Stuff Flashcards

1
Q

Lisfranc

A

Tarsometatarsal joint (TMTJ) complex injury

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2
Q

Causes of Lisfranc injuries

Classification

A

RTA
Fall from height
Field sports like rugby

Classification: Myerson classification

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3
Q

TMTJ complex contents

A
  • 5 MTs
  • 3 Cuneiforms
  • Cuboid
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4
Q

Lisfranc ligament
x3

A
  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

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5
Q

Lisfranc injury mechanisms

A

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

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6
Q

Pathognomonic sign for Lisfranc

A

Plantar ecchymosis
(24-48h after)

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7
Q

Special tests for Lisfranc

A
  1. Pronation-abduction test
  2. TMT squeeze test
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8
Q

Fleck sign for Lisfranc injury

A

Pathognomonic

Avulsion fracture of medial cuneiform or 2nd MT

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9
Q

Cx of Lisfranc injuries

A

Acute
- Vascular compromise
- Nerve injury
- Compartment syndrome

Chronic
- OA
- Chronic midfoot pain

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10
Q

Normal Foot XR findings

A

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

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11
Q

Carpal bones

A

Trapezium Trapezoid Capitate Hamate
Scaphoid Lunate Triquetral Pisiform

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12
Q

Anatomical snuffbox

A

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

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13
Q

Jefferson #

A

anterior and posterior arches of C1

C1 (atlas) burst #

from axial load on back of head or hyperextension of neck

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14
Q

Hangman #

A

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

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15
Q

Jefferson bit off a hangman’s thumb

A
  • Jefferson #
  • Bilateral facet dislocation
  • Odontoid #
  • Atlanto-axial and Atlanto-occipital dislocation
  • Hangman # (hyperextension)
  • Teardrop #
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16
Q

Central cord syndrome

A

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

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17
Q

Anterior cord syndrome

A

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

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18
Q

Posterior cord syndrome
(less common)

A

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

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19
Q

NEXUS criteria full name

A

National emergency X-radiography utilization study

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20
Q

NEXUS criteria
(x5)

A
  1. No focal neurology
  2. No midline C-spine tenderness
  3. Conscious
  4. No intoxication
  5. No distracting injury
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21
Q

ABCD2 score for TIA

A

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

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22
Q

Dengue fever symptoms

A

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

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23
Q

Segond fracture

A

Avulsion # of lateral surface of lateral tibial condyle

Excessive internal rotation + varus stress

ACL tear; also MCL and lateral meniscus injury

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24
Q

Arcuate sign

A

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

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25
Q

Reverse Segond #

A

Avulsion # of medial tibial plateau

Valgus stress + External rotation

PCL, MCL, Medial meniscus injury

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26
Q

Chauffeur’s # / Hutchinson #

A

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

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27
Q

Purple glove syndrome

A

IV Dilantin (Phenytoin)

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28
Q

Tillaux fracture

A

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.

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29
Q

Common medical causes of blindness (x4)

A

Cataract
Glaucoma
Age related macular degeneration
Diabetic retinopathy

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30
Q

Takotsubo cardiomyopathy

A

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
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31
Q

SDH chronicity

A

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

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32
Q

Fluid level in knee XR
post trauma

A

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

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33
Q

Common causes of primary PPH
4Ts

A
  1. Tone
  2. Tissue
  3. Trauma
  4. Thrombin
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34
Q

Common causes of primary PPH
4Ts

A
  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
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35
Q

Cord prolapse initial Mx

ALSO

A
  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

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36
Q

Bells palsy description
x4

A

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

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37
Q

Other symptoms of facial nerve palsy

A

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

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38
Q

Causes of facial n. palsy
x6

A
  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
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39
Q

Ramsay Hunt syndrome triad

A

Ipsilateral facial paralysis
Otalgia
Vesicles in auditory canal / on auricle

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40
Q

Acyclovir renal adjustment

A

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

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41
Q

Life threatening cause of chest pain
x5

A
  1. ACS
  2. PE
  3. Aortic dissection
  4. Cardiac tamponade
  5. Esophageal rupture
    Tension PTX
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42
Q

Boerhaave syndrome

A

aka Effort rupture of esophagus

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

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43
Q

Mackler’s triad

A

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

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44
Q

Hamman’s sign / crunch

A

pneumomediastinum
heard over precordium in spontaneous mediastinal emphysema

Mediastinal crackling sound synchronus with heart beat

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45
Q

Cx of Boerhaave syndrome
x6

A
  1. Pneumomediastinum
  2. Mediastinitis
  3. Hydropneumothorax
  4. Empyema
  5. Sepsis
  6. Multiorgan dysfunction syndrome
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46
Q

Ix for Boerhaave syndrome

A

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

CT thorax

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47
Q

RV STEMI ECG features
(when have inferior STEMI)

A
  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
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48
Q

Clinical significance of RV infarction

A

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

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49
Q

STEMI meds

A

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

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50
Q

CI of Fibrinolytic for STEMI

A

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

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51
Q

Cx of fibrinolytics

A
  1. ICH (~1%)
  2. Bleeding risk, most common GIB
  3. Hypersitivity reaction, hypotension, reperfusion arrhythmias
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52
Q

Cx of AMI

A
  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)
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53
Q

Steps for transcutaneous pacing

A

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)

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54
Q

Causes of 3rd n. palsy

A

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

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55
Q

5 causes of headache

A

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

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56
Q

CTB finding of basal cistern SAH

A
  1. Hyperdensity over subarachnoid space and basal cistern
  2. Dilated temporal horn of lateral ventricles, suggestive of obstructive hydrocephalus
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57
Q

Causes of primary SAH

A

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

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58
Q

2 classifications / grading of SAH

A
  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

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59
Q

Immediate Tx of SAH on warfarin (meds)

A
  1. PCC Prothrombin complex concentrate
    (Beriplex: 4-factor PCC)
  2. Vitamin K1
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60
Q

Cx of SAH

A
  1. Cerebral vasospasm
  2. Obstructive hydrocephalus, raised ICP
  3. Seizure
  4. Recurrent SAH (rebleeding)
  5. Cerebral salt wasting syndrome
  6. Neurogenic pul edema
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61
Q

Wellens syndrome

A

Critical stenosis of proximal LAD
Recent chest pain now resolved

Do not perform stress test e.g. treadmill

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62
Q

ECG features of Wellens syndrome

A

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)

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63
Q

ECG V7-9 placement

A

for posterior MI
same horizontal plane as V6

V7: left posterior axillary line
V8: tip of left scapula
V9: left paraspinal region

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64
Q

Sgarbossa criteria

A
  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

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65
Q

STEMI equivalents

A
  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
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66
Q

DDx for hyperthermia, tachycardia, agitation

A

CNS
1. CNS infection
2. Stroke, tumor (involve thermoregulatory pathway)
3. Status epilepticus

  1. 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

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67
Q

Tx for sympathomimetic toxidrome

A
  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
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68
Q

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

A

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

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69
Q

Na channel blockers
TCA-PP-DV

Toxi book

A

T - Tricyclic antidepressants
C - Carbamazepine, Cocaine, Citalopram
A - Antiarrhythmic 1A (Procainamide) / 1C (Flecainide), Amantadine

P - Propranolol
P - Phenothiazine (Thioridazine)

D - Diphenhydramine (Benadryl)
V - Venlafaxine

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70
Q

Mx of Na channel blockers overdose

A

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

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71
Q

Mx of hyperthermia (cooling method)

A
  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

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72
Q

Serotonin syndrome
3 As

A

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

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73
Q

Features of Serotonin syndrome

A

usually clonus over LL

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74
Q

Antidote of Serotonin syndrome

A

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

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75
Q

Cocaine intoxication drug CI

A

Beta blockers - unoppposed alpha effect -> paradoxical HT

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76
Q

Tx of HT in cocaine intoxication

A
  1. Benzodiazepine
  2. Phentolamine
  3. Nitroglycerin, Nitroprusside
  4. CCB
  5. Labetalol (controversial)
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77
Q

Phlegmasia cerulea dolens

A

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

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78
Q

Massive blood transfusion definition

A

10 units packed red cells within 24h

or more than 1 blood volume within 24h

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79
Q

Beck’s triad

A

of Cardiac tamponade

  1. Hypotension, narrow pulse pressure
  2. Distended neck veins (jugular veins)
  3. Muffled heart sounds
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80
Q

Colistin

A

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

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81
Q

HBOT indications currently

A

Life-threatening
1. Severe decompression sickness
2. Cerebral arterial gas embolism

Emergency
3. CO poisoning
4. Necrotizing soft tissue infection
5. CRAO

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82
Q

Absolute CI for HBOT

A
  1. Unresolved PTX
  2. Pneumocephalus
  3. Hollow orbital prosthesis
  4. Currently on Bleomycin / Adriamycin (Doxorubicin)
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83
Q

AACG Glaucoma Mx
STAMP

ATM PBL

A

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)

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84
Q

Osborn wave

A

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

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85
Q

Causes of Osborn wave

A

Hypothermia

HyperCa
AMI
Takotsubo cardiomyopathy
LV hypertrophy due to hypertension
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)

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86
Q

Brudzinski’s sign

A

Passive neck flexion -> Flexion of hips and knees

specific but not sensitive

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87
Q

Kernig’s sign

A

Supine, hip and knee flex to 90 deg
Resistant / Pain during passive extension of leg

specific but not sensitive

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88
Q

Echo
Parasternal short axis view

A

look for RWMA

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89
Q

PE classification

A
  1. Massive (hemo unstable)
  2. Submassive (RV strain)
  3. Non-massive (no RV strain)
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90
Q

ECG low voltage

A

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

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91
Q

Posterior MI ECG changes

A

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)

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92
Q

Posterior MI
litfl

A
  • 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

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93
Q

RV infarction

A

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

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94
Q

Right side ECG

A

V1-2 same position
V3-6 to V3R - V6R

Most useful = V4R (R 5th ICS, MCL)

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95
Q

De Winter T waves
STEMI equivalent

A

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

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96
Q

STE in aVR, diffuse STD in other leads

A

LMCA occlusion
or pLAD stenosis, severe TVD…

cause by diffuse subendocardial ischemia / infarction of basal septum

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97
Q

5 types of MI
(EM book)

A

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

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98
Q

ECG mimics of STEMI

A
  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
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99
Q

BER (Benign early repolarization) vs Pericarditis
ECG

A

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

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100
Q

Acute epiglottitis most common microbe

A

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

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101
Q

Chest pain life threatening causes (x6)

EM book

A
  1. Acute coronary syndrome
  2. Acute aortic syndrome
  3. PE
  4. Tension PTX
  5. Cardiac tamponade
  6. Eso rupture (Boerhaave’s syndrome)
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102
Q

Hamman’s sign

A

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

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103
Q

Westermark sign

A

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
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104
Q

Echo findings of cardiac tamponade

A
  1. Pericardial effusion
  2. Diastolic RV collapse (highly specific)
  3. Systolic RA collapse (earliest sign)
  4. Dilated IVC w/o insp collapse (highly sensitive)
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105
Q

SVT vs VT features

EM book

A
  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…
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106
Q

Causes of VT

A
  1. Coronary artery disease
  2. Hypertrophic cardiomyopathy
  3. MV prolapse
  4. Drug toxicity
  5. Electrolyte disturbance
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107
Q

Torsades de pointes
Tx

A

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

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108
Q

Score for unsalvageable limb
MESS

A

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!

