level 4. Absence of pheochromocytoma or myocarditis

Question 31

SDH chronicity

Answer 31

hyperacute <12h - isodense acute 12h-2d - hyperdense subacute 2d-1 month - isodense chronic > 1month - hypodense anemia / if on NOAC -> will affect density, hyperdensity will become isodense

Question 32

Fluid level in knee XR post trauma

Answer 32

Lipohemarthrosis results from an intra-articular fracture with escape of fat and blood from the bone marrow into the joint asso w/ tibial plateau fracture or distal femoral fracture

Question 33

Common causes of primary PPH 4Ts

Answer 33

1. Tone - Uterine atony, tx: Syntocinon infusion, bimanual uterine massage, other: Ergometrine, Prostaglandin F2alpha analog (Hemabate) 2. Tissue - Retained tissue of conception, may need surgical removal 3. Trauma - Perineal, vulva, vaginal or lower uterine segment laceration 4. Thrombin - Clotting abnormality - primary or secondary due to DIC

Question 34

Cord prolapse initial Mx ALSO

Answer 34

1. O2 by mask 2. Head down position (Sims or Knee-chest) to avoid compression of cord by presenting part 3. Do not handle cord excessively to avoid vasospasm 4. Elevate presenting part to ensure umbilical flow until delivery 5. If prolonged transfer -> Instillation of bladder by Foley (500-750ml NS), may help pushing the present part up and ease pressure on prolapsed cord 6. Monitor fetal HR ALSO 1. Call for help 2. Assess fetal HR 3. Assess labour progress (dilatation, station) 4. Do not attempt to reposition cord into uterus 5. Adopt materal position in Trendelenburg or exaggerated Sims' or knee-chest position 6. Elevate presenting part from cord manually 7. Fill bladder rapidly with 500-700ml NS followed by clamping the catheter 8. Consider tocolysis if there are regular uterine contactions (terbutaline 0.25mg SC) 9. Emergency C/S if vaginal delivery not imminent

Question 35

Bells palsy description x4

Answer 35

Lack of wrinkling of forehead Impaired closure of eye Flattened nasolabial fold Drooping of mouth corner

Question 36

Other symptoms of facial nerve palsy

Answer 36

Postauricular pain Eye pain / tearing Hyperacusis (n. to stapedius) Loss of sensation of anterior 2/3 of tongue

Question 37

Causes of facial n. palsy x6

Answer 37

1. Bell's palsy 2. Ramsay Hunt syndrome aka Herpes zoster oticus (Herpes zoster infection of geniculate ganglion) 3. Middle ear infection / pathology (OM, cholesteatoma) 4. Temporal bone # 5. Parotid tumor 6. Cerebellopontine angle tumor - Acoustic neuroma

Question 38

Ramsay Hunt syndrome triad

Answer 38

Ipsilateral facial paralysis Otalgia Vesicles in auditory canal / on auricle

Question 39

Acyclovir renal adjustment

Answer 39

Increase interval but keep same dose (poor oral bioavailability) CrCl 10-50: 800mg BD-TDS CrCl <10: 200mg BD

Question 40

Life threatening cause of chest pain x5

Answer 40

1. ACS 2. PE 3. Aortic dissection 4. Cardiac tamponade 5. Esophageal rupture Tension PTX

Question 41

Boerhaave syndrome

Answer 41

aka Effort rupture of esophagus Spontaneous perforation of eso caused by sudden increase in intraeso pressure + negative intrathoracic pressure (vomit, severe straining)

Question 42

Mackler's triad

Answer 42

of Boerhaave syndrome 1. vomiting 2. chest pain 3. subcutaneous emphysema

Question 43

Hamman's sign / crunch

Answer 43

pneumomediastinum heard over precordium in spontaneous mediastinal emphysema Mediastinal crackling sound synchronus with heart beat

Question 44

Cx of Boerhaave syndrome x6

Answer 44

1. Pneumomediastinum 2. Mediastinitis 3. Hydropneumothorax 4. Empyema 5. Sepsis 6. Multiorgan dysfunction syndrome

Question 45

Ix for Boerhaave syndrome

Answer 45

Gastrografin swallow (cannot use barium as perforation, will cause mediastinitis) CT thorax

Question 46

RV STEMI ECG features (when have inferior STEMI)

Answer 46

1. STE in V1 2. STE in V1 and STD in V2 (highly specific for RV infarction) 3. Isoelectric ST segment in V1 with marked STD in V2 4. STE in III > II

Question 47

Clinical significance of RV infarction

Answer 47

Isolated RV infarction is rare Most with inferior STEMI Most useful V4R (5th ICS, Rt MCL) - Nitrates contraindicated - treat with IVF when hypotension (250ml NS bolus x1; avoid excessive fluids as dilated RV may impair LV function due to ventricular interdependence) Very preload sensitive (due to poor RV contractility) and can develop severe hypotension in response to nitrates or other preload-reducing agents

Question 48

STEMI meds

Answer 48

Aspirin Clopidogrel Fibrinolytics - Tenecteplase (TNK) - IV bolus x1 - Alteplase (rt-PA) - IV bolus then 2 infusions - Reteplase (r-PA) - IV bolus x2 similar effect, TNK easier as one dose no need infusion

Question 49

CI of Fibrinolytic for STEMI

Answer 49

Absolute 1 Any prior ICH 2 Known structural cerebral vascular lesion (e.g. AVM) 3. Known malignant intracranial neoplasm (primary or met) 4. Ischemic stroke within 3 months (except within 4.5h) 5. Suspected aortic dissection 6. Active bleeding (excluse menses) or bleeding diathesis 7. Significant closed-head or facial trauma within 3 months

Question 50

Cx of fibrinolytics

Answer 50

1. ICH (~1%) 2. Bleeding risk, most common GIB 3. Hypersitivity reaction, hypotension, reperfusion arrhythmias

Question 51

Cx of AMI

Answer 51

1. Arrhythmia: VT, VF, heart blocks; bradyarrhythmia common in inferior MI 2. Mechanical: papillary muscle rupture (acute MR), ventricular free wall rupture, LV aneurysm 3. Inflammatory: Early pericarditis (transmural infarction); Dressler's syndrome (AI; 2-10 weeks) 4. Thromboembolic: DVT, PE, LV thrombus -> stroke 5. Systemic: heart failure, APO, cardiogenic shock (low LVEF)

Question 52

Steps for transcutaneous pacing

Answer 52

Explain procedure, consent Sedation, analgesics Electrodes placement (anterolateral or anteroposterior) Set cardiac monitor to pacing mode / demand mode Set pacing rate 10-30bpm higher than patient's HR (~60-70) Increase current output until electrical capture Check for mechanical capture by feeling femoral pulse (cuz upper body is twitching)

Question 53

Causes of 3rd n. palsy

Answer 53

DM neuropathy Demyelineating disease (MS, Miller Fisher) Brain tumor, Trauma Cerebral aneurysm (Berry aneurysm)

Question 54

5 causes of headache

Answer 54

Intracranial 1. Acute SAH 2. CNS infection 3. Cerebral venous thrombosis 4. Brain tumor 5. HT encephalopathy Extracranial 6. Temporal arteritis 7. Acute angle closure glaucoma 8. Carotid / vertebral artery dissection 9. Tension headache 10. TMJ disorder

Question 55

CTB finding of basal cistern SAH

Answer 55

1. Hyperdensity over subarachnoid space and basal cistern 2. Dilated temporal horn of lateral ventricles, suggestive of obstructive hydrocephalus

Question 56

Causes of primary SAH

Answer 56

Rupture of berry aneurysm AVM Coagulopathy Brain tumor Arterial dissection Vasculitis Cocaine use

Question 57

2 classifications / grading of SAH

Answer 57

1. Hunt and Hess scale Grade 1-5 (depends on symptoms) 2. World Federation of Neurological Surgeons grading system Grade 1-5 (depends on GCS, motor deficit) 1: 15 no focal deficit 2: 13-14 no focal deficit 3: 13-14 with focal deficit 4: 7-12 5: 3-6

Question 58

Immediate Tx of SAH on warfarin (meds)

Answer 58

1. PCC Prothrombin complex concentrate (Beriplex: 4-factor PCC) 2. Vitamin K1

Question 59

Cx of SAH

Answer 59

Intracranial 1. Cerebral vasospasm 2. Obstructive hydrocephalus, raised ICP 3. Recurrent SAH (rebleeding) Extracranial 4. Seizure 5. Cerebral salt wasting syndrome 6. Neurogenic pul edema

Question 60

Wellens syndrome

Answer 60

Critical stenosis of proximal LAD Recent chest pain now resolved Do not perform stress test e.g. treadmill

Question 61

ECG features of Wellens syndrome

Answer 61

Type A (25%): Biphasic T waves in V2,3 Type B (75%): Deeply symmetrically TWI in V2,3 Pseudo-normalization when LAD occlude again (T waves become upright, signifies hyperacute STEMI)

Question 62

ECG V7-9 placement

Answer 62

for posterior MI same horizontal plane as V6 V7: left posterior axillary line V8: tip of left scapula V9: left paraspinal region

Question 63

Sgarbossa criteria

Answer 63

1. Concordant STE >= 1mm any lead 2. Concordant STD >= 1mm V1, V2, V3 3. Discordant STE >= 5mm in leads with negative QRS Modified: 3. Proportionally excessive discordant STE in ≥ 1 lead anywhere with ≥ 1 mm STE, as defined by ≥ 25% of the depth of the preceding S-wave

Question 64

STEMI equivalents

Answer 64

1. Posterior MI (STD V1-3, do posterior leads) 2. new LBBB Sgarbossa criteria 3. De Winter T waves (complete LAD occlusion) 4. Hyperacute T waves (early anterior STEMI) 5. Wellens syndrome (proximal LAD critical stenosis) **not any more 6. STE in aVR - Left main coronary artery (LMCA) occlusion, Proximal LAD stenosis, severe TVD

Question 65

DDx for hyperthermia, tachycardia, agitation

Answer 65

CNS 1. CNS infection 2. Stroke, tumor (involve thermoregulatory pathway) 3. Status epilepticus 4. Sepsis Endocrine 5. Thyroid storm 6. Pheochromocytoma Environmental 7. Heat stroke Toxicological 8. Sympathomimetic toxidrome 9. Anticholinergic toxidrome 10. Salicylate poisoning 11. Serotonin syndrome 12. Neuroleptic malignant syndrome 13. Benzodiazepine / alcohol withdrawal 14. Malignant hyperthermia

Question 66

Tx for sympathomimetic toxidrome

Answer 66

1. Physical restraint followed by chemical restraint 2. Rapid and aggressive cooling for hyperthermia 3. Aggressive fluid resuscitation 4. Benzodiazepine - can treat agitation, hyperthermia, HT, tachycardia - antidote of cocaine and other stimulants

Question 67

ECG findings of Na channel blocker overdose (e.g. cocaine)

Answer 67

Wide complex tachycardia Right axis deviation Dominant terminal R wave in aVR

Question 68

Na channel blockers TCA-PP-DV Toxi book

Answer 68

T - Tricyclic antidepressants C - Carbamazepine, Cocaine, Citalopram A - Antiarrhythmic 1A (Procainamide) / 1C (Flecainide), Amantadine P - Propranolol P - Phenothiazine (Thioridazine) D - Diphenhydramine (Benadryl) V - Venlafaxine

Question 69

Mx of Na channel blockers overdose

Answer 69

Antidote: NaHCO3 50-100ml IV bolus Indication 1. QRS >100ms 2. Ventricular arrhythmias 3. Hypotension CI 1. Serum pH >7.5-7.55 2. Intolerable to fluid / Na overload Endpoint - QRS <100ms - No more ventricular arrhythmias - BP stabilize GI decon: gastric lavage, activated charcoal within 1-2h

Question 70

Mx of hyperthermia (cooling method)

Answer 70

1. Remove clothing 2. Water mist spray and fanning 3. Ice packs at neck, axillae, groin 4. Bladder irrigation with ice water 5. Peritoneal lavage with cold dialysate aim: reduce core temp to <40 in 30 mins

Question 71

Serotonin syndrome 3 As

Answer 71

Antidepressants (SSRI) Analgesics (Tramadol, Pethidine, Fentanyl) Abusive drugs (cocaine, MDMA (ecstasy), Methamphetamine (ice))

Question 72

Features of Serotonin syndrome

Answer 72

usually clonus over LL

Question 73

Antidote of Serotonin syndrome

Answer 73

Cyproheptadine (antihistamine + antiserotonergic) 8-12mg PO x1 2mg Q2H till symptom resolve Up to 32mg / day

Question 74

Cocaine intoxication drug CI

Answer 74

Beta blockers - unoppposed alpha effect -> paradoxical HT

Question 75

Tx of HT in cocaine intoxication

Answer 75

1. Benzodiazepine 2. Phentolamine 3. Nitroglycerin, Nitroprusside 4. CCB 5. Labetalol (controversial)

Question 76

Phlegmasia cerulea dolens

Answer 76

uncommon DVT congestion and cyanosis of a limb due to massive venous thrombosis

Question 77

Massive blood transfusion definition

Answer 77

10 units packed red cells within 24h or more than 1 blood volume within 24h Pedi: 40ml/kg blood products (4 units) in 4h

Question 78

Beck's triad

Answer 78

of Cardiac tamponade 1. Hypotension, narrow pulse pressure 2. Distended neck veins (jugular veins) 3. Muffled heart sounds

Question 79

Colistin

Answer 79

Polymyxin E Last resort for Gram neg infections SE: Nephotoxicity, neurotoxicity

Question 80

HBOT indications currently

Answer 80

Life-threatening 1. Severe decompression sickness 2. Cerebral arterial gas embolism Emergency 3. CO poisoning 4. Necrotizing soft tissue infection 5. CRAO

Question 81

Absolute CI for HBOT

Answer 81

1. Unresolved PTX 2. Pneumocephalus 3. Hollow orbital prosthesis 4. Currently on Bleomycin / Adriamycin (Doxorubicin)

Question 82

AACG Glaucoma Mx STAMP ATM PBL

Answer 82

Supine Timolol eye drops (Topical BB - decrease production aqueous humor) Acetazolamide IV (Systemic carbonic anhydrase inhibitor - decrease production aqueous humor) - caution in renal failure Mannitol IV (Systemic osmotic diuretic - decrease volume of vitreous humor) Pilocarpine eye drops (Topical muscarinic agonist - constrict pupil, facilitate drainage from ant chamber) Latanoprost (Topical prostaglandin - increase outflow of aq humor) Brimonidine (Alpha 2 agonist - decrease production aqueous humor)

Question 83

Osborn wave

Answer 83

Positive deflection seen at the J point in precordial and true limb leads. Most commonly associated with hypothermia Reciprocal, negative deflection in aVR and V1

Question 84

Causes of Osborn wave

Answer 84

Hypothermia HyperCa AMI Takotsubo cardiomyopathy LVH due to HT Normal variant and early repolarization Neurological insults such as intracranial hypertension, severe head injury and SAH Severe myocarditis Brugada syndrome Le syndrome d’Haïssaguerre (idiopathic VF)

Question 85

Brudzinski's sign

Answer 85

Passive neck flexion -> Flexion of hips and knees specific but not sensitive

Question 86

Kernig's sign

Answer 86

Supine, hip and knee flex to 90 deg Resistant / Pain during passive extension of leg specific but not sensitive

Question 87

Echo Parasternal short axis view

Answer 87

look for RWMA

Question 88

PE classification

Answer 88

1. Massive (hemo unstable) 2. Submassive (RV strain) 3. Non-massive (no RV strain)

Question 89

ECG low voltage

Answer 89

QRS all limb leads <5mm or all precordial leads <10mm

Question 90

Posterior MI ECG changes

Answer 90

Look at V1-3 Horizontal STD, tall & broad R waves, upright T wave, dominant R wave in V2 (R/S >1) -> do V7-9 (posterior leads)

Question 91

Posterior MI litfl

Answer 91

- usu w/ inferior or lateral STEMI - implies a much larger area of myocardial damage, with an increased risk of LV dysfunction and death Isolated posterior MI is less common (3-11% of infarcts) -> needs urgent PCI

Question 92

RV infarction

Answer 92

usu with inferior STEMI (in 40% of inferior MI) -> preload sensitive, nitrates contraindicated STE in V1 STE in V1 + STD in V2 Isoelectric V1 + marked STD in V2 STE Lead 3 > 2

Question 93

Right side ECG

Answer 93

V1-2 same position V3-6 to V3R - V6R Most useful = V4R (R 5th ICS, MCL)

Question 94

De Winter T waves STEMI equivalent

Answer 94

Tall, prominent, symmetrical T waves in precordial leads Upsloping STD > 1mm at the J point in precordial leads Absence of STE in precordial leads Reciprocal STE (0.5mm – 1mm) in aVR Signifies LAD occlusion

Question 95

STE in aVR, diffuse STD in other leads

Answer 95

LMCA occlusion or pLAD stenosis, severe TVD... cause by diffuse subendocardial ischemia / infarction of basal septum

Question 96

5 types of MI (EM book)

Answer 96

Type 1: related to atherosclerotic plaque rupture with thrombosis 2: related to ischemia due to imbalance btn oxygen demand and supply 3: cardiac death with S/S of coronary ischemia but death before blood samples taken 4a: related to PCI 4b: related to stent thrombosis 5: related to CABG

Question 97

ECG mimics of STEMI

Answer 97

1. Acute pericarditis 2. LV aneurysm 3. Benign early repolarization (BER) 4. Prinzmetal's angina (coronary vasospasm) 5. Brugada syndrome 6. LVH 7. HOCM 8. SAH (raised ICP) 9. HyperK 10. LBBB

Question 98

BER (Benign early repolarization) vs Pericarditis ECG

Answer 98

ST segment / T wave ratio in V6 >0.25 = Pericarditis <0.25 = BER

Question 99

Acute epiglottitis most common microbe

Answer 99

Haemophilus influenzae type B (historically) Now: Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus

Question 100

Chest pain life threatening causes (x6) EM book

Answer 100

1. Acute coronary syndrome 2. Acute aortic syndrome 3. PE 4. Tension PTX 5. Cardiac tamponade 6. Eso rupture (Boerhaave's syndrome)

Question 101

Hamman's sign

Answer 101

For pneumo-mediastinum a crunching, rasping sound, synchronous with the heartbeat, heard over the precordium in spontaneous mediastinal emphysema result from heart beating against air-filled tissues

Question 102

Westermark sign

Answer 102

PE sign seen on CXR - focal peripheral hyperlucency secondary to oligemia resulting in a collapsed appearance of vessels distal to the occlusion - central pulmonary vessels may also be dilated

Question 103

Echo findings of cardiac tamponade

Answer 103

1. Pericardial effusion 2. Diastolic RV collapse (highly specific) 3. Systolic RA collapse (earliest sign) 4. Dilated IVC w/o insp collapse (highly sensitive)

Question 104

SVT vs VT features EM book

Answer 104

1. QRS >0.14s in RBBB / >0.16s in LBBB 2. AV dissociation 3. Capture or fusion beats 4. Precordial QRS complex concordance 5. Axis -90 to +180 6. QRS configuration...

Question 105

Causes of VT

Answer 105

1. Coronary artery disease 2. Hypertrophic cardiomyopathy 3. MV prolapse 4. Drug toxicity 5. Electrolyte disturbance

Question 106

Torsades de pointes Tx

Answer 106

MgSO4 1-2g over 60-90 seconds Isoproterenol 1-8 mcg/min

Question 107

Score for unsalvageable limb MESS

Answer 107

Mangled Extremity Severity Score - Skeletal and soft tissue injury (injury mechanism) (1-4) - Limb ischemia (1-3) - Shock (0-2) - Age (0-2) >= 7 amputation!

Question 108

CXR PE findings

Answer 108

1. Westermark sign (focal oligemia) 2. Hampton's hump (peripheral wedge shaped opacity) 3. Palla's sign (enlarged right dsc pul a)

Question 109

Echo findings acute PE

Answer 109

1. RV dilatation 2. RV hypokinesis (w/ sparing of apex) "McConnell's sign" 3. D shaped LV 4. TR 5. IV septal flattening

Question 110

TCA poisoning clinical features PIC

Answer 110

Toxicity within 6h; 1-2h if sig poisoning (>10-20mg/kg adult / >5mg/kg pedi) Cardiac toxicity (hypotension, tachyarrhythmia) CNS toxicity (lethargy, confusion, coma, seizure) Anticholinergic toxidrome

Question 111

Radio-opaque meds COINS / CHIPS

Answer 111

Chloral hydrate / Cocaine packets Opiate packets Iron and heavy metal Neuroleptic agents (e.g. TCA) Sustained release medications C Chlorinated hydrocarbons (eg, chloral hydrate, carbon tetrachloride) Calcium salts (eg, calcium carbonate) Crack vials H Heavy metals (eg, iron, arsenic, mercury, thallium, lead) I Iodinated compounds (eg, thyroxine) P Psychotropics (eg, phenothiazines, lithium, cyclic antidepressants) Packets of drugs (eg, cocaine and heroin "body packers") Play-Doh Potassium salts E Enteric-coated tablets (eg, aspirin) S Salicylates Sodium salts Sustained-release preparations

Question 112

Blast injury 1/2/3/4

Answer 112

Primary - caused by the blast wave moving through the body Secondary - caused by debris that is displaced by the blast wind of the explosion Tertiary - caused when the person in displaced through the air and impacts on another object by the blast wind, or when a structure collapses and causes injury to the person Quaternary - comprised of all injuries that are not included in primary, secondary, or tertiary blast injury categories. - can be caused by exposure to resulting, fire, fumes, radiation, biological agents, smoke, dust, toxins, environmental exposure, and the psychological impact of the event

Question 113

Pedi BP

Answer 113

SBP: (Age x2) + 90 Hypotension SBP: (Age x2) + 70

Question 114

Pediatric Endotracheal Tube Size / Depth

Answer 114

Uncuffed = (age/4) + 4 Cuffed = (age/4) + 3 Depth = ETT size x3

Question 115

Tibial plateau # classification

Answer 115

Schatzker (type 1-6)

Question 116

Pedi maintenance IVF formula (4-2-1)

Answer 116

First 10kg = 4ml/kg/hr = 40ml/hr Next 10kg = 2ml/kg/hr = 20ml/hr Then 1ml/kg/hr Shock: 20ml/kg bolus

Question 117

Eclampsia Mx

Answer 117

Loading: MgSO4 4-6g IV over 15-20 mins Maintenance MgSO4 2g/hr (for 24h after last seizure)

Question 118

MgSO4 toxicity monitoring

Answer 118

- Loss of deep tendon reflex (patella reflex; 1st sign) - Resp depression (RR >12) - Foley to BSB for u/o monitoring (>100ml/4h) also: GCS, serum Mg level Reverse with Calcium gluconate 10% 10ml over 10 mins CI of MgSO4: Myasthenia gravis

Question 119

Delayed cord clamping pros and cons

Answer 119

Pros 1. Increase Hb at birth, improves iron store in first few months 2. Better for preterm - improved transitional circulation - better establishment of red blood cell volume - decreased need for blood transfusion - lower incidence of necrotizing enterocolitis and intraventricular hemorrhage Cons - Increase neonatal jaundice

Question 120

BRASH syndrome

Answer 120

Bradycardia Renal Failure AV blockade Shock HyperK

Question 121

SCORTEN score for TEN/SJS mortality

Answer 121

1. Age (>40) 2. Associated malignancy 3. HR (>120) 4. Detached or compromised body surface (>10%) 5. Serum urea (>10) 6. Serum HCO3 (<20) 7. Serum glucose (>14)

Question 122

Etiology of SJS/TEN

Answer 122

1. Drugs (allopurinol, AED carbamazepine, lamotrigine, NSAIDs) 2. Infection (Mycoplasma pneumoniae)

Question 123

WPW ECG features

Answer 123

1. Short PR interval < 120ms 2. Delta wave: slurring slow rise of initial portion of the QRS 3. Prolong QRS 110ms 4. Discordant ST/T changes 5. Pseudo-infarction pattern in up to 70% of patients — due to negatively deflected delta waves in inferior/anterior leads (“pseudo-Q waves”), or prominent R waves in V1-3 (mimicking posterior infarction)

Question 124

Drug Tx for thyroid storm

Answer 124

1. BB (control increased adrenergic tone) - Propranolol PO 60-80mg Q4H - Esmolol (short acting) IV 250-500mcg/kg stat, then 50-100mcg/kg/min infusion 2. Thiondamides (Antithyroid drug; inhibit TH synthesis and T4 to T3 conversion): - Propylthiouracil (also blocks peripheral conversion to T4 to T3) 500mg stat then 250mg Q4H PO - Methimazole / Carbimazole 3. Iodide (inhibit release of TH) - Lugol's solution (Potassium iodide, SSKI *saturated solution of potassium iodide) 5 drops Q6H - Give 1h after PTU as iodine maybe used for new hormone synthesis 4. Steroid (reduce T4 to T3 conversion) - Hydrocortisone 200mg stat, then 100mg Q8H

