Stuff Flashcards
Lisfranc
Tarsometatarsal joint (TMTJ) complex injury
Causes of Lisfranc injuries
Classification
RTA
Fall from height
Field sports like rugby
Classification: Myerson classification
TMTJ complex contents
- 5 MTs
- 3 Cuneiforms
- Cuboid
Lisfranc ligament
x3
- Dorsal ligament (weakest)
- Interosseus ligament (aka Lisfranc ligament; strongest)
- Plantar ligament
All run obliquely from medial border of 2nd MT to lateral aspect of medial cuneiform
Lisfranc injury mechanisms
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
Pathognomonic sign for Lisfranc
Plantar ecchymosis
(24-48h after)
Special tests for Lisfranc
- Pronation-abduction test
- TMT squeeze test
Fleck sign for Lisfranc injury
Pathognomonic
Avulsion fracture of medial cuneiform or 2nd MT
Cx of Lisfranc injuries
Acute
- Vascular compromise
- Nerve injury
- Compartment syndrome
Chronic
- OA
- Chronic midfoot pain
Normal Foot XR findings
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
Carpal bones
Trapezium Trapezoid Capitate Hamate
Scaphoid Lunate Triquetral Pisiform
Anatomical snuffbox
Medial: EPL
Lateral: EPB, APL
Proximal: Radius styloid
Floor: Scaphoid, Trapezium
Jefferson #
anterior and posterior arches of C1
C1 (atlas) burst #
from axial load on back of head or hyperextension of neck
Hangman #
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
Jefferson bit off a hangman’s thumb
- Jefferson #
- Bilateral facet dislocation
- Odontoid #
- Atlanto-axial and Atlanto-occipital dislocation
- Hangman # (hyperextension)
- Teardrop #
Central cord syndrome
Hyperextension injuries
Cervical spondylosis
UL > LL neurological deficit
Bladder dysfunction
Variable sensory loss
Anterior cord syndrome
Paralysis
Loss of pain / temp
Preserved propioception / vibration / 2-point
Posterior cord syndrome
(less common)
Loss of proprioception / vibration
Ataxic gait
Hypotonia
Loss of deep tendon reflexes
Romberg +ve
NEXUS criteria full name
National emergency X-radiography utilization study
NEXUS criteria
(x5)
- No focal neurology
- No midline C-spine tenderness
- Conscious
- No intoxication
- No distracting injury
ABCD2 score for TIA
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
Dengue fever symptoms
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
Segond fracture
Avulsion # of lateral surface of lateral tibial condyle
Excessive internal rotation + varus stress
ACL tear; also MCL and lateral meniscus injury
Arcuate sign
Avulsion fracture of fibular head (at site of insertion of arcuate ligament complex)
asso w/ cruciate ligament injury
Reverse Segond #
Avulsion # of medial tibial plateau
Valgus stress + External rotation
PCL, MCL, Medial meniscus injury
Chauffeur’s # / Hutchinson #
Oblique # of radial styloid
FOOSH, compression of scaphoid against radial styloid
Purple glove syndrome
IV Dilantin (Phenytoin)
max rate: 50mg/min (Pedi: 1-3mg/kg/min)
Tillaux fracture
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.
Common medical causes of blindness (x4)
Cataract
Glaucoma
Age related macular degeneration
Diabetic retinopathy
Takotsubo cardiomyopathy
aka stress cardiomyopathy, “broken heart syndrome”
- 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
- Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture
- New ECG abnormalities (either ST-segment elevation and/or T-wave inversion) or modest elevation in the cardiac troponin level
- Absence of pheochromocytoma or myocarditis
SDH chronicity
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
Fluid level in knee XR
post trauma
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
Common causes of primary PPH
4Ts
- Tone
- Uterine atony, tx: Syntocinon infusion, bimanual uterine massage, other: Ergometrine, Prostaglandin F2alpha analog (Hemabate) - Tissue
- Retained tissue of conception, may need surgical removal - Trauma
- Perineal, vulva, vaginal or lower uterine segment laceration - Thrombin
- Clotting abnormality - primary or secondary due to DIC
Cord prolapse initial Mx
ALSO
- O2 by mask
- Head down position (Sims or Knee-chest) to avoid compression of cord by presenting part
- Do not handle cord excessively to avoid vasospasm
- Elevate presenting part to ensure umbilical flow until delivery
- If prolonged transfer -> Instillation of bladder by Foley (500-750ml NS), may help pushing the present part up and ease pressure on prolapsed cord
- 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
Bells palsy description
x4
Lack of wrinkling of forehead
Impaired closure of eye
Flattened nasolabial fold
Drooping of mouth corner
Other symptoms of facial nerve palsy
Postauricular pain
Eye pain / tearing
Hyperacusis (n. to stapedius)
Loss of sensation of anterior 2/3 of tongue
Causes of facial n. palsy
x6
- Bell’s palsy
- Ramsay Hunt syndrome aka Herpes zoster oticus (Herpes zoster infection of geniculate ganglion)