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109
Q

CXR PE findings

A
  1. Westermark sign (focal oligemia)
  2. Hampton’s hump (peripheral wedge shaped opacity)
  3. Palla’s sign (enlarged right dsc pul a)
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110
Q

Echo findings acute PE

A
  1. RV dilatation
  2. RV hypokinesis (w/ sparing of apex) “McConnell’s sign”
  3. D shaped LV
  4. TR
  5. IV septal flattening
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111
Q

TCA poisoning clinical features
PIC

A

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

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112
Q

Radio-opaque meds

COINS
/ CHIPS

A

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

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113
Q

Blast injury 1/2/3/4

A

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

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114
Q

Pedi BP

A

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

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115
Q

Pediatric Endotracheal Tube Size / Depth

A

Uncuffed = (age/4) + 4
Cuffed = (age/4) + 3

Depth = ETT size x3

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116
Q

Tibial plateau # classification

A

Schatzker (type 1-6)

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117
Q

Pedi maintenance IVF formula
(4-2-1)

A

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

Shock: 20ml/kg bolus

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118
Q

Eclampsia Mx

A

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

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119
Q

MgSO4 toxicity monitoring

A
  • 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

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120
Q

Radio-opaque meds

COINS

A

Chloral hydrate / Cocaine packets
Opiate packets
Iron and heavy metal
Neuroleptic agents (TCA)
Sustained release medications

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121
Q

Delayed cord clamping pros and cons

A

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

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122
Q

BRASH syndrome

A

Bradycardia
Renal Failure
AV blockade
Shock
HyperK

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123
Q

SCORTEN score
for TEN/SJS mortality

A
  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)
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124
Q

Etiology of SJS/TEN

A
  1. Drugs (allopurinol, AED carbamazepine, lamotrigine, NSAIDs)
  2. Infection (Mycoplasma pneumoniae)
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125
Q

WPW ECG features

A
  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)
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126
Q

Drug Tx for thyroid storm

A

BB: Propranolol, Esmolol (short acting)

Thiondamides (Antithyroid drug): Propylthiouracil, Methimazole

Iodide (inhibit release of stored thyroid hormone): Lugol’s solution
-give 1h after PTU as iodine maybe used for new hormone synthesis

Steroid
- reduce T4 to T3 conversion

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127
Q

Risk factor of testicular torsion

A
  1. Bell-clapper deformity
  2. Cryptorchidism
  3. Testicular tumor
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128
Q

NMS Tx

A
  1. Dantrolene (also use in malig hyperthermia)
  2. Bromocriptine (dopamine agonist)
  3. Amantadine
  4. Benzo: Lorazepam, Diazepam
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129
Q

Panadol overdose values

A

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

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130
Q

Panadol overdose types

A
  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
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131
Q

GI decontamination for panadol overdose

A

Activated charcoal 1g/kg within 1-2h of ingestion

if significant co-ingestion / massive overdose >1g/kg, consider gastric lavage

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132
Q

Panadol nomogram name

A

Rumack-Matthew nomogram

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133
Q

Poor prognostic marker for liver/death from panadol overdose

A
  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
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134
Q

Burn care classification
3 levels

A

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

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135
Q

Methods of GI decontamination

Book

A
  1. Single dose Activated Charcoal (AC)
  2. Gastric lavage (GL)
  3. Multiple dose Activated Charcoal (MDAC)
  4. Whole bowel irrigation (WBI)
  5. Surgical intervention
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136
Q

AC dose
Book

A

adult 50-100g
children 1g/kg

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137
Q

Indication of AC
Book

A

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

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138
Q

CI of AC
Book

A
  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
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139
Q

MDAC dose
Book

A

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

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140
Q

Cx of MDAC
Book

A
  1. Fatal aspiration
  2. Pneumonitis
  3. SB obstruction
  4. Appendicitis
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141
Q

Indication of GL
Book

A
  • A life threatening posion ingestion where poison likely still in stomach
  • Preferred within 1h
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142
Q

CI of GL
Book

A
  1. Caustic ingestion
  2. Large FB or sharp objects
  3. Inability to protect airway
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143
Q

Cx of GL
Book

A
  1. Aspiration pneumonia
  2. Eso / Gastric perforation
  3. Tension PTX and empyema
  4. Decreased oxygentation during procedure
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144
Q

Indication of WBI
Book

A
  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
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145
Q

CI of WBI
Book

A
  1. Absent bowel sound
  2. Bowel obstruction / perforation
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146
Q

Hydroxocobalamin indication

A

Cyanide poisoning

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147
Q

Hydroxocobalamin SE

A
  1. Reversible pink discoloration of skin, mucous membrane, urine
  2. Muscle spasm and twitching
  3. Hypertension
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148
Q

Sodium nitrite indication

A

Cyanide poisoning (prefer to use hydroxocobalamin)
Hydrogen sulphide poisoning

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149
Q

Sodium nitrite SE

A
  1. Hypotension
  2. Methemoglobinemia
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150
Q

ABCD2 score for TIA

A

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

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151
Q

High AG acidosis (HAGMA)

CAT MUD PILES

KULT

A

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)

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152
Q

Substances not binding to AC

PHAILS

A

Pesticides
Heavy metals
Acid / Alkali / Alcohol
Iron
Lithium
Solvents

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153
Q

Maisonneuve fracture

A

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

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154
Q

Sign of basal skull #

A
  1. Battle’s sign (bruising of mastoid process of temporal bone)
  2. Raccoon eyes (periorbital ecchymosis)
  3. CSF rhinorrhea
  4. Hemotympanum
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155
Q

Croup score

A

Westley Croup Severity Score

Level of consciousness
Cyanosis
Stridor
Air entry
Retractions

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156
Q

Dog / Cat bite micro-organisms

A

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

Capnocytophaga canimorsus

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157
Q

Rolando #

A

comminuted intra-articular # base of 1st MC

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158
Q

Bennett #

A

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

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159
Q

Digoxin toxicity
when to expect

A
  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
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160
Q

Digoxin toxicity ECG changes

A

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

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161
Q

Digoxin toxicity specific treatment

A

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

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162
Q

4 types of shock

COHD

A
  1. Cardiogenic (AMI, CHF)
  2. Obstructive (3Ps - Tension PTX, cardiac tamponade, PE)
  3. Hypovolemic
  4. Distributive (septic, anaphylactic, neurogenic)
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163
Q

Anion gap calculation

(3 components)

A

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)

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164
Q

Osmolar gap calculation

(3 components)

A

Calculated:
Na x2 + Glucose + Urea

Measured - Calculated
Normal <10

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165
Q

Score for NF

A

LRINEC Score
Laboratory Risk Indicator for Necrotizing Fasciitis score

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166
Q

Hypertropic cardiomyopathy (HCM) ECG features

A

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

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167
Q

Classification of mid face fracture

A

Le Fort

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168
Q

Lemierre’s syndrome

A

infectious thrombophlebitis of IJV

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169
Q

C1/2 subluxation classification
(atlantoaxial rotatory subluxation)

A

Fielding and Hawkins classification

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170
Q

CRITOE (1-11y)

A

Appearance of ossification centers

Capitellum 1y
Radial head 3y
Internal epicondyle 5y
Trochlea 7y
Olecranon 9y
External epicondyle 11y

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171
Q

3 common elbow injuries in children

A
  1. Supracondylar fracture
  2. Radial head subluxation
  3. Lateral condyle fracture
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172
Q

Human bite micro-organism

A

Eikenella corrodens

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173
Q

CRAO management

A
  1. Ocular massage
  2. Breathe into a paper bag
  3. IV Acetazolamide, Timolol eye drops
  4. HBOT
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174
Q

ACLS modifications for pregnant women

A
  1. Manual displacement of uterus to left
  2. IV set above diaphragm
  3. Airway / ventilation priority (expect laryngeal edema)
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175
Q

6P for Compartment syndrome

A
  1. Pain
  2. Poikilothermia (Perishing cold)
  3. Paresthesia
  4. Paralysis
  5. Pulselessness
  6. Pallor
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176
Q

MR SOPA for NRP

A

Mask adjustment
Reposition airway

Suction mouth and nose
Open mouth

Pressure increase (up to 40)

Alternate airway

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177
Q

Neck zones 1-3

A

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

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178
Q

Difficult laryngoscopy

LEMON rule

A

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
- Hyoid-thyrioid distance 2 finger breadths

Mallampati (>=3 is difficult)

Obstruction (epiglottitis, quinsy, trauma) / Obesity

Neck mobility

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179
Q

Ramp position for obesity intubation

A

head and torso are elevated such that the external auditory meatus and the sternal notch are horizontally aligned

CI if neck injury

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180
Q

Lethal triad of trauma

(HCA)

A

Hypothermia
Acidosis
Coagulopathy

Lethal diamond: hypoCa

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181
Q

Cushing triad for raised ICP

A
  1. Widened pulse pressure
  2. Bradycardia
  3. Irregular respiration (Cheyne–Stokes respirations)
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182
Q

Quetiapine overdose effects

A

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

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183
Q

Magnesium sulphate for Asthma dose

A

MgSO4 2g over 20 mins IV

CI: MG, heart block, severe renal impairment, hypoCa, hyperMg

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184
Q

Chance fracture

A

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

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185
Q

Massive zopiclone overdose

A

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

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186
Q

Tuna Fish for LBP red flags

A

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

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187
Q

CXR signs for aortic dissection
x7

EM handbook

A
  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
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188
Q