Question 125

Risk factor of testicular torsion

Answer 125

1. Bell-clapper deformity 2. Cryptorchidism 3. Testicular tumor

Question 126

NMS Tx

Answer 126

1. Dantrolene (also use in malig hyperthermia) 2. Bromocriptine (dopamine agonist) 3. Amantadine 4. Benzo: Lorazepam, Diazepam

Question 127

Panadol overdose values

Answer 127

Toxic: >7.5g or >150mg/kg Massive: 0.5-1g/kg

Question 128

Panadol overdose types

Answer 128

1. Acute single overdose (single ingestion) 2. Staggered overdose (multiple ingestions in 1-24 hrs; <4h interval treat as acute) NAC indicated if >150mg/kg 3. Chronic supratherapeutic overdose (multiple ingestions in >2 days with dose >4g/day adult or 90mg/kg/day pedi) NAC indicated if S/S of hepatitis, dLFT, Panadol level suggesting delayed clearance 4. Massive overdose (acute ingestion >1g/kg) early onset coma, met (lactic) acidosis, early coagulopathy acute tubular necrosis, ARDS, myocardial injury, thrombocytopenia, high amylase, pyroglutamic acidosis

Question 129

GI decontamination for panadol overdose

Answer 129

Activated charcoal 1g/kg within 1-2h of ingestion if significant co-ingestion / massive overdose >1g/kg, consider gastric lavage

Question 130

Panadol nomogram name

Answer 130

Rumack-Matthew nomogram

Question 131

Poor prognostic marker for liver/death from panadol overdose

Answer 131

1. pH < 7.30 after fluid and hemodynamic resuscitation. 2. Coexistence of PT>100s, Cr >300 and grade III/IV hepatic encephalopathy 3. Serum lactate >3.0 to 3.5 4. Serum phosphate > 1.2 at 40-92 hr 5. Serum AFP > 3.9 on day+1 after peak ALT identifies patients with favourable outcome 6. Coagulation factor VIII/V ratio > 30; factor VIII is produced by endothelial cells while Factor V is made by hepatocytes

Question 132

Burn care classification 3 levels

Answer 132

Level 1. Gen sur / Ortho Level 2. Burn facility (KWH/QEH/TMH) - 5-20% TBSA - Cosmetic - Full thickness burn - Electrical / Chemical burn - Circumferential burn Level 3. Burn unit (QMH/PWH) - 20% TBSA for adults / 10% for children <= 12

Question 133

Methods of GI decontamination Book

Answer 133

1. Single dose Activated Charcoal (AC) 2. Gastric lavage (GL) 3. Multiple dose Activated Charcoal (MDAC) 4. Whole bowel irrigation (WBI) 5. Surgical intervention

Question 134

AC dose Book

Answer 134

adult 50-100g children 1g/kg

Question 135

Indication of AC Book

Answer 135

A potential toxic ingestion within 1-2h up to few hours

Question 136

CI of AC Book

Answer 136

1. Corrosive 2. Rapidly absorbed e.g. ethanol 3. Small molecular size e.g. lithium 4. Unprotected airway 5. GIT injury (e.g. corrosive injury) 6. Non-functioning GIT (e.g. absent gut motility) 7. GI endoscopic visualization considered essential

Question 137

MDAC dose Book

Answer 137

Initial single dose AC then 0.5g/kg Q2-4h x4

Question 138

Cx of MDAC Book

Answer 138

1. Fatal aspiration 2. Pneumonitis 3. SB obstruction 4. Appendicitis

Question 139

Indication of GL Book

Answer 139

- A life threatening posion ingestion where poison likely still in stomach - Preferred within 1h

Question 140

CI of GL Book

Answer 140

1. Caustic ingestion 2. Large FB or sharp objects 3. Inability to protect airway

Question 141

Cx of GL Book

Answer 141

1. Aspiration pneumonia 2. Eso / Gastric perforation 3. Tension PTX and empyema 4. Decreased oxygentation during procedure

Question 142

Indication of WBI Book

Answer 142

1. Potentially toxic ingestions of sustained release / enteric coated drugs, particially >2h 2. Toxic ingestion of iron, lithium, potassium 3. Removal of ingested packets of illicit drugs in body packers

Question 143

CI of WBI Book

Answer 143

1. Absent bowel sound 2. Bowel obstruction / perforation

Question 144

Hydroxocobalamin indication

Answer 144

Cyanide poisoning

Question 145

Hydroxocobalamin SE

Answer 145

1. Reversible pink discoloration of skin, mucous membrane, urine 2. Muscle spasm and twitching 3. Hypertension

Question 146

Sodium nitrite indication

Answer 146

Cyanide poisoning (prefer to use hydroxocobalamin) Hydrogen sulphide poisoning

Question 147

Sodium nitrite SE

Answer 147

1. Hypotension 2. Methemoglobinemia

Question 148

ABCD2 score for TIA

Answer 148

A: Age >60 B: BP >= 140/90 C: Clinical features of TIA Unilateral weakness +2 Speech disturbance +1 Others 0 D (1). Duration of symptoms <10mins 0 10 mins-1h +1 >=1h +2 D (2). DM

Question 149

High AG acidosis (HAGMA) CAT MUD PILES KULT

Answer 149

Cyanide, CO, colchicine Alcoholic ketoacidosis, acetaminophen (in large doses) Toluene Methanol, metformin Uremia DKA Paraldehyde Isoniazid, iron Lactic acidosis Ethylene glycol Salicylates KULT - Ketones (DM/Alcohol/Starvation) - Uremia - Lactate (Metformin, Poisons causing convulsion or shock) - Toxin (methanol, ethylene glycol, salicylate)

Question 150

Substances not binding to AC PHAILS

Answer 150

Pesticides Heavy metals Acid / Alkali / Alcohol Iron Lithium Solvents

Question 151

Maisonneuve fracture

Answer 151

spiral # of the proximal third of fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane

Question 152

Sign of basal skull #

Answer 152

1. Battle's sign (bruising of mastoid process of temporal bone) 2. Raccoon eyes (periorbital ecchymosis) 3. CSF rhinorrhea 4. Hemotympanum

Question 153

Croup score

Answer 153

Westley Croup Severity Score Level of consciousness Cyanosis Stridor Air entry Retractions

Question 154

Dog / Cat bite micro-organisms

Answer 154

Pasteurella (G-ve coccobacilli) - canis, multocida, septica Capnocytophaga canimorsus

Question 155

Rolando #

Answer 155

comminuted intra-articular # base of 1st MC

Question 156

Bennett #

Answer 156

intra-articular, simple, oblique fracture at base of 1st MC (2 parts) mechanism: axial force to partially flexed thumb (fist fight, fall onto thumb) unstable # require CR/ORIF ; pulled by APL, EPL, adductor pollicis reverse Bennett # - fracture-dislocation of base of 5th MC

Question 157

Digoxin toxicity when to expect

Answer 157

1. Unexplained bradycardia 2. Non-specific GI/ Neuro complaints 3. ECG changes 4. Unexplained hyperK 5. RF for chronic digoxin toxicity - increase sensitivity: hypoK/ hyperCa / hypoMg, hypoxia, underlying cardiomyopathy, ischemia, conduction problems - increase serum digoxin levels: CKD, CCB use, recent macrolide, dehydration

Question 158

Digoxin toxicity ECG changes

Answer 158

Scooped ST segments (reverse tick appearance) Prolong PR ventricular arrhythmias sinus bradycardia, impaired AVN conduction

Question 159

Digoxin toxicity specific treatment

Answer 159

Digoxin-specific antibody fragments (Fab) K>5.0 = indication for acute single overdose other 1. GI decontam - AC / MDAC / GL 2. Atropine / pacing for bradyarrhythmias 3. Replace K / Mg, amiodarone, lignocaine when tachyarrhythmias

Question 160

4 types of shock COHD

Answer 160

1. Cardiogenic (AMI, CHF) 2. Obstructive (3Ps - Tension PTX, cardiac tamponade, PE) 3. Hypovolemic 4. Distributive (septic, anaphylactic, neurogenic)

Question 161

Anion gap calculation (3 components)

Answer 161

Na - (Cl + HCO3) >10 = high anion gap adjust for albumin (every 1g/L dec in albumin = dec 0.25 mmol in AG): + 0.25 x (40-alb)

Question 162

Osmolar gap calculation (3 components)

Answer 162

Calculated: Na x2 + Glucose + Urea Measured - Calculated Normal <10

Question 163

Score for NF

Answer 163

LRINEC Score Laboratory Risk Indicator for Necrotizing Fasciitis score

Question 164

Hypertropic cardiomyopathy (HCM) ECG features

Answer 164

LVH with increased precordial voltages and non-specific ST/T abnormalities Deep, narrow (“dagger-like”) Q waves in lateral (I, aVL, V5-6) +/- inferior (II, III, aVF) leads

Question 165

Classification of mid face fracture

Answer 165

Le Fort

Question 166

Lemierre's syndrome

Answer 166

infectious thrombophlebitis of IJV

Question 167

C1/2 subluxation classification (atlantoaxial rotatory subluxation)

Answer 167

Fielding and Hawkins classification

Question 168

CRITOE (1-11y)

Answer 168

Appearance of ossification centers Capitellum 1y Radial head 3y Internal epicondyle 5y Trochlea 7y Olecranon 9y External epicondyle 11y

Question 169

3 common elbow injuries in children

Answer 169

1. Supracondylar fracture 2. Radial head subluxation 3. Lateral condyle fracture

Question 170

Human bite micro-organism

Answer 170

Eikenella corrodens

Question 171

CRAO management

Answer 171

1. Ocular massage 2. Breathe into a paper bag 3. IV Acetazolamide, Timolol eye drops 4. HBOT

Question 172

ACLS modifications for pregnant women

Answer 172

1. Manual displacement of uterus to left 2. IV set above diaphragm 3. Airway / ventilation priority (expect laryngeal edema)

Question 173

6P for Compartment syndrome

Answer 173

1. Pain 2. Poikilothermia (Perishing cold) 3. Paresthesia 4. Paralysis 5. Pulselessness 6. Pallor

Question 174

MR SOPA for NRP

Answer 174

Mask adjustment Reposition airway Suction mouth and nose Open mouth Pressure increase (up to 40) Alternate airway

Question 175

Neck zones 1-3

Answer 175

Zone 1: Clavicle / sternal notch to Cricoid cartilage Zone 2: Cricoid cartilage to angle of mandible Zone 3: Angle of mandible to base of skull 2 most common, easier exploration 1 most dangerous

Question 176

Difficult laryngoscopy LEMON rule

Answer 176

Look externally - Facial trauma - Large incisors - Beard / moustache - Large tongue Evaluate 3-3-2 rule - Inter-incisor distance 3 finger breadths - Hyoid-mental distance 3 finger breadths (chin to neck) - Hyoid-thyroid distance 2 finger breadths (chin/neck junction to thyroid) Mallampati (>=3 is difficult) Obstruction (epiglottitis, quinsy, trauma) / Obesity Neck mobility

Question 177

Ramp position for obesity intubation

Answer 177

head and torso are elevated such that the external auditory meatus and the sternal notch are horizontally aligned CI if neck injury

Question 178

Lethal triad of trauma (HCA)

Answer 178

Hypothermia Acidosis Coagulopathy Lethal diamond: hypoCa

Question 179

Cushing triad for raised ICP

Answer 179

1. Widened pulse pressure 2. Bradycardia 3. Irregular respiration (Cheyne–Stokes respirations)

Question 180

Quetiapine overdose effects

Answer 180

Dose-dependent CNS depression Peripheral alpha blockade -> parodixcal hypotension if given adrenaline (beta 2 mediated vasodilatation) Clinical features -Sedation -Tachycardia, common to be 120 bpm -Hypotension -Mild to moderate anticholinergic syndrome

Question 181

Magnesium sulphate for Asthma dose

Answer 181

MgSO4 2g over 20 mins IV CI: MG, heart block, severe renal impairment, hypoCa, hyperMg

Question 182

Chance fracture

Answer 182

Unstable Flexion-distraction injury Seatbelt sign (typical no shoulder straps) typical in TL junction asso w/ intra-abd injury e.g. duodenum, pancreas

Question 183

Massive zopiclone overdose

Answer 183

Methemoglobinemia (within 24h) Hemolytic anemia (within 1-3d) Renal impairment (within 1-3d)

Question 184

Tuna Fish for LBP red flags

Answer 184

Trauma Unexplained weight loss Neurological symptoms / signs Age > 50 Fever Intravenous drug use Steroid use History of cancer

Question 185

CXR signs for aortic dissection x7 EM handbook

Answer 185

1. Widened mediastinum 2. Left pleural effusion 3. R sided tracheal deviation 4. Calcium sign (separation of calcification at aortic arch) 5. Double aortic knob sign 6. Pericardial effusion 7. Displacement of NG tube to right

Question 186

Echo signs for aortic dissection EM handbook

Answer 186

1. Aortic root dilatation 2. Aortic regurgitation (AR) 3. Pericardial effusion 4. Ventricular wall regional wall abnormalities implying coronary ostial occlusion

Question 187

Echo probe manipulation POCUS

Answer 187

1. Sliding 2. Rocking (towards and away indicator) 3. Tiliting (Fanning) 4. Rotation

Question 188

McConnell's sign for PE

Answer 188

RV free wall akinesis with sparing of the apex

Question 189

Echo findings of PE

Answer 189

RV dilatation RV free wall hypokinesis McConnell’s sign IV septum flattening -> D shaped LV Tricuspid regurgitation 60/60 sign

Question 190

Drug cause of prolonged QTc 5A + CLAM Toxi book

Answer 190

5A + CLAM 1. Anti-arrhythmic 2. Anti-depressants 3. Anti-psychotic 4. Anti-histamine 5. Anti-microbial (Macrolide, FQ, Amantadine, Antifungal) 6. CLAM (Cisapride, Cesium, Lithium, Arsenic, Methadone) PMHAD

Question 191

HyperK ECG changes

Answer 191

1. Peaked T waves 2. P wave widening/flattening, PR prolongation 3. Bradyarrhythmias: sinus bradycardia, high-grade AV block with slow junctional and ventricular escape rhythms, slow AF 4. Conduction blocks (bundle branch block, fascicular blocks) 5. QRS widening with bizarre QRS morphology

Question 192

Triad of opioid toxidrome Tox book

Answer 192

CNS depression Resp depression Miosis

Question 193

Methadone Diploma

Answer 193

Long acting synthetic opioid Prolong QTc

Question 194

Na channel blockade toxidrome SALT Diploma

Answer 194

Shock Altered mental status Long QRS Terminal right axis deviation

Question 195

One tab kill (10kg infant) NOCT 1234 Diploma FL

Answer 195

Narcotic Oral hypoglycemic, Oil (Methylsalicylate) CCB, Camphor, Chloroquine/Quinine TCA, Theophylline, Thioridazine/Chlorpromazine, Toxic alcohol

Question 196

Toxic alcohol x3 Toxi book

Answer 196

Methanol Ethylene glycol (EG) Diethylene glycol (DEG)

Question 197

CNS stimulants example x3 Toxi book

Answer 197

1. Methamphetamine 2. MDMA (3,4-Methyl​enedioxy​methamphetamine), aka Ecstasy (tablet), Molly (crystal) 3. Cocaine

Question 198

CNS depressants example x6 Toxi book

Answer 198

1. Opioids 2. Benzodiazepines 3. GHB (gamma-hydroxybutyrate) 4. Organic solvent 5. Barbiturates 6. Ethanol

Question 199

Dissociatives example x3 Toxi book

Answer 199

1. Ketamine 2. Dextromethorphan (DXM) 3. Phencyclidine Blocks NMDA receptor

Question 200

Hallucinogens example x2 Toxi book

Answer 200

1. Cannabis 2. LSD (lysergic acid diethylamide)

Question 201

Urine ABON for cocaine Toxi book

Answer 201

Unlikely false positive Detects Benzoylecgonine

Question 202

Toxicity of Cocaine Toxi book

Answer 202

1. Sympathomimetic toxidrome 2. CNS (psychomotor agitiation, seizure, ICH, TIA, infarct) 3. CVS (ACS, HT emergency, AAS, arrhythmia, vasospasm) Cocaine ACS: enhanced platelet aggregation and reduces endogenous thrombolysis 4. Pulmonary (Pneumothorax, Pneumomediastinum, Pneumopericardium; non-cardiogenic pul edema, asthma exacerbation) "Crack lung": diffuse alveolar damage and hemorrhagic alveolitis occuring within 48h of smoking crack. Present w/ fever, dyspnea, hemoptysis, hypoxia, ARDS

Question 203

Cocaine common killer x3 Toxi book

Answer 203

1. Hyperthermia 2. Arrhythmia 3. ICH

Question 204

Tx for cocaine Toxi book

Answer 204

Rapid cooling, use of BZD and supportive measures Avoid BB in early phase due to unopposed alpha-adrenergic effect (use Phentolamine) Treat ACS Treat HT emergency / seizure Treat widening QRS and ventricular arrhythmia (NaHCO3) Treat limb and bowel ischemia

Question 205

Cannabis - major active ingredient Toxi book

Answer 205

THC (Delta-9-tetrahydrocannabinol) **CBD (Cannabidiol) does not interact with cannabinoid receptors and does not have same psychoactivity as THC

Question 206

Complications of Cannabis use Toxi book

Answer 206

1. Pneumothorax 2. Pneumomediastinum 3. Paroxysmal AF

Question 207

Urine ABON for Cannabis Toxi book

Answer 207

False positive: Naproxen, Ibuprofen, Efavirenz Look for THC and its metabolites

Question 208

GHB and GBL Toxi book

Answer 208

Gamma-hydroxybutyrate (GHB) - odorless Gamma-butyrolactone (GBL) is prodrug of GHB - melon aroma Urine ABON cannot detect Send blood/urine sample to TRL in 6 hours

Question 209

Organic solvents / Volatile hydrocarbon 3 types Toxi book

Answer 209

1. Aliphatic HC - Butane (Lighter fuel) 2. Halogenated HC - Trichloroethylene (Correction fluid) - Trichloroethane 3. Aromatic HC - Toluene (Thinner) - Xylene (Glue)

Question 210

Toxicity of volatile hydrocarbon Toxi book

Answer 210

Aliphatic: CNS, chemical pneumonitis from aspiration Halogenated: also cardiac (sudden sniffing death -sudden surge of endogenous catecholamines + sensitize myocardium causing ventricular arrhythmia) and liver toxicities Aromatic: Toluene - renal tubular acidosis + profound hypoK Benzene - hematotoxicity (hemolysis, aplastic anemia), carcinogenicity

Question 211

Treatment of volatile HC Toxi book

Answer 211

1. Supportive care, avoid catecholamine surge 2. BZD to control agitation 3. Early use of BB (e.g. esmolol) as anti-arrhythmic in resuscitation of sudden sniffing ventricular tachyarrhythmia

Question 212

Ketamine Toxi book

Answer 212

Dissociative anesthetic agent Mainly act on CNS + CVS Snorted in white powder Binds to NMDA receptors, biogenic amine uptake complex, sigma receptor, ACh receptor

Question 213

Ketamine - clinical presentation Toxi book

Answer 213

Altered mental status (most common), with mild sympathomimetic Chronic: ketamine associated urinary tract dysfunction, ketamine associated abdominal pain reversible dilated CBD

Question 214

Urine ABON for ketamine Toxi book

Answer 214

False positive common

Question 215

Tx for Ketamine Toxi book

Answer 215

1. Supportive care, prevent secondary injury 2. BZD to control agitation 3. Observe 4-6 hours for effect to wean off

Question 216

Poppers Toxi book

Answer 216

Various volatile alkyl nitrites used in chemsex relaxes anal sphincter for MSM May cause MetHb

Question 217

Drugs used in Chemsex Toxi book

Answer 217

Metamphetamine Mephedrone GHB, GBL Alkyl nitrites, ecstasy (MDMA), foxy, ketamine, cocaine, cannabis, sildenafil

Question 218

Body packer Toxi book

Answer 218

Individuals who attempt to smuggle drugs inside their bodies Drugs well packed and concealed by ingestion or insertion into body orifices (rectum, vagina) Cocaine is most common in HK

Question 219

Body stuffer Toxi book

Answer 219

Individuals who ingest or insert illegal drugs hastily to evade law enforcement officials Drugs poorly wrapped, more than one class of drugs can be ingested Variable patterns of poisoning Most are asymptomatic / mildly toxic

Question 220

Cardioactive steroids Toxi book

Answer 220

- A class of naturally occuring compounds, contains a steroid nucleus - Causes positive inotropic effect and decrease HR at therapeutic dose 2 major actions 1. Inhibit myocardial cells Na-K ATPase pump Toxic dose: excessive increase intracellular Ca -> tachydysrhythmia 2. Increase vagal tone Sinus bradycardia, AV block, bradydysrhythmia Toxic effects enchaned by hypoK and hypoMg

Question 221

Causes of acute Digoxin / Cardioactive steroids poisoning Toxi book

Answer 221

1. Intentional overdose 2. Cardioactive steroids exposure (accidental Chan Su overdose)

Question 222

Causes of chronic Digoxin / Cardioactive steroids poisoning Toxi book

Answer 222

1. Dosing error 2. Decreased renal digoxin elimination (dehydration, impaired renal fx, nephrotoxic drug use) 3. Increased sensitivity to digoxin (decompensated cardiac conditions, concomitant use of negative inotropic or chronotropic agents, hypoK)

Question 223

Presentation of Digoxin / Cardioactive steroids poisoning Toxi book

Answer 223

GI: Nausea, vomiting, anorexia CNS: headache, confusion, visual disturbance (alteration in color perception: xanthopsia) Metabolic: HyperK

Question 224

Risk stratification for Digoxin / Cardioactive steroids poisoning Toxi book

Answer 224

HyperK (>5.5 all dead)

Question 225

ECG change of Digoxin / Cardioactive steroids poisoning Toxi book

Answer 225

Scooped ST segments (reverse tick appearance) Prolong PR *Increase automaticity with high degree AV block Fast AF not compatible, otherwise all arrhythmia can happen

Question 226

Ix for Digoxin / Cardioactive steroids poisoning Toxi book

Answer 226

Urgent serum digoxin level (normal 1.1-2.6nmol/L) ng/ml x 1.3 = nmol/L undectable digoxin level cannot exclude cardioactive steroid poisoning may be detectable due to cross-reactivitiy

Question 227

Mx for Digoxin / Cardioactive steroids poisoning Toxi book

Answer 227

1. ABC 2. GI decon: GL + AC within 1-2h; consider MDAC in severe cases 3. Digoxin specific Ab fragments (Digoxin-specific Fab) - binds and eliminates intravascular free digoxin - thus facilitates dissociation of digoxin from its intracellular binding sites (Na-K ATPase) 4. HyperK to be treated by DigiFab, no DI drip unless marked hyperK 5. Avoid Calcium - may arrest, give Digifab before IV calciuim if really indicated, e.g. concomittant CCB poisoning 6. Cardioversion - start with low energy e.g. 10-25J 7. Hemoperfusion / HD not useful

Question 228

Indications of Digoxin specific Ab fragments Toxi book

Answer 228

Any of 1. Life threatening clinical presentation (ventricular dysrhythmia, bradydysrhythmia not responsive to atropine) 2. Serum K >5 (attributable to digoxin / cardioactive steroid) 3. Serum digoxin level >10ng/ml (13nmol/L) at 6h post ingestion or >15 ng/ml (19.5nmol/L) at any time for acute ingestion 4. Digoxin ingestion of >10mg in adult or >4mg in child

Question 229

How to give Digoxin specific Ab fragments (DigiFab) Toxi book

Answer 229

Empirical : Acute - 10 vials (same for adult/child) Chronic - Start with 1-2 vials, titrate with clinical effect Ingestion amount in mg x 1.6 = x vials Serum digoxin (nmol/L) x body weight (kg) / 130 = x vials

Question 230

SE of Digoxin specific Ab fragments (DigiFab) Toxi book

Answer 230

1. HypoK 2. Exacerbate CHF 3. Increase ventricular response in AF patients Renal failure patients may have digoxin re-intoxication Falsely elevated serum digoxin level after treatment (measures both free and Fab-bound digoxin in serum)

Question 231

Which vitamin acute overdose has toxicity x3 Toxi book

Answer 231

A (>300kIU or >25kIU/kg in children) B3, i.e. Niacin Iron

Question 232

Which vitamin chronic overdose has toxicity x4 Toxi book

Answer 232

A B6, i.e. Pyridoxine C D

Question 233

Vit A overdose Toxi book

Answer 233

Acute + Chronic possible Present with nausea, vomiting, diarrhea, abd pain severe cases: CNS - headache, visual disturbance, increased ICP Pruritus, skin peeling Supportive Mx Blood vit A level available in TRL