- Middle ear infection / pathology (OM, cholesteatoma)
- Temporal bone #
- Parotid tumor
- Cerebellopontine angle tumor - Acoustic neuroma
Ramsay Hunt syndrome triad
Ipsilateral facial paralysis
Otalgia
Vesicles in auditory canal / on auricle
Acyclovir renal adjustment
Increase interval but keep same dose (poor oral bioavailability)
CrCl 10-50: 800mg BD-TDS
CrCl <10: 200mg BD
Life threatening cause of chest pain
x5
- ACS
- PE
- Aortic dissection
- Cardiac tamponade
- Esophageal rupture
Tension PTX
Boerhaave syndrome
aka Effort rupture of esophagus
Spontaneous perforation of eso caused by sudden increase in intraeso pressure + negative intrathoracic pressure (vomit, severe straining)
Mackler’s triad
of Boerhaave syndrome
1. vomiting
2. chest pain
3. subcutaneous emphysema
Hamman’s sign / crunch
pneumomediastinum
heard over precordium in spontaneous mediastinal emphysema
Mediastinal crackling sound synchronus with heart beat
Cx of Boerhaave syndrome
x6
- Pneumomediastinum
- Mediastinitis
- Hydropneumothorax
- Empyema
- Sepsis
- Multiorgan dysfunction syndrome
Ix for Boerhaave syndrome
Gastrografin swallow
(cannot use barium as perforation, will cause mediastinitis)
CT thorax
RV STEMI ECG features
(when have inferior STEMI)
- STE in V1
- STE in V1 and STD in V2 (highly specific for RV infarction)
- Isoelectric ST segment in V1 with marked STD in V2
- STE in III > II
Clinical significance of RV infarction
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
STEMI meds
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
CI of Fibrinolytic for STEMI
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
Cx of fibrinolytics
- ICH (~1%)
- Bleeding risk, most common GIB
- Hypersitivity reaction, hypotension, reperfusion arrhythmias
Cx of AMI
- Arrhythmia: VT, VF, heart blocks; bradyarrhythmia common in inferior MI
- Mechanical: papillary muscle rupture (acute MR), ventricular free wall rupture, LV aneurysm
- Inflammatory: Early pericarditis (transmural infarction); Dressler’s syndrome (AI; 2-10 weeks)
- Thromboembolic: DVT, PE, LV thrombus -> stroke
- Systemic: heart failure, APO, cardiogenic shock (low LVEF)
Steps for transcutaneous pacing
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)
Causes of 3rd n. palsy
DM neuropathy
Demyelineating disease (MS, Miller Fisher)
Brain tumor, Trauma
Cerebral aneurysm (Berry aneurysm)
5 causes of headache
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
CTB finding of basal cistern SAH
- Hyperdensity over subarachnoid space and basal cistern
- Dilated temporal horn of lateral ventricles, suggestive of obstructive hydrocephalus
Causes of primary SAH
Rupture of berry aneurysm
AVM
Coagulopathy
Brain tumor
Arterial dissection
Vasculitis
Cocaine use
2 classifications / grading of SAH
- Hunt and Hess scale
Grade 1-5 (depends on symptoms) - 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
Immediate Tx of SAH on warfarin (meds)
- PCC Prothrombin complex concentrate
(Beriplex: 4-factor PCC) - Vitamin K1
Cx of SAH
Intracranial
1. Cerebral vasospasm
2. Obstructive hydrocephalus, raised ICP
3. Recurrent SAH (rebleeding)
Extracranial
4. Seizure
5. Cerebral salt wasting syndrome
6. Neurogenic pul edema
Wellens syndrome
Critical stenosis of proximal LAD
Recent chest pain now resolved
Do not perform stress test e.g. treadmill
ECG features of Wellens syndrome
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)
ECG V7-9 placement
for posterior MI
same horizontal plane as V6
V7: left posterior axillary line
V8: tip of left scapula
V9: left paraspinal region
Sgarbossa criteria
- Concordant STE >= 1mm any lead
- Concordant STD >= 1mm V1, V2, V3
- 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
STEMI equivalents
- Posterior MI (STD V1-3, do posterior leads)
- new LBBB Sgarbossa criteria
- De Winter T waves (complete LAD occlusion)
- Hyperacute T waves (early anterior STEMI)
- Wellens syndrome (proximal LAD critical stenosis) **not any more
- STE in aVR - Left main coronary artery (LMCA) occlusion, Proximal LAD stenosis, severe TVD
DDx for hyperthermia, tachycardia, agitation
CNS
1. CNS infection
2. Stroke, tumor (involve thermoregulatory pathway)
3. Status epilepticus
- 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
Tx for sympathomimetic toxidrome
- Physical restraint followed by chemical restraint
- Rapid and aggressive cooling for hyperthermia
- Aggressive fluid resuscitation
- Benzodiazepine
- can treat agitation, hyperthermia, HT, tachycardia
- antidote of cocaine and other stimulants
ECG findings of Na channel blocker overdose (e.g. cocaine)
Wide complex tachycardia
Right axis deviation
Dominant terminal R wave in aVR
Na channel blockers
TCA-PP-DV
Toxi book
T - Tricyclic antidepressants
C - Carbamazepine, Cocaine, Citalopram