Echo signs for aortic dissection

EM handbook

A
  1. Aortic root dilatation
  2. Aortic regurgitation (AR)
  3. Pericardial effusion
  4. Ventricular wall regional wall abnormalities implying coronary ostial occlusion
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189
Q

Echo probe manipulation

POCUS

A
  1. Sliding
  2. Rocking (towards and away indicator)
  3. Tiliting (Fanning)
  4. Rotation
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190
Q

McConnell’s sign for PE

A

RV free wall akinesis with sparing of the apex

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191
Q

Echo findings of PE

A

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

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192
Q

Drug cause of prolonged QTc
5A + CLAM

Toxi book

A

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

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193
Q

HyperK ECG changes

A
  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
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194
Q

Triad of opioid toxidrome

Tox book

A

CNS depression
Resp depression
Miosis

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195
Q

Methadone

Diploma

A

Long acting synthetic opioid
Prolong QTc

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196
Q

Na channel blockade toxidrome

SALT
Diploma

A

Shock
Altered mental status
Long QRS
Terminal right axis deviation

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197
Q

One tab kill (10kg infant)

NOCT 1234
Diploma FL

A

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

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198
Q

Toxic alcohol
x3
Toxi book

A

Methanol
Ethylene glycol (EG)
Diethylene glycol (DEG)

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199
Q

CNS stimulants example

x3
Toxi book

A
  1. Methamphetamine
  2. MDMA (3,4-Methyl​enedioxy​methamphetamine), aka Ecstasy (tablet), Molly (crystal)
  3. Cocaine
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200
Q

CNS depressants example

x6
Toxi book

A
  1. Opioids
  2. Benzodiazepines
  3. GHB (gamma-hydroxybutyrate)
  4. Organic solvent
  5. Barbiturates
  6. Ethanol
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201
Q

Dissociatives example

x3
Toxi book

A
  1. Ketamine
  2. Dextromethorphan (DXM)
  3. Phencyclidine

Blocks NMDA receptor

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202
Q

Hallucinogens example

x2
Toxi book

A
  1. Cannabis
  2. LSD (lysergic acid diethylamide)
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203
Q

Urine ABON for cocaine

Toxi book

A

Unlikely false positive
Detects Benzoylecgonine

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204
Q

Toxicity of Cocaine

Toxi book

A
  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

  1. 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

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205
Q

Cocaine common killer

x3
Toxi book

A
  1. Hyperthermia
  2. Arrhythmia
  3. ICH
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206
Q

Tx for cocaine

Toxi book

A

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

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207
Q

Cannabis - major active ingredient

Toxi book

A

THC (Delta-9-tetrahydrocannabinol)

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

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208
Q

Complications of Cannabis use

Toxi book

A
  1. Pneumothorax
  2. Pneumomediastinum
  3. Paroxysmal AF
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209
Q

Urine ABON for Cannabis

Toxi book

A

False positive: Naproxen, Ibuprofen, Efavirenz

Look for THC and its metabolites

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210
Q

GHB and GBL

Toxi book

A

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

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211
Q

Organic solvents / Volatile hydrocarbon
3 types

Toxi book

A
  1. Aliphatic HC
    - Butane (Lighter fuel)
  2. Halogenated HC
    - Trichloroethylene (Correction fluid)
    - Trichloroethane
  3. Aromatic HC
    - Toluene (Thinner)
    - Xylene (Glue)
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212
Q

Toxicity of volatile hydrocarbon

Toxi book

A

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

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213
Q

Treatment of volatile HC

Toxi book

A
  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
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214
Q

Ketamine

Toxi book

A

Dissociative anesthetic agent
Mainly act on CNS + CVS
Snorted in white powder

Binds to NMDA receptors, biogenic amine uptake complex, sigma receptor, ACh receptor

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215
Q

Ketamine - clinical presentation

Toxi book

A

Altered mental status (most common), with mild sympathomimetic

Chronic: ketamine associated urinary tract dysfunction, ketamine associated abdominal pain
reversible dilated CBD

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216
Q

Urine ABON for ketamine

Toxi book

A

False positive common

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217
Q

Tx for Ketamine

Toxi book

A
  1. Supportive care, prevent secondary injury
  2. BZD to control agitation
  3. Observe 4-6 hours for effect to wean off
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218
Q

Poppers

Toxi book

A

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

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219
Q

Drugs used in Chemsex

Toxi book

A

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

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220
Q

Body packer

Toxi book

A

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

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221
Q

Body stuffer

Toxi book

A

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

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222
Q

Cardioactive steroids

Toxi book

A
  • 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

  1. Increase vagal tone
    Sinus bradycardia, AV block, bradydysrhythmia

Toxic effects enchaned by hypoK and hypoMg

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223
Q

Causes of acute Digoxin / Cardioactive steroids poisoning

Toxi book

A
  1. Intentional overdose
  2. Cardioactive steroids exposure (accidental Chan Su overdose)
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224
Q

Causes of chronic Digoxin / Cardioactive steroids poisoning

Toxi book

A
  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)
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225
Q

Presentation of Digoxin / Cardioactive steroids poisoning

Toxi book

A

GI: Nausea, vomiting, anorexia

CNS: headache, confusion, visual disturbance (alteration in color perception: xanthopsia)

Metabolic: HyperK

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226
Q

Risk stratification for Digoxin / Cardioactive steroids poisoning

Toxi book

A

HyperK
(>5.5 all dead)

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227
Q

ECG change of Digoxin / Cardioactive steroids poisoning

Toxi book

A

Scooped ST segments (reverse tick appearance)
Prolong PR

*Increase automaticity with high degree AV block
Fast AF not compatible, otherwise all arrhythmia can happen

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228
Q

Ix for Digoxin / Cardioactive steroids poisoning

Toxi book

A

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

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229
Q

Mx for Digoxin / Cardioactive steroids poisoning

Toxi book

A
  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
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230
Q

Indications of Digoxin specific Ab fragments

Toxi book

A

Any of
1. Life threatening clinical presentation (ventricular dysrhythmia, bradydysrhythmia not responsive to atropine)

  1. Serum K >5 (attributable to digoxin / cardioactive steroid)
  2. Serum digoxin level >10ng/ml (13nmol/L) at 6h post ingestion or >15 ng/ml (19.5nmol/L) at any time for acute ingestion
  3. Digoxin ingestion of >10mg in adult or >4mg in child
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231
Q

How to give Digoxin specific Ab fragments (DigiFab)

Toxi book

A

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

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232
Q

SE of Digoxin specific Ab fragments (DigiFab)

Toxi book

A
  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)

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233
Q

Which vitamin acute overdose has toxicity

x3
Toxi book

A

A (>300kIU or >25kIU/kg in children)

B3, i.e. Niacin

Iron

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234
Q

Which vitamin chronic overdose has toxicity

x4
Toxi book

A

A

B6, i.e. Pyridoxine

C

D

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235
Q

Vit A overdose

Toxi book

A

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

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236
Q

Vit B3 (Niacin) overdose

Toxi book

A

Only acute

Present with GI disturbance, DKA like syndrome
Supportive Mx

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237
Q

Vit B6 (Pyridoxine) overdose

Toxi book

A

Only chronic
acute non-toxic

Present with sensory peripheral neuropathy

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238
Q

Vit C overdose

Toxi book

A

Only chronic
acute non-toxic

Renal failure patients -> graft failure
high dose parenteral -> oxidative hemolysis, MetHb, AKI in G6PD def

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239
Q

Vit D

Toxi book

A

Only chronic
acute non-toxic

Present with hyperCa, GI disturbance, dehydration
Supportive Mx, correct hyperCa/rehydration

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240
Q

Indications of IV lipid emulsion (ILE)

Toxi book

A
  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
end point = cumulative 10ml/kg

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241
Q

SE of IV lipid emulsion (ILE)

Toxi book

A
  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
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242
Q

When to consider Enchanced elimination

Toxi book

A

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

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243
Q

Common routes of EE

Toxi book

A
  1. GIT: MDAC
  2. Urine: Urine alkalinization
  3. Blood: ECTR (Extrocorporeal tx): HD, HP, HF

Forced diuresis, urine acidification, PD no longer considered

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244
Q

Urine alkalinization indication (which drugs)

x6
Toxi book

A
  1. Aspirin
  2. Phenobarbital
  3. Chlorpropamide
  4. Formate
  5. MTX
  6. 2-4 D (2,4-dichlorophenoxyacetic acid)
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245
Q

Mechanism of urine alkalinization

Toxi book

A

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

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246
Q

How to do urine alkalinization

Toxi book

A

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

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247
Q

Choice of ECTR (Extracorporeal tx)

Toxi book

A

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

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248
Q

Antidotes Lvl 1
NAC, Atropine, Bromocriptine, Calcium

Toxi book

A

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

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249
Q

Antidotes Lvl 1
Cyproheptadine, Dantrolene, Desferrioxamine, Digoxin Fab

Toxi book

A

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

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250
Q

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

Toxi book

A

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

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251
Q

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

Toxi book

A

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)

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252
Q

Antidotes Lvl 1
Methylene blue, Naloxone, Penicillamine, Physostigmine

Toxi book

A

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

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253
Q

Antidotes Lvl 1
Pralidoxime, Pyridoxine, Protamine, Sodium bicarbonate

Toxi book

A

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
Monitor and replace K

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254
Q

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

Toxi book

A

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

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255
Q

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

Toxi book

A

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

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256
Q

Antidotes Lvl 2
Antiveom x4

Toxi book

A

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)

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257
Q

Antidotes Lvl 3

Acetamide
Botulism antitoxin heptavalent
Fomepizole
DMPS (oral)
Methionine
Prussian blue
Silibinin / Silymarin
Succimer (DMSA)

Toxi book

A

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

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258
Q

Antidotes Lvl 3

Antivenom x6

Toxi book

A

Agkistrodon acutus
Russell’s viper
Tr. Muscrosqumatus + Tr. Gramineus

Scorpion
Sea snake
Stonefish

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259
Q

4 types of mushroom poisoning syndromes

Monograph / Book

A
  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)
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260
Q