Question 234

Vit B3 (Niacin) overdose Toxi book

Answer 234

Only acute Present with GI disturbance, DKA like syndrome Supportive Mx

Question 235

Vit B6 (Pyridoxine) overdose Toxi book

Answer 235

Only chronic acute non-toxic Present with sensory peripheral neuropathy

Question 236

Vit C overdose Toxi book

Answer 236

Only chronic acute non-toxic Renal failure patients -> graft failure high dose parenteral -> oxidative hemolysis, MetHb, AKI in G6PD def

Question 237

Vit D Toxi book

Answer 237

Only chronic acute non-toxic Present with hyperCa, GI disturbance, dehydration Supportive Mx, correct hyperCa/rehydration

Question 238

Indications of IV lipid emulsion (ILE) Toxi book

Answer 238

1. Severe LA poisoning 2. Life threatening lipophilic drug poisoning, esp TCA, CCB Dose: Intralipid 20% 1.5ml/kg IV bolus over 1 min, then infusion 0.25ml/kg/min (15ml/kg/h) end point = cumulative 10ml/kg

Question 239

SE of IV lipid emulsion (ILE) Toxi book

Answer 239

1. lipemic serum, affecting lab tests 2. elevated amylase 3. fever 4. transient dLFT 5. resp distress 6. coagulopathy 7. circuit obstruction of extracorporeal devices, e.g. ECMO, hemofiltration, plasmapheresis

Question 240

When to consider Enchanced elimination Toxi book

Answer 240

Life threatening clinical toxicity Dose exposed / blood level indicate severe morbidity / likely mortality Impaired normal route of elimination Fail to respond to maximal supportive measures

Question 241

Common routes of EE Toxi book

Answer 241

1. GIT: MDAC 2. Urine: Urine alkalinization 3. Blood: ECTR (Extrocorporeal tx): HD, HP, HF Forced diuresis, urine acidification, PD no longer considered

Question 242

Urine alkalinization indication (which drugs) x6 Toxi book

Answer 242

1. Aspirin 2. Phenobarbital 3. Chlorpropamide 4. Formate 5. MTX 6. 2-4 D (2,4-dichlorophenoxyacetic acid)

Question 243

Mechanism of urine alkalinization Toxi book

Answer 243

Works by ion trapping Urine pH >7-8 to be effective Avoid hypoK - will dump H to reabsorb K - less effective

Question 244

How to do urine alkalinization Toxi book

Answer 244

1-2ml/kg 8.4% NaHCO3 bolus Continuous infusion of 50ml 8.4% NaHCO3 in 500ml D5 and titrate Avoid serum pH >7.55 (serial monitor) Avoid hypoK

Question 245

Choice of ECTR (Extracorporeal tx) Toxi book

Answer 245

Poison factor - HD preferred if not absorbed by charcoal - HP preferred if high protein binding Patient factor - HF more hemodynamically tolerable Other factors - facilities, equipment, expertise

Question 246

Antidotes Lvl 1 NAC, Atropine, Bromocriptine, Calcium Toxi book

Answer 246

NAC (N-Acetylcysteine) Paracetamol poisoning Also used in Amatoxin, Chloroform, Carbon tetrachloride, Acrylonitrile, Doxorubicin, Cyclophosphamide, Paraquat, Radiographic contrast nephropathy 3-bag regime - 150mg/kg in 200ml D5 over 1h (15min if no asthma and present >8h) - 50mg/kg in 500ml D5 over 4h - 100mg/kg in 1L D5 over 16h (double if massive overdose) 2-bag regime - 200mg/kg in 500ml D5 over 4h - 100mg/kg in 1L D5 over 16h (double if massive overdose) Atropine - in Cholinergic poisoning (OP, carbamate insecticide) 0.6-1.2mg IV Endpoint: Drying of secretions, clearing of bronchial/pul rales - in Poison induced bradycardia Endpoint: reverse life threatening bradycardia SE: anticholinergic effects Bromocriptine - Dopamine D2 agonist - used in NMS / L-dopa withdrawal Calcium - in CCB poisoning 1g CaCl2 or 3g Ca gluconate slow IV Up to 3g CaCl2 without serum Ca monitor Titrated Ca infusion Tolerable level at serum Ca <2x ULN or ionized Ca <2mmol/L -in Hydrofluoric acid poisoning Topical Ca gluconate gel / local infiltration / intra-arterial Ca gluconate for sig hand exoisures SE: Local irritation, hyperCa

Question 247

Antidotes Lvl 1 Cyproheptadine, Dantrolene, Desferrioxamine, Digoxin Fab Toxi book

Answer 247

Cyproheptadine used in Serotonin syndrome PO 8-12mg, then 2mg Q2H; Max 32mg in first 24h Dantrolene Postsynaptic muscle relaxant used in Malignant hyperthermia Desferrioxamine - Iron poisoning with systemic toxicity OR - Serum iron >500ug/dL (88.8umol/L) Start with 5mg/kg/h titrate up to 15mg/kg/h IV 6-8g over 24h for adults SE: rate related hypotension, flushing erythemia, urticaria, increased infection (Yersinia), acute lung injury, vin rose urine Digoxin Fab - Digoxin and cardioactive steroids poisoning 10 vials empirical

Question 248

Antidotes Lvl 1 Dimercaprol (BAL), DMPS (Injection), Ethanol, Flumazenil Toxi book

Answer 248

Dimercaprol (BAL i.e. British anti-lewisite) given IMI Chelation for lead encephalopathy, acute mercury and arsenic poisoning 75mg/m2 IMI Q4H for 3-5 days DMPS (Injection), aka Dimaval, [RS]- 2,3-Bis(sulfanyl) propane-1-sulfonic acid given Oral/IV Chelation in arsenic, lead, mercury poisoning Ethanol - used in Toxic alcohol poisoning Flumazenil - Competitive BZD receptor antagonist - used in CNS depression caused by BZD, zopiclone, zolpidem overdose Risk: precipitate seizure in epileptics, withdrawal seizures in BZD dependent patients, induce arrhythmia in cardiotoxic drugs co-ingestion CI: 1. Long term use of supratherapeutic dose of BZD, zopiclone or zolpidem 2. TCA poisoning 3. Co-ingestion of pro-seizure or pro-arrhythmic agents (e.g. abusive drugs, tramadol, bupropion) 4. Known epilepsy SE: seizure, arrhythmia Start with 0.2mg IV, onset 1-2 mins Repeated dose of 0.2-0.3mg IV every 1-2 mins up to 1mg total

Question 249

Antidotes Lvl 1 Glucagon, Hydroxocobalamin, Idarucizumab, Intralipid 20% Toxi book

Answer 249

Glucagon - used in BB or CCB overdose with hypotension and/or bradycardia Start with IV bolus 2-5mg IVI over 1 min (up to 10mg) Maintenance: initial response dose/h in D5, titrate clinically SE: N/V, hyperglycemia, hypoK, hypoglycemia after prolonged infusion Hydroxocobalamin - Cyanide poisoning - indication: cardiac arrest, GCS <=13, hypotension, lactate >10mmol/L Adult 5g IV, repeat same dose in severe SE: reversible red discoloration of skin, mucous membrane and urine Idarucizumab - Dabigatran reversal - 5g IV over 5-10 mins or bolus if emergency SE: thrombotic events, allergic reactions Intralipid - Severe LA poisoning with systemic toxicity - Investigational therapy for lipophilic drug poisoning (TCA, CCB) 1.5ml/kg bolus over 1 min, followed by infusion 0.25ml/kg/min Repeat bolus if persistent severe SE: Lipemic serum affecting lab Ix, elevated amylase, fever, transient dLFT, resp distress, coagulopathy, potential circuit obstruction in extracorporeal devices (ECMO, HF)

Question 250

Antidotes Lvl 1 Methylene blue, Naloxone, Penicillamine, Physostigmine Toxi book

Answer 250

Methylene blue - MetHbemia with sig symptoms of hypoxia - Consider for asymptomatic patients with MetHb>20% 1-2mg/kg IV over 5 min; may need repeat dose/infusion SE: blue/green discoloration of urine, transient worsening of apparent pulse oximeter reading, cautious in G6PD def patients, potential drug-drug interaction with serotonergic drugs resulting SS Naloxone - Opioid receptor antagonist - Reversal of CNS/Resp depression in opioid overdose: RR <12, coma, small pupils Occasionally effective in Clonidine or other alpha2 agonist, VPA, ACEI overdose 0.4 to 2mg IV bolus; up to 2mg (natural e.g. morphine) or 10mg (synthetic, e.g. tramadol) Start with lower if chronic user at 0.05-0.1mg to avoid withdrawal Goal is to keep breathing/oxygenating Infusion: 2/3 of initial effective bolus dose on hourly basis SE: opioid withdrawal Penicillamine Chelating agent, used in Wilson's disease (copper poisoning), cystinuria, lead poisoning Physostigmine used in Central anticholinergic poisoning Initial dose 1-2mg IV in adult slow IV over 5 mins Repeat in 10-15 mins if inadequate effect Put on cardiac monitor, with atropine and resus equipment standby, stop if cholinergic symptom SE: precipitate seizure / asystole esp if IV too rapid, cholinergic crisis if wrong Dx

Question 251

Antidotes Lvl 1 Pralidoxime, Pyridoxine, Protamine, Sodium bicarbonate Toxi book

Answer 251

Pralidoxime - used in OP poisoning 30mg/kg up to 2g over 30 mins Followed by infusion 8-10mg/kg/h in adult, titrate down in 24-48h according to clinical response SE: headache, dizziness, diplopia, blurred vision, HT, ECG TWI Pyridoxine (Vit B6) - used in Isoniazid, Hydrazine, Gyromitra mushroom, Ginkgo seeds poisoning - adjunct use in tetramine, ethylene glycol poisoning SE: Neurotoxicity - peripheral neuropathy Protamine - used in heparin reversal Sodium bicarbonate (NaHCO3) For sodium load / blood alkalinization Indication: TCA / other Na channel blockers poisoning with QRS >100ms, Salicylate poisoning 1-2ml/kg 8.4% NaHCO3 IV bolus to achieve serum pH 7.45-7.55 CI: - serum pH >7.55 (consider hypertonic saline as alternative) - Intolerable Na/fluid load (consider hyperventilation as alternative) SE: Na/fluid load, hypoK For urine alkalinization Indication: Enhance excretion of Salicylate, Phenobarbitone**, MTX, Chlorpropamide, 2,4-dichlorophenoxyacetic acid, Formate Generally use MDAC for Phenobarbitone as much more effective 1-2ml/kg 8.4% NaHCO3 IV bolus 50ml in 500ml D5 Q4H and titrate Aim: serum pH 7.45-7.55, urine pH 7-8 ?7.5-8 Monitor and replace K

Question 252

Antidotes Lvl 1 Sodium nitrite, Sodium thiosulphate, Sucralfate, Vit K1 Toxi book

Answer 252

Sodium nitrite / thiosulphate - used in Cyanide poisoning (but hydroxocobalamin is preferred) 3% sodium nitrite 10ml (300mg) 25% sodium thiosulphate 50ml (12.5g) SE: hypotension, MetHBemia Sucralfate Protect against GIT corrosive injury For button battery ingestion Suspension 5ml (containing 1g sucralfate) PO every 10 mins, up to 3 doses, within 12h **Honey 10ml Q10 mins till arrive hospital for button battery Vit K1 For warfarin/superwarfarin poisoning 1mg to 10mg as starting dose, titrate according to INR, clinical bleeding; severe cases may need >100mg/day PO/SC preferred SE: rarely Anaphylaxis in IV

Question 253

Antidotes Lvl 2 Calcium EDTA, Folinic acid, L-Carnitine, Octreotide, Phentolamine Toxi book

Answer 253

Calcium disodium EDTA - for lead poisoning Folinic acid - for MTX poisoning - also methanol poisoning L-Carinitine - for VPA induced hyperammonemia, encephalopathy, hepatotoxicity - consider in massive VPA overdose: >400mg/kg or VPA level >450mg/L (3123umol/L) Loading 100mg/kg, maintenance 50mg/kg Q8H for 24h SE: minimal in general Octreotide - Refractory hypoglycemia with sulphonylurea poisoning - Consider in quinine, newer insulin secretagogues, insulin overdose 50ug SC or IV Q6H for 24h (dilute in 50ml NS/D5 over 15-30 mins for IV) Further observe hypogly for 24h after stopping SE: stinging sensation at injection site, N/D, abd pain, anaphylactoid Phentolamine - Non-selective alpha blocker, can treat HT crisis - Reversal of vasoconstriction and treatment of dermal necrosis and sloughing following extravasation of peripheral administration of vasoconstrictor e.g. noradrenaline

Question 254

Antidotes Lvl 2 Antiveom x4 Toxi book

Answer 254

Bungarus multicinctus antivenin (for many banded krait) Naja Naja (atra) antivenin (for chinese cobra) Green pit viper antivenin (for bamboo snake) Neuro polyvalent snake antivenin (for banded krait, king cobra, naja kaouthia, malayan krait)

Question 255

Antidotes Lvl 3 Acetamide Botulism antitoxin heptavalent Fomepizole DMPS (oral) Methionine Prussian blue Silibinin / Silymarin Succimer (DMSA) Toxi book

Answer 255

Acetamide - for rodenticide Sodium monofluoroacetic acid (SMFA) poisoning Botulism antitoxin heptavalent - for botulism Fomepizole - for toxic alcohol poisoning (methanol, ethylene glycol) DMPS (oral) - for arsenic, lead, mercury poisoning Methionine - precursor of glutathione - for paracetamol poisoning, less preferred than NAC - only use when definite history of life-threatening NAC hypersensitivity reaction Prussian blue - works by ion trapping in GIT for Cesium and thallium poisoning Silibinin (IV) / Silymarin (PO) - used for Amatoxin mushroom poisoning Silibinin 5mg/kg IV over 2h Q6H x 24-48h Silymarin if silibinin not a/v, 700mg TDS x 4 days SE: N, GI discomfort, urticaria Succimer (DMSA) - used for lead, mercury, arsenic poisoning SE: GI upset, mild dLFT, neutropenia (rare), allergic reactions

Question 256

Antidotes Lvl 3 Antivenom x6 Toxi book

Answer 256

Agkistrodon acutus Russell's viper Tr. Muscrosqumatus + Tr. Gramineus Scorpion Sea snake Stonefish

Question 257

4 types of mushroom poisoning syndromes Monograph / Book

Answer 257

1. Gastroenteritic (Chlorophyllum molybdites, Russula emetic, Porcini) – 80% 2. Hepatotoxic (Amanita exitialis, A. rimosa) 3. Cholinergic (Inocybe rimosa, Mycena pura) 4. Hallucinogenic (Porcini – VH of micropsia or macropsia)

Question 258

Amatoxin present in which species Monograph / Book

Answer 258

Amanita species (A. Phalloides, A. verna, A. virosa) Galerina species (G. autumnalis, G. marginata, G. veneta) Lepiota species (L. helveola, L. josserandi, L. brunneoincarnata) Fatal cases: Amanita exitialis

Question 259

Toxicokinetic / pathophysiology of Amatoxin mushroom poisoning Monograph

Answer 259

Toxin: Alpha-amanitin Interferes RNA polymerase, inhibit protein synthesis, causing cell death Mainly excrete in urine but also significant amount in bile

Question 260

Clinical features of Amatoxin mushroom poisoning Monograph

Answer 260

Delayed onset GI symptoms >= 6 hours after ingestion Triphasic syndrome Phase 1: GE start 6-24h; Vomiting, abd pain, cholera-like watery diarrhea Phase 2: Lucent period with improving symptoms at 12-36h Phase 3: Liver, renal failure, death after 2-6 days. Presents with jaundice, HE, coagulopathy, hypoglycemia

Question 261

Ix of Amatoxin mushroom poisoning Monograph

Answer 261

CBC, LRFT, Clotting, blood gas Serial serum lactate Q6H Hourly urine output Save mushroom samples, contact HKPIC for urgent mycologist identification Send blood and urine to TRL

Question 262

Mx of Amatoxin mushroom poisoning Monograph

Answer 262

1. IVF rehydration (most important): aim >150ml/hr // 2-3ml/kg/hr 2. Silibinin IV, useful within 120 hours after ingestion, 5mg/kg IV over 2h Q6H Silymarin PO if Silibinin not a/v, 700mg TDS for adult or 10mg/kg for children, do not give AC at same time, defer if nasobiliary drainage can be arranged within 2h MDAC, give for at least 3 days, defer if nasobiliary drainage can be arranged within 2h NAC full course + maintenance 3. Contact QMH LT unit 4. Urgent ERCP nasobiliary drain placement without sphincterotomy, preferably within 2h 5. May consider: High dose Pen G, early charcoal HP Not useful: PO cimetidine, forced diuresis, HF or HD, steroid, thioctic acid

Question 263

Scombroid food poisoning Which fish Book

Answer 263

Scombridae: Tuna, Mackerel, Bonito Non-scombridae: sardine, mahi-mahi, amberjack, albacore Usually on spoiled fish skin

Question 264

Clinical features of Scombroid food poisoning Book

Answer 264

Symptom onset within minutes to hours after ingestion Flushing, urticaria, headache, N/V Bronchospasm, angioedema, hypotension Self-limiting, resolves within 6-8 hours

Question 265

Mx of Scombroid food poisoning Book

Answer 265

1. Supportive tx 2. IVF for hypotension 3. Antihistamine for symptoms 4. Bronchodilator for bronchospasm 5. Adrenaline seldom needed 6. Normal serum tryptase (taken 1-2h from onset) -> exclude food allergy/anaphylaxis

Question 266

Mad honey poisoning Which toxin Book

Answer 266

Grayanotoxin From Rhododendrons flowers, common in Black Sea area of Turkey and Nepal

Question 267

Clinical features of Mad honey poisoning Book

Answer 267

Dose dependent onset, from few mins to 2 hours or more Bitter / astringent taste of honey Mild: GI: N/V/D, burning throat sensation Neuro: dizziness, weakness, paresthesia, blurred vision, hypersalivation, excessive perspiration Severe: Hypotension, bradycardia, AV block, shock, asystole, convulsion Mimics AMI

Question 268

Biotoxins for food poisoning x4 Book

Answer 268

Ciguatoxin (coral fish) Tetrodotoxin (pufferfish) Saxitoxin (paralytic shellfish) Histamine (scombroid) Short incubation more likely toxin Long incubation more likely infective

Question 269

Food type food poisoning of the following Vibrio parahaemolyticus Botulism Clenbuterol Pesticide Book

Answer 269

Vibrio – undercooked seafood Botulism – Canned food Clenbuterol – Pigs’ offal Pesticide – vegetables

Question 270

Toxin causing GI symptoms within 6h Book

Answer 270

Staph enterotoxin (S. aureus) Cereulide (Bacillus cereus) Ca oxalate raphides (Alocasia macrorrhiza) Colchicine (Fresh Jin Zhen) Phytohaemagglutinin (undercooked green bean) Solanine (green/sprouting potato) Metallic ions (acidic beverages from metal containers, copper/zinc/tin) GI irritants (GI irritant mushrooms, e.g. Chlorophyllum molybdites)

Question 271

Toxin causing GI symptoms beyond 6 hours Book

Answer 271

Clostridium perfringens (8-16h, toxin production in gut) Salmonella, Shigella, Vibrio parahaemolyticus (16-72h) Amatoxin (>6h)

Question 272

Toxin causing Early neuro and systemic symptoms (Within few hrs) Book

Answer 272

Ciguatoxin Brevetoxin (neurotoxic shellfish poisoning) Saxitoxin (paralytic shellfish poisoning) Domoic acid (amnesic shellfish poisoning) Tetrodotoxin Nitrites Organophosphorus insecticide

Question 273

Toxin causing delayed neuro symptoms >6h Book

Answer 273

Botulinum toxin Methanol Cyanogenic glycosides Methoxypyridoxine (Ginkgotoxin)

Question 274

Bongkrekic acid poisoning Book

Answer 274

Produced by Burkholderia gladioli pv. Cocovenenans (BGC); Gram neg, aerobic bacillus In fermented corn and coconut products, improperly soaked black fungus Heat stable polypeptide Mitochondrial toxin by inhibiting adeneine nucleotide translocase (ANT)

Question 275

Clinical features of Bongkrekic acid poisoning Book

Answer 275

Onset 1-10h Abd pain, V/D Hyperglycemia initially then hypoglycemia Hypotension, arrhythmia Liver + renal derangement Hematochezia, hematuria, oliguria, coma, death

Question 276

Diagnosis of BA poisoning Book

Answer 276

Epidemiological link Demo of BGC by either culture or 16S rDNA sequencing Demo of BA in food residues

Question 277

Mx of BA poisoning Book

Answer 277

Supportive Dextrose for hypoglycemia Renal support for renal failure

Question 278

Ciguatera poisoning in which fish Book

Answer 278

Groupers, snappers, moray eel, hump head wrasse

Question 279

Pathophysiology of Ciguatera poisoning Book

Answer 279

Ciguatoxin produced by dinoflagellate Gambierdiscus toxicus Concentrated in liver, gonads, viscera Heat and acid stable Act on Na channels, increasing their permeability

Question 280

Clinical features of Ciguatera poisoning Book

Answer 280

Within 6h Subside in days, may last for months Mainly GI, neuro, CVS symptoms Neuro symptoms typically most troubling and persistent GI symptoms Abd pain, D, painful defecation Neuro symptoms Paresthesia, dysesthesia Tingling sensation in extremities or mouth Cold dysesthesia over extremities (pathognomonic) Metallic taste in mouth, sensation of itchy/loose teeth Others: bradycardia, hypotension, altered mental state, resp failure

Question 281

Mx of Ciguatera poisoning Book

Answer 281

Supportive GI decon if early IV mannitol 1g/kg over 1h Gabapentin 400mg TDS

Question 282

Preventing Ciguatera poisoning Book

Answer 282

Avoid eating large coral fish >3 catties, esp head, skin, viscera Recovered patients should avoid consuming alcohol, peanuts or beans; avoid further coral fish consumption (Avoid lose weight?)