A - Antiarrhythmic 1A (Procainamide) / 1C (Flecainide), Amantadine
P - Propranolol
P - Phenothiazine (Thioridazine)
D - Diphenhydramine (Benadryl)
V - Venlafaxine
Mx of Na channel blockers overdose
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
Mx of hyperthermia (cooling method)
- Remove clothing
- Water mist spray and fanning
- Ice packs at neck, axillae, groin
- Bladder irrigation with ice water
- Peritoneal lavage with cold dialysate
aim: reduce core temp to <40 in 30 mins
Serotonin syndrome
3 As
Antidepressants (SSRI)
Analgesics (Tramadol, Pethidine, Fentanyl)
Abusive drugs (cocaine, MDMA (ecstasy), Methamphetamine (ice))
Features of Serotonin syndrome
usually clonus over LL
Antidote of Serotonin syndrome
Cyproheptadine (antihistamine + antiserotonergic)
8-12mg PO x1
2mg Q2H till symptom resolve
Up to 32mg / day
Cocaine intoxication drug CI
Beta blockers - unoppposed alpha effect -> paradoxical HT
Tx of HT in cocaine intoxication
- Benzodiazepine
- Phentolamine
- Nitroglycerin, Nitroprusside
- CCB
- Labetalol (controversial)
Phlegmasia cerulea dolens
uncommon DVT
congestion and cyanosis of a limb due to massive venous thrombosis
Massive blood transfusion definition
10 units packed red cells within 24h
or more than 1 blood volume within 24h
Pedi: 40ml/kg blood products (4 units) in 4h
Beck’s triad
of Cardiac tamponade
- Hypotension, narrow pulse pressure
- Distended neck veins (jugular veins)
- Muffled heart sounds
Colistin
Polymyxin E
Last resort for Gram neg infections
SE: Nephotoxicity, neurotoxicity
HBOT indications currently
Life-threatening
1. Severe decompression sickness
2. Cerebral arterial gas embolism
Emergency
3. CO poisoning
4. Necrotizing soft tissue infection
5. CRAO
Absolute CI for HBOT
- Unresolved PTX
- Pneumocephalus
- Hollow orbital prosthesis
- Currently on Bleomycin / Adriamycin (Doxorubicin)
AACG Glaucoma Mx
STAMP
ATM PBL
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)
Osborn wave
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
Causes of Osborn wave
Hypothermia
HyperCa
AMI
Takotsubo cardiomyopathy
LVH due to HT
Normal variant and early repolarization
Neurological insults such as intracranial hypertension, severe head injury and SAH
Severe myocarditis
Brugada syndrome
Le syndrome d’Haïssaguerre (idiopathic VF)
Brudzinski’s sign
Passive neck flexion -> Flexion of hips and knees
specific but not sensitive
Kernig’s sign
Supine, hip and knee flex to 90 deg
Resistant / Pain during passive extension of leg
specific but not sensitive
Echo
Parasternal short axis view
look for RWMA
PE classification
- Massive (hemo unstable)
- Submassive (RV strain)
- Non-massive (no RV strain)
ECG low voltage
QRS all limb leads <5mm or all precordial leads <10mm
Posterior MI ECG changes
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)
Posterior MI
litfl
- 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
RV infarction
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
Right side ECG
V1-2 same position
V3-6 to V3R - V6R
Most useful = V4R (R 5th ICS, MCL)
De Winter T waves
STEMI equivalent
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
STE in aVR, diffuse STD in other leads
LMCA occlusion
or pLAD stenosis, severe TVD…
cause by diffuse subendocardial ischemia / infarction of basal septum
5 types of MI
(EM book)
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
ECG mimics of STEMI
- Acute pericarditis
- LV aneurysm
- Benign early repolarization (BER)
- Prinzmetal’s angina (coronary vasospasm)
- Brugada syndrome
- LVH
- HOCM
- SAH (raised ICP)
- HyperK
- LBBB
BER (Benign early repolarization) vs Pericarditis
ECG
ST segment / T wave ratio in V6
>0.25 = Pericarditis
<0.25 = BER
Acute epiglottitis most common microbe
Haemophilus influenzae type B (historically)
Now: Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus
Chest pain life threatening causes (x6)
EM book
- Acute coronary syndrome
- Acute aortic syndrome
- PE
- Tension PTX
- Cardiac tamponade
- Eso rupture (Boerhaave’s syndrome)
Hamman’s sign
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
Westermark sign
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
Echo findings of cardiac tamponade
- Pericardial effusion
- Diastolic RV collapse (highly specific)
- Systolic RA collapse (earliest sign)
- Dilated IVC w/o insp collapse (highly sensitive)
SVT vs VT features
EM book
- QRS >0.14s in RBBB / >0.16s in LBBB
- AV dissociation
- Capture or fusion beats
- Precordial QRS complex concordance
- Axis -90 to +180
- QRS configuration…
Causes of VT
- Coronary artery disease
- Hypertrophic cardiomyopathy
- MV prolapse
- Drug toxicity
- Electrolyte disturbance
Torsades de pointes
Tx
MgSO4 1-2g over 60-90 seconds
Isoproterenol 1-8 mcg/min
Score for unsalvageable limb
MESS
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!