Amatoxin present in which species

Monograph / Book

A

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

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261
Q

Toxicokinetic / pathophysiology of Amatoxin mushroom poisoning

Monograph

A

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

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262
Q

Clinical features of Amatoxin mushroom poisoning

Monograph

A

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

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263
Q

Ix of Amatoxin mushroom poisoning

Monograph

A

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

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264
Q

Mx of Amatoxin mushroom poisoning

Monograph

A
  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
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265
Q

Scombroid food poisoning
Which fish

Book

A

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

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266
Q

Clinical features of Scombroid food poisoning

Book

A

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

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267
Q

Mx of Scombroid food poisoning

Book

A
  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
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268
Q

Mad honey poisoning
Which toxin

Book

A

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

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269
Q

Clinical features of Mad honey poisoning

Book

A

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

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270
Q

Biotoxins for food poisoning
x4

Book

A

Ciguatoxin (coral fish)
Tetrodotoxin (pufferfish)
Saxitoxin (paralytic shellfish)
Histamine (scombroid)

Short incubation more likely toxin
Long incubation more likely infective

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271
Q

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

Book

A

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

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272
Q

Toxin causing GI symptoms within 6h

Book

A

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)

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273
Q

Toxin causing GI symptoms beyond 6 hours

Book

A

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

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274
Q

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

Book

A

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

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275
Q

Toxin causing delayed neuro symptoms >6h

Book

A

Botulinum toxin
Methanol
Cyanogenic glycosides
Methoxypyridoxine (Ginkgotoxin)

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276
Q

Bongkrekic acid poisoning

Book

A

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)

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277
Q

Clinical features of Bongkrekic acid poisoning

Book

A

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

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278
Q

Diagnosis of BA poisoning

Book

A

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

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279
Q

Mx of BA poisoning

Book

A

Supportive
Dextrose for hypoglycemia
Renal support for renal failure

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280
Q

Ciguatera poisoning in which fish

Book

A

Groupers, snappers, moray eel, hump head wrasse

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281
Q

Pathophysiology of Ciguatera poisoning

Book

A

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

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282
Q

Clinical features of Ciguatera poisoning

Book

A

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

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283
Q

Mx of Ciguatera poisoning

Book

A

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

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284
Q

Preventing Ciguatera poisoning

Book

A

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?)

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285
Q

Clenbuterol poisoning

Book

A

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

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286
Q

Cyanogenic glycoside poisoning

Book

A

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

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287
Q

Clinical features of cyanogenic glycoside poisoning

Book

A

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

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288
Q

Mx for cyanogenic glycoside poisoning

Book

A

Supportive and symptomatic for mild cases
Antidote for cyanide if severe

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289
Q

Haff’s disease

Book

A

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

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290
Q

Clinical features of Haff’s disease

Book

A

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

291
Q

3 forms of Mercury

Book

A

Elemental
Inorganic
Organic

Considered as different toxins

292
Q

Which form of mercury poisoning is most common in HK

Book

A

Inorganic mercury poisoning from adulterated facial whitening cream / Chinese med

293
Q

Source of elemental mercury

Book

A

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

293
Q

Toxicokinetic/dynamics of elemental mercury

Book

A

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

294
Q

Clinical features of elemental mercury poisoning

Book

A

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

295
Q

Ix of elemental mercury poisoning

Book

A

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

296
Q

Mx of elemental mercury poisoning

Book

A

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

297
Q

Sources of Inorganic mercury poisoning

Book

A

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

298
Q

Ix of Inorganic mercury poisoning

Book

A
  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
299
Q

Mx of Inorganic mercury poisoning

Book

A

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

300
Q

When to start chelation therapy for inorganic mercury poisoning

Book

A

Clinical features + elevated mercury level

Oral succimer (DMSA- Dimercaptosuccinic acid) for subacute/chronic inorganic
Dimercaprol (BAL - British anti-Lewisite) for acute inorganic

301
Q

Sources of organic mercury

Book

302
Q

Clinical features of organic mercury

Book

A

Neurological toxicity

Chelation therapy not useful in organic mercury poisoning

303
Q

Arsenic poisoning, which one more toxic

Trivalent vs Pentavalent
Inorganic vs Organic

Book

A

Trivalent arsenic more toxic than pentavalent

Inorganic arsenic more toxic than organic

304
Q

Ix for Arsenic poisoning

Book

A

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

305
Q

Mx of Arsenic poisoning

Book

A

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

306
Q

Chelation for Arsenic poisoning

Book

A

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

307
Q

Salicylate found in

Book

A

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

308
Q

Pharmacokinetics of salicylate

Book

A

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

309
Q

Pathophysiology of salicylate

Book

A

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

310
Q

Clinical manifestation of salicylate poisoning

Book

A

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

311
Q

Classical acid-base abnormality for salicylate poisoning

Book

A

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

312
Q

Toxic/Fatal dose of salicylate

Book

A

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

313
Q

Serum salicylate limited role

Book

A

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

314
Q

Electrolyte disturbance of salicylate poisoning

Book

A

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

315
Q

Tx of salicylate poisoning

Book

A

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

316
Q

Indication of serum/urine alkalinization for salicylate poisoning

Book

A

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

317
Q

How to give NaHCO3 for salicylate poisoning

Book

A

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

318
Q

When to HD / HF for salicylate poisoning

Book

A

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

319
Q

Delta gap

A

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

320
Q

Delta ratio

A

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

321
Q

MEN 1 / 2A / 2B

A

1: Pituitary adenoma, Parathyroid hyperplasia, Pancreas tumor

2A: Parathyoid hyperplasia, Medullary thyroid carcinoma, Pheochromocytoma

2B: Medullary thyroid carcinoma, Pheochromocytoma, Mucosal neuroma, Marfarnoid habitus

322
Q

PRISMA

A

Preferred Reporting Items for Systematic reviews and Meta-Analyses

323
Q

Emphysematous cholecystitis USG sign

A

Champagne sign (gas in GB)

324
Q

Toxicology Mx triangle

A

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

325
Q

Toxicological causes of status epilepticus

SF ppt

A
  1. Sympathomimetic poisoning
  2. Withdrawal of: ethanol, benzo, sedatives/hypnotics
  3. Bupropion
  4. Oral DM meds
  5. CO poisoning
  6. Isoniazid, gyromitrin
  7. Theophylline
326
Q

Mechanism of Theophylline induced seizure

SF

A

Theophylline is adenosine antagonist
and Adenosine is CNS inhibitory neurotransmitter

327
Q

Metabolic effects of Theophylline poisoning

SF

A
  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)
328
Q

Mx of Theophylline induced seizure epilepticus

SF

A

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

Phenytoin contraindicated

329
Q

Cause of death in Theophylline poisoning
SF

A

Cardiac toxicity (tachyarrhythmia, hypotension)
Status epilepticus

330
Q

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

A

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

331
Q

Absolute CI of Physostigmine
x2
Monograph

A

TCA poisoning
New onset QRS prolongation

332
Q

Relative CI of Physostigmine

Monograph

A
  1. Asthma
  2. Underlying cardiac disease
  3. Perpheral vascular disease
  4. Mechanical intestinal/bladder obstruction
  5. Concomintant use of depolarizing muscle relaxant
333
Q

NRP first step
3 things to consider after birth

A
  1. Term gestation?
  2. Good tone?
  3. Breathing or crying?
334
Q

Apgar score

A

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

335
Q

NRP initial steps

not: Term gestation / Good tone / Breathing or crying

A

Warm
Dry
Stimulate
Poisition airway
Suction if needed

336
Q

Ventilation corrective steps
MR SOPA

NRP

A

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)

337
Q

Chest compression in NRP

A

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

338
Q

Adrenaline dose for NRP
Volume expander dose

A

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

339
Q

Sepsis 1 hour bundle

A
  1. Measure 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)
340
Q

SIRS criteria
(Systemic inflammatory response syndrome)

A

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

341
Q

Delayed sequence intubation (DSI)

A

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

342
Q

ATP in central line

A

reduce dose to 5mg

as ATP is rapidly used up peripherally, central injection -> higher dose

343
Q

Cormack-Lehane scoring system for laryngoscopy

A

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

344
Q

Post intubation hypotension
(AH SHITE mnemonic)

A
  1. Anaphylaxis, acidosis
  2. Heart (Cardiac tamponade, pulmonary HT)
  3. Stacking of breath
  4. Hypovolemia
  5. Induction agents
  6. Tension PTX
  7. Electrolyte disturbances
345
Q

Estimated body weight for age 1-10y

A

(Age + 4) x 2

346
Q

Antidote for Rivaroxaban and Apixaban

A

Andexanet alfa

347
Q

Brugada syndrome types

litfl / ppt

A

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

348
Q

J wave (Osborn wave)

litfl

A

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)

349
Q

Hypothermia ECG changes

litfl

A

Osborn wave!!

  1. Sinus bradycardia
  2. Prolong QTc
  3. AV block
  4. Supraventricular arrhythmias
  5. ?U waves
350
Q

U wave ECG

litfl

A

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

351
Q

Delta wave

litfl

A

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

352
Q

Epsilon wave

A

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

353
Q

Portal venous gas vs Pneumobilia

A

PV gas: peripheral

Pneumobilia (CBD gas): central

354
Q

HIV PEP regime

COC

A

Truvada 1 tab daily + Raltegravir 400mg Q12H

*Truvada = Tenofovir 300mg + Emtricitabine 200mg

355
Q

SE of HIV PEP

COC

A

Truvada
- GI intolerance, headache
- rare: renal insufficiency, Fanconi syndrome, lactic acidosis, hepatic steatosis

Raltegravir
- GI intolerance, headahce
- fatigue, sleep disturbance
- rare: rhabomyolysis

356
Q

SAH scores / classification systems

A
  1. Hunt and Hess scale
  2. World Federation of Neurosurgical Societies grading system
  3. Modified Fisher scale
357
Q

qSOFA score

A

quick Sequential Organ Failure Assessment

for sepsis

358
Q

Trifascicular block

A

Bifasicular block + 1st degree HB

359
Q

Bifasicular block

A

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

360
Q

Cardiac axis

litfl

A

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

361
Q

Bohler angle

A

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

362
Q

Gissane angle

A

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

363
Q

Status epilepticus toxicology cause

A

Isoniazid
Theophylline
OHA (hypogly)
Bupropion
Tetramine
SMFA
CO
Hydrazine

Camphor
Lignocaine
OP

364
Q

DDx of RUQ gas

ppt

A
  1. Pneumobilia
  2. Portal venous gas
  3. Emphysematous cholecystitis
  4. Chilaiditi sign
  5. Liver abscess with gas forming organism
365
Q