Question 283

Clenbuterol poisoning Book

Answer 283

Beta-2-adrenergic agonist with anabolic and lipolytic effect Pig’s meat / offal Stimulate beta-2 adrenergic receptor -> dilate BV to skeletal muscles inducing muscle hypertrophy Influx of K into cell -> hypoK, muscle paralysis Cautious hypoK replacement as shifting rather than deficient Mild symptoms require no tx, beta blocker if symptomatic

Question 284

Cyanogenic glycoside poisoning Book

Answer 284

Causes cyanide poisoning Food involved: kernel of fruits of Prunus specieis, e.g. apricot, peaches, pears, apples; bitter almond; cassava; bamboo shorts; young sorghum

Question 285

Clinical features of cyanogenic glycoside poisoning Book

Answer 285

Early may be non-specific: GI disturbance, dizziness, headache, weakness Chronic: toxic ataxic neuropathy (optic atrophy, sensorineural hearing loss, posterior column involvement, ataxia), Konzo (spastic paraparesis), hypothyroidism

Question 286

Mx for cyanogenic glycoside poisoning Book

Answer 286

Supportive and symptomatic for mild cases Antidote for cyanide if severe

Question 287

Haff’s disease Book

Answer 287

Syndrome of unexplained rhabdomyolysis onset within 24h after cooked freshwater food consumption Burbot, pike, buffalo fish, eel Freshwater crayfish Postulated to be an unidentifiable heat stable toxin

Question 288

Clinical features of Haff's disease Book

Answer 288

Pain in trunk / limbs, often severe and disproportional to CK level Gross myoglobinuria in severe Chest pain, SOB, diaphoresis Rarely ARF, multiorgan failure/death Myalgia subsides in a few days, CK normalize in a week Tx: supportive, ensure adequate urine output, urine alkalization (NaHCO3) for severe myoglobinuria, RRT for ARF

Question 289

3 forms of Mercury Book

Answer 289

Elemental Inorganic Organic Considered as different toxins

Question 290

Which form of mercury poisoning is most common in HK Book

Answer 290

Inorganic mercury poisoning from adulterated facial whitening cream / Chinese med

Question 291

Source of elemental mercury Book

Answer 291

Sphygmomanometer, thermometer, fluorescent light tube, compact fluorescent light bulb

Question 291

Toxicokinetic/dynamics of elemental mercury Book

Answer 291

Vaporize at room temp Absorption mainly by inhalation (negligible oral absorption with normal GIT) To CNS, kidney, crosses placenta Convert to inorganic ion forms by enzyme catalase

Question 292

Clinical features of elemental mercury poisoning Book

Answer 292

Occupational Cough, chills, fever, SOB N/V/D, metallic taste Interstitial pneumonitis, ARDS if severe

Question 293

Ix of elemental mercury poisoning Book

Answer 293

CXR for acute inhalation / suspected aspiration AXR for ingestion X ray of body parts in SC/IV Whole blood, 24h urine mercury

Question 294

Mx of elemental mercury poisoning Book

Answer 294

Environmental decontam, do not use vacuum cleaner Supportive care for acute inhalation Ingestion – FU X ray

Question 295

Sources of Inorganic mercury poisoning Book

Answer 295

Skin whitening cream adulterated with inorganic mercury Certain Chinese meds, e.g. cinnabar Ayurvedic medicinal products Mercurochrome

Question 296

Ix of Inorganic mercury poisoning Book

Answer 296

1. Whole blood mercury: reflect intense, acute inorganic mercury exposure, less reliable after redistribution to tissues 2. Spot urine mercury (need to adjust for Cr conc.) 3. 24h urine mercury (correlate roughly exposure severity and neuropsychiatric symptoms; confirm exposure and monitor chelation therapy) 4. Renal biopsy (membranous glomerulonephritis and minimal change disease most common for nephrotic syndrome in inorganic mercury poisoning) 5. CBC, LRFT, AXR

Question 297

Mx of Inorganic mercury poisoning Book

Answer 297

Source identification + exposure termination GI decon (GL/AC if early; WBI) Supportive tx, adequate hydration OGD if significant corrosive effects Chelation therapy

Question 298

When to start chelation therapy for inorganic mercury poisoning Book

Answer 298

Clinical features + elevated mercury level Oral succimer (DMSA- Dimercaptosuccinic acid) for subacute/chronic inorganic Dimercaprol (BAL - British anti-Lewisite) for acute inorganic

Question 299

Sources of organic mercury Book

Answer 299

Seafood

Question 300

Clinical features of organic mercury Book

Answer 300

Neurological toxicity Chelation therapy not useful in organic mercury poisoning

Question 301

Arsenic poisoning, which one more toxic Trivalent vs Pentavalent Inorganic vs Organic Book

Answer 301

Trivalent arsenic more toxic than pentavalent Inorganic arsenic more toxic than organic

Question 302

Ix for Arsenic poisoning Book

Answer 302

24h urine arsenic Speciation of arsenic (differentiate organic and inorganic arsenic)

Question 303

Mx of Arsenic poisoning Book

Answer 303

Source identification + exposure termination Aggressive fluid replacement Treat prolonged QTc GI decontamination Acutely poisoned patients usually had already vomited Activated charcoal +/- airway protection can be considered although arsenic is poorly adsorbed by charcoal

Question 304

Chelation for Arsenic poisoning Book

Answer 304

BAL IV for acute who cannot tolerate oral intake DMPS IV for acute or PO for subacute or chronic Succimer PO in subacute or chronic

Question 305

Salicylate found in Book

Answer 305

Aspirin Cortal (aspirin + caffeine) Methyl salicylate (e.g. Wintergreen oil) Salicylic acid (keratolytic agent for corn)

Question 306

Pharmacokinetics of salicylate Book

Answer 306

Peak serum conc in 1-2 hours Bezoar possible in aspirin overdose Weak acid with poor CNS distribution at physiological pH If academia, shifts to non-ionized form and penetrate BB and tissues, CNS toxicity Mainly conjugated in liver, only small portion excreted in urine Overdose, metabolic enzymes saturated -> become zero order kinetics, serum half life 15-20h Renal elimination becomes critical when hepatic metabolism saturated

Question 307

Pathophysiology of salicylate Book

Answer 307

Initial direct stimulation of CNS resp center -> hyperventilation + resp alkalosis Uncouple phosphorylation, increasing tissue oxygen consumption and hyperthermia Metabolic acidosis resulting from lactate (anaerobic metabolism), ketoacid, and salicylate itself

Question 308

Clinical manifestation of salicylate poisoning Book

Answer 308

Minimal symptoms if early despite lethal dose Early symptoms: N/V, hyperventilation (resp alkalosis), tinnitus, lethargy Life threatening symptoms: CNS toxicity (confusion, convulsion, coma, cerebral edema), acute lung injury (non-cardiogenic pul edema), dehydration, hyperthermia, metabolic acidosis, BG disturbance, hepatic/renal failure, coagulopathy, impaired platelets

Question 309

Classical acid-base abnormality for salicylate poisoning Book

Answer 309

Initial resp alkalosis, then metabolic acidosis Alkalemic in early phase, with mixed resp alkalosis and metabolic acidosis pH <7.4 = life threatening, poor prognostic marker

Question 310

Toxic/Fatal dose of salicylate Book

Answer 310

Toxicity: >150mg/kg Fatal: >500mg/kg

Question 311

Serum salicylate limited role Book

Answer 311

Monitor serial salicylate level, check Q2-4h till 2-3 consecutive falling levels Focus on clinical status, symptoms, acid-base status

Question 312

Electrolyte disturbance of salicylate poisoning Book

Answer 312

Increase AG Hypergly – increase gluconeogenesis, glycogenolysis Hypogly – depletion of easily mobilized glucose stores Relative CNS hypoglycemia HypoK Urine alkalinization is impaired if hypoK

Question 313

Tx of salicylate poisoning Book

Answer 313

GI decon Adequate hydration Serum and urine alkalinization Monitor serum salicylate Consider MDAC (for aspirin) and enhanced elimination Pretreat with NaHCO3 to prevent resp acidosis before intubation

Question 314

Indication of serum/urine alkalinization for salicylate poisoning Book

Answer 314

Symptomatic patients with supratherapeutic salicylate level Serum salicylate >40mg/dL (>2.9mmol/L)

Question 315

How to give NaHCO3 for salicylate poisoning Book

Answer 315

Bolus: 1-2ml/kg 8.4% NaHCO3 Maintenance: 50ml NaHCO3 in 500ml D5 Q4H and titrate, monitor and replace K Aim: serum pH 7.45-7.55, urine pH 7.5-8

Question 316

When to HD / HF for salicylate poisoning Book

Answer 316

Severe end-organ toxicity (convulsion, pul edema, renal failure, altered mental state) Clinical deterioration despite standard therapy Serum salicylate >100mg/dL (>7.2mmol/L) HF as alternative if HD not a/v

Question 317

Delta gap

Answer 317

Change in Anion gap - Change in HCO3 = [AG -12] - [HCO3 gap] = (Na - Cl - HCO3 - 12) - (24-HCO3) = Na - Cl - 36 -6 = Mixed high and normal AG acidosis -6 to 6 = Only high AG acidosis >6 = Mixed high AG acidosis and metabolic alkalosis

Question 318

Delta ratio

Answer 318

Change in AG / Change in HCO3 0.4 = NAGMA 0.4-0.7 = mixed HAGMA and NAGMA 0.8-2 = pure HAGMA >2 = HAGMA + pre-existing metabolic alkalosis

Question 319

MEN 1 / 2A / 2B

Answer 319

1: Pituitary adenoma, Parathyroid hyperplasia, Pancreas tumor 2A: Parathyoid hyperplasia, Medullary thyroid carcinoma, Pheochromocytoma 2B: Medullary thyroid carcinoma, Pheochromocytoma, Mucosal neuroma, Marfarnoid habitus

Question 320

PRISMA

Answer 320

Preferred Reporting Items for Systematic reviews and Meta-Analyses

Question 321

Emphysematous cholecystitis USG sign

Answer 321

Champagne sign (gas in GB)

Question 322

Toxicology Mx triangle

Answer 322

EE / Specific Tx Antidote Decontamination / Exposure termination Supportive Mx / Monitoring

Question 323

Toxicological causes of status epilepticus SF ppt

Answer 323

1. Sympathomimetic poisoning 2. Withdrawal of: ethanol, benzo, sedatives/hypnotics 3. Bupropion 4. Oral DM meds 5. CO poisoning 6. Isoniazid, gyromitrin 7. Theophylline

Question 324

Mechanism of Theophylline induced seizure SF

Answer 324

Theophylline is adenosine antagonist and Adenosine is CNS inhibitory neurotransmitter

Question 325

Metabolic effects of Theophylline poisoning SF

Answer 325

1. HypoK (surrogate marker for Theo toxicity) 2. Hypergly (increase catecholamines) 3. Resp alkalosis (hyperventilate) 4. Lactic acidosis (seizure, hypovolemia from repeated vomiting) 5. Hyperthermia (increase metabolic activity, increase muscle activity)

Question 326

Mx of Theophylline induced seizure epilepticus SF

Answer 326

Lorazepam 4mg Phenobarbital 10mg/kg IV or Propofol 1-2mg/kg IV Phenytoin contraindicated

Question 327

Cause of death in Theophylline poisoning SF

Answer 327

Cardiac toxicity (tachyarrhythmia, hypotension) Status epilepticus

Question 328

Specific end organ toxicity for toxic alcohol Methanol / Ethylene glycol / Diethylene glycol

Answer 328

Methanol - Retinal toxicity (snowfield vision, blindness; fundoscope: hyperemia, pale optic disc, papilledema) - BG infarct, renal failure, pancreatitis, rhabdomyolysis Co-factor therapy: Folate Putaminal hypodensity/hemorrhage Ethylene glycol - Acute renal failure (Ca oxalate crystals) - HypoCa, multiple CN palsies Co-factor therapy: Thiamine (B1), Pyridoxine (B6) Diethylene glycol - Acute renal failure, unilateral or bilateral facial n palsy, peripheral neuropathy with limb weakness, encephalopathy, coma

Question 329

Absolute CI of Physostigmine x2 Monograph

Answer 329

TCA poisoning New onset QRS prolongation

Question 330

Relative CI of Physostigmine Monograph

Answer 330

1. Asthma 2. Underlying cardiac disease 3. Perpheral vascular disease 4. Mechanical intestinal/bladder obstruction 5. Concomintant use of depolarizing muscle relaxant

Question 331

NRP first step 3 things to consider after birth

Answer 331

1. Term gestation? 2. Good tone? 3. Breathing or crying?

Question 332

Apgar score

Answer 332

Appearance (skin color) blue // body pink + blue extremities (acrocyanosis) // pink Pulse (HR) absent // <100 // >=100 Grimace (reflex irritability) no response to stimulation / on aggressive stimulation // cry on stimulation Activity (muscle tone) absent // flexed limbs // active Respiration (resp effort) absent // weak, irregular, gasping // strong and robust cry Score 0 // 1 // 2

Question 333

NRP initial steps not: Term gestation / Good tone / Breathing or crying

Answer 333

Warm Dry Stimulate Poisition airway Suction if needed

Question 334

Ventilation corrective steps MR SOPA NRP

Answer 334

Mask adjustment (good seal on face) Reposition head (sniffing position) Suction mouth and nose Open mouth (mouth slightly open and lift jaw forward) Pressure increase Alternate airway (ETT/ LMA)

Question 335

Chest compression in NRP

Answer 335

3:1 ratio of compressions to ventilations in 2-second cycle (one and two and three and breath and) depth: 1/3 AP diameter of chest 2-thumb encircling hands technique

Question 336

Adrenaline dose for NRP Volume expander dose

Answer 336

1:10000 IV preferred (umbilical vein); or IO / ETT IV: 0.02mg/kg + 3ml NS flush ETT: 0.1mg/kg Repeat every 3-5 mins Volume expander: NS or Type O Rh -ve blood 10ml/kg over 5-10 mins IV/IO

Question 337

Sepsis 1 hour bundle

Answer 337

1. Measure blood lactate; retake if >2 mmol/L q2-4h till normal 2. Blood culture 3. Broad spectrum antibiotics 4. Crystalloid fluid 30ml/kg (if hypotension or lactate >4) 5. Maintain MAP >= 65mmHg (may need vasopressor i.e. noradrenaline) Refractory shock: + IV hydrocortisone

Question 338

SIRS criteria (Systemic inflammatory response syndrome)

Answer 338

Temp >38 or <36 HR >90 RR >20 or PaCO2 <32mmHg WBC >12 or <4

Question 339

Delayed sequence intubation (DSI)

Answer 339

Procedural sedation, where the procedure is preoxygenation May be useful in the patient for whom RSI would inevitably result in significant hypoxaemia because they cannot be preoxygenated by other means Ketamine is the ideal DSI induction agent as it preserves airway reflexes and respiratory drive

Question 340

ATP in central line

Answer 340

reduce dose to 5mg as ATP is rapidly used up peripherally, central injection -> higher dose

Question 341

Cormack-Lehane scoring system for laryngoscopy

Answer 341

Grade I: complete glottis visible Grade II: anterior glottis not seen; and only the posterior extremity of the glottis is visible Grade III: epiglottis seen, but not glottis Grade IV: epiglottis not seen

Question 342

Post intubation hypotension (AH SHITE mnemonic)

Answer 342

1. Anaphylaxis, acidosis 2. Heart (Cardiac tamponade, pulmonary HT) 3. Stacking of breath 4. Hypovolemia 5. Induction agents 6. Tension PTX 7. Electrolyte disturbances

Question 343

Estimated body weight for age 1-10y

Answer 343

(Age + 4) x 2

Question 344

Antidote for Rivaroxaban and Apixaban

Answer 344

Andexanet alfa

Question 345

Brugada syndrome types litfl / ppt

Answer 345

Type 1: Coved STE>2mm in >1 of V1-3 followed by a negative T wave "Brugada sign" Clinical criteria (any 1) 1. Documented VF or polymorphic VT 2. FHx of sudden cardiac death <45y 3. Coved-type ECGs in family members 4. Inducible VT with programmed electrical stimulation 5. Syncope 6. Nocturnal agonal respiration Type 2 and 3 non-diagnostic Type 2: >2mm saddleback shaped STE Type 3: Morphology of either type 1 or 2; but with <2mm STE Autosomal dominant, variable penetrance; SCN-5A gene (Na channel) Flecainide challenge Implant ICD; Quinidine; Radiofrequency ablation of anterior part of RVOT

Question 346

J wave (Osborn wave) litfl

Answer 346

Positive deflection seen at J point in precordial and true limb leads Most commonly associated with hypothermia (<30oC) Recioprocal, negative deflection in aVR and V1 **J point = Point where QRS complex joins ST segment Other causes of J wave 1. HyperCa 2. AMI 3. Takotsubo cardiomyopathy 4. LVH due to HT 5. Normal variant and early repolarization 6. Raised ICP, SAH 7. Severe myocarditis 8. Brugada syndrome 9. Idiopathic VF (Le syndrome d'Haissaguerre)

Question 347

Hypothermia ECG changes litfl

Answer 347

Osborn wave!! 1. Sinus bradycardia 2. Prolong QTc 3. AV block 4. Supraventricular arrhythmias 5. ?U waves

Question 348

U wave ECG litfl

Answer 348

Small (0.5mm) deflection immediately following T wave - usu same direction as T wave - best seen at V2-3 - prominent if >1-2mm or >25% height of T wave Prominent U most commonly found in 1. Bradycardia 2. Severe hypoK also in 3. HypoCa 4. HypoMg 5. Hypothermia 6. Raised ICP 7. LVH 8. HCM 9. Drugs: Digoxin; Class 1a: Quinidine, Procainamide; Class 3: Sotalol, Amiodarone Inverted U: 1. CAD, HT, valvular heart disease, cardiomyopathy, hyperthyroidism

Question 349

Delta wave litfl

Answer 349

Slurred upstroke in QRS complex In pre-excitation syndromes such as WPW

Question 350

Epsilon wave

Answer 350

Small deflection buried at end of QRS complex Best seen at V1-2 (usu V1-4) Caused by post-excitation of myocytes in RV Characteristic finding in Arrhythmogenic right ventricular dysplasia (ARVD) also seen in 1. Posterior MI 2. RV AMI 3. Infiltrative disease 4. Sarcoidosis

Question 351

Portal venous gas vs Pneumobilia

Answer 351

PV gas: peripheral Pneumobilia (CBD gas): central

Question 352

HIV PEP regime COC

Answer 352

Truvada 1 tab daily + Raltegravir 400mg Q12H *Truvada = Tenofovir 300mg + Emtricitabine 200mg

Question 353

SE of HIV PEP COC

Answer 353

Truvada - GI intolerance, headache - rare: renal insufficiency, Fanconi syndrome, lactic acidosis, hepatic steatosis Raltegravir - GI intolerance, headahce - fatigue, sleep disturbance - rare: rhabomyolysis

Question 354

SAH scores / classification systems

Answer 354

1. Hunt and Hess scale 2. World Federation of Neurosurgical Societies grading system 3. Modified Fisher scale

Question 355

qSOFA score

Answer 355

quick Sequential Organ Failure Assessment for inpatient mortality in sepsis 1. Altered mental status: GCS <15 2. RR >= 22 3. SBP <= 100

Question 356

Trifascicular block

Answer 356

Bifasicular block + 1st degree HB

Question 357

Bifasicular block

Answer 357

RBBB + LAFB (=> Left axis deviation) *more common as single LAD to anterior fascicle or RBBB + LPFB (=> Right axis deviation) **Left anterior fasicular block / Left posterior fascicular block

Question 358

Cardiac axis litfl

Answer 358

Normal = 2-6 (-30 to +90 degree) LAD = 12-2 (-90 to 0 degree) RAD = 6-9 (90-180 degree) LAD: Lead 1, aVL positive; lead 2, 3, aVF negative RAD: Lead 1, aVL negative, lead 2, 3, aVF positive

Question 359

Bohler angle

Answer 359

Between a line joining: Highest point of (Anterior process of calcaneus and Posterior articular facet) and Highest point of (Posterior articular facet and Calcaneal tuberosity) Normal value = 20-40 degree; # usu <20 Compare with other side

Question 360

Gissane angle

Answer 360

Calcaneal # Formed by 2 strong cortical struts of the calcaneus that lie beneath the lateral process of the talus Along superior aspect of posterior facet and superior aspect of anterior process Normal: 100-130 degrees

Question 361

Status epilepticus toxicology cause

Answer 361

Isoniazid Theophylline OHA (hypogly) Bupropion Tetramine SMFA CO Hydrazine Camphor Lignocaine OP

Question 362

DDx of RUQ gas ppt

Answer 362

1. Pneumobilia 2. Portal venous gas 3. Emphysematous cholecystitis 4. Chilaiditi sign 5. Liver abscess with gas forming organism

Question 363

X ray view for SCJ dislocation

Answer 363

Serendipity view (40 degree cephalic tilt)

Question 364

Mechanism of injury of SCJ dislocation

Answer 364

Fall on outstretched hand or a direct blow to shoulder

Question 365

Tourniquet test for Dengue fever

Answer 365

Capillary fragility test Pressure cuff applied and inflated to midway between systolic and diastolic BP for > 1 minutes Test is positive if >=10 petechiae per square inch of skin underneath the cuff

Question 366

Dengue fever classication

Answer 366

Dengue without warning signs Dengue with warning signs Severe Dengue fever

Question 367

Warning signs for Dengue fever

Answer 367

Abd pain/tenderness Persistent vomiting Clinical fluid accumulation (ascites, pleural effusion) Mucosal bleed Lethargy, restlessness Liver enlargement >2cm Increase hematocrit concurrent with rapid decrease in platelet count

Question 368

Criteria for severe Dengue

Answer 368

1. Shock 2. Fluid accumulation with resp distress 3. Severe bleeding 4. Severe organ involvement Liver: (AST/ALT >=1000) CNS: impaired consciousness Heart / other organs

Question 369

Dengue without warning signs diagnosis

Answer 369

Endemic area, with fever + 2 of: 1. Nausea/vomiting 2. Rash 3. Headache, eye pain, myalgia, joint pain 4. Leukopenia 5. Tourniquet test +ve

Question 370

Clinical signs for acute appendicitis ppt

Answer 370

1. Psoas sign - RLQ pain with hyperextension of R hip 2. Obturator sign RLQ pain with internal rotation of R hip (Knee flexed) 3. Rovsing's sign RLQ pain with palpation of LLQ

Question 371

Volkmann ischemic contracture

Answer 371

From compartment syndrome of upper limb Claw-hand deformity of hand classical in supracondylar # in pedi

Question 372

Coiled spring sign

Answer 372

Sign of Intussusception in contrast enema

Question 373

Steinstrasse

Answer 373

means "stone street" in German Complication of ESWL; develop after 1 day to 3 months, most common in distal ureter

Question 374

Alvarado Score

Answer 374

for acute appendicitis Signs RLQ tenderness Yes+2 Elevated temperature (37.3°C) Yes+1 Rebound tenderness Yes+1 Symptoms Migration of pain to RLQ Yes+1 Anorexia Yes+1 Nausea or vomiting Yes+1 Laboratory Values Leukocytosis >10,000 Yes+2 Leukocyte left shift, >75% neutrophils Yes+1 Use to r/o if <3-4 score

Question 375

Sever's disease

Answer 375

Calcaneal apophysitis

Question 376

Fracture C2 odontoid process classification

Answer 376

Anderson and D'Alonzo classification

Question 377

Calcaneal # classification

Answer 377

Sanders classification (for CT)

Question 378

Bidirectional VT (BVT) cause litfl

Answer 378

1. Severe digoxin toxicity (most commonly) 2. Familial catecholaminergic polymorphic VT (CPVT) 3. Aconite poisoning Alternating QRS axis with each beat

Question 379

Rigler triad in GS ileus

Answer 379

1. Pneumobilia 2. SB obstruction 3. Ectopic calcified GS, usually in the right iliac fossa

Question 380

Medical Control Officer (MCO) role LDD

Answer 380

Command (take charge of the appropriate response) Control (deploy and utilize resources) Communication (obtain info from various sources) Coordination (liase with other involved parties) Overall command of medical service Coordinate the medical and first aid services e.g. AMS, St John Communicate with HODO (HA head office duty officer) and the respective receiving AEDs on situation update, casualty condition and conveyance Advise on casualty destination and diversion ?Set up Triage point and Casualty clearing station (CCS) -Uphill, upwind, upstream Decision for stand down Mobile Casualty Treatment Center (MCTC) Prep course: - On site medical commander and liason officer - Liasion (E-team, AED, HADO, AIO) - Diversion of patient - Dispatch 2nd EMT *AIO = Ambulance Incidence Officer

Question 381

Bouveret syndrome

Answer 381

GS causing GOO

Question 382

REBOA 3 zones

Answer 382

Resuscitative endovascular balloon occlusion of the aorta Zone 1: Left subclavian a. to celiac a. Zone 2: Celiac a. to most distal renal a. Zone 3: Most distal renal a. to aortic bifurcation

Question 383

CXR sign for pneumothorax (supine CXR) deepseek

Answer 383

1. Deep sulcus sign 2. Double diaphragm sign 3. Sharp mediastinal contour 4. Increased radiolucency

Question 384

B lines lung USG

Answer 384

Comet tail artifacts - Reverberation artifacts, appears as hyperechoic vertical lines without fading - APO / consolidation - no PTX (high negative predictive value)

Question 385

Wallenberg syndrome

Answer 385

aka Lateral medullary syndrome PICA (posterior inferior cerebellary artery) occlusion Vertigo Ipsilateral cerebellar ataxia Ipsilateral Horner's syndrome Loss of pain and temperature from ipsilateral face and contralateral trunk/limbs Dysphagia, hoarseness

Question 386

Thinner hypoK reason ppt

Answer 386

Contains Toluene causes type 1 renal tubular acidosis NAGMA, hyperchloremic, hypoK, inappropriately high urine pH >5.5

Question 387

Rasmussen aneurysm ppt

Answer 387

Cx of pTB Pulmonary artery aneurysm adjacent or within a tuberculous cavity

Question 388

Osgood-Schlatter disease ppt

Answer 388

Traction apophysitis of proximal tibial tubercle at insertion of patellar tendon In adolescents, overuse condition

Question 389

Tongue blade test for mandibular #

Answer 389

Bite the wooden tongue depressor then twist high NPV Physical signs for mandibular # - malocclusion - trismus - chin paresthesia - sublingual hematoma, floor of mouth ecchymosis

Question 390

Guardsman #

Answer 390

aka Parade ground # Mandibular # caused by a fall on the midpoint of the chin resulting in fracture of the symphysis as well as both condyles usu seen in epileptics, elderly and occasionally in soldiers who fall forwards due to syncope after standing for long periods on parade

Question 391

Facial nerve palsy grading system

Answer 391

House-Brackmann Facial Paralysis Scale

Question 392

Reverse Bennett fracture-dislocation

Answer 392

fracture-dislocation of 5th MC base unstable due to unopposed extensor carpi ulnaris (ECU) pull on the fracture fragment required CRIF/ORIF

Question 393

Gas gangrene microorganism

Answer 393

Clostridium perfringens

Question 394

Gunshot wound Entry vs Exit ppt

Answer 394

Entry wound - circular, with blackened, seared skin margins - round wound with sharp margins and an abrasion ring on surrounding skin - muzzle imprint - powder tattooing Exit wound - irregular - no soot deposition, muzzle imprint, stippling of blackening of skin edges

Question 395

Hill-Sachs lesion

Answer 395

Cortical depression in humeral head (caused by glenoid rim) In posterolateral aspect