CXR PE findings
- Westermark sign (focal oligemia)
- Hampton’s hump (peripheral wedge shaped opacity)
- Palla’s sign (enlarged right dsc pul a)
Echo findings acute PE
- RV dilatation
- RV hypokinesis (w/ sparing of apex) “McConnell’s sign”
- D shaped LV
- TR
- IV septal flattening
TCA poisoning clinical features
PIC
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
Radio-opaque meds
COINS
/ CHIPS
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
Blast injury 1/2/3/4
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
Pedi BP
SBP: (Age x2) + 90
Hypotension SBP: (Age x2) + 70
Pediatric Endotracheal Tube Size / Depth
Uncuffed = (age/4) + 4
Cuffed = (age/4) + 3
Depth = ETT size x3
Tibial plateau # classification
Schatzker (type 1-6)
Pedi maintenance IVF formula
(4-2-1)
First 10kg = 4ml/kg/hr = 40ml/hr
Next 10kg = 2ml/kg/hr = 20ml/hr
Then 1ml/kg/hr
Shock: 20ml/kg bolus
Eclampsia Mx
Loading: MgSO4 4-6g IV over 15-20 mins
Maintenance MgSO4 2g/hr (for 24h after last seizure)
MgSO4 toxicity monitoring
- 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
Delayed cord clamping pros and cons
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
BRASH syndrome
Bradycardia
Renal Failure
AV blockade
Shock
HyperK
SCORTEN score
for TEN/SJS mortality
- Age (>40)
- Associated malignancy
- HR (>120)
- Detached or compromised body surface (>10%)
- Serum urea (>10)
- Serum HCO3 (<20)
- Serum glucose (>14)
Etiology of SJS/TEN
- Drugs (allopurinol, AED carbamazepine, lamotrigine, NSAIDs)
- Infection (Mycoplasma pneumoniae)
WPW ECG features
- Short PR interval < 120ms
- Delta wave: slurring slow rise of initial portion of the QRS
- Prolong QRS 110ms
- Discordant ST/T changes
- 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)
Drug Tx for thyroid storm
- BB (control increased adrenergic tone)
- Propranolol PO 60-80mg Q4H
- Esmolol (short acting) IV 250-500mcg/kg stat, then 50-100mcg/kg/min infusion - Thiondamides (Antithyroid drug; inhibit TH synthesis and T4 to T3 conversion):
- Propylthiouracil (also blocks peripheral conversion to T4 to T3)
500mg stat then 250mg Q4H PO
- Methimazole / Carbimazole - Iodide (inhibit release of TH)
- Lugol’s solution (Potassium iodide, SSKI *saturated solution of potassium iodide)
5 drops Q6H
- Give 1h after PTU as iodine maybe used for new hormone synthesis - Steroid (reduce T4 to T3 conversion)
- Hydrocortisone 200mg stat, then 100mg Q8H
Risk factor of testicular torsion
- Bell-clapper deformity
- Cryptorchidism
- Testicular tumor
NMS Tx
- Dantrolene (also use in malig hyperthermia)
- Bromocriptine (dopamine agonist)
- Amantadine
- Benzo: Lorazepam, Diazepam
Panadol overdose values
Toxic: >7.5g or >150mg/kg
Massive: 0.5-1g/kg
Panadol overdose types
- Acute single overdose
(single ingestion) - Staggered overdose
(multiple ingestions in 1-24 hrs; <4h interval treat as acute)
NAC indicated if >150mg/kg - 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 - 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
GI decontamination for panadol overdose
Activated charcoal 1g/kg within 1-2h of ingestion
if significant co-ingestion / massive overdose >1g/kg, consider gastric lavage
Panadol nomogram name
Rumack-Matthew nomogram
Poor prognostic marker for liver/death from panadol overdose
- pH < 7.30 after fluid and hemodynamic resuscitation.