X ray view for SCJ dislocation

A

Serendipity view (40 degree cephalic tilt)

366
Q

Mechanism of injury of SCJ dislocation

A

Fall on outstretched hand or a direct blow to shoulder

367
Q

Tourniquet test for Dengue fever

A

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

368
Q

Dengue fever classication

A

Dengue without warning signs
Dengue with warning signs
Severe Dengue fever

369
Q

Warning signs for Dengue fever

A

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

370
Q

Criteria for severe Dengue

A
  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
371
Q

Dengue without warning signs diagnosis

A

Endemic area, with fever + 2 of:

  1. Nausea/vomiting
  2. Rash
  3. Headache, eye pain, myalgia, joint pain
  4. Leukopenia
  5. Tourniquet test +ve
372
Q

Clinical signs for acute appendicitis

ppt

A
  1. Psoas sign
    - RLQ pain with hyperextension of R hip
  2. Obturator sign
    RLQ pain with internal rotation of R hip
  3. Rovsing’s sign
    RLQ pain with palpation of LLQ
373
Q

Volkmann ischemic contracture

A

From compartment syndrome of upper limb
Claw-hand deformity of hand

classical in supracondylar # in pedi

374
Q

Coiled spring sign

A

Sign of Intussusception in contrast enema

375
Q

Steinstrasse

A

means “stone street” in German

Complication of ESWL; develop after 1 day to 3 months, most common in distal ureter

376
Q

Alvarado Score

A

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

377
Q

Sever’s disease

A

Calcaneal apophysitis

378
Q

Fracture C2 odontoid process classification

A

Anderson and D’Alonzo classification

379
Q

Calcaneal # classification

A

Sanders classification (for CT)

380
Q

Bidirectional VT (BVT) cause

litfl

A
  1. Severe digoxin toxicity (most commonly)
  2. Familial catecholaminergic polymorphic VT (CPVT)
  3. Aconite poisoning

Alternating QRS axis with each beat

381
Q

Rigler triad in GS ileus

A
  1. Pneumobilia
  2. SB obstruction
  3. Ectopic calcified GS, usually in the right iliac fossa
382
Q

Medical Control Officer (MCO) role

A

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 Casualty clearing station (CCS) with AIO
*AIO = Ambulance Incidence Officer

Prep course:
- Liasion (E-team, AED, HADO, AIO)
- Diversion of patient
- Dispatch 2nd EMT

383
Q

Bouveret syndrome

A

GS causing GOO

384
Q

REBOA
3 zones

A

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

385
Q

CXR sign for pneumothorax (supine CXR)

deepseek

A
  1. Deep sulcus sign
  2. Double diaphragm sign
  3. Sharp mediastinal contour
  4. Increased radiolucency
386
Q

B lines lung USG

A

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

387
Q

Wallenberg syndrome

A

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

388
Q

Thinner hypoK reason

ppt

A

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

389
Q

Rasmussen aneurysm

ppt

A

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

390
Q

Osgood-Schlatter disease

ppt

A

Traction apophysitis of proximal tibial tubercle at insertion of patellar tendon

In adolescents, overuse condition

391
Q

Tongue blade test for mandibular #

A

Bite the wooden tongue depressor then twist
high NPV

Physical signs for mandibular #
- malocclusion
- trismus
- chin paresthesia
- sublingual hematoma, floor of mouth ecchymosis

392
Q

Guardsman #

A

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

393
Q

Facial nerve palsy grading system

A

House-Brackmann Facial Paralysis Scale

394
Q

Reverse Bennett fracture-dislocation

A

fracture-dislocation of 5th MC base

unstable due to unopposed extensor carpi ulnaris (ECU) pull on the fracture fragment
required CRIF/ORIF

395
Q

Gas gangrene microorganism

A

Clostridium perfringens

396
Q

Gunshot wound
Entry vs Exit

ppt

A

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

397
Q

Hill-Sachs lesion

A

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

398
Q

Bankart lesion

A

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

399
Q

Endpoint of pre-oxygenation in AED

A

SpO2 >= 95% for 2-3 mins

400
Q

Pediatric assessment triangle

A

Appearance
Work of breathing
Circulation

401
Q

CMV / SIMV ventilator

A

Synchronized Intermittent Mandatory Ventilation

Continuous/Controlled Mandatory Ventilation

402
Q

Why deep seedation for AECOPD intubated in AED

A

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

403
Q

Insp hold for high airway pressure

A

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

404
Q

Sepsis bundle name

A

Surviving Sepsis Campaign hour-1 bundle

405
Q

XR line for SCFE

A

Klein’s line
Line drawn along superior border of femoral neck, shoulder intersect on femoral head

Positive -> Trethowan’s sign

406
Q

CPR coach

A

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

407
Q

XR signs for posterior shoulder dislocation

A
  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

408
Q

Associated injuries of posterior shoulder dislocation

ppt

A
  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

409
Q

CMCJ dislocation XR line name

A
  1. Chmell’s oblique MC line
  2. Broken zigzag line sign
410
Q

Confirmation of ETT placement

ppt

A

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

411
Q

Winter’s formula

A

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

412
Q

Scores for thyroid storm

A
  1. Burch–Wartofsky Point Scale (BWPS)
  2. Japanese Thyroid Association Criteria
413
Q

Forceful dorsiflexion, MVC
Driving pedal

A

neck of talus

414
Q

Test for pancreatitis

A

Urine trypsinogen-2 test

415
Q

Radial head # classification

A

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)

416
Q

Radial head # nerve injury

A

Posterior interosseous nerve (PIN)
- check thumb extension

associated injury: ulnar coronoid process #, LCL tear (also MCL?), interosseous membrane injury, elbow dislocation, Monteggia #

417
Q

Status epilepticus toxicological cause cofactor therapy

A

IV pyridoxine (B6) 50-70mg/kg

Ethylene glycol
Ginkgo seed poisoning
Gyrometra/false morel Monomethylhydrazine mushroom poisoning
Tetramine
Hydrazine (fuel)

418
Q

San Francisco Syncope rule

A

CHESS

Hx of CHF
Hematocrit <30%
Abnormal ECG/cardiac monitor
SOB
SBP <90 at triage

Other rules: Canadian syncope risk rule, Boston syncope rule

419
Q

Terrible triad of elbow injury

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

Instability, recurrence

420
Q

Pelvic # classifications

A

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

421
Q

VT vs SVT with abberancy

list 3 criteria

A

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

422
Q

Mangled limb test

A

Arterial pressure index (aka Ankle brachial index)

> =0.9 maybe salvageable limb
<0.9 = compromised arterial flow
<0.5 likely limb loss

423
Q

Massive hemothorax definition

A
  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

424
Q

Classification of traumatic aortic injury

A

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

425
Q

RUSH exam USG

protocol

A

Rapid Ultrasound for Shock and Hypotension

HIAMP

Heart
IVC
Aorta
Morison’s pouch
Pulmonary (PTX)

426
Q

Lunate vs Perilunate dislocation

ppt

A

Lunate dislocation: Lunate does not articulate with capitate or radius

Perilunate: Lunate remains aligned with radius

427
Q

Mechanism of Lunate dislocation

A

FOOSH, forceful dorsiflexion (extension) of wrist

428
Q

Cx of Lunate dislocation

A
  1. Median n. entrapment
  2. Chronic pain
  3. AVN of lunate
429
Q

Classification of Lunate dislocation

A

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

430
Q

Terry-Thomas sign

A

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

431
Q

Triquetral avulsion # mechanism

A

Fall on outstretched arm with wrist extended and ulnar deviation; or extreme flexion

seen dorsal to proximal row of carpal bone

432
Q

Snowboarder’s #

A

lateral process of talus

MOI: external rotation + dorsiflexion + axial load

433
Q

QTc calculation formula

A
  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

434
Q

Erythema multiforme

A

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

435
Q

Erythema nodosum

A

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

436
Q

Morel Lavallee Lesion

A
  • 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
437
Q

NICE traffic light system

A

For <5y
Identify likelihood of serious illness

Components
Color
Activity
Respiratory
Circulation and hydration
Others

438
Q

AVM grading scale

A

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)

439
Q

Syndrome associated with telangiectasia and AVM

A

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

440
Q

Clinical findings suggesting spinal cord injury in unconscious trauma patient

ppt

A
  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

441
Q

Parkland formula

A

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

*3ml in children

442
Q

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

ppt

A

Kocher criteria

  1. NWB
  2. T >38.5
  3. ESR >40
  4. WBC >12
443
Q

Scale for patient agitation or aggression

ppt

A

Overt aggression scale

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

444
Q

RVOT VT ECG features

A

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

445
Q

AVNRT ECG features

A

No visible P waves
Pseudo R’ waves (retrograde P waves) in V1-2
Normal axis, narrow QRS

Tx: ATP

446
Q

AF with WPW ECG features

A

Irregular, HR >200
Wide and polymorphic QRS complex
Normal axis

Tx: Procainamide, synchronized cardioversion
Avoid nodal blockers

447
Q

Left posterior fascicular VT ECG features

A

Regular wide complex
QRS 100-140ms
RBBB
LAD
Capture beat

*originate from LV -> RBBB (delayed RV activation)

Tx: Verapamil, synchronized cardioversion

448
Q

Cutaneous larva migrans

A

Parasite infection (hookworm)
Cannot penetrate through dermis
Self limiting

449
Q

Neurocysticercosis

A

Parasitic CNS infection
caused by Taenia Solium (pork tapeworm)

*larval stage (cysticercus)