Question 396

Bankart lesion

Answer 396

Abruption of antero-inferior aspect of glenoid labrum Humeral head strikes the inferior margin of glenoid +/- bony avulsion

Question 397

Endpoint of pre-oxygenation in AED

Answer 397

SpO2 >= 95% for 2-3 mins

Question 398

Pediatric assessment triangle

Answer 398

Appearance Work of breathing Circulation to skin

Question 399

CMV / SIMV ventilator

Answer 399

Synchronized Intermittent Mandatory Ventilation Continuous/Controlled Mandatory Ventilation

Question 400

Why deep seedation for AECOPD intubated in AED

Answer 400

Deep sedation to prevent hyperventilation and then breath stacking and auto-PEEP

Question 401

Insp hold for high airway pressure

Answer 401

Hold -> can equalize -> measure plateau pressure Peak pressure = airway resistance + alveolar resistance Plateau pressure = alveolar resistance (lung compliance) Peak + Plateau pressure high - increased alveolar resistance, i.e. decreased lung compliance Peak high but Plateau normal - increased airway resistance

Question 402

Sepsis bundle name

Answer 402

Surviving Sepsis Campaign hour-1 bundle

Question 403

XR line for SCFE

Answer 403

Klein's line Line drawn along superior border of femoral neck, should intersect on lateral aspect of superior femoral epiphysis AP view Positive -> Trethowan's sign

Question 404

CPR coach

Answer 404

Provides real-time, verbal feedback on chest compression quality to compressors during a cardiac arrest Povide feedback on the CPR quality, to coordinate provider switches, and to coordinate key tasks (i.e. defibrillation and intubation) while minimizing interruptions to CPR

Question 405

XR signs for posterior shoulder dislocation

Answer 405

1. Lightbulb sign Internal rotation of humerus 2. Rim sign AP view, the distance between the anterior glenoid rim and the medial humeral head is increased (typically >6 mm) 3. Trough line sign A vertical line of sclerosis or compression fracture on the anteromedial aspect of the humeral head. This is caused by impaction of the humeral head against the posterior glenoid rim Axillary view better than scapula Y view

Question 406

Associated injuries of posterior shoulder dislocation ppt

Answer 406

1. Tuberosity or surgical neck # 2. Reverse Hill-Sachs lesion or reverse Bankart lesion 3. Glenolabral injury 4. Rotator cuff injury Classically caused by: Epilepsy, Electricity, Ethanol

Question 407

CMCJ dislocation XR line name

Answer 407

1. Chmell's oblique MC line 2. Broken zigzag line sign

Question 408

Confirmation of ETT placement ppt

Answer 408

Primary 1. Direct visualization of ETT through the vocal cords 2. Misting of tube during ventilation 3. 5-point auscultation 4. Chest rise on ventilation Secondary 1. EtCO2 waveform 2. Improvement in condition e.g. SpO2 3. Hold up of gum elastic bougie at 30-40cm 4. Esophageal detector CXR is wrong - cannot exclude eso intubation

Question 409

Winter's formula

Answer 409

Calculates the expected pCO₂ compensation in a purely metabolic acidosis (in mmHg) (1.5 x HCO3) + (8 +/- 2) Estimate: expected pCO2 = ~first 2 decimal of pH CO2 mmHg to kPa: x 0.1333 **(1/7.5) /5 +1

Question 410

Scores for thyroid storm

Answer 410

1. Burch–Wartofsky Point Scale (BWPS) 2. Japanese Thyroid Association Criteria

Question 411

Forceful dorsiflexion, MVC Driving pedal

Answer 411

neck of talus

Question 412

Test for pancreatitis

Answer 412

Urine trypsinogen-2 test

Question 413

Radial head # classification

Answer 413

Mason classification 1: non-displaced 2: marginal # with displacement 3: communited # involving entire head 4: asso w/ dislocation of elbow Can do radio-capitellar view (greenspan view)

Question 414

Radial head # nerve injury

Answer 414

Posterior interosseous nerve (PIN) - check thumb extension associated injury: ulnar coronoid process #, LCL tear (also MCL?), interosseous membrane injury, elbow dislocation, Monteggia #

Question 415

Status epilepticus toxicological cause cofactor therapy

Answer 415

IV pyridoxine (B6) 50-70mg/kg Ethylene glycol Ginkgo seed poisoning Gyrometra/false morel Monomethylhydrazine mushroom poisoning Tetramine Hydrazine (fuel)

Question 416

San Francisco Syncope rule

Answer 416

CHESS Hx of CHF Hematocrit <30% Abnormal ECG/cardiac monitor SOB SBP <90 at triage Other rules: Canadian syncope risk rule, Boston syncope rule

Question 417

Terrible triad of elbow injury

Answer 417

1. Elbow dislocation (posterior) 2. # Radial head (or neck) 3. # Coronoid process of ulna Instability, recurrence

Question 418

Pelvic # classifications

Answer 418

Tile classification (based on bio-mechanical stability) - A / B / C A1/2: Stable B1/2/3: Rotationally unstable C1/2/3: Rotationally and vertically unstable Young Burgess (based on mechanism of injury) - Lateral compression - Anterior posterior compression - Vertical shear - Combined mechanism

Question 419

VT vs SVT with abberancy list 3 criteria

Answer 419

Vereckei criteria (aVR): dominant R in aVR... etc. Brugada criteria Pava criteria (lead 2): R Wave Peak Time > 50ms

Question 420

Mangled limb test

Answer 420

Arterial pressure index (aka Ankle brachial index) >=0.9 maybe salvageable limb <0.9 = compromised arterial flow <0.5 likely limb loss

Question 421

Massive hemothorax definition

Answer 421

1. Blood loss > 1.5L or 1/3 of blood volume 2. Blood loss >200 mL/h (3 mL/kg/h) for 2-4 hours Need for thoracotomy

Question 422

Classification of traumatic aortic injury

Answer 422

Grade 1: Intimal tear 2: Intramural hematoma 3: Pseudoaneurysm 4: Rupture most common site = aortic isthmus **btn origin of L subclavian a. and attachment of ligamentum arteriosum next common = asc aorta

Question 423

RUSH exam USG protocol

Answer 423

Rapid Ultrasound for Shock and Hypotension HIAMP ED Heart IVC Aorta Morison's pouch Pulmonary (PTX) Ectopic pregnancy DVT

Question 424

Lunate vs Perilunate dislocation ppt

Answer 424

Lunate dislocation: Lunate does not articulate with capitate or radius Perilunate: Lunate remains aligned with radius

Question 425

Mechanism of Lunate dislocation

Answer 425

FOOSH, forceful dorsiflexion (extension) of wrist

Question 426

Cx of Lunate dislocation

Answer 426

1. Median n. entrapment 2. Chronic pain 3. AVN of lunate

Question 427

Classification of Lunate dislocation

Answer 427

Mayfield classification of carpal instability Stage 1: Scapholunate dissociation Stage 2: Perilunate dislocation // Lunocapitate disruption Stage 3: Midcarpal dislocation // Lunotriquetral disruption Stage 4: Lunate dislocation

Question 428

Terry-Thomas sign

Answer 428

Increase in the scapholunate space (3-4mm) Indicates scapholunate dissociation (often with rotary subluxation of the scaphoid) due to ligamentous injury

Question 429

Triquetral avulsion # mechanism

Answer 429

Fall on outstretched arm with wrist extended and ulnar deviation; or extreme flexion seen dorsal to proximal row of carpal bone

Question 430

Snowboarder's #

Answer 430

lateral process of talus MOI: external rotation + dorsiflexion + axial load

Question 431

QTc calculation formula

Answer 431

1. Bazett's formula: QT/ √RR 2. Fridericia's formula: QT / cubic root of RR 3. Hodges formula: QT + 1.75 x (HR-60) 4. Framingham formula: QT + 0.154 x (1-RR) **RR unit in sec prolonged: 440ms in men; 460ms in women >500 = increased risk of torsades de pointes <350 = short

Question 432

Erythema multiforme

Answer 432

Type 4 (delayed type) hypersensitivity reaction - Target lesions; can involve mucosa Most commonly caused by infection - HSV - Mycoplasma pneumoniae in children Subside in 2 weeks

Question 433

Erythema nodosum

Answer 433

Type 4 (delayed type) hypersensitivity reaction resulting from exposure to various antigens Immune complex deposition in subcutaneous fat Typical: erythematous, tender nodules on shins Streptococcal infection most common infectious cause

Question 434

Morel Lavallee Lesion

Answer 434

- Soft tissue injuries seen in high-velocity trauma - Usually associated with underlying fractures of the pelvis, acetabulum, or proximal femur - Development of a cavity in the pre-fascial plane, which occurs due to the generation of shearing effect in between underlying fascial layers and superficial subcutaneous tissues

Question 435

NICE traffic light system

Answer 435

For <5y Identify likelihood of serious illness Components Color Activity Respiratory Circulation and hydration Others

Question 436

AVM grading scale

Answer 436

Spetzler Martin grading scale for intracranial arteriovenous malformations - size 1/2/3 <3cm, 3-6cm, <6cm - location 0/1 - deep venous drainage 0/1 Point 1 to 5 (implies surgical risk)

Question 437

Syndrome associated with telangiectasia and AVM

Answer 437

Hereditary hemorrhagic telangiectasia (aka Osler-Weber-Rendu syndrome)

Question 438

Clinical findings suggesting spinal cord injury in unconscious trauma patient ppt

Answer 438

1. Paradoxical breathing or abd breathing (if loss of diaphragm innervation) 2. Priapism 3. Flaccid paralysis 4. Flaccid anal sphincter 5. Persistent bradycardia and hypotension (neurogenic shock) 6. LL flaccid but normal UL tone (paraplegia) ?Areflexia JCM

Question 439

Parkland formula

Answer 439

4ml x BW (kg) x TBSA (%) Half in first 8 hours; half in next 16 hours Count from injury time *3ml in children

Question 440

Clinical prediction rule for septic arthritis in children (vs transient synovitis) ppt

Answer 440

Kocher criteria 1. NWB 2. T >38.5 3. ESR >40 4. WBC >12

Question 441

Scale for patient agitation or aggression ppt

Answer 441

Overt aggression scale component - Verbal aggression - Physical aggression against self // object // people

Question 442

RVOT VT ECG features

Answer 442

LBBB Inferior axis Epsilon waves in V1-4 (during SR) - should be ARVD only **because originate from RV -> inferior axis; delayed LV activation -> LBBB Tx: ATP, synchronized cardioversion

Question 443

AVNRT ECG features

Answer 443

No visible P waves Pseudo R' waves (retrograde P waves) in V1-2 Normal axis, narrow QRS Tx: ATP

Question 444

AF with WPW ECG features

Answer 444

Irregular, HR >200 Wide and polymorphic QRS complex Normal axis Tx: Procainamide, synchronized cardioversion Avoid nodal blockers

Question 445

Left posterior fascicular VT ECG features

Answer 445

Regular wide complex QRS 100-140ms RBBB LAD Capture beat *originate from LV -> RBBB (delayed RV activation) Tx: Verapamil, synchronized cardioversion

Question 446

Cutaneous larva migrans

Answer 446

Parasite infection (hookworm) Cannot penetrate through dermis Self limiting

Question 447

Neurocysticercosis

Answer 447

Parasitic CNS infection caused by Taenia Solium (pork tapeworm) *larval stage (cysticercus)

Question 448

Wrist TFCC full name

Answer 448

Triangular fibrocartilage complex Ulnar wrist pain Clicking or point tenderness between pisiform and ulnar head *Piano key test

Question 449

Difficult BVM ROMAN

Answer 449

Radiation (H&N) / Restriction (poor lung compliance) Obstruction / Obesity / OSA Mask seal / Mallampati / Male Age >55y No teeth

Question 450

Difficult extraglottic device RODS

Answer 450

Restricted mouth opening Obstruction / Obesity Disrupted / Distorted airway Stiff lungs

Question 451

Difficult cricothyrotomy SHORT/SMART

Answer 451

Surgery Hematoma / Mass Obesity / Access Radiation Trauma

Question 452

SALAD technique

Answer 452

Suction assisted laryngoscopy and airway decontamination indication: massive airway contamination with blood or vomitus - to prevent aspiration place rigid suction catether at upper left eso inlet and left in place - vigorous suctioning of upper airway - use laryngoscope to distract mandible and contain tongue into floor of mouth

Question 453

CVC endovenous placement confirmation NLTH

Answer 453

Primary 1. Direct visualization of needle tip during venous puncture by access needle 2. Direct visualization of guidewire within venous lumen by USG before dilatation Secondary 1. Pressure waveform check 2. Blood gas analysis (low pO2 and O2 saturation for venous blood) 3. Microbubble test for supradiaphragmatic CVC - 10ml agitated saline, presence of RA swirl sign with 2sec by echo at subcostal/apical 4 view

Question 454

Spondylolysis

Answer 454

Stress # in pars interarticularis most common in L5

Question 455

Myopericarditis vs Perimyocarditis

Answer 455

Myoperi - acute pericarditis with elevated TnI, normal LVEF Perimyo - acute pericarditis with elevated TnI, reduced LVEF

Question 456

Cause of Myopericarditis statpearls

Answer 456

Infectious Causes Viral: Coxsackievirus, adenoviruses, herpes viruses, echovirus, Ebstein-Barr virus, cytomegalovirus, influenza virus, hepatitis C virus, parvovirus B19 Bacterial: Mycobacterium tuberculosis, Streptococcus, Staphylococcus, Haemophilus, Legionella, Mycoplasma Fungal: Histoplasma, Aspergillus, Blastomyces, coccidioidomycosis Parasites: Toxoplasma, amebic, Chaga disease Non-Infectious Causes Drugs (cardiotoxic effects or hypersensitivity reactions): procainamide, isoniazid, hydralazine, alcohol, anthracycline, heavy metals Post-radiation to the chest cavity Systemic inflammatory diseases: SLE, RA, scleroderma, Sjogren, mixed connective tissue disease Other inflammatory conditions: Granulomatosis, IBD Metastatic cancers: CA lung, CA breast, melanoma Primary cardiac tumors: Rhabdomyosarcoma Metabolic: Hypothyroidism, Renal failure/uremia Vaccine-associated myopericarditis

Question 457

Young patient syncope, important ECG diagnosis for sudden cardiac death x7 ppt

Answer 457

1. Brugada syndrome 2. HCM 3. Long QT syndrome 4. Arrhythmogenic RV dysplasia (ARVD) 5. WPW syndrome 6. Early repolarization syndrome 7. Catecholaminergic polymorphic VT

Question 458

Potential life-threatening marine animal exposure ppt

Answer 458

1. Pufferfish - resp failure 2. Paralytic shellfish - resp failure 3. Freshwater crayfish -rhabdo, ARF 4. Large reef-dwelling fish (Ciguatera) - CVS collapse, resp failure 5. Sea snake - myotoxic, neurotoxic, rhabdo, muscle paralysis, resp failure 6. Jellyfish (box jellyfish) - cariopulmonary arrest, anaphylaxis 7. Blue-ringed octopus - tetrodotoxin, muscle paralysis, resp failure 8. Cone snail (cone shell) - muscle paralysis, resp failure 9. Stonefish (Hot water immersion 45oC)

Question 459

Lokelma

Answer 459

Sodium zirconium cyclosilicate Bind K in GIT -> increases fecal K excretion

Question 460

Risk of anti-thyroid drug ppt

Answer 460

1. Potential teratogenicity (CBZ > PTU) 2. Agranulocytosis (PTU > CBZ) 3. Hepatotoxicity

Question 461

Agitation / Sedation scale ppt

Answer 461

Richmond Agitation and Sedation Scale (RASS) Ramsay sedation scale

Question 462

DOPES

Answer 462

Displaced ETT Obstruction PTX Equipment failure Stacked breaths

Question 463

DOTTS

Answer 463

Disconnect patient from ventilator Oxygen via BVM, check for chest rise and cuff leak Tube position and patency - with bougie and suction catheter Tweak ventilator Sonography and CXR for PTX

Question 464

CI for permissive hypercapnia

Answer 464

Cerebral edema, increased ICP, seizure prep: Severe metabolic acidosis, CVS instability

Question 465

Cat scratch disease organism

Answer 465

Bartonella henselae

Question 466

DC vs AC electrical injury

Answer 466

DC: -single muscle spasm, throws victim away -short duration of exposure but higher chance of trauma AC: -tetanic contractions (often hand contact; flexors stronger than extensors) -grasping the source, prolong exposure

Question 467

CI of delayed sequence intubation ketamine 1-2mg/kg IV

Answer 467

1. Inability to breathe spontaneously 2. Inability to protect own airway

Question 468

Medical Cx of molar pregnancy ppt

Answer 468

1. Thyrotoxicosis 2. Hyperemesis gravidarum 3. Early onset pre-eclampsia

Question 469

Sheehan syndrome

Answer 469

Postpartum pituitary gland necrosis

Question 470

Asherman syndrome

Answer 470

Intrauterine adhesion/scarring after surgery of uterus Amenorrhea, recurrent pregnancy loss, IU adhesions

Question 471

Cupola sign

Answer 471

pneumoperitoneum seen on supine X ray - air beneath central tendon of diaphragm in midline

Question 472

Mechanism of lightning injury ppt EM book

Answer 472

1. Direct strike (5%) 2. Side flash (30%) 3. Contact (15%) 4. Ground current (50%) Book also: 5. Upward streamer 6. Ball lightning 7. Blunt trauma

Question 473

Delayed Cx of lightning injury ppt

Answer 473

Psy: - memory, concentration impairment - depression, personality change ENT: - hearing loss CVS: - delayed pericarditis Skin - delayed SCC Eye - cataract - optic neuritis

Question 474

Strychnine poisoning book

Answer 474

Spinal glycine receptor blocker Spinal seizures - 4 limbs twitching, sparing face and with intact sensorium Mimics tetanus, can cause resp failure Tx: BZD, muscle relaxant, resp support Fruit of Ma-Quan-Zi

Question 475

FAST-ED scale for stroke

Answer 475

Field Assessment Stroke Triage for Emergency Destination scale

Question 476

Etomidate

Answer 476

inhibit 11 beta hydroxylase which is responsible for the final conversion of 11-deoxycortisol to cortisol

Question 477

Button battery severe outcome predictors

Answer 477

1. Lodged in eso 2. >20mm 3. <6y 4. multiple button batteries ingestion

Question 478

Triad for Aconite poisoning

Answer 478

GI upset - N/V/D/abd pain Neuro symptoms - numbness (face, then spread to limbs) - diaphoresis, carpopedal spasm, syncope CVS - palpitation, hypotension - sinus bradycardia, HB, AF, tachycardia, ventricular ectopics/arrhythmias - ventricular tachyarrhythmias: VF, sustained VT, polymorphic VT (torsades), cardiac arrest rapid onset 0.5-4h; improve after 12-24h

Question 479

Penetrating neck injury Hard signs of vascular injury

Answer 479

Signs suggestive of vascular injury: 1. Expanding or pulsatile hematoma 2. Active hemorrhage 3. Vascular bruit or palpable thrill 4. Shock refractory to fluid resuscitation 5. Absent pulse ?Wound bubbling Neurologic deficit (On physical examination, this is suggestive of cerebral ischemia) Signs suggestive of esophageal injury: 1. Massive hemoptysis 2. Significant hematemesis 3. Respiratory distress

Question 480

Penetrating neck injury Soft signs of vascular injury

Answer 480

1. Dysphonia 2. Dysphagia 3. Non-expanding hematoma 4. Subcutaneous or mediastinal air 5. Minor hemoptysis or hematemesis

Question 481

Transcutanous pacing

Answer 481

Anterolateral leads placement better as closer to apex No capture despite high mA: Hair shave, avoid air/fluid like PTX/pericardiac effusion, correct electrolytes

Question 482

Acute mountain sickness (AMS) Tx

Answer 482

Tx: Acetazolamide, O2, Dexamethasone, HBOT, Descent Cardinal feature = headache

Question 483

High altitude cerebral edema (HACE) Tx

Answer 483

AMS with mental state change or ataxia Tx: Dexamethasone, Acetazolamide

Question 484

High altitude pulmonary edema (HAPE) Tx

Answer 484

Tx: O2, rest, HBOT, descent, Nifedipine, Tadalafil, Sildenafil Prevention: Nifedipine

Question 485

Doppler USG sign for testicular torsion

Answer 485

Whirlpool sign

Question 486

DDx of Testicular torsion

Answer 486

Torsion of appendix testis (blue dot sign on PE)

Question 487

Acid/Alkali injury necrosis type

Answer 487

Acid ingestion: coagulation necrosis Alkali ingestion: liquefactive necrosis

Question 488

Gamekeeper’s thumb

Answer 488

aka Skier's thumb Injury of Ulnar collateral ligament of thumb MCPJ Forced abduction and hyperextension Valgus stress test Thumb spica splint Stener lesion: Aponeurosis of adductor pollicis muscle becomes interposed between ruptured UCL and its site of insertion (MCPJ)

Question 489

Cx of Basal skull #

Answer 489

1. Meningitis, CNS infection 2. CSF fistula 3. Cavernous sinus thrombosis 4. Pneumocephalus

Question 490

CSF rhinorrhea

Answer 490

Bedside glucose test for clear fluid (present in CSF) If blood stained – dab on tissue paper to look for halo/ring Gold standard: test for beta-2-transferrin

Question 491

Hamate # classification

Answer 491

Milch classification 1: hook of hamate 2: body (2a: coronal; 2b: transverse)

Question 492

ACJ injury classification

Answer 492

Rockwood classification 3 ligaments: Acromio-clavicular (AC); Coraco-clavicular (CC); Coraco-acromial (CA)

Question 493

Inferior shoulder dislocation associated injury

Answer 493

Axillary artery

Question 494

Mangled limb definition

Answer 494

A limb with an injury to at least three out of four components 1. soft tissue 2. bone 3. nerves 4. vessels

Question 495

Open fracture classification

Answer 495

Gustilo-Anderson classification Type 1: wound <1cm 2: wound 1-10cm 3A: >10cm 3B: bone exposure 3C: vascular injury

Question 496

Galeazzi fracture-dislocation MUGGER

Answer 496

Radius (distal 1/3) + DRUJ dislocation

Question 497

Monteggia fracture-dislocation MUGGER

Answer 497

Ulnar (proximal 1/3) + radial head dislocation

Question 498

Terrible triad of shoulder injury

Answer 498

Shoulder dislocation Rotator cuff tear Brachial plexus injury

Question 499

Boutonniere deformity

Answer 499

rupture of central slip of extensor tendon at PIPJ

Question 500

Tourniquet for bleeding name

Answer 500

Combat application tourniquet

Question 501

Bleeding not detected by FAST scan

Answer 501

Retroperitoneal bleeding External bleeding Long bone fracture/bleeding <200ml intra-capsular

Question 502

Damage control resuscitation 3 components

Answer 502

Permissive hypotension Hemostatic resuscitation (early transfusion, prevent acidemia) Damage control surgery

Question 503

Damage control surgery litfl

Answer 503

Limited surgical interventions to control haemorrhage and minimize contamination until the patient has sufficient physiological reserve to undergo definitive interventions

Question 504

Inhalational burn injury signs

Answer 504

1. Facial burn 2. Singed eyebrow / facial hair 3. Soot over nasal cavity 4. Oropharyngeal swelling 5. Hoarseness of voice 6. Stridor 7. Carbonaceous sputum

Question 505

Severe burn scores

Answer 505

1. Modified Baux score Age + TBSA of full thickness burn + 17 (if inhalational injury) >140 = non survivable 2. Abbreviated Burn Severity Index (ABSI) Age, sex, TBSA (%), presence of full thickness burn, inhalational injury

Question 506

Pott puffy tumor

Answer 506

Forehead swelling due to frontal bone osteomyelitis with associated subperiosteal abscess Rare complication of sinusitis

Question 507

Orbital # common location

Answer 507

Lamina papyracea aka orbital lamina of the ethmoid bone forms medial wall of orbit

Question 508

Penumbra

Answer 508

Reversibly injured brain tissue around the ischemic core which is the target for the treatment of acute stroke

Question 509

NF USG STAFF

Answer 509

Subcutaneous thickening Air Fascial Fluid

Question 510

Mount Fuji sign in CTB

Answer 510

Tension pneumocephalus

Question 511

NAI ordinance

Answer 511

Cap 213 Protection of Children and Juveniles Ordinance Children <14y; Juveniles 14-18y

Question 512

Kleihauer-Betke test

Answer 512

Check on maternal blood Determine the amount of HbF that has passed into the maternal circulation

Question 513

Atracurium vs Cisatracurium

Answer 513

Atracurium has histamine release - not to use in asthma

Question 514

Dynamic hyperinflation

Question 515

Sepsis definition

Answer 515

Life-threatening organ dysfunction as a result of dysregulated host response due to an infection

Question 516

Septic shock

Answer 516

Sepsis III definition of SEPTIC SHOCK: Infection causing vasopressor requirement to maintain a MAP > 65 mm (despite fluid resuscitation) plus a serum lactate >2 mM.