- Coexistence of PT>100s, Cr >300 and grade III/IV hepatic encephalopathy
- Serum lactate >3.0 to 3.5
- Serum phosphate > 1.2 at 40-92 hr
- Serum AFP > 3.9 on day+1 after peak ALT identifies patients with favourable outcome
- Coagulation factor VIII/V ratio > 30; factor VIII is produced by endothelial cells while Factor V is made by hepatocytes
Burn care classification
3 levels
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
Methods of GI decontamination
Book
- Single dose Activated Charcoal (AC)
- Gastric lavage (GL)
- Multiple dose Activated Charcoal (MDAC)
- Whole bowel irrigation (WBI)
- Surgical intervention
AC dose
Book
adult 50-100g
children 1g/kg
Indication of AC
Book
A potential toxic ingestion within 1-2h
up to few hours
CI of AC
Book
- Corrosive
- Rapidly absorbed e.g. ethanol
- Small molecular size e.g. lithium
- Unprotected airway
- GIT injury (e.g. corrosive injury)
- Non-functioning GIT (e.g. absent gut motility)
- GI endoscopic visualization considered essential
MDAC dose
Book
Initial single dose AC
then 0.5g/kg Q2-4h x4
Cx of MDAC
Book
- Fatal aspiration
- Pneumonitis
- SB obstruction
- Appendicitis
Indication of GL
Book
- A life threatening posion ingestion where poison likely still in stomach
- Preferred within 1h
CI of GL
Book
- Caustic ingestion
- Large FB or sharp objects
- Inability to protect airway
Cx of GL
Book
- Aspiration pneumonia
- Eso / Gastric perforation
- Tension PTX and empyema
- Decreased oxygentation during procedure
Indication of WBI
Book
- Potentially toxic ingestions of sustained release / enteric coated drugs, particially >2h
- Toxic ingestion of iron, lithium, potassium
- Removal of ingested packets of illicit drugs in body packers
CI of WBI
Book
- Absent bowel sound
- Bowel obstruction / perforation
Hydroxocobalamin indication
Cyanide poisoning
Hydroxocobalamin SE
- Reversible pink discoloration of skin, mucous membrane, urine
- Muscle spasm and twitching
- Hypertension
Sodium nitrite indication
Cyanide poisoning (prefer to use hydroxocobalamin)
Hydrogen sulphide poisoning
Sodium nitrite SE
- Hypotension
- Methemoglobinemia
ABCD2 score for TIA
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
High AG acidosis (HAGMA)
CAT MUD PILES
KULT
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)
Substances not binding to AC
PHAILS
Pesticides
Heavy metals
Acid / Alkali / Alcohol
Iron
Lithium
Solvents
Maisonneuve fracture
spiral # of the proximal third of fibula
associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane
Sign of basal skull #
- Battle’s sign (bruising of mastoid process of temporal bone)
- Raccoon eyes (periorbital ecchymosis)
- CSF rhinorrhea
- Hemotympanum
Croup score
Westley Croup Severity Score
Level of consciousness
Cyanosis
Stridor
Air entry
Retractions
Dog / Cat bite micro-organisms
Pasteurella (G-ve coccobacilli)
- canis, multocida, septica
Capnocytophaga canimorsus
Rolando #
comminuted intra-articular # base of 1st MC
Bennett #
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
Digoxin toxicity
when to expect
- Unexplained bradycardia
- Non-specific GI/ Neuro complaints
- ECG changes
- Unexplained hyperK
- 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
Digoxin toxicity ECG changes
Scooped ST segments (reverse tick appearance)
Prolong PR
ventricular arrhythmias
sinus bradycardia, impaired AVN conduction
Digoxin toxicity specific treatment
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
4 types of shock
COHD
- Cardiogenic (AMI, CHF)
- Obstructive (3Ps - Tension PTX, cardiac tamponade, PE)
- Hypovolemic
- Distributive (septic, anaphylactic, neurogenic)
Anion gap calculation
(3 components)
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)
Osmolar gap calculation
(3 components)
Calculated:
Na x2 + Glucose + Urea
Measured - Calculated
Normal <10
Score for NF
LRINEC Score
Laboratory Risk Indicator for Necrotizing Fasciitis score
Hypertropic cardiomyopathy (HCM) ECG features
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
Classification of mid face fracture
Le Fort
Lemierre’s syndrome
infectious thrombophlebitis of IJV
C1/2 subluxation classification
(atlantoaxial rotatory subluxation)
Fielding and Hawkins classification
CRITOE (1-11y)
Appearance of ossification centers
Capitellum 1y
Radial head 3y
Internal epicondyle 5y
Trochlea 7y
Olecranon 9y
External epicondyle 11y
3 common elbow injuries in children
- Supracondylar fracture
- Radial head subluxation
- Lateral condyle fracture
Human bite micro-organism
Eikenella corrodens
CRAO management
- Ocular massage