450
Q

Wrist TFCC full name

A

Triangular fibrocartilage complex

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

451
Q

Difficult BVM

ROMAN

A

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

452
Q

Difficult extraglottic device

RODS

A

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

453
Q

Difficult cricothyrotomy

SHORT/SMART

A

Surgery
Hematoma / Mass
Obesity / Access
Radiation
Trauma

454
Q

SALAD technique

A

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

455
Q

CVC endovenous placement confirmation

NLTH

A

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

456
Q

Spondylolysis

A

Stress # in pars interarticularis
most common in L5

457
Q

Myopericarditis vs Perimyocarditis

A

Myoperi
- acute pericarditis with elevated TnI, normal LVEF

Perimyo
- acute pericarditis with elevated TnI, reduced LVEF

458
Q

Cause of Myopericarditis

statpearls

A

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

459
Q

Young patient syncope, important ECG diagnosis for sudden cardiac death

x7
ppt

A
  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
460
Q

Potential life-threatening marine animal exposure

ppt

A
  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)
461
Q

Lokelma

A

Sodium zirconium cyclosilicate

Bind K in GIT -> increases fecal K excretion

462
Q

Risk of anti-thyroid drug

ppt

A
  1. Potential teratogenicity (CBZ > PTU)
  2. Agranulocytosis (PTU > CBZ)
  3. Hepatotoxicity
463
Q

Agitation / Sedation scale

ppt

A

Richmond Agitation and Sedation Scale (RASS)

Ramsay sedation scale

464
Q

DOPES

A

Displaced ETT
Obstruction
PTX
Equipment failure
Stacked breaths

465
Q

DOTTS

A

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

466
Q

CI for permissive hypercapnia

A

Cerebral edema, high ICP, seizure

467
Q

Cat scratch disease organism

A

Bartonella henselae

468
Q

DC vs AC electrical injury

A

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

469
Q

CI of delayed sequence intubation

ketamine 1-2mg/kg IV

A
  1. Inability to breathe spontaneously
  2. Inability to protect own airway
470
Q

Medical Cx of molar pregnancy

ppt

A
  1. Thyrotoxicosis
  2. Hyperemesis gravidarum
  3. Early onset pre-eclampsia
471
Q

Sheehan syndrome

A

Postpartum pituitary gland necrosis

472
Q

Asherman syndrome

A

Intrauterine adhesion/scarring after surgery of uterus

Amenorrhea, recurrent pregnancy loss, IU adhesions

473
Q

Cupola sign

A

pneumoperitoneum

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

474
Q

Mechanism of lightning injury

ppt
EM book

A
  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

475
Q

Delayed Cx of lightning injury

ppt

A

Psy:
- memory, concentration impairment
- depression, personality change

ENT:
- hearing loss

CVS:
- delayed pericarditis

Skin
- delayed SCC

Eye
- cataract
- optic neuritis

476
Q

Strychnine poisoning

book

A

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

477
Q

FAST-ED scale for stroke

A

Field Assessment Stroke Triage for Emergency Destination scale

478
Q

Etomidate

A

inhibit 11 beta hydroxylase

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

479
Q

Button battery severe outcome predictors

A
  1. Lodged in eso
  2. > 20mm
  3. <6y
  4. multiple button batteries ingestion
480
Q

Triad for Aconite poisoning

A

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

481
Q

Penetrating neck injury

Hard signs of vascular injury

A

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

482
Q

Penetrating neck injury

Soft signs of vascular injury

A
  1. Dysphonia
  2. Dysphagia
  3. Non-expanding hematoma
  4. Subcutaneous or mediastinal air
  5. Minor hemoptysis or hematemesis
483
Q

Transcutanous pacing

A

Anterolateral leads placement better as closer to apex

No capture despite high mA: Hair shave, avoid air/fluid like PTX/pericardiac effusion, correct electrolytes

484
Q

Acute mountain sickness (AMS)
Tx

A

Tx: Acetazolamide, O2, Dexamethasone, HBOT, Descent

Cardinal feature = headache

485
Q

High altitude cerebral edema (HACE)
Tx

A

AMS with mental state change or ataxia

Tx: Dexamethasone, Acetazolamide

486
Q

High altitude pulmonary edema (HAPE)
Tx

A

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

Prevention: Nifedipine

487
Q

Doppler USG sign for testicular torsion

A

Whirlpool sign

488
Q

DDx of Testicular torsion

A

Torsion of appendix testis (blue dot sign on PE)

489
Q

Acid/Alkali injury necrosis type

A

Acid ingestion: coagulation necrosis

Alkali ingestion: liquefactive necrosis

490
Q

Gamekeeper’s thumb

A

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)

491
Q

Cx of Basal skull #

A
  1. Meningitis, CNS infection
  2. CSF fistula
  3. Cavernous sinus thrombosis
  4. Pneumocephalus
492
Q

CSF rhinorrhea

A

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

493
Q

Hamate # classification

A

Milch classification

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

494
Q

ACJ injury classification

A

Rockwood classification

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

495
Q

Inferior shoulder dislocation associated injury

A

Axillary artery

496
Q

Mangled limb definition

A

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

497
Q

Open fracture classification

A

Gustilo-Anderson classification

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

498
Q

Galeazzi fracture-dislocation

MUGGER

A

Radius (distal 1/3) + DRUJ dislocation

499
Q

Monteggia fracture-dislocation

MUGGER

A

Ulnar (proximal 1/3) + radial head dislocation

500
Q

Terrible triad of shoulder injury

A

Shoulder dislocation
Rotator cuff tear
Brachial plexus injury

501
Q

Boutonniere deformity

A

rupture of central slip of extensor tendon at PIPJ

502
Q

Tourniquet for bleeding name

A

Combat application tourniquet

503
Q

Bleeding not detected by FAST scan

A

Retroperitoneal bleeding
External bleeding
Long bone fracture/bleeding

504
Q

Damage control resuscitation
3 components

A

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

505
Q

Damage control surgery

litfl

A

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

506
Q

Inhalational burn injury signs

A
  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
507
Q

Severe burn scores

A
  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
508
Q

Pott puffy tumor

A

Forehead swelling due to frontal bone osteomyelitis with associated subperiosteal abscess

Rare complication of sinusitis

509
Q

Orbital # common location

A

Lamina papyracea
aka orbital lamina of the ethmoid bone

forms medial wall of orbit

510
Q

Penumbra

A

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

511
Q

NF USG

STAFF

A

Subcutaneous thickening
Air
Fascial Fluid

512
Q

Mount Fuji sign in CTB

A

Tension pneumocephalus

513
Q

NAI ordinance

A

Cap 213
Protection of Children and Juveniles Ordinance

Children <14y; Juveniles 14-18y

514
Q

Kleihauer-Betke test

A

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

515
Q

Atracurium vs Cisatracurium

A

Atracurium has histamine release - not to use in asthma

516
Q

Dynamic hyperinflation

517
Q

Sepsis definition

A

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

518
Q

Septic shock

A

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

519
Q

60/60 sign

A

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

520
Q

Pre-eclampsia medication dosage

A
  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 PO BD
Methyldopa 250mg TDS

Treatment threshold: BP 160/110

521
Q

NRP adrenaline dose

A

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

522
Q

Scrub typhus
organism and vector

A

Orientia tsutsugamushi
Mites

523
Q

Ix

A

USG
Doppler USG

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

524
Q

Keraunoparalysis

A

can be caused by lightning strike

transient weakness affecting the lower limbs more commonly and automatically reverses in a matter of few hours

525
Q

Major incident managment
METHANE

A

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

526
Q

Major incident response - 4Cs

A

Communicate
Coordinate
Command
Control

527
Q

Hazmat agents

Pulmonary
Vesicant
Blood agent
Nerve agent

A

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

528
Q

Types of data

A

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

529
Q

Stat tests

A

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

530
Q

CONSORT

A

Consolidated Standards of Reporting Trials

  • provides checklist for essential items to be reported in RCTs
531
Q

Cronbach’s alpha

A

Assess reliability

> 0.9 = excellent
<0.7 = questionable

532
Q

Number needed to treat (NNT)

A

1/ Absolute risk reduction (ARR)

533
Q

ROC curve

A

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)

534
Q

Power of study

A

1 - beta

i.e. “1- type 2 error”

535
Q

Applicability
5 Killer Bs

A
  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
536
Q

Pre-test probability

A

= Prevalence

537
Q

Pre-test odds

A

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

538
Q

Post-test odds

A

= pre-test odds x likelihood ratio

539
Q

Power of study
3 factors affecting

LAW

A
  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)
540
Q

Vertical line of RR =1

A

The line of no effect

541
Q

Concept on thinking to start conducting a study

FINER

A

Feasible
Interesting
Novel
Ethical
Relevant

542
Q

PICO / PEO

A

Patient
Intervention
Comparison
Outcome

Patient
Exposure
Outcome

543
Q

Study design level of evidence

LAW

A

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

544
Q

Elements of validity in RCT

RAMBO

A

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

545
Q

Intention to treat vs Per protocol analysis vs Sensitivity analysis

LAW

A

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

546
Q

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

A

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)

547
Q

3 pillars in EBM

LAW

A

Validity
Result
Applicability

548
Q

Simpson’s paradox

A

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

549
Q

Bonferroni correction

A

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

550
Q

Sensitivity
Specificity
Prevalence
Accuracy

Positive predictive value (PPV)
Negative predictive value (NPV)
Positive likelihood ratio (PLR)
Negative likelihood ratio (NLR)

A

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

551
Q

Probability and odds equation

A

odds = p / (1-p)

probability = odds / (1+odds)

552
Q

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

A

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

553
Q

Estimation of post-test probability from pre-test probability

A

Fagan’s nomogram (Likelihood ratio nomogram)

554
Q

Spectrum bias

A

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

555
Q

Verification bias

A

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

556
Q

Causality criteria

A

Bradford Hill criteria (9 criteria)

  1. Strength
  2. Consistency
  3. Specificity
  4. Temporality
  5. Biological gradient
  6. Plausibility
  7. Coherence
  8. Experiment
  9. Analogy
557
Q

Funnel plot

A

For systematic review/meta-analysis

Scatterplot of treatment effects
Detects bias / heterogeneity

Assymetrical -> publication bias (but not only cause)

558
Q

Fixed effect model vs Random effect model

A

For meta analysis

Fixed effect model: use if no sig heterogeneity

Random effect model: use if moderate/high heterogeneity
Wider confidence interval

559
Q

Forest plot

A

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

560
Q

Test for heterogeneity

A
  1. Eyeball test (look at forest plot)
  2. Cochran’s Q test (Chi square test, p value)
  3. I2 test
561
Q

Prognosis use which study

A

Cohort study

562
Q

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

A
  1. Cox proportional hazard model
  2. Log rank test
563
Q

Trauma scores

A

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)

Combined
7. Trauma score - Injury severity score (TRISS)
8. Kampala trauma score (KTS)