Question 517

60/60 sign

Answer 517

Pulmonary acceleration time <60 ms (normal >130) Pulmonary arterial systolic pressure (TR jet gradient) <60 mmHg

Question 518

Pre-eclampsia medication dosage

Answer 518

1. MgSO4 4-6g in 100ml NS over 15 mins; infusion 2g/h 2. Labetalol 20mg IV bolus, repeat in 10 min interval 3. Hydralazine 5mg IV (Nicardipine infusion 5mg/h uptodate) Oral meds Labetalol 100mg BD Nifedipine 10mg BD Methyldopa 250mg TDS Treatment threshold: BP 160/110

Question 519

NRP adrenaline dose

Answer 519

IV: 0.02mg/kg ETT: 0.1mg/kg

Question 520

Scrub typhus organism and vector

Answer 520

Orientia tsutsugamushi Mites

Question 521

Ix

Answer 521

USG Doppler USG QE Patrick EM book Prep course ppt KWC ppt JCM PIC COC Guidelines

Question 522

Keraunoparalysis

Answer 522

can be caused by lightning strike transient weakness affecting the lower limbs more commonly and automatically reverses in a matter of few hours

Question 523

Major incident managment METHANE

Answer 523

Major incident declared Exact location Time Hazard Access Number of patients EMT / Emergency services required

Question 524

Major incident response - 4Cs

Answer 524

Communicate Coordinate Command Control

Question 525

Hazmat agents Pulmonary Vesicant Blood agent Nerve agent

Answer 525

Pulmonary agent: Phosgene, Chlorine Vesicant (blistering agent): Sulphur mustard Blood agent: Hydrogen cyanide Nerve agent (AChE inhibitor): Tarun, Sarin, Soman, VX Thallium / Cesium: Prussian blue as antidote

Question 526

Types of data

Answer 526

Nominal - categorical - cannot rank - e.g. name, gender, race, zip code, favorite song, yes/no Ordinal - categorical with an order - can rank; but difference between adjacent scores are not equal - e.g. agree/strongly agree; beginner/intermediate/advanced; age subset; stage of cancer Interval - numerical - can rank; and differences between adjacent scores are equal - no true zero - e.g. IQ, Celsius Ratio scale - numerical - has true zero - e.g. Kelvin, length, area, population - discrete: only in countable numbers e.g. integers - continuous: infinite values

Question 527

Stat tests

Answer 527

t test: - compare the means of two groups - assume: data are independent; normally distributed; similar variance - if more than 2 groups, use ANOVA (Analysis of Variance) test - predictor categorical (1 predictor), outcome quantitiative Fisher's exact test: - non-parametric - can be used when sample size is small Chi-square test: - non-parametric - no normal distribution - Categorical predictor and outcome variable (nominal or ordinal data) Mann–Whitney U test: - non-parametric - Categorical predictor variable - Quantitative outcome variable

Question 528

CONSORT

Answer 528

Consolidated Standards of Reporting Trials - provides checklist for essential items to be reported in RCTs

Question 529

Cronbach’s alpha

Answer 529

Assess reliability >0.9 = excellent <0.7 = questionable

Question 530

Number needed to treat (NNT)

Answer 530

1/ Absolute risk reduction (ARR)

Question 531

ROC curve

Answer 531

Receiver operating characteristic curve TP rate (y-axis) against FP rate (x-axis) Slope = positive likelihood ratio (PLR) TP rate = sensitivity FP rate = 1-specificity Area under curve (AUC) = diagnostic accuracy Optimal point of cutoff = most NW point (left uppermost corner) DeLong's test to compare 2 ROC curves (area under curve)

Question 532

Power of study

Answer 532

1 - beta i.e. "1- type 2 error"

Question 533

Applicability 5 Killer Bs

Answer 533

1. Biology: any difference in ethnics or disease severity 2. Barrier: the availability in our local department or locality 3. Bargain: the benefit, compared to the risk, cost and any competitors 4. Belief: the degree of acceptance in local community, or in local professions 5. Burden: the prevalence of the disease in the locality, amount of patient load

Question 534

Pre-test probability

Answer 534

= Prevalence

Question 535

Pre-test odds

Answer 535

= pre-test probability / (1-pre-test probability)

Question 536

Post-test odds

Answer 536

= pre-test odds x likelihood ratio

Question 537

Power of study 3 factors affecting LAW

Answer 537

1. Sample size (larger sample size larger power) 2. Effect size (for same power, needs larger sample size to detect smaller difference) 3. alpha value (higher alpha value -> more likely to have stat sig result -> reject null hypothesis)

Question 538

Vertical line of RR =1

Answer 538

The line of no effect

Question 539

Concept on thinking to start conducting a study FINER

Answer 539

Feasible Interesting Novel Ethical Relevant

Question 540

PICO / PEO

Answer 540

Patient Intervention Comparison Outcome Patient Exposure Outcome

Question 541

Study design level of evidence LAW

Answer 541

RCT > Cohort (prospective > retrospective) > Case control (nestsed > others) > Cross-sectional > Retrospective case series

Question 542

Elements of validity in RCT RAMBO

Answer 542

Randomization Ascertainment (Intention to treat analysis + FU adequacy) Blinding Measurement objective

Question 543

Intention to treat vs Per protocol analysis vs Sensitivity analysis LAW

Answer 543

ITT - analyze subject in group in which he was randomized/allocated - even if switched groups - preserve power of randomization Per protocol analysis - non-compliant patients not included in analysis Sensitivity analysis - worst case scenario calculation

Question 544

Experimental event rate (EER) Control event rate (CER) Relative risk (RR) Relative risk reduction (RRR) Absolute risk reduction (ARR) Number needed to treat (NNT) Odds ratio (OR) calculations

Answer 544

EER = a/(a+b) CER = c/(c+d) RR = EER / CER = [a/(a+b)] / [c/(c+d)] RRR = (CER-EER)/CER *i.e. 1-RR or 1-(EER-CER) ARR = CER-EER NNT = 1/ARR RRR and ARR shows clinical significance but not stat sig (need 95% CI / p value) Odds ratio = (a/b) / (c/d) = ad/cb *OR approximates RR when prevalence is very low (i.e. a and c is small)

Question 545

3 pillars in EBM LAW

Answer 545

Validity Result Applicability

Question 546

Simpson's paradox

Answer 546

A paradox is a logically self contradictory statement or a statement that runs contrary to one's expectation. Simpson's paradox is a phenomenon in which a trend appears in several different groups of data but disappears or reverses when these groups are combined

Question 547

Bonferroni correction

Answer 547

method to counteract the multiple comparisons problem all comparisons should be performed at the α/d significance level, not at the α level α = desired overall α level d = no. of comparison

Question 548

Sensitivity Specificity Prevalence Accuracy Positive predictive value (PPV) Negative predictive value (NPV) Positive likelihood ratio (PLR) Negative likelihood ratio (NLR)

Answer 548

a = TP b = FP c = FN d= TN Sn = a/(a+c) i.e. TP / (TP + FN) *TP/Disease positive Sp = d/(b+d) i.e. TN / (TN + FP) *TN/Disease negative Prevalence = (a+c) / (a+b+c+d) i.e. Disease / Total Accuracy = (a+d) / (a+b+c+d) i.e. (TP+TN) / Total *Test positive / Total PPV = a/(a+b) i.e. TP / (TP + FP) *TP/Test positive NPV = d/(c+d) i.e. TN / (TN + FN) *TN/Test negative *both changes with prevalence PLR = a/b = TP / FP = Sen/(1-spec) *>10 = good NLR = c/d = FN / TN = (1-Sen) / Spec *<0.1 = good

Question 549

Probability and odds equation

Answer 549

odds = p / (1-p) probability = odds / (1+odds)

Question 550

Pre-test probability Pre-test odds Post-test odds Post-test probability

Answer 550

Pre-test probability = Prevalence Pre-test odds = p / (1-p) = pretest probability / (1-pretest probability) Post-test odds = Pre-test odds x likelihood ratio Post-test probability = Posttest odds / (Posttest odds + 1) *Post-test probability better than PPV for estimating subject with positive diagnostic test

Question 551

Estimation of post-test probability from pre-test probability

Answer 551

Fagan's nomogram (Likelihood ratio nomogram)

Question 552

Spectrum bias

Answer 552

Subjects included in a study are not representative of the population, leading to clinically significant differences in post-test probabilities.

Question 553

Verification bias

Answer 553

Patients with negative results are not evaluated with the gold standard test

Question 554

Causality criteria

Answer 554

Bradford Hill criteria (9 criteria) 1. Strength 2. Consistency 3. Specificity 4. Temporality 5. Biological gradient 6. Plausibility 7. Coherence 8. Experiment 9. Analogy

Question 555

Funnel plot

Answer 555

For systematic review/meta-analysis Scatterplot of treatment effects Detects bias / heterogeneity Assymetrical -> publication bias (but not only cause)

Question 556

Fixed effect model vs Random effect model

Answer 556

For meta analysis Fixed effect model: use if no sig heterogeneity Random effect model: use if moderate/high heterogeneity Wider confidence interval

Question 557

Forest plot

Answer 557

For systematic review/meta-analysis Graphical display of estimated results from a number of scientific studies addressing the same question, along with the overall results Detects heterogeneity x-axis: clinical effects, e.g. RR, OR, ARR, NNT Vertical line: line of no effect Square: weight of each study; line through the square is 95% CI Diamond: overal estimate, center represents pooled point estimate, horizontal ends is 95% CI

Question 558

Test for heterogeneity

Answer 558

1. Eyeball test (look at forest plot) 2. Cochran's Q test (Chi square test, p value) 3. I2 test

Question 559

Prognosis use which study

Answer 559

Cohort study

Question 560

Statistical tests to test for any difference between 2 or more survival curves

Answer 560

1. Cox proportional hazard model 2. Log rank test

Question 561

Trauma scores

Answer 561

Anatomical 1. Abbreviated injury scale (AIS) 2. Injury severity score (ISS) - 9 regions each 6 gradings; sum of square of 3 highest regions; score 1-75 3. New ISS (NISS) Physiological 4. Pediatric trauma score (PTS) 5. Revised trauma score (RTS) - GCS, SBP, RR 6. APACHE score (Acute physiology and chronic health evaluation) 7. GCS Combined 8. Trauma score - Injury severity score (TRISS) 9. Kampala trauma score (KTS)

Question 562

Score for predicting massive transfusion

Answer 562

ABC score (Assessment of blood consumption) <2: unlikely; 3: 45%; 4: 100% - penetrating injury - SBP <90 in AED - HR >120 in AED - FAST +ve TASH score (Trauma associated severe hemorrhage) - Sex - Hb - BE - SBP - HR - FAST +ve - Clinically unstable pelvic # - Open or dislocated femur # PWH score (Rainer score) >=6 - SBP <90 (3) - HR >120 (1) - GCS <= 8 (1) - Displaced pelvic # (1) - CT/USG +ve for fluid (2) - BE >5 (1) - Hb <= 7 (10) / Hb 7-10 (1) Shock index (HR/SBP) >0.9 = higher risk of massive transfusion

Question 563

Risk factor of Ovarian hyperstimulation syndrome (OHSS)

Answer 563

1. Young age 2. Low BMI 3. PCOS 4. Previous OHSS 5. Elevated estradiol level

Question 564

OHSS avoid what PE

Answer 564

Avoid pelvic examination -> trauma to ovary -> induce rupture of cysts

Question 565

Cx of OHSS

Answer 565

1. Ovarian torsion 2. Ruptured ovarian cyst 3. Thromboembolism 4. Pericardial effusion, CHF 5. Renal failure 6. ARDS

Question 566

Features of severe pre-eclampsia qe

Answer 566

1. Headache 2. Blurring of vision 3. Altered mental status 4. Plt <100 5. Pul edema 6. dLFT ALT > 2x ULN

Question 567

Signs of imminent delivery qe

Answer 567

1. Regular uterine contractions of 1-2 min interval 2. Increase in bloody show 3. Irresistible urge to bear down 4. Crowning of baby's head or breech presentation part appear in vulva 5. Bulging of perineum 6. Dilatation of anal sphincter 7. Bowel movement

Question 568

Shoulder dystocia HELPER4

Answer 568

Call for help early Evaluate and explain the clinical situation Legs - McRoberts maneuver Suprapubic pressure Enter birth canal posteriorly and assess the need for episiotomy Remove posterior arm Rotational maneuvers (Rubin II; Rubin II + Woods screw; Reverse Woods screw) Roll patient to hands and knees (all 4 position) Repeat

Question 569

Active management of third stage of labor (AMTSL) ALSO

Answer 569

1. Oxytocin 10U IV bolus over 1-2 min (or IMI; IV preferred) with delivery of infant ASAP 2. Delayed cord clamping for 1-3 mins 3. Continuous, gentle cord traction (Brandt maneuver) 4. Transabdominal uterine massage after placenta delivers

Question 570

Medications for uterine atony / PPH ALSO

Answer 570

1. Oxytocin 20IU IMI, or 10U IV over 10 mins then infusion 2. Syntometrine 1 ampoule IMI (5u Syntocinon + 0.5mg ergometrine) - caution for pt with HT 3. Carboprost 0.25mg IMI - caution for pt with asthma, sig renal/hepatic/cardiac disease 4. Misoprostol 600 mcg SL (PR, PV PO) 5. Tranexamic acid 1g over 10 mins

Question 571

Fitz-Hugh–Curtis syndrome

Answer 571

Uncommon Cx from pelvic inflammatory disease Perihepatitis, by perihepatic adhesions RUQ pain, referred pain to R shoulder

Question 572

Rhesus hemolytic disease of the newborn

Answer 572

Give Anti-D immunoglobulin Do Kleihauer-Betke test to determine amount of fetal Hb in materal circulation

Question 573

Special consideration of resuscitation for pregnant women ABC

Answer 573

A - Anticipate difficult airway - Apply apneic oxygentation technique to prolong safe apneic time - Apply cricoid pressure to reduce risk of aspiration (laxed LES) - Use ETT of 1 size smaller due to airway edema - Use laryngoscopy with short handle for larger breasts B - Baseline resp alkalosis; normocapnia may imply impending resp failure - Increase O2 consumption by 20%; rapid decrease in PaO2 leads to hypoxia - Decrease tidal volume (TV) and functional residual capacity (FRC) C - Manual lateral uterine displacement to relieve aortocaval compression - IV access set above diaphragm to bypass aortocaval compression - Fetal monitoring beyond 20-24 wk ges - Remove fetal monitoring device before defib - Early fluid and blood products resuscitation; avoid vasopressors

Question 574

Emergency contraception

Answer 574

1. Levonorgestrel 1.5mg PO once (within 72h) -progestogen 2. Ulipristal 30mg PO once (within 120h) - selective progesterone receptor modulator 3. Copper IUCD insertion (within 120h)

Question 575

Croup treatment

Answer 575

1. Dexamethasone 0.6 mg/kg PO/IM/IV 2. Nebulized adrenaline 1:1000 solution 0.5 mg/kg (max 5mL)

Question 576

Pyloric stenosis USG findings

Answer 576

Target sign Cervix sign 3.1415 Pyloric muscle thickness >3mm Pyloric transverse diameter >14mm Pyloric muscle length (longitudinal) >15mm

Question 577

IO sites for pedi qe

Answer 577

1. Proximal humerus: 2cm above the surgical neck at greater tubercle 2. Proximal tibia: 1-2cm inferior and medial to tibial tuberosity 3. Distal tibia: 3 cm proximal to most prominent part of medial malleolus 4. Iliac crest 5. Distal femur: anterolateral surface, 3 cm above lateral condyle 6. Sternum Pink needle: <6m Blue needle: >6m Yellow needle: >40kg

Question 578

Test for rash of meningococcemia

Answer 578

Glass test - does not fade against pressure

Question 579

Pedi status epilepticus drug dose

Answer 579

First line 1. Lorazepam IV 0.1mg/kg max 4mg 2. Diazepam IV 0.2mg/kg max 10mg; PR 0.5mg/kg 3. Midazolam IV 0.2mg/kg Second line 4. Phenytoin (Dilantin) IV 20mg/kg, max 1.5g 5. Levetiracetam (Keppra) IV 60mg/kg, max 4.5g 6. Valproic acid (Epilim) IV 40mg/kg, max 3g 7. Phenobarbital IV 20mg/kg, max 1g Third line 8. Midazolam infusion 0.2mg/kg bolus, then 0.05-0.1mg/kg/h 9. Pentobarbital infusion 5-15mg/kg bolus, then 0.5mg/kg/h **Pentobarbital not phenobarbital! seldom use propofol for pedi Naloxone 0.1mg/kg/dose for narcotic overdose Pyridoxine 50-100mg IV if isoniazid toxicity

Question 580

Hypoglycemia for children treatment dose

Answer 580

D10 2ml/kg, repeat after 15-20mins then D5/10 infusion Glucagon 0.5mg (<25kg) / 1mg (>25kg) IMI *only useful in insulin mediated hypoglycemia (e.g. sulphonylurea, accident insulin)

Question 581

3 narrow points for esophagus button battery ingestion

Answer 581

1. Upper esophageal sphincter (cricopharyngeus - C6) 2. Aortic arch constriction (T4) 3. Lower esophageal sphincter (T10)

Question 582

Auto-AED use in Pedi

Answer 582

1 years old cutoff for pedi mode <1y - manual defibrillator 1-8y - pedi mode >8y - adult mode

Question 583

Defib dose Pedi

Answer 583

1st defib: 2J/kg 2nd defib: 4J/kg Subsequent >4J/kg, max 10J/kg or adult dose Adrenaline 0.01mg/kg IV (0.1mg/kg ETT) Amiodarone 5mg/kg Lignocaine 1mg/kg loading, then 20-50mcg/kg/min infusion

Question 584

Chikungunya fever

Answer 584

Chikungunya virus Vector = Aedes aegypti; can also be Aedes albopictus Fever and debilitating joint pain Can cause GBS Symptoms similar to Dengue

Question 585

Malaria parasites / vectors

Answer 585

Plasmodium falciparum P. malariae P. ovale P. vivax (can cause severe disease) P. knowlesi (can cause severe disease) Vector: Anopheles mosquito Incubation 12-35 days

Question 586

Severe malaria definition

Answer 586

Presence of P. falciparum parasitemia + 1 of 1. Impaired consciousness 2. Multiple convulsions 3. Acidosis 4. Hypoglycemia 5. Severe anemia 6. Renal impairment 7. Jaundice 8. Pul edema 9. Sig bleeding 10. Shock 11. Hyperparasitemia 12. Prostation (generalized weakness)

Question 587

Tx of malaria

Answer 587

Severe: IV artesunate 2.4mg/kg over 1-2 minutes Alternative: Quinine IV + Doxycycline PO

Question 588

Hereditary angioedema enzyme deficiency

Answer 588

C1 esterase inhibitor deficiency Tx: C1 inhibitor concentrate, FFP, Icatibant, Ecallantide Given transamin if on ACEI

Question 589

Cerebral venous sinus thrombosis (CVST) signs

Answer 589

Plain CT: 1. Dense clot sign 2. Cord sign (hyperdensity of sinus) CT venogram: 3. Empty delta sign

Question 590

Risk factor for Cerebral venous sinus thrombosis (CVST)

Answer 590

1. Thrombophilia (Protein C or S deficiency; lupus anticoagulant, antiphospholipid syndrome) 2. Estrogen (preg, OCP, tamoxifen) 3. Smoker 4. Female 5. Age <50 6. Malignancy 7. Parameningeal infections 8. Trauma

Question 591

Cause of Young stroke qe

Answer 591

Vasculitis - moyamoya diseases, Behcets syndrome Carotid / vertebral a. dissection - traumatic Thrombophilia / hypercoagulable state - antiphospholipid syndrome, protein C/S def, leukemia, thrombocytopenia, preg, OCP Embolic - prothetic heart valve, IE Drugs - Cocaine, heroin, amphetamines Cerebral venous sinus thrombosis

Question 592

Waterhouse–Friderichsen syndrome

Answer 592

Bilateral adrenal gland failure due to hemorrhage Caused by sepsis, meningococcemia

Question 593

Purple Urine Bag Syndrome

Answer 593

Female, constipation on LT foley E coli, proteus, klebsiella

Question 594

Tumor lysis syndrome electrolytes

Answer 594

HyperK, HyperPO4, Hyper-uricemia HypoCa ARF due to CaPO4 and uric crystal formation in renal tubules

Question 595

Hyperviscosity syndrome Symptom triad

Answer 595

1. Mucosal bleeding 2. Visual change 3. Neurological deficit

Question 596

Hyperviscosity syndrome Common cause

Answer 596

1. Waldenstrom macroglobulinemia (type of B-cell lymphoma) 2. Multiple myeloma 3. Leukemia

Question 597

Dressler syndrome

Answer 597

aka postmyocardial infarction syndrome secondary pericarditis with or without pericardial effusion as a result of injury to the heart or pericardium (MI or recent cardiac surgery) Tx: high dose aspirin; steroid if refractory

Question 598

Tx of Torsades de pointes

Answer 598

Polymorphic VT; QTc prolongation in SR 1. Prompt defib if hemo unstable 2. MgSO4 1-2g IV over 15 mins 3. Temp transvenous overdrive pacing at 100bpm 4. Isoproterenol IV if triggered by pauses/bradycardia

Question 599

Echo findings in hypertrophic cardiomyopathy (HCM)

Answer 599

1. Asymmetrical septal hypertrophy 2. Systolic anterior motion of the mitral valve (SAM) 3. Dynamic LVOT obstruction

Question 600

Wilson’s disease

Answer 600

Kayser-Fleischer ring Low serum ceruloplasmin level High serum copper High 24hr urine copper Tx Chelator: D-penicillamine, Trientine

Question 601

Denver criteria

Answer 601

Determine whether CT angiography of the neck is indicated To detect blunt cerebrovascular injury (BCVI) with trauma patients

Question 602

Anterior Atlanto-dens interval (ADI) cutoff

Answer 602

<3mm in adults

Question 603

Posterior shoulder dislocation reduction method

Answer 603

Depalma method arm is first adducted and internally rotated, with caudal traction applied. Then, maintaining traction and internal rotation, the medial aspect of the upper arm is pushed laterally, disengaging the humeral head from the glenoid fossa. Finally the arm is extended, and the humerus falls back into place.