- Breathe into a paper bag
- IV Acetazolamide, Timolol eye drops
- HBOT
ACLS modifications for pregnant women
- Manual displacement of uterus to left
- IV set above diaphragm
- Airway / ventilation priority (expect laryngeal edema)
6P for Compartment syndrome
- Pain
- Poikilothermia (Perishing cold)
- Paresthesia
- Paralysis
- Pulselessness
- Pallor
MR SOPA for NRP
Mask adjustment
Reposition airway
Suction mouth and nose
Open mouth
Pressure increase (up to 40)
Alternate airway
Neck zones 1-3
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
Difficult laryngoscopy
LEMON rule
Look externally
- Facial trauma
- Large incisors
- Beard / moustache
- Large tongue
Evaluate 3-3-2 rule
- Inter-incisor distance 3 finger breadths
- Hyoid-mental distance 3 finger breadths (chin to neck)
- Hyoid-thyroid distance 2 finger breadths (chin/neck junction to thyroid)
Mallampati (>=3 is difficult)
Obstruction (epiglottitis, quinsy, trauma) / Obesity
Neck mobility
Ramp position for obesity intubation
head and torso are elevated such that the external auditory meatus and the sternal notch are horizontally aligned
CI if neck injury
Lethal triad of trauma
(HCA)
Hypothermia
Acidosis
Coagulopathy
Lethal diamond: hypoCa
Cushing triad for raised ICP
- Widened pulse pressure
- Bradycardia
- Irregular respiration (Cheyne–Stokes respirations)
Quetiapine overdose effects
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
Magnesium sulphate for Asthma dose
MgSO4 2g over 20 mins IV
CI: MG, heart block, severe renal impairment, hypoCa, hyperMg
Chance fracture
Unstable
Flexion-distraction injury
Seatbelt sign (typical no shoulder straps)
typical in TL junction
asso w/ intra-abd injury e.g. duodenum, pancreas
Massive zopiclone overdose
Methemoglobinemia (within 24h)
Hemolytic anemia (within 1-3d)
Renal impairment (within 1-3d)
Tuna Fish for LBP red flags
Trauma
Unexplained weight loss
Neurological symptoms / signs
Age > 50
Fever
Intravenous drug use
Steroid use
History of cancer
CXR signs for aortic dissection
x7
EM handbook
- Widened mediastinum
- Left pleural effusion
- R sided tracheal deviation
- Calcium sign (separation of calcification at aortic arch)
- Double aortic knob sign
- Pericardial effusion
- Displacement of NG tube to right
Echo signs for aortic dissection
EM handbook
- Aortic root dilatation
- Aortic regurgitation (AR)
- Pericardial effusion
- Ventricular wall regional wall abnormalities implying coronary ostial occlusion
Echo probe manipulation
POCUS
- Sliding
- Rocking (towards and away indicator)
- Tiliting (Fanning)
- Rotation
McConnell’s sign for PE
RV free wall akinesis with sparing of the apex
Echo findings of PE
RV dilatation
RV free wall hypokinesis
McConnell’s sign
IV septum flattening -> D shaped LV
Tricuspid regurgitation
60/60 sign
Drug cause of prolonged QTc
5A + CLAM
Toxi book
5A + CLAM
- Anti-arrhythmic
- Anti-depressants
- Anti-psychotic
- Anti-histamine
- Anti-microbial (Macrolide, FQ, Amantadine, Antifungal)
- CLAM (Cisapride, Cesium, Lithium, Arsenic, Methadone)
PMHAD
HyperK ECG changes
- Peaked T waves
- P wave widening/flattening, PR prolongation
- Bradyarrhythmias: sinus bradycardia, high-grade AV block with slow junctional and ventricular escape rhythms, slow AF
- Conduction blocks (bundle branch block, fascicular blocks)
- QRS widening with bizarre QRS morphology
Triad of opioid toxidrome
Tox book
CNS depression
Resp depression
Miosis
Methadone
Diploma
Long acting synthetic opioid
Prolong QTc
Na channel blockade toxidrome
SALT
Diploma
Shock
Altered mental status
Long QRS
Terminal right axis deviation
One tab kill (10kg infant)
NOCT 1234
Diploma FL
Narcotic
Oral hypoglycemic, Oil (Methylsalicylate)
CCB, Camphor, Chloroquine/Quinine
TCA, Theophylline, Thioridazine/Chlorpromazine, Toxic alcohol
Toxic alcohol
x3
Toxi book
Methanol
Ethylene glycol (EG)
Diethylene glycol (DEG)
CNS stimulants example
x3
Toxi book
- Methamphetamine
- MDMA (3,4-Methylenedioxymethamphetamine), aka Ecstasy (tablet), Molly (crystal)
- Cocaine
CNS depressants example
x6
Toxi book
- Opioids
- Benzodiazepines
- GHB (gamma-hydroxybutyrate)
- Organic solvent
- Barbiturates
- Ethanol
Dissociatives example
x3
Toxi book
- Ketamine
- Dextromethorphan (DXM)
- Phencyclidine
Blocks NMDA receptor
Hallucinogens example
x2
Toxi book
- Cannabis
- LSD (lysergic acid diethylamide)
Urine ABON for cocaine
Toxi book
Unlikely false positive
Detects Benzoylecgonine
Toxicity of Cocaine
Toxi book
- Sympathomimetic toxidrome
- CNS (psychomotor agitiation, seizure, ICH, TIA, infarct)