564
Q

Score for predicting massive transfusion

A

ABC score (Assessment of blood consumption)
- 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)
- SBP <90
- HR >120
- GCS <= 8
- Displaced pelvic #
- CT/USG +ve for fluid
- BE >5
- Hb <= 7 / Hb 7-10

565
Q

Risk factor of Ovarian hyperstimulation syndrome (OHSS)

A
  1. Young age
  2. Low BMI
  3. PCOS
  4. Previous OHSS
  5. Elevated estradiol level
566
Q

OHSS avoid what PE

A

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

567
Q

Cx of OHSS

A
  1. Ovarian torsion
  2. Ruptured ovarian cyst
  3. Thromboembolism
  4. Pericardial effusion, CHF
  5. Renal failure
  6. ARDS
568
Q

Features of severe pre-eclampsia

qe

A
  1. Headache
  2. Blurring of vision
  3. Altered mental status
  4. Plt <100
  5. Pul edema
  6. dLFT ALT > 2x ULN
569
Q

Signs of imminent delivery

qe

A
  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 presnation part appear in vulva
  5. Bulging of perineum
  6. Dilatation of anal sphincter
  7. Bowel movement
570
Q

Shoulder dystocia

HELPER4

A

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

571
Q

Active management of third stage of labor (AMTSL)

ALSO

A
  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
572
Q

Medications for uterine atony / PPH

ALSO

A
  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
573
Q

Fitz-Hugh–Curtis syndrome

A

Uncommon Cx from pelvic inflammatory disease
Perihepatitis, by perihepatic adhesions

RUQ pain, referred pain to R shoulder

574
Q

Rhesus hemolytic disease of the newborn

A

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

575
Q

Special consideration of resuscitation for pregnant women

ABC

A

A
- Anticipate difficult airway
- Apply apneic oxygentation technique to prolong safe apneic time
- Apply cricoid pressure to reduce risk of aspiration
- 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 functional residual capacity (FRC)

C
- Manual lateral uterine displacement to relieve aortocaval compression
- IV access set above diaphragm to bypass aortocaval compression

576
Q

Emergency contraception

A
  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)
577
Q

Croup treatment

A
  1. Dexamethasone 0.6 mg/kg PO/IM/IV
  2. Nebulized adrenaline 1:1000 solution 0.5 mg/kg (max 5mL)
578
Q

Pyloric stenosis

USG findings

A

Target sign
Cervix sign

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

579
Q

IO sites for pedi

qe

A
  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

580
Q

Test for rash of meningococcemia

A

Glass test
- does not fade against pressure

581
Q

Pedi status epilepticus drug dose

A

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

582
Q

Hypoglycemia for children treatment dose

A

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)

583
Q

3 narrow points for esophagus button battery ingestion

A
  1. Upper esophageal sphincter (cricopharyngeus - C6)
  2. Aortic arch constriction (T4)
  3. Lower esophageal sphincter (T10)
584
Q

Auto-AED use in Pedi

A

1 years old cutoff for pedi mode

<1y - manual defibrillator
1-8y - pedi mode
>8y - adult mode

585
Q

Defib dose Pedi

A

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

586
Q

Chikungunya fever

A

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

587
Q

Malaria parasites / vectors

A

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

588
Q

Severe malaria definition

A

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)
589
Q

Tx of malaria

A

Severe: IV artesunate 2.4mg/kg over 1-2 minutes

Alternative: Quinine IV + Doxycycline PO

590
Q

Hereditary angioedema enzyme deficiency

A

C1 esterase inhibitor deficiency

Tx: C1 inhibitor concentrate, FFP, Icatibant, Ecallantide

Given transamin if on ACEI

591
Q

Cerebral venous sinus thrombosis (CVST) signs

A

Plain CT:
1. Dense clot sign
2. Cord sign (hyperdensity of sinus)

CT venogram:
3. Empty delta sign

592
Q

Risk factor for Cerebral venous sinus thrombosis (CVST)

A
  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
593
Q

Cause of Young stroke

qe

A

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

594
Q

Waterhouse–Friderichsen syndrome

A

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

595
Q

Purple Urine Bag Syndrome

A

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

596
Q

Tumor lysis syndrome electrolytes

A

HyperK, HyperPO4, Hyper-uricemia
HypoCa

ARF due to CaPO4 and uric crystal formation in renal tubules

597
Q

Hyperviscosity syndrome
Symptom triad

A
  1. Mucosal bleeding
  2. Visual change
  3. Neurological deficit
598
Q

Hyperviscosity syndrome
Common cause

A
  1. Waldenstrom macroglobulinemia (type of B-cell lymphoma)
  2. Multiple myeloma
  3. Leukemia
599
Q

Dressler syndrome

A

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

600
Q

Tx of Torsades de pointes

A

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
601
Q

Echo findings in hypertrophic cardiomyopathy (HCM)

A
  1. Asymmetrical septal hypertrophy
  2. Systolic anterior motion of the mitral valve (SAM)
  3. Dynamic LVOT obstruction
602
Q

Wilson’s disease

A

Kayser-Fleischer ring

Low serum ceruloplasmin level
High serum copper
High 24hr urine copper

Tx
Chelator: D-penicillamine, Trientine

603
Q

Denver criteria

A

Determine whether CT angiography of the neck is indicated

To detect blunt cerebrovascular injury (BCVI) with trauma patients

604
Q

Anterior Atlanto-dens interval (ADI) cutoff

A

<3mm in adults

605
Q

Posterior shoulder dislocation reduction method

A

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.

606
Q

3 in 1 protocol for pelvic fracture

A
  1. Pelvic external fixation
  2. Retroperitoneal pelvic packing
  3. Angiographic embolization
607
Q

Hip dislocation classification

A

Thompson-Epstein system (based on X ray)
Stewart-Milford system (based on functional hip stability)

90% hip dislocations are posterior

608
Q

Posterior hip dislocation
Reduction techniques

A
  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

609
Q

Neurogenic shock above which level

A

T6

Triad: hypotension, hypothermia, bradycardia

610
Q

Spinal shock resolution first clinical indicator

A

Return of bulbocavernosus reflex

611
Q

Spinal cord injury classification

A

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

612
Q

Pilon #

A

Distal tibia involving articulating surface
High energy trauma

613
Q

Pre-hospital stroke scale
FAST-ED

A

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

614
Q

Alcohol driving limit
blood/breath/urine

A

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

615
Q

Stonefish toxin name

A

Stonustoxin

abbreviation of STOnefish National University of Singapore + toxin

616
Q

Early sign of LA toxicity

qe

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

*web

617
Q

Cyanide source

A
  1. Fire victims (combustion of nitrogen-containing materials e.g. wool)
  2. Electroplating
  3. Bitter almond intake
  4. IV nitroprusside
618
Q

4 indications for antidote in cyanide poisoning

A
  1. Cardiac arrest
  2. Impaired GCS <=13
  3. Hypotension
  4. Lactate >10mmol/L
619
Q

Indication of HBOT in fire victims

A
  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
620
Q

Heavy metal posioning associated conditions

qe / book

A

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

621
Q

Plants toxin matching

qe

A

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

622
Q

Food toxin matching

qe

A
  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
623
Q

Orbital compartment syndrome USG sign

A

Guitar pick sign

624
Q

Carotid blowout syndrome (epistaxis after RT HN cancer)
Types

qe

A

Type 1: Threatened
Type 2: Impending
Type 3: Acute

Involves ICA/CCA

Tx; Endovascular embolization / stenting; Surgical ligation

625
Q

Forms of elderly abuse

COC

A
  1. Physical
  2. Sexual
  3. Psychological
  4. Neglect
  5. Abandonment
  6. Financial exploitation
626
Q

Indicators of potential elder abuse from history

COC

A
  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
627
Q

Psychological or behavioral signs of elderly abuse

COC

A
  1. Apprehension
  2. Withdrawal
  3. Depression
  4. Being passive
628
Q

Screening tools for elder abuse

COC

A
  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)
629
Q

Warning signs of elder abuse
Physical abuse
Sexual abuse

COC

A

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

630
Q

Warning signs of elder abuse
Psychological abuse
Neglect

COC

A

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

631
Q

Child abuse
Indicators relating to physical harm/abuse

physical vs behavioral

A

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

632
Q

Child abuse
Indicators relating to sexual harm/abuse

physical vs behavioral

A

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

633
Q

Child abuse
Indicators relating to neglect

physical vs environmental vs behavioral

A

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

634
Q

Child abuse
Indicators relating to psychological harm/abuse

physical vs behavioral

A

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

635
Q

PEP for STD

COC

A

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

636
Q

Psychological and counselling support services in HK for rape case

COC

A
  1. CEASE Crisis Center
  2. RainLily
637
Q

Risk factors for escalating violence in Intimate partner violence

COC

A
  1. Isolation
  2. Threatens to kill
  3. Presence of a weapon
  4. Pathological jealousy
  5. Use of drugs/alcohol
  6. Children at home
638
Q

Score for mortality of unstable angina / NSTEMI

A

TIMI Risk Score for UA/NSTEMI

639
Q

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

A

HEART Score for Major Cardiac Events

Hx
ECG
Age
RF
TnI

640
Q

Tx for HT crisis from pheochromocytoma

A
  1. Phentolamine
  2. Phenoxybenzamine, Terazocin, Prazocin

Avoid BB as unopposed alpha action

641
Q

Coracoid process # classification

A
  1. Ogawa classification
  2. Eyres classification
642
Q

Medications hypoK if taken excessive amounts

JCM

A
  1. Diuretics
  2. Laxatives
  3. Steroids
  4. Insulin
  5. Abx (penicillin, ampicillin, amphotericin B)
643
Q

Composition of staghorn stone

JCM

A

Struvite
(magnesium ammonium phosphate)

644
Q

Tripod fracture components

A

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
645
Q

Pericarditis Tx

A
  1. Aspirin / NSAID
  2. Colchicine
  3. Glucocorticoid (Prednisolone)
646
Q

Risk factor of posterior reversible encephalopathy syndrome (PRES)

A
  1. HT
  2. Eclampsia
  3. Vasculitis (SLE)
  4. Kidney disease
  5. Chemo/cytotoxic drugs
  6. Post organ transplant
647
Q

Xanthogranulomatous pyelonephritis (XGP)

A

Rare form of chronic pyelonephritis
Chronic granulomatous disease resulting in a non-functioning kidney
Specific imaging features