Question 604

3 in 1 protocol for pelvic fracture

Answer 604

1. Pelvic external fixation 2. Retroperitoneal pelvic packing 3. Angiographic embolization

Question 605

Hip dislocation classification

Answer 605

Thompson-Epstein system (based on X ray) Stewart-Milford system (based on functional hip stability) 90% hip dislocations are posterior

Question 606

Posterior hip dislocation Reduction techniques

Answer 606

1. Allis technique 2. Stimson technique 3. Captain Morgan technique 4. Whistler/Rochester technique 5. Bigelow technique Do within 6h to prevent AVN of femoral head Cx of posterior hip dislocation: AVN fem head, secondary OA, sciatic n injury, vascular injury

Question 607

Neurogenic shock above which level

Answer 607

T6 Triad: hypotension, hypothermia, bradycardia

Question 608

Spinal shock resolution first clinical indicator

Answer 608

Return of bulbocavernosus reflex

Question 609

Spinal cord injury classification

Answer 609

American spinal injury association (ASIA) classification Sudden, temporary loss or impairment of spinal cord function below the level of injury that occurs after an acute spinal cord injury, including the motor, sensory, reflex, and autonomic neural systems Flaccid paralysis, areflexia, loss of sphincter control

Question 610

Pilon #

Answer 610

Distal tibia involving articulating surface High energy trauma

Question 611

Pre-hospital stroke scale FAST-ED

Answer 611

Field Assessment Stroke Triage for Emergency Destination scale - Facial palsy - Arm weakness - Speech changes - Eye deviation - Denial / neglect Others 1. Cincinnati pre-hospital stroke scale 2. Los Angeles pre-hospital stroke screen

Question 612

Alcohol driving limit blood/breath/urine

Answer 612

50 mg of alcohol per 100ml (1dL) of blood; or **11mmol/L 22 micrograms of alcohol per 100ml of breath; or 67 mg of alcohol per 100ml of urine

Question 613

Stonefish toxin name

Answer 613

Stonustoxin abbreviation of STOnefish National University of Singapore + toxin

Question 614

Early sign of LA toxicity qe

Answer 614

1. Tinnitus 2. Perioral numbness 3. Visual disturbance 4. Agitation* 5. Confusion* 6. Arrhythmia 7. Convulsion *web

Question 615

Cyanide source

Answer 615

1. Fire victims (combustion of nitrogen-containing materials e.g. wool) 2. Electroplating 3. Bitter almond intake 4. IV nitroprusside

Question 616

4 indications for antidote in cyanide poisoning

Answer 616

1. Cardiac arrest 2. Impaired GCS <=13 3. Hypotension 4. Lactate >10mmol/L

Question 617

Indication of HBOT in fire victims

Answer 617

1. Syncope / LOC 2. Severe metabolic acidosis pH <7.1 3. Evidence of end organ damage (coma, seizure, cognitive deficits, MI) 4. COHb >25% // 15% in preg / children

Question 618

Heavy metal posioning associated conditions qe / book

Answer 618

Lead - basophilic stippling Arsenic - Mee's line on nail Inorganic mercury - Acrodynia Silver - Argyria Manganese - Parkinsons disease - Chelate with CaNa2-EDTA Cadmium - Itai Itai disease - Renal insufficiency and painful bones secondary to osteomalacia **Barium - hypoK - GL, oral MgSO4, can HD **Cesium - Cardiotoxicity, torsades de pointes - Prussian blue as antidote **Copper - GIB, AKI, hepatotoxicity - can try IMI BAL (British anti-lewisite) **Thallium - alopecia - Prussian blue

Question 619

Plants toxin matching qe

Answer 619

癲茄 - Toxin: Scopolamine - Anticholinergic 馬錢子 - Toxin: Strychnine - Spinal seizure, mimics tetanus - Resp failure 斑蝥 (Ban Mao) - Toxin: Cantharidin - Mucosal irritation, GIB, hematuria 斷腸草/鉤吻 - Toxin: Gelsemium - CNS depression, Resp depression, eye features 夾竹桃 - Toxin: Oleandrin - Digoxin like toxicity 杜鵑 - Toxin: Grayanotoxin - Altered mental state, bradycardia, hypotension

Question 620

Food toxin matching qe

Answer 620

1. Pufferfish - Tetrodotoxin 2. Shellfish - Paralytic/Neurotoxic/Amnesic/Diarrhetic/Azaspiracid shellfish poisoning 3. Coral reel fish - Ciguatoxin 4. Bitter almond / Bamboo shoot / Cassava / Apricots - Cyanide (Cyanogenic glycoside) 5. Ginkgo seed - Ginkgotoxin (Tx = Pyridoxine B6; can cause status epilepticus) 6. Crayfish - Haff's disease (rhabdomyolysis) 7. Sprouting potato - Solanine (GI upset) 8. Choi sum - OP 9. Canned food - Food botulism 10. Spinach - Methemoglobinemia 11. Starfruit - Neurotoxin (Caramboxin), oxalate (AKI/Neurotoxicity) 12. Lychee - Hypoglycin A (hypoglycemia, encephalopathy) / Methylenecyclopropylglycine (MCPG) 13. Pig's offal - Clenbuterol (B2 agonist) 14. Tuna - Scombroid 15. Uncooked green bean - Phytohemagglutinin (GI upset) 16. Hairy crab - Dioxin 17. Sushi - Anisakiasis 18. False taro (Alocasia) - Ca oxalate crystal

Question 621

Orbital compartment syndrome USG sign

Answer 621

Guitar pick sign

Question 622

Carotid blowout syndrome (epistaxis after RT HN cancer) Types qe

Answer 622

Type 1: Threatened Type 2: Impending Type 3: Acute Involves ICA/CCA Tx: Endovascular embolization / stenting; Surgical ligation

Question 623

Forms of elderly abuse COC

Answer 623

1. Physical 2. Sexual 3. Psychological 4. Neglect 5. Abandonment 6. Financial exploitation

Question 624

Indicators of potential elder abuse from history COC

Answer 624

1. Unexplained injuries 2. Past history of frequent injuries 3. Elderly patient referred to as “accident prone" 4. Delay between onset of medical illness or injury and seeking of medical attention 5. Recurrent visits to ED for similar injuries 6. Using multiple physicians or EDs for care 7. Non-compliance to medications or appointments

Question 625

Psychological or behavioral signs of elderly abuse COC

Answer 625

1. Apprehension 2. Withdrawal 3. Depression 4. Being passive

Question 626

Screening tools for elder abuse COC

Answer 626

1. Elder Abuse Assessment Instrument (EAAI) 2. Senior Abuse Identification tool (Senior AID) 3. Elder Abuse Suspicion Index (EASI) 4. Vulnerability to Abuse Screening Scale (VASS)

Question 627

Warning signs of elder abuse Physical abuse Sexual abuse COC

Answer 627

Physical 1. Unexplained bruises at multipl parts of body or of different colors 2. Unusual fractures 3. Cigarette burn marks, mouth/pharynx scalds (force-feeding) 4. Unusual pattern of injuries, e.g. bite mark, rope mark 5. Unexplained intracranial hematoma Sexual 1. Bruises or bleeding around ano-genital region 2. Evidence of veneral diseases 3. Unexplained urethritis 4. Torn, stained or bloody underwear

Question 628

Warning signs of elder abuse Psychological abuse Neglect COC

Answer 628

Psychological 1. Extremely passive 2. Depressed mood 3. Suicidal thought or attempt 4. Afraid of abuser 5. Avoid contacts with others 6. Hysteria Neglect 1. Dehydration, malnutrition 2. Injury without proper care 3. Neglected pressure ulcers 4. Inappropriate or soiled clothing 5. Poor hygiene

Question 629

Child abuse Indicators relating to physical harm/abuse physical vs behavioral

Answer 629

Physical 1. Bruises and welts 2. Lacerations and abrasion 3. Burns and scalds 4. Fractures 5. Internal injuries Behavioral 1. Explanations of cause of injury by carer unconvincing / inconsistent 2. Failure or delay in seeking medical advice 3. Excessive amount of clothes worn to cover body 4. Enacting/reproducing scenes of harm/maltreatment in play or daily behaviors by the child

Question 630

Child abuse Indicators relating to sexual harm/abuse physical vs behavioral

Answer 630

Physical 1. Torn, stained or bloodstained underwear 2. Bruises, bleeding/lacerations in external genitalia, vaginal, anus, mouth/throat 3. Vaginal/penile discharge 4. STD 5. Repeated UTI 6. Pregnancy Behavioral 1. Sleep disturbance 2. Excessive masturbation 3. Hypersensitive to being touched 4. Knowledge about sex beyond the expectation of their age

Question 631

Child abuse Indicators relating to neglect physical vs environmental vs behavioral

Answer 631

Physical 1. Malnutrition, underweight, frail 2. Developmental delay 3. Severe rash or other skin problems 4. Frequent accidental injuries Environmental 1. Confined at home 2. Absent from school 3. Insanitary home conditions 4. Unsafe living environment Behavioral 1. Addiction 2. Delinquency (minor crime) 3. Persistent complaints of hunger

Question 632

Child abuse Indicators relating to psychological harm/abuse physical vs behavioral

Answer 632

Physical 1. Underweight or frail 2. Developmental delay 3. Eating disorder 4. Psychosomatic symptoms Behavioral 1. Anxiety symtoms 2. Language delay 3. Self harm, suicidal thoughts/attempts

Question 633

PEP for STD COC

Answer 633

Female victim 1. Ceftriaxone 500mg IMI single dose 2. Doxycyline 100mg BD PO x 1 week // Azithromycin 1g PO once if preg 3. Metronidazole 500mg BD PO x 1 week Male victim 1. Ceftriaxone 500mg IMI single dose 2. Doxycyline 100mg BD PO x 1 week

Question 634

Psychological and counselling support services in HK for rape case COC

Answer 634

1. CEASE Crisis Center 2. RainLily

Question 635

Risk factors for escalating violence in Intimate partner violence COC

Answer 635

1. Isolation 2. Threatens to kill 3. Presence of a weapon 4. Pathological jealousy 5. Use of drugs/alcohol 6. Children at home

Question 636

Score for mortality of unstable angina / NSTEMI

Answer 636

TIMI Risk Score for UA/NSTEMI

Question 637

Score for chest pain in AED - predicts 6-week risk of major adverse cardiac events in patients with chest pain

Answer 637

HEART Score for Major Cardiac Events Hx ECG Age RF TnI

Question 638

Tx for HT crisis from pheochromocytoma

Answer 638

1. Phentolamine 2. Phenoxybenzamine, Terazocin, Prazocin Avoid BB as unopposed alpha action

Question 639

Coracoid process # classification

Answer 639

1. Ogawa classification 2. Eyres classification

Question 640

Medications hypoK if taken excessive amounts JCM

Answer 640

1. Diuretics 2. Laxatives 3. Steroids 4. Insulin 5. Abx (penicillin, ampicillin, amphotericin B)

Question 641

Composition of staghorn stone JCM

Answer 641

Struvite (magnesium ammonium phosphate)

Question 642

Tripod fracture components

Answer 642

aka Zygomaticomaxillary complex fracture (Lateral orbit + Zygoma + Maxilla) 1. Zygomatic arch 2. Inferior orbital rim, and anterior and posterior maxillary sinus walls 3. Lateral orbital rim

Question 643

Pericarditis Tx

Answer 643

1. Aspirin / NSAID 2. Colchicine 3. Glucocorticoid (Prednisolone)

Question 644

Risk factor of posterior reversible encephalopathy syndrome (PRES)

Answer 644

1. HT 2. Eclampsia 3. Vasculitis (SLE) 4. Kidney disease 5. Chemo/cytotoxic drugs 6. Post organ transplant

Question 645

Xanthogranulomatous pyelonephritis (XGP)

Answer 645

Rare form of chronic pyelonephritis Chronic granulomatous disease resulting in a non-functioning kidney Specific imaging features Staghorn stone CT: Bear's paw sign

Question 646

Penetrating neck injury Procedures to avoid JCM

Answer 646

1. BVM (dissect air into neck) 2. C-spine immobilization (unless direct cord injury) 3. Wound exploration at AED (may dislodge clots) 4. CVC insertion 5. R/T insertion

Question 647

Dystonia / Oculogyric crisis Tx meds

Answer 647

1. Benztropine (Cogentin) 1-2mg IM/IV 2. Diphenhydramine (Benadryl) 25-50mg IM/IV

Question 648

DDx of Acute painless visual loss

Answer 648

1. Retinal detachment 2. Vitreous hemorrhage 3. CRAO 4. CRVO 5. Stroke/TIA (amaurosis fugax) 6. Ischemic optic neuropathy

Question 649

Clinical prediction rule for CT brain with HI

Answer 649

1. Canadian CT head rule 2. New Orleans criteria 3. NEXUS CT head instrument

Question 650

Bedside Ix for raised ICP

Answer 650

USG measuring optic nerve sheath diameter (ONSD) - measured at 3mm behind eye globe - repeat few times and take average - >5mm = ICP >20mmHg

Question 651

LGL syndrome

Answer 651

Lown–Ganong–Levine syndrome Pre-excitation syndrome ECG: Short PR, no delta wave

Question 652

Coronoid process of ulna Classification

Answer 652

Regan and Morrey classification 1: Avulsion # 2: # of <50% coronoid 3: # of >50% coronoid

Question 653

Intussusception USG signs

Answer 653

1. Target sign; aka doughnut sign 2. Pseudokidney sign Red currant jelly stool

Question 654

Neck of talus X ray view

Answer 654

Canale view (medial oblique axial talus view) Foot plantarflexed, 15 degree eversion (pronation)

Question 655

Neck of talus classification

Answer 655

Hawkins classification 1: Nondisplaced talar neck fracture 2. Talar neck fracture with subtalar dislocation 3: Talar neck fracture with subtalar and tibiotalar dislocation 4: Talar neck fracture with subtalar and tibiotalar and talonavicular dislocation

Question 656

Anti-impulse therapy for aortic dissection

Answer 656

Aim HR <60 SBP 100-120 BB: Labetalol, Esmolol CCB: Verapamil, Diltiazem

Question 657

Acute non-traumatic headache decision x CT

Answer 657

Ottawa SAH rule Age ≥40 Neck pain or stiffness Witnessed loss of consciousness Onset during exertion Thunderclap headache (instantly peaking pain) Limited neck flexion on examination

Question 658

Cause of pneumobilia radiopedia

Answer 658

1. ERCP 2. GS ileus (spontaneous biliary-enteric fistula) 3. Infection: cholangitis, emphysematous cholecystitis, liver abscess 4. Biliary-enteric surgical anastomosis (Whipple, choledochoduodenostomy) 5. Incompetent sphincter of Oddi

Question 659

Cause of portal venous gas radiopedia

Answer 659

1. Ischemic bowel 2. Intra abd sepsis / abscess (diverticulitis, cholangitis, cholecystitis) 3. IBD 4. PPU Pedi: post UVC, necrotizing enterocolitis

Question 660

Prevertebral soft tissue thickness at C3 and C7 JCM

Answer 660

C3: 7mm C7: 18mm Not measured at C4/5 as variable position of eso and larynx

Question 661

Radiological measurement of hydrocephalus

Answer 661

Evan's index Ratio of maximum width of frontal horns of lateral ventricles and maximal internal diameter of the skull at the same level (CT or MRI) Normal <0.3, M>F, higher in elderly For normal pressure hydrocephalus

Question 662

Unstable C-spine orthosis

Answer 662

Sterno-Occipital Mandibular Immobilizer (SOMI) for stable injury Halo vest immobilizer for unstable injury

Question 663

Acute infectious flexor tenosynovitis Kanavel cardinal signs of flexor sheath infection x4

Answer 663

Kanavel signs 1. Finger in flexion posture 2. Fusiform swelling of finger 3. Tenderness along flexor tendon sheath 4. Intense pain on passive extension of finger

Question 664

Necrotizing fasciitis (NF) classification

Answer 664

Type 1: Polymicrobial *most common 80-90% 2: Monomicrobial (Group A streptococcus most common) 3: Vibrio vulnificus 4. Fungal (immunocompromised)

Question 665

Eczema herpeticum virus

Answer 665

Herpes simplex virus (type 1) Sudden onset papulovesicular lesions with punched out, crusted ulcers in chronic dermatitis

Question 666

Hypocalcemia elicited signs

Answer 666

Chvostek's sign -Twitching of the facial muscles in response to tapping over the area of the facial nerve Trousseau's sign -Carpopedal spasm caused by inflating the BP cuff to a level above SBP for 3 minutes

Question 667

Decompression sickness types

Answer 667

Type 1: MSK, cutaneous, lymphatic MSK pain Skin: cutis marmorata; rash itchy Lymph: subcutaneous swelling Type 2: neurological, cardio-pulmonary Neuro: cognitive impaitment, VF changes, limb weakness, ataxia Cardiopul: pul edema, near-drowning, MI *Self-contained underwater breathing apparatus (SCUBA)

Question 668

Ludwig angina 3 compartments of floor of mouth

Answer 668

1. Sublingual 2. Submental 3. Submandibular

Question 669

Systematic review (SR) definition LAW EEEM 2021

Answer 669

A review concerning a clearly formulated clinical question that uses systematic, explicit and reproducible methods to identify, select, and critically appraise relevant researches, and to collect and analyze data from them, arriving at a conclusion.

Question 670

Brain abscess microbe

Answer 670

Streptococcus anginosus

Question 671

Stroke score for AF name

Answer 671

CHA2DS2-VASc score

Question 672

GIB score for low risk OP Mx

Answer 672

Glasgow-Blatchford Bleeding Score

Question 673

Rewarming methods

Answer 673

1. Passive external - Remove wet clothing - Blanket 2. Active external - Bair hugger (active rewarming blanket) - Radiant heat 3. Active internal - Warm saline infusion - Bladder irrigation with warm saline - Peritoneal / pleural irrigation

Question 674

Flail chest definition

Answer 674

3 or more adjacent ribs are each fractured in two places, creating one floating segment comprised of several rib sections and the soft tissues between them Clinically diagnosed by the observation of paradoxical motion of the chest wall with respiration

Question 675

HAZMAT decontamination

Answer 675

Universal decontamination agent: Hypochlorite solution (0.5% for skin, 5% for equipment) Copious amount of water equally effective

Question 676

Lichtenberg figures Book

Answer 676

Fern-like pattern Imprints from electron showering on the skin, not true burns Appear within 1 hour Disappear in 24-36h

Question 677

Heat stroke types Book

Answer 677

1. Classical heat stroke (CHS) Summer months Elderly living in under-ventilated dwellings, patients with chronic medical conditions or debilitated persons who have limited access to oral fluid. Hallmark = anhidrosis 2. Exertional heat stroke (EHS) Young, healthy individuals who have strenuous exertion under heat stress e.g. athletes and military recruits Sweating is still present in half of EHS cases More severe organ dysfunction including rhabdomyolysis, myoglobinuria, acute renal failure, marked lactic acidosis and coagulopathy. Hypoglycemia may occur as the result of increased glucose metabolism and impaired gluconeogenesis

Question 678

Acute radiation syndrome 3 classical syndromes

Answer 678

1. Bone marrow syndrome (0.7Gy) - BM destruction, causing infection/hemorrhage 2. GI syndrome (10Gy) - Unlikely survive, die within 2 weeks 3. CVS/CNS syndrome (50Gy) - Die within 3 days 4 stages 1. Prodromal stage - N/V/D 2. Latent stage 3. Manifest illness stage 4. Recovery stage Tx: Treat vomiting, rehydration CBC, look at lymphocyte count every 2-3h for first 8-12h

Question 679

Adult status epilepticus drug dose

Answer 679

BZD 1. Lorazepam (0.1mg/kg) max 4mg IV 2. Diazepam (0.15mg/kg) max 10mg IV 3. Midazolam 10mg (0.2mg/kg) IMI / nasal (5mg each nostril) Anti-seizure medication (ASM) 1. Levetiracetam 60mg/kg IV (max 4500mg) 2. Phenytoin 20mg/kg IV **max rate 50mg/min 3. Valproate 40mg/kg IV (max 3000mg) Refractory SE (requires continuous EEG monitoring) 1. Midazolam infusion 0.2mg/kg IV bolus, then 0.1mg/kg/hr, max 3mg/kg/hr 2. Propofol 1-2mg/kg loading over 5 mins, then repeat 0.5-2mg/kg until seizure stops, infusion at 0.2mcg/kg/min 3. Pentobarbital 5mg/kg over 10 mins, max 50mg/min; 5mg/kg bolus still seizure stops, infusion 1mg/kg/hr

Question 680

Risk factor of placental abruption EM book

Answer 680

1. Maternal HT 2. Previous hx of placental abruption 3. Smoking / cocaine use 4. Advanced maternal age 5. Trauma 6. Retroplacental fibroid 7. Multiparity

Question 681

Burn total BSA (body surface area) chart

Answer 681

1. Wallace rule of nines 2. Lund and Browder Chart - more precise

Question 682

ECG South African flag sign

Answer 682

High lateral STEMI STE in lead 1, aVL, and V2 STD in lead 3 acute occlusion of the D1 (first diagonal) branch LAD

Question 683

RAPD causes deepseek

Answer 683

1. Optic neuritis 2. Ischemic optic neuropathy 3. Retinal detachment 4. CRAO, CRVO

Question 684

Pre-transport preparation framework Prep course Tai / SF doc

Answer 684

Indications and CI and alternatives Communication - patient, relative, receiving facility, transport team, ambulance - consent Proper documentation - interhospital transfer form, condition upon dispatch, en route vitals and Mx Prepare patient - head to toe, ensure all equipment, iv lines, tubes and drains and secured and functioning - vital signs before dispatch Prepare staff - Select experienced staff for transport Prepare equipment / meds - transport kits, meds, monitoring device, ventilator - prepare necessary meds: pre-drawn meds, limit to 1-2 Anticipated problems - predict possible complications and actions ********************************** Communication - patient, relative, receiving facility, transport team, ambulance - consent Staff - Select appropriate staff for transport - Risk of deterioration, competency Equipment support - transport kits, meds, monitoring device - prepare necessary meds: pre-drawn meds, limit to 1-2 Pre-transport assessment - head to toe, ensure all equipment, iv lines, tubes and drains and secured and functioning - vital signs before dispatch Write up Mx plan of emergency - predict possible complications and actions Documentation - Indication, pt condition upon dispatch, enroute mx and vitals

Question 685

Bedside echo LVEF estimate

Answer 685

Mitral valve E point septal separation (EPSS) **>=7mm = reduced LVEF (<30%) Parasternal long view M mode over distal tip of the anterior leaflet of MV

Question 686

Emergency Medical Team (EMT) role

Answer 686

Prep course: - Triage - Treatment - Transfer Field triage, on scene treatment, decision for diversion of patients to hospitals

Question 687

Level C PPE

Answer 687

Protective suit and filter type respirator 1. Personal protective suit 2. A pair of nitrile gloves 3. A pair of chemical resistant boots 4. Full face mask with vapour or particulate air-filter or Powered Air-Purifying Respirator 5. Sealing tape

Question 688

Level A and B PPE

Answer 688

Level A: Gas-proof protective suit and self-contained breathing apparatus (SCBA) Level B: Splash-proof suit and SCBA

Question 689

Physiological criteria for primary trauma diversion / trauma call activation

Answer 689

1. GCS <= 13 2. SBP <90 3. RR <10 or >29

Question 690

Anatomical criteria for primary trauma diversion / trauma call activation

Answer 690

1. Flail chest 2. LL # involving 2 or more femur/tibia 3. Penetrating trauma to head/neck/torso 4. Limb paralysis 5. Pelvic # 6. Burn 2nd+ degree involving >= 20% TBSA 7. Amputation proximal to wrist or ankle

Question 691

Pneumoperitoneum XR sign

Answer 691

Cupola/saddlebag/mustache sign — Seen on a supine radiograph, refers to air accumulation underneath the central tendon of the diaphragm in the midline. Rigler's sign — Air outlining both sides of the bowel wall. Lucent liver sign – Reduction of liver opacity due to air located anterior to the liver. Football sign — Seen in massive pneumoperitoneum, where the abdominal cavity is outlined by gas. Silver's sign (aka Falciform ligament sign) - where air outlines the falciform ligament. Inverted V sign — Air outlining lateral umbilical ligaments (inferior epigastric vessels). Doge's cap sign — Triangular collection of gas in Morison pouch. Telltale triangle sign — Triangular air pocket between three loops of bowel. Urachus sign — Outline of middle umbilical ligament.