- CVS (ACS, HT emergency, AAS, arrhythmia, vasospasm)
Cocaine ACS: enhanced platelet aggregation and reduces endogenous thrombolysis
- 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
Cocaine common killer
x3
Toxi book
- Hyperthermia
- Arrhythmia
- ICH
Tx for cocaine
Toxi book
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
Cannabis - major active ingredient
Toxi book
THC (Delta-9-tetrahydrocannabinol)
**CBD (Cannabidiol) does not interact with cannabinoid receptors and does not have same psychoactivity as THC
Complications of Cannabis use
Toxi book
- Pneumothorax
- Pneumomediastinum
- Paroxysmal AF
Urine ABON for Cannabis
Toxi book
False positive: Naproxen, Ibuprofen, Efavirenz
Look for THC and its metabolites
GHB and GBL
Toxi book
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
Organic solvents / Volatile hydrocarbon
3 types
Toxi book
- Aliphatic HC
- Butane (Lighter fuel) - Halogenated HC
- Trichloroethylene (Correction fluid)
- Trichloroethane - Aromatic HC
- Toluene (Thinner)
- Xylene (Glue)
Toxicity of volatile hydrocarbon
Toxi book
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
Treatment of volatile HC
Toxi book
- Supportive care, avoid catecholamine surge
- BZD to control agitation
- Early use of BB (e.g. esmolol) as anti-arrhythmic in resuscitation of sudden sniffing ventricular tachyarrhythmia
Ketamine
Toxi book
Dissociative anesthetic agent
Mainly act on CNS + CVS
Snorted in white powder
Binds to NMDA receptors, biogenic amine uptake complex, sigma receptor, ACh receptor
Ketamine - clinical presentation
Toxi book
Altered mental status (most common), with mild sympathomimetic
Chronic: ketamine associated urinary tract dysfunction, ketamine associated abdominal pain
reversible dilated CBD
Urine ABON for ketamine
Toxi book
False positive common
Tx for Ketamine
Toxi book
- Supportive care, prevent secondary injury
- BZD to control agitation
- Observe 4-6 hours for effect to wean off
Poppers
Toxi book
Various volatile alkyl nitrites
used in chemsex
relaxes anal sphincter for MSM
May cause MetHb
Drugs used in Chemsex
Toxi book
Metamphetamine
Mephedrone
GHB, GBL
Alkyl nitrites, ecstasy (MDMA), foxy, ketamine, cocaine, cannabis, sildenafil
Body packer
Toxi book
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
Body stuffer
Toxi book
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
Cardioactive steroids
Toxi book
- 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
- Increase vagal tone
Sinus bradycardia, AV block, bradydysrhythmia
Toxic effects enchaned by hypoK and hypoMg
Causes of acute Digoxin / Cardioactive steroids poisoning
Toxi book
- Intentional overdose
- Cardioactive steroids exposure (accidental Chan Su overdose)
Causes of chronic Digoxin / Cardioactive steroids poisoning
Toxi book
- Dosing error
- Decreased renal digoxin elimination (dehydration, impaired renal fx, nephrotoxic drug use)
- Increased sensitivity to digoxin (decompensated cardiac conditions, concomitant use of negative inotropic or chronotropic agents, hypoK)
Presentation of Digoxin / Cardioactive steroids poisoning
Toxi book
GI: Nausea, vomiting, anorexia
CNS: headache, confusion, visual disturbance (alteration in color perception: xanthopsia)
Metabolic: HyperK
Risk stratification for Digoxin / Cardioactive steroids poisoning
Toxi book
HyperK
(>5.5 all dead)
ECG change of Digoxin / Cardioactive steroids poisoning
Toxi book
Scooped ST segments (reverse tick appearance)
Prolong PR
*Increase automaticity with high degree AV block
Fast AF not compatible, otherwise all arrhythmia can happen
Ix for Digoxin / Cardioactive steroids poisoning
Toxi book
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
Mx for Digoxin / Cardioactive steroids poisoning
Toxi book
- ABC
- GI decon: GL + AC within 1-2h; consider MDAC in severe cases
- 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) - HyperK to be treated by DigiFab, no DI drip unless marked hyperK
- Avoid Calcium - may arrest, give Digifab before IV calciuim if really indicated, e.g. concomittant CCB poisoning
- Cardioversion - start with low energy e.g. 10-25J
- Hemoperfusion / HD not useful
Indications of Digoxin specific Ab fragments
Toxi book
Any of
1. Life threatening clinical presentation (ventricular dysrhythmia, bradydysrhythmia not responsive to atropine)
- Serum K >5 (attributable to digoxin / cardioactive steroid)
- Serum digoxin level >10ng/ml (13nmol/L) at 6h post ingestion or >15 ng/ml (19.5nmol/L) at any time for acute ingestion
- Digoxin ingestion of >10mg in adult or >4mg in child
How to give Digoxin specific Ab fragments (DigiFab)
Toxi book
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
SE of Digoxin specific Ab fragments (DigiFab)
Toxi book
- HypoK
- Exacerbate CHF
- 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)
Which vitamin acute overdose has toxicity
x3
Toxi book
A (>300kIU or >25kIU/kg in children)
B3, i.e. Niacin
Iron
Which vitamin chronic overdose has toxicity
x4
Toxi book
A
B6, i.e. Pyridoxine
C
D
Vit A overdose
Toxi book
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
Vit B3 (Niacin) overdose
Toxi book
Only acute
Present with GI disturbance, DKA like syndrome
Supportive Mx
Vit B6 (Pyridoxine) overdose
Toxi book
Only chronic
acute non-toxic
Present with sensory peripheral neuropathy
Vit C overdose
Toxi book
Only chronic
acute non-toxic
Renal failure patients -> graft failure
high dose parenteral -> oxidative hemolysis, MetHb, AKI in G6PD def
Vit D
Toxi book
Only chronic
acute non-toxic
Present with hyperCa, GI disturbance, dehydration
Supportive Mx, correct hyperCa/rehydration
Indications of IV lipid emulsion (ILE)
Toxi book
- Severe LA poisoning
- Life threatening lipophilic drug poisoning, esp TCA, CCB
Dose: Intralipid 20% 1.5ml/kg IV bolus over 1 min, then infusion 0.25ml/kg/min (15ml/kg/h)
end point = cumulative 10ml/kg
SE of IV lipid emulsion (ILE)
Toxi book
- lipemic serum, affecting lab tests
- elevated amylase
- fever
- transient dLFT
- resp distress
- coagulopathy
- circuit obstruction of extracorporeal devices, e.g. ECMO, hemofiltration, plasmapheresis
When to consider Enchanced elimination
Toxi book
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
Common routes of EE
Toxi book
- GIT: MDAC
- Urine: Urine alkalinization
- Blood: ECTR (Extrocorporeal tx): HD, HP, HF
Forced diuresis, urine acidification, PD no longer considered
Urine alkalinization indication (which drugs)
x6
Toxi book
- Aspirin
- Phenobarbital
- Chlorpropamide
- Formate
- MTX
- 2-4 D (2,4-dichlorophenoxyacetic acid)
Mechanism of urine alkalinization
Toxi book
Works by ion trapping
Urine pH >7-8 to be effective
Avoid hypoK - will dump H to reabsorb K - less effective
How to do urine alkalinization
Toxi book
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
Choice of ECTR (Extracorporeal tx)
Toxi book
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
Antidotes Lvl 1
NAC, Atropine, Bromocriptine, Calcium
Toxi book
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
Antidotes Lvl 1
Cyproheptadine, Dantrolene, Desferrioxamine, Digoxin Fab
Toxi book
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
Antidotes Lvl 1
Dimercaprol (BAL), DMPS (Injection), Ethanol, Flumazenil
Toxi book
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
Antidotes Lvl 1
Glucagon, Hydroxocobalamin, Idarucizumab, Intralipid 20%
Toxi book
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)
Antidotes Lvl 1
Methylene blue, Naloxone, Penicillamine, Physostigmine
Toxi book
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
Antidotes Lvl 1
Pralidoxime, Pyridoxine, Protamine, Sodium bicarbonate
Toxi book
Pralidoxime
- used in OP poisoning
30mg/kg up to 2g over 30 mins
Followed by infusion 8-10mg/kg/h in adult, titrate down in 24-48h according to clinical response
SE: headache, dizziness, diplopia, blurred vision, HT, ECG TWI
Pyridoxine (Vit B6)
- used in Isoniazid, Hydrazine, Gyromitra mushroom, Ginkgo seeds poisoning
- adjunct use in tetramine, ethylene glycol poisoning
SE: Neurotoxicity - peripheral neuropathy
Protamine
- used in heparin reversal
Sodium bicarbonate (NaHCO3)
For sodium load / blood alkalinization
Indication: TCA / other Na channel blockers poisoning with QRS >100ms, Salicylate poisoning
1-2ml/kg 8.4% NaHCO3 IV bolus to achieve serum pH 7.45-7.55
CI:
- serum pH >7.55 (consider hypertonic saline as alternative)
- Intolerable Na/fluid load (consider hyperventilation as alternative)
SE: Na/fluid load, hypoK
For urine alkalinization
Indication: Enhance excretion of Salicylate, Phenobarbitone**, MTX, Chlorpropamide, 2,4-dichlorophenoxyacetic acid, Formate
Generally use MDAC for Phenobarbitone as much more effective
1-2ml/kg 8.4% NaHCO3 IV bolus
50ml in 500ml D5 Q4H and titrate
Aim: serum pH 7.45-7.55, urine pH 7-8 ?7.5-8
Monitor and replace K
Antidotes Lvl 1
Sodium nitrite, Sodium thiosulphate, Sucralfate, Vit K1
Toxi book
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
Antidotes Lvl 2
Calcium EDTA, Folinic acid, L-Carnitine, Octreotide, Phentolamine
Toxi book
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
Antidotes Lvl