Staghorn stone
CT: Bear’s paw sign

648
Q

Penetrating neck injury

Procedures to avoid

JCM

A
  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
649
Q

Dystonia / Oculogyric crisis Tx meds

A
  1. Benztropine (Cogentin) 1-2mg IM/IV
  2. Diphenhydramine (Benadryl) 25-50mg IM/IV
650
Q

DDx of Acute painless visual loss

A
  1. Retinal detachment
  2. Vitreous hemorrhage
  3. CRAO
  4. CRVO
  5. Stroke/TIA (amaurosis fugax)
  6. Ischemic optic neuropathy
651
Q

Clinical prediction rule for CT brain with HI

A
  1. Canadian CT head rule
  2. New Orleans criteria
  3. NEXUS CT head instrument
652
Q

Bedside Ix for raised ICP

A

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

653
Q

LGL syndrome

A

Lown–Ganong–Levine syndrome
Pre-excitation syndrome

ECG: Short PR, no delta wave

654
Q

Coronoid process of ulna
Classification

A

Regan and Morrey classification

1: Avulsion #
2: # of <50% coronoid
3: # of >50% coronoid

655
Q

Intussusception USG signs

A
  1. Target sign; aka doughnut sign
  2. Pseudokidney sign

Red currant jelly stool

656
Q

Neck of talus X ray view

A

Canale view
(medial oblique axial talus view)

Foot plantarflexed, 15 degree eversion (pronation)

657
Q

Neck of talus classification

A

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

658
Q

Anti-impulse therapy for aortic dissection

A

Aim HR <60
SBP 100-120

BB: Labetalol, Esmolol
CCB: Verapamil, Diltiazem

659
Q

Acute non-traumatic headache decision x CT

A

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

660
Q

Cause of pneumobilia

radiopedia

A
  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
661
Q

Cause of portal venous gas

radiopedia

A
  1. Ischemic bowel
  2. Intra abd sepsis / abscess (diverticulitis, cholangitis, cholecystitis)
  3. IBD
  4. PPU

Pedi: post UVC, necrotizing enterocolitis

662
Q

Prevertebral soft tissue thickness at C3 and C7

JCM

A

C3: 7mm
C7: 18mm

Not measured at C4/5 as variable position of eso and larynx

663
Q

Radiological measurement of hydrocephalus

A

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

664
Q

Unstable C-spine orthosis

A

Sterno-Occipital Mandibular Immobilizer (SOMI) for stable injury

Halo vest immobilizer for unstable injury

665
Q

Acute infectious flexor tenosynovitis

Kanavel cardinal signs of flexor sheath infection
x4

A

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

666
Q

Necrotizing fasciitis (NF) classification

A

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

667
Q

Eczema herpeticum virus

A

Herpes simplex virus (type 1)

Sudden onset papulovesicular lesions with punched out, crusted ulcers in chronic dermatitis

668
Q

Hypocalcemia elicited signs

A

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

669
Q

Decompression sickness types

A

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)

670
Q

Ludwig angina 3 compartments of floor of mouth

A
  1. Sublingual
  2. Submental
  3. Submandibular
671
Q

Systematic review (SR) definition

LAW
EEEM 2021

A

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.

672
Q

Brain abscess microbe

A

Streptococcus anginosus

673
Q

Stroke score for AF name

A

CHA2DS2-VASc score

674
Q

GIB score for low risk OP Mx

A

Glasgow-Blatchford Bleeding Score

675
Q

Rewarming methods

A
  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
676
Q

Flail chest definition

A

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

677
Q

HAZMAT decontamination

A

Universal decontamination agent: Hypochlorite solution (0.5% for skin, 5% for equipment)

Copious amount of water equally effective

678
Q

Lichtenberg figures

Book

A

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

679
Q

Heat stroke types

Book

A
  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
680
Q

Acute radiation syndrome

3 classical syndromes

A
  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

681
Q

Adult status epilepticus drug dose

A

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
3. Valproate 40mg/kg IV

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

682
Q

Risk factor of placental abruption

EM book

A
  1. Maternal HT
  2. Previous hx of placental abruption
  3. Smoking / cocaine use
  4. Advanced maternal age
  5. Trauma
  6. Retroplacental fibroid
  7. Multiparity
683
Q

Burn total BSA (body surface area) chart

A
  1. Wallace rule of nines
  2. Lund and Browder Chart
    - more precise
684
Q

ECG South African flag sign

A

High lateral STEMI

STE in lead 1, aVL, and V2
STD in lead 3

acute occlusion of the D1 (first diagonal) branch LAD

685
Q

RAPD causes

deepseek

A
  1. Optic neuritis
  2. Ischemic optic neuropathy
  3. Retinal detachment
  4. CRAO, CRVO
686
Q

Pre-transport preparation

Tai / SF doc

A

Communication
- patient, relative, receiving facility, transport team, ambulance

Documentation
- Indication, pt condition upon dispatch, enroute mx and vitals

Consent

Select appropriate transport personnel
- risk of deterioration, compentency

Equpiment 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

687
Q

Bedside echo LVEF estimate

A

E point septal separation (EPSS)
**>=7mm = reduced LVEF (<30%)

Parasternal long view
M mode over distal tip of the anterior leaflet of MV

688
Q

Emergency Medical Team (EMT) role

A

Prep course:
- Triage
- Treatment
- Transfer

Field triage, on scene treatment, decision for diversion of patients to hospitals

689
Q

Level C PPE

A

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
690
Q

Level A and B PPE

A

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

Level B: Splash-proof suit and SCBA

691
Q

Physiological criteria for primary trauma diversion / trauma call activation

A
  1. GCS <= 13
  2. SBP <90
  3. RR <10 or >29
692
Q

Anatomical criteria for primary trauma diversion / trauma call activation

A
  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
693
Q

Pneumoperitoneum XR sign

A

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.

694
Q

Ix to do

A
  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
695
Q

AIRS full name

A

Advance Incident Reporting System (AIRS)

696
Q

Fishbone diagram

A

Ishikawa diagram / Cause-and-effect diagram

Visual tool to identify and analyze potential cause of a problem

697
Q

Sentinel events (SE)
醫療風險警示事件

9 categories

A

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]
698
Q

Phenytoin why CI in toxicology causes of seizure

A

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

699
Q

Toxicology causes of Hypoglycemia

Book

A
  1. Insulin
  2. Oral hypoglycemic agents
  3. Ethanol
  4. Salicylate
  5. BB
  6. Quinine
700
Q

Maternal cardiac arrest causes

ABCDEFGH

A

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, HyperK
Tamponade, Tension PTX, Thrombosis (PE), Thrombosis (AMI), Toxin

Hypertension (Preeclampsia, Eclampsia, HELLP, ICH)

701
Q

Serious untoward events (SUE)
重要風險事件

2 categories

A

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]
702
Q

Penetrating abdominal injury

A

Stab / gunshot wound

4 regions
- Anterior abdomen
- Thoracoabdominal area
- Flanks
- Back

703
Q

Pediatric scores for at risk of deterioration

A
  1. Pediatric early warning score (PEWS)
  2. NICE traffic light system
704
Q

CI for Permissive hypotension

A
  1. Traumatic brain injury
  2. Spinal cord injury

BP aim
- SBP 80-90
- MAP 50-60 ?65

705
Q

Diabetic ketoacidosis (DKA) diagnostic criteria

A
  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
706
Q

Pedi ABC compared to adult

Ying

A

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

707
Q

Severe asthma cutoff for RR and HR

A

RR 30
HR 120

708
Q

Pedi uncuff vs cuff ETT

A

Uncuff pros
1. Larger internal diameter for age
(less resistance to airflow, reduced blockage by secretions, easier suction)
2. Minimal mucosal pressure

Uncuff cons
1. Leakage of air
2. 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

Cuff cons
1. Smaller internal diameter
2. Airway injury (tracheal rupture, mucosal ischemia)

709
Q

Ventilator settings for severe pneumonia

CS

A

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%

710
Q

Ventilator settings for asthma/COPD

CS

A

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

711
Q

Peak and plateau pressure high causes

A

Compliance problems

  1. One lung intubation
  2. PTX
  3. Atelectasis
  4. APO
  5. ARDS
712
Q

AMPLE history

A

Allergy
Medication
PMH
Last meal
Event

713
Q

Cx of massive transfusion

A
  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

714
Q

USG jellyfish sign

A

Atelectatic lung “swimming” within a large pleural effusion

715
Q

High dose insulin (HDI) therapy dose

Book

A

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

716
Q

SE of high dose insulin (HDI) therapy

Book

A
  1. Hypoglycemia
    - BG Q10-30min, keep >5.6
  2. HypoK
    - K Q1H, keep >2.8
  3. Exacerbate LV outflow obs in HCM pateints

Blood x Mg, PO4 daily
Rebound hyperK after stopping HDI

717
Q

Mx of BB overdose

Book

A
  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

  1. Glucagon
    - bolus 2-5mg IV (50mcg/kg children)
    - maintenance: 2-5mg/h in D5 (20-50mcg/kg/h in children), titrate clinically
  2. Calcium
    - same as CCB; 1gCaCl or 3g Ca glu
  3. HDI
    - 1U/kg bolus, followed by infusion 0.5-2U/kg/h
  4. Inotropes and Vasopressors
    - Adrenaline or NA
  5. IV lipid emulsion (ILE)
    - Lipid sink for BB with high lipid solubility (propranolol, sotalol)
    - reserved for life threatening toxicity / cardiac arrest
  6. 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 poiusoning
11. MgSO4 2g IV infusion for QTc >500ms

Enhanced elimination
12. HD/HF for life threatening atenolol/sotalol poisoning
- not recommended in propranolol poisoning

718
Q

CURB-65 for pneumonia severity

A

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

719
Q

Wells’ score for PE

A
  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

720
Q

SILENT (lithium)

A

Syndrome of irreversible lithium-effectuated neurotoxicity

Irreversible neuropsychiatric sequelae, persistent after cessation of lithium use
- Cerebellar dysfunction predominates

721
Q

Dialysable drugs characteristics

deepseek

A
  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

722
Q

PECARN rule

A

Pediatric Emergency Care Applied Research Network

Predicts need for CT brain in pediatric head injury
Under 2y and over 2y

723
Q

Shoulder dystocia

ALSO

A

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 pateint to hands and knees (all 4 position)
R4: Repeat