Question 692

Ix to do

Answer 692

1. H'stix 2. ECG 3. Blood x CBC, LRFT, CaPO4, Clotting profile, CK, TnI, VBG/ABG, amylase, RG, osmo, TFT, cortisol, lactate, paracetamol/ethanol/salicylate, c/st; T&S; valproate, iron, lithium, PTH/Vit D, COHb, MetHb, VDRL/Folate/B12, LDSST 4. CXR, AXR, C-spine, Pelvis, LS spine 5. USG: E-FAST, Echo (TTE/TEE), DVT, Doppler, Lung, Eye 6. CT: brain, contrast, CTA, CT venogram 7. MRI 8. Urine x pregnancty test, bedside immunoassay, toxicology, c/st; osmo/Na; multistix; protein/creatinine 9. Stool x c/st 10. NPS x CoV/Flu/Resp virus/Mycoplasma 11. Sputum x c/st, AFB, cytology 12. Vomitus / GL content x toxin 13. POCT blood iStat / GEM: MetHb, CyanoHb, Electrolytes, Lactate 14. LP, EEG 15. IOP

Question 693

AIRS full name

Answer 693

Advance Incident Reporting System (AIRS)

Question 694

Fishbone diagram

Answer 694

Ishikawa diagram / Cause-and-effect diagram Visual tool to identify and analyze potential cause of a problem

Question 695

Sentinel events (SE) 醫療風險警示事件 9 categories

Answer 695

Definition: Unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof 1. Surgery / interventional procedure involving the wrong patient or body part [Wrong patient/part] 2. Retained instruments or other material after surgery / interventional procedure [Retained instruments/material] 3. ABO incompatibility blood transfusion [Blood incompatibility] 4. Medication error resulting in major permanent loss of function or death [Medication error] 5. Intravascular gas embolism resulting in death or neurological damage [Gas embolism] 6. Death of an inpatient from suicide (including home leave) [Inpatient suicide] 7. Maternal death or serious morbidity associated with labor or delivery [Maternal death/morbidity] 8. Infant discharged to wrong family or infant abduction [Wrong infant/abduction] 9. Other adverse events resulting in permanent loss of function or death (excluding Cx) [Others]

Question 696

Phenytoin why CI in toxicology causes of seizure

Answer 696

Its mechanism is to stop propagation of seizure focus Poison case -> generalized seizure focus

Question 697

Toxicology causes of Hypoglycemia Book

Answer 697

1. Insulin 2. Oral hypoglycemic agents 3. Ethanol 4. Salicylate 5. BB 6. Quinine

Question 698

Maternal cardiac arrest causes ABCDEFGH

Answer 698

Anesthetic Cx (loss of airway, aspiration, LAST etc.) Bleeding (uterine atony, placental abruption, uterine rupture, trauma etc.) CVS causes (cardiomyopathy, MI, AD, arrhythmia) Drugs (anaphylaxis, Mg, opioid, insulin, oxytocin overdose) Embolic (PE, amniotic fluid embolism, air) Fever (infection, sepsis) General non-obs causes -> 5H5T Hypoxia, Hypovolemia, Hypothermia, H+ acidosis, Hypo/hyperK Tamponade, Tension PTX, Thrombosis (PE), Thrombosis (AMI), Toxin Hypertension (Preeclampsia, Eclampsia, HELLP, ICH)

Question 699

Serious untoward events (SUE) 重要風險事件 2 categories

Answer 699

Definition: Unexpected occurrence which could have led to death or permanent harm 1. Medication error which could have led to death or permanent harm [Medication error] 2. Patient misidentification which could have led to death or permanent harm [Patient misidentification]

Question 700

Penetrating abdominal injury

Answer 700

Stab / gunshot wound 4 regions - Anterior abdomen - Thoracoabdominal area - Flanks - Back

Question 701

Pediatric scores for at risk of deterioration

Answer 701

1. Pediatric early warning score (PEWS) 2. NICE traffic light system

Question 702

CI for Permissive hypotension

Answer 702

1. Traumatic brain injury 2. Spinal cord injury BP aim - SBP 80-90 - MAP 50-60 ?65

Question 703

Diabetic ketoacidosis (DKA) diagnostic criteria

Answer 703

1. Hyperglycemia: BG >11.1mmol/L or hx of DM 2. Ketosis (in blood/urine): BHBA >= 3.0 or urine ketone strip 2+ 3. Metabolic acidosis: pH <7.3 and HCO3 <18

Question 704

Pedi ABC compared to adult Ying

Answer 704

Airway - Larger tongue to oral cavity - Large occiput (tendency to flex neck) - Avoid hyperextend neck as lead to airway obs - <6m are obligate nasal breathers, can get resp distress - Trachea more cartilagenous and soft, more prone to collapse and obs - Larynx higher (C2-3) vs C6-7 in adults - Horseshoe shaped epiglottis, projects anteriorly at 45 deg - Cricoid ring narrowest, susceptible to edema, hence uncuffed ETT - Trachea short, increase dislodgement chance Breathing - Ribs more horizontal, less TV - Diaphragm most important muscle for breathing, decompression of stomach important esp in PPV - Higher RR (higher metabolic rate and O2 demand) Circulation - Blood volume relatively larger but less absolute amount - Systemic vascular resistance is lower - Hypotension is late sign

Question 705

Severe asthma cutoff for RR and HR

Answer 705

RR 30 HR 120

Question 706

Pedi uncuff vs cuff ETT CS

Answer 706

Uncuff (preferred <8y) Pros 1. Larger internal diameter for age (less resistance to airflow, reduced blockage by secretions, easier suction) 2. Minimal mucosal pressure Cons 1. Leakage of air 2. Aspiration 3. Airway injury by oversized (pressure on cricoid mucosa) /undersized (movement trauma) tubes Cuff Pros 1. Smaller external diameter for age 2. Improved ventilation and respiration 3. Reduce aspiration risk 4. Reduce air pollution 5. Less pressure on cricoid mucosa 6. Easier intubation Cons 1. Smaller internal diameter 2. Airway injury (tracheal rupture, mucosal ischemia)

Question 707

Ventilator settings for severe pneumonia (ARDS) CS

Answer 707

Lung protective strategy TV 6ml/kg ideal BW RR 16-18 I:E ratio 1:1.5 PEEP 5-10cmH2O FiO2 0.4-1.0 Pmax 30cm H2O Aim SpO2 88-95%

Question 708

Ventilator settings for asthma/COPD CS

Answer 708

Permissive hypercapnia TV: 6ml/kg ideal BW RR: 10 I:E ratio 1:3 - 1:4 PEEP 0-5cmH2O FiO2 minimal Deep sedation to prevent hyperventilation and breath stacking / auto PEEP

Question 709

Peak and plateau pressure high causes

Answer 709

Compliance problems 1. One lung intubation 2. PTX 3. Atelectasis 4. APO 5. ARDS

Question 710

AMPLE history

Answer 710

Allergy Medication PMH Last meal Event

Question 711

Cx of massive transfusion

Answer 711

1. Coagulopathy 2. Hypothermia 3. Electrolyte disturbance: hypoCa, hyperK 4. Metabolic alkalosis (citrate metabolize to HCO3) 5. Transfusion related acute lung injury (TRALI) 6. Transfusion associated circulatory overload (TACO) Others: - acute hemolytic transfusion reaction - transfusion associated sepsis - anaphylactic transfusion reaction - allergic transfusion reaction - febrile non-hemolytic transfusion reaction - hypotensive transfusion reaction

Question 712

USG jellyfish sign

Answer 712

Atelectatic lung "swimming" within a large pleural effusion

Question 713

High dose insulin (HDI) therapy dose Book

Answer 713

Initial 1U/kg bolus, followed by infusion 0.5-2U/kg/h (also dextrose bolus 0.5g/kg if BG <11.1; and continuous dextrose solution 0.5g/kg/h) Increase infuson rate by 2U/kg/h every 10 min to max 10U/kg/h if no increase in cardiac output or clinical improvement Takes 30 mins to 1h to have effect Mechanism - Exogenous insulin increase myocardial glucose uptake and utilization - Vasodilatory effects and improved perfusion over essential vasculatures (coronary, pul) - Increase available IC Ca and improve myocardial contractility

Question 714

SE of high dose insulin (HDI) therapy Book

Answer 714

1. Hypoglycemia - BG Q10-30min, keep >5.6 2. HypoK - K Q1H, keep >2.8 3. Exacerbate LV outflow obs in HCM patients Blood x Mg, PO4 daily Rebound hyperK after stopping HDI

Question 715

Mx of BB overdose Book

Answer 715

1. Ensure ABC 2. GI decon (GL, AC within 1-2h; WBI, MDAC in sustained release) For hypotension/bradycardia, 3. Atropine 0.6mg IV; 0.02mg/kg in children 4. Glucagon - bolus 2-5mg IV (50mcg/kg children) - maintenance: 2-5mg/h in D5 (20-50mcg/kg/h in children), titrate clinically 5. Calcium - same as CCB; 1gCaCl or 3g Ca glu 6. HDI - 1U/kg bolus, followed by infusion 0.5-2U/kg/h 7. Inotropes and Vasopressors - Adrenaline or NA 8. IV lipid emulsion (ILE) - Lipid sink for BB with high lipid solubility (propranolol, sotalol) - reserved for life threatening toxicity / cardiac arrest 9. Others: Pacing, Intraaortic balloon pump, ECMO For prolonged QRS in Propranolol poisoning 10. NaHCO3 1-2mmol/kg bolus for QRS >100ms For prolonged QTc in sotalol poisoning 11. MgSO4 2g IV infusion for QTc >500ms Enhanced elimination 12. HD/HF for life threatening atenolol/sotalol poisoning - not recommended in propranolol poisoning

Question 716

CURB-65 for pneumonia severity

Answer 716

Clinical prediction rule Predicts mortality in community-acquired pneumonia Confusion BUN >19 mg/dL (>7 mmol/L urea) Respiratory Rate >=30 SBP <90 or DBP <=60 Age >=65

Question 717

Wells' score for PE

Answer 717

1. Clinical S/S of DVT (+3) 2. PE is top DDx (+3) 3. HR >100 (+1.5) 4. Immobilization at least 3 days or surgery in previous 4 weeks (+1.5) 5. Previous PE or DVT (+1.5) 6. Hemoptysis (+1) 7. Malignancy with tx within 6 months or palliative (+1) 0-1 = low risk (3.6%) 2-6 = moderate risk (20.5%) >6 = high risk (66.7%) Modified Wells - Likely >4 - Unlikely <= 4

Question 718

SILENT (lithium)

Answer 718

Syndrome of irreversible lithium-effectuated neurotoxicity Irreversible neuropsychiatric sequelae, persistent after cessation of lithium use - Cerebellar dysfunction predominates

Question 719

Dialysable drugs characteristics deepseek

Answer 719

1. Low molecular weight 2. Low protein binding 3. Small volume of distribution (<1L/kg) 4. Hydrophilic (pass through dialysis membranes more easily) e.g. Methanol, Ethylene glycol, Lithium, Salicylate, Theophylline, Metformin, VPA, Phenytoin

Question 720

PECARN rule

Answer 720

Pediatric Emergency Care Applied Research Network Predicts need for CT brain in pediatric head injury Under 2y and over 2y

Question 721

Shoulder dystocia ALSO

Answer 721

HELPER4 H: Call for help early E: Evaluate and explain clinical situation L: Legs: McRoberts maneuver P: Suprapubic pressure E: Enter birth canal posteriorly and assess need for episiotomy R: Remove posterior arm (follow posterior arm to elbow, flex arm at elbow, sweep forearm across chest and out of vagina) R2: Rotational maneuvers (Rubin II, Rubin II + Woods screw, Reverse Woods screw) R3: Roll patient to hands and knees (all 4 position) R4: Repeat

Question 722

Complaint management SF short case

Answer 722

1. Open disclosure 2. Review the case 3. Explained what has happened and post event management 4. Report to COS/ Consultant / AIRS 5. Staff management 6. Education / Root cause analysis

Question 723

Why aspirin not good for thyroid storm

Answer 723

Displace thyroid hormone from binding proteins Increase serum free T4 and T3

Question 724

Sign of placental separation after birth x3

Answer 724

1. Gush of blood 2. Lengthening of cord 3. Globular and firm uterus

Question 725

Mx of SE and SUE prep

Answer 725

Immediate response 1. Assess patient condition and provide care to minimize harm to patient 2. Notify senior staff (e.g. COS) without delay 3. Immediate response plan (worked out by departmental and hospital management staff) - Disclosure to patient/relatives - When to notify HAHO - Public relations issues and media handling - Appropriate support / staff counselling Reporting 1. AIRS within 24h 2. Coroner (if applicable) Ix 1. Root cause analysis (RCA) panel appointment within 48h SE by HAHO; SUE by respective hospital 2. Final Ix report submission to HCE within 6wk and HAHO within 8wk FU 1. Implement of action plan (department and HA-wide changes) 2. Learning and sharing

Question 726

Root cause analysis (RCA) prep

Answer 726

A comprehensive and systematic medtodology to identify gaps in systems and processes that may not be immediately apparent and which may have contributed to the occurrence of an event Goals of RCA is to determine 1. What has happened? 2. Why did it happen? 3. What can be done to prevent it from happenening again?

Question 727

Complaint management prep

Answer 727

1. Ackowledge the complaint in a timely manner 2. Apologies of any distress caused (not admission of liability) 3. Determine the complaints 4. Immediate support for the complainant (call back for re-ax and tx if necessary) 5. Undertake to investigate 6. Arrange FU 7. Internal Ix 8. Assess both systematic and individual factors 9. Gather info e.g. case notes, individual staff 10. Support staff and maintain confidentiality 11. Inform administration and stakeholders 12. Consider legal implications 13. Incident Mx and RCA as appropriate 14. Determine what actions need to be taken 15. FU with complainant 16. Feedback 17. Revise existing protocol and implement changes 18. Education and learning 19. Re-audit

Question 728

Disaster definition prep

Answer 728

Any adverse incident in which the demand for emergency medical care is beyond the capacity of a single hospital

Question 729

START and JumpSTART

Answer 729

Simple triage and rapid treatment (START) triage system 4 steps: - walking - ventilation - pulse / circulation - mental status 3 components (RPM) - Respiration - Perfusion - Mental status JumpSTART: - Difference in "normal" RR for children - Assess pediatric patients better - Age cutoff for use 8y/o (infant to 8y/o) - Five rescue breaths are to be given to apneic children with a pulse; then, they are given a black tag. - Normal RR are more than 15 or less than 45 - Neurological assessment is done using the mnemonic AVPU (alert, responds to verbal stimuli, responds to painful stimuli, and unresponsive). Any patient who has abnormal posturing to painful stimuli or is unresponsive gets a red tag designation. BLACK: (Deceased/expectant) injuries incompatible with life or without spontaneous respiration; should not be moved forward to the collection point RED: (Immediate) severe injuries but high potential for survival with treatment; taken to collection point first YELLOW: (Delayed) serious injuries but not immediately life-threatening GREEN: (Walking wounded) minor injuries

Question 730

MDAC useful in Book

Answer 730

1. Phenobarbital 2. Dapsone 3. Theophylline 4. Digitoxin 5. Phenytoin 6. Carbamazepine 7. Quinine in general sustained release, drugs that form concretions in GIT considered for poison with enterohepatic recirculation or pharmacokinetic properties favor gut dialysis

Question 731

Secondary PPH

Answer 731

Any significant uterine bleeding occurring between 24h and 12 weeks postpartum Definitions vary between 48h and 6 weeks postpartum

Question 732

Postpartum hemorrhage (PPH) definition

Answer 732

WHO: Blood loss >= 500ml within 24h after birth American OG college: Cumulative blood loss ≥1000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process (includes intrapartum loss) regardless of route of delivery

Question 733

PSA agents Sedatives choice Midazolam, Propofol NLTH PSA

Answer 733

1. Midazolam - Short acting BZD - SE: Resp depression, apnea; Pedi: Parodoxical reactions including hyperactivity, aggressive behavior and crying in 1-3% pediatric patients 2. Propofol - Non-opioid, non-barbiturate sedative agents - Pros: Rapid onset, short recovery time, easily titrated, antiemetic properties - No analgesic effect - SE: Resp depression, apnea, hypotension - Hypotension mx with IVF folus, phenylephrine bolus - CI in egg/soybean oil allegy

Question 734

PSA agents Sedatives choice Etomidate, Ketamine, Dexmedetomidine NLTH PSA

Answer 734

3. Etomidate - Non-barbiturate hypotic agents (GABAA agonist) - No analgesic effect - Pros: Rapid onset and rapid recovery, hemodynamic stability usually maintained - SE: injection site pain, vomiting, transient myoclonus 4. Ketamine - Dissociative agent with sedative, analgesics, amnesic properties - Pros: Maintain protective airway reflexes, spontaneous respiration and cardiopulmonary stability - SE: vomiting, sympathomimetic effects (HT, tachycardia, transient laryngospasm, apnea, resp depression, rasied ICP, hypersalivation, emergence reaction - undesirable psychological experience like vivid dreams - CI: <3m old, psychosis, uncontrolled raised ICP/IOP, thyrotoxicosis, airway instability 5. Dexmedetomidine (Precedex) - Centrally acting seletive alpha 2 adrenergic agonist - Potent sedative effects with modest analgesic effects - Pros: maintain spontaneous respiration and upper airway reflexes - SE: bradycardia, hypotension / HT - CI: receiving AVN (digoxin, BB, CCB), high degree HB, severe ventricular dysfunction

Question 735

IO site anatomy adult

Answer 735

1. Proximal tibia - 2cm medial and below tibial tuberosity 2. Proximal humerus - 1cm above surgical neck at greater tubercle 3. Distal tibia - 3cm proximal to most prominent part of medial malleolus

Question 736

CI of Intraosseous (IO) insertion

Answer 736

1. Previous IO attempt at same site within 24h 2. Fracture 3. Overlying skin infection 4. Osteogenesis imperfecta (OI) 5. Unable to locate bony landmarks 6. Vascular injury

Question 737

Cx of IO

Answer 737

1. Extravasation 2. Fat / BM embolism 3. Compartment syndrome 4. Infection 5. Growth plate injury 6. Lab results not reliable: Na/K/Ca, pCO2, WBC, platelet

Question 738

Primary survey ATLS ABCDE

Answer 738

Airway maintenance with restriction of cervical spine motion Breathing and ventilation Circulation with hemorrhage control Disability (assessment of neurologic status) Exposure/Environmental control

Question 739

Adjuncts to primary survey with resuscitation ATLS

Answer 739

1. Cardiac monitor 2. Pulse oximetry 3. EtCO2 monitor, ventilatory rate monitor 4. ABG 5. Foley to monitor urine output and assess for hematuria 6. Gastric catheters decompress distention and assess for evidence of blood 7. Blood lactate 8. X ray: CXR, pelvis 9. USG: Extended focused assessment with sonography for trauma (eFAST) 10. Diagnostic peritoneal lavage (DPL)

Question 740

Penetrating chest injury Lethal six and hidden six

Answer 740

Lethal 6 1. Airway obs 2. Tension PTX 3. Open PTX 4. Massive hemothorax 5. Flail chest 6. Cardiac tamponade Hidden 6 1. Thoracic aortic disruption 2. Tracheobronchial disruption 3. Esophageal distruption 4. Myocardiac contusion 5. Pulmonary contusion 6. Diaphragmatic tear

Question 741

Penetrating chest injury cardiac box

Answer 741

high risk of injury to the heart and other mediastinal structures superiorly by the clavicles and sternal notch laterally by nipple line inferiorly by costal margins

Question 742

ROTEM, TEG

Answer 742

ROTEM: Rotational thromboelastometry TEG: Thromboelastography

Question 743

RSI meds pros and cons Etomidate COC

Answer 743

Etomidate 0.3mg/kg (0.2mg/kg if pretx with opioid) Pros: 1. CVS stable 2. Ability to reduce cerebral blood flow and O2 consumption 3. Does not cause histamine release Cons: 1. Adrenocortical suppression 2. Painful on injection 3. Myoclonus 4. Laryngospasm For trauma, hypotension

Question 744

RSI meds pros and cons Propofol COC

Answer 744

Propofol 1-2mg/kg Pros: 1. Decrease ICP, cerebral metabolic rate of oxygen, cerebral blood flow (useful in brain injury / ICH) 2. Anticonvulsant properties 3. Bronchodilation (useful in asthma and bronchospasm) Cons: 1. Hypotension For seizure, asthma

Question 745

RSI meds pros and cons Thiopental COC

Answer 745

Thiopental 4mg/kg (2mg/kg if hypotensive) Pros: 1. Decrease ICP and cerebral blood volume (by cerebral vasoconstriction) Cons: 1. Hypotension (also cause histamine release) For status epilepticus, CVS stable

Question 746

RSI meds pros and cons Ketamine COC

Answer 746

Ketamine 1-2mg/kg Pros: 1. Bronchodilatory effect 2. Analgesic, amnesia effect 3. Preserves resp drive (for awake intubation) 4. Increase BP, reduce airway resistance (stimulate sympathetic outflow) Cons: 1. Laryngospasm 2. Stimulate oral secretion, hypersalivation 3. Emergence reaction (reduced by giving BZD as well) 4. HT CI: 1. Acute intraocular injury, glaucoma 2. Coronary artery disease, CHF, HT Use for septic shock, ?asthma

Question 747

Morphine avoid in asthma

Answer 747

Causes mast cell degranulation -> histamine release -> bronchoconstriction

Question 748

Succinylcholine CI COC

Answer 748

Dose: 1.5mg/kg 1. Significant hyperK (e.g. with ECG changes) 2. Major crush injuries beyond 48h 3. Extensive burns more than 48h 4. Subacute major nerve or spinal cord injuries (denervation syndromes) 5. Muscular dystrophies (e.g. Duchenne muscular dystrophy) 6. Hx of malignant hyperthermia 7. Previous allergy to succinylcholine

Question 749

SVCO causes

Answer 749

Malignant causes 1. CA lung 2. Lymphoma 3. Metastases Non-malignant causes 4. Thrombosis (indwelling CVC, PICC) 5. Aortic aneurysm 6. Restrosternal goiter 7. Mediastinitis (radiation induced, TB, abscess)

Question 750

DDx Chest pain + Bradycardia deepseek

Answer 750

Cardiac cause 1. AMI 2. SSS 3. High degree HB 4. Myocarditis Metabolic cause 5. HyperK 6. Hypothermia Toxicological cause 7. BB / CCB overdose 8. Digoxin toxicity 9. OP poisoning Neurological cause 10. Raised ICP e.g. SAH; chest pain from neurogenic pul edema +/- vasovagal syncope Endocrine cause 11. Hypothyroidism

Question 751

Vasopressors vs Inotropes examples

Answer 751

Vasopressors + Inotropes (Inopressors) 1. Adrenaline 2. NA 3. Dopamine Vasopressors 1. Vasopressin 2. Angiotensin II 3. Phenylephrine Inotropes 1. Milrinone 2. Isoproterenol 3. Dobutamine

Question 752

RSI 7Ps COC

Answer 752

1. Preparation 2. Pre-oxygenation 3. Pre-intubation optimization (fluid resus for hypotension, apneic oxygenation or BiPAP/CPAP for refractory hypoxia; treat tension PTX, pre-tx with fentanyl, lignocaine) 4. Paralysis with induction 5. Positioning and protection 6. Placement with proof 7. Post-intubation mx

Question 753

Opioid pre-tx in RSI

Answer 753

Fentanyl 1-3ug/kg Alfentanil 0.01mg/kg Blunts sympathetic discharge and ICP rise associated with DL and intubation Consider in raised ICP, aortic dissection, ruptured aortic aneurysm, IHD Lignocaine 1.5mg/kg

Question 754

Trauma: Indication for laparotomy prep

Answer 754

1. Blunt abd trauma with hypotension, FAST +ve 2. Hypotension with abd wound penetrating anterior fascia 3. Gunshot wound traverse peritoneal cavity 4. Eviseration 5. Bleeding from stomach, rectum, genitourinary tract with penetrating injury 6. Peritonitis 7. Free air, retroperitoneal air, rupture of hemidiaphragm 8. Contast CT showing ruptured GIT, intraperitoneal bladder injury, renal pedicle injury, severe visceral parenchymal injury after blunt/penetrating trauma

Question 755

Ventilator monitor

Answer 755

Pressure Flow Volume

Question 756

Measure intrinsic PEEP

Answer 756

Expiratory hold (need to be intubated)

Question 757

Post cardiac arrest Resp / hemodynamic parameters ACLS

Answer 757

Early placement of ETT Resp parameters - 10 breaths / min - SpO2 92-98% - PaCO2 35-45mmHg Hemodynamic parameters - SBP >90 - MAP >65

Question 758

Post cardiac arrest Targeted temperature management (TTM) ACLS

Answer 758

Improves survival and brain function Start if patient not following commands Begin at 32-36C for 24h (by using cooling device with feedback loop)

Question 759

Bradycardia medication ACLS

Answer 759

1. Atropine 1mg bolus, repeat every 3-5 mins, max 3mg 2. Dopamine infusion 5-20ug/kg/min (0.3-1.2mg/kg/h) (50kg: 15-60mg/h) [200mg in 100ml NS: 2mg/ml: 7.5-30ml/h] 3. Adrenaline infusion 2-10ug/min (0.12-0.6mg/h) [4mg in 50ml NS: 0.08mg/ml: 1.5-7.5ml/h]

Question 760

Extracorporeal CPR (ECPR) Indications and CI prep

Answer 760

Indication 1. Good premorbid 2. Reversible diease process 3. Overall goals of therapy are curative CI 1. Irreversible organ damage 2. Multiorgan failure 3. CI to anticoagulation 4. Severe AR or aortic dissection

Question 761

ACLS medication dose

Answer 761

Adrenaline (1:10000) IV/IO 1mg every 3-5 min Amiodarone IV/IO 1st dose: 300mg bolus 2nd dose: 150mg Lignocaine IV/IO 1st dose: 1-1.5mg/kg 2nd dose: 0.5-0.75mg/kg

Question 762

DDx sore throat deepseek

Answer 762

Infective 1. Acute pharyngitis 2. Acute tonsillitis 3. Peritonsillar abscess (quinsy) 4. Acute epiglottitis 5. Retropharyngeal abscess (look for trismus) 6. Ludwig angina Non-infective 1. Foreign body ingestion 2. Malignancy: CA larynx, lymphoma 3. GERD 4. Carotid artery dissection

Question 763

Centor Score for Strep Pharyngitis

Answer 763

Used in acute pharyngitis <3d To Dx Group A streptococcus infection / streptococcal pharyngitis 1. Age 3-14 +1 15-44 0 >= 45 -1 2. Exudates / swelling on tonsils 0/1 3. Tender/Swollen anterior cervical LNs 0/1 4. Fever (T>38) 0/1 5. Cough present 0 absent 1 >=2 points for throat culture

Question 764

FBI site of impaction

Answer 764

1. Palatine tonsils 2. Tongue base 3. Vallecula 4. Pyriform fossa

Question 765

Cx of FBI

Answer 765

Early 1. Mucosal laceration, ulceration, bleeding 2. Abscess formation 3. Deep neck infection (Ludwig) Late 1. Esophageal perforation 2. Mediastinitis 3. Vascular injury: carotid a erosion, IJV thrombosis 4. Tracheo-esophageal fistula 5. PTX

Question 766

Risk factor for pre-eclampsia

Answer 766

1. Previous pre-eclampsia 2. Nulliparity 3. Multiple pregnancy 4. Chronic HT 5. DM / GDM 6. SLE 7. Advanced maternal age >35y

Question 767

USG sign for pneumoperitoneum

Answer 767

Peritoneal stripe sign

Question 768

BVM better seal

Answer 768

2 thumbs down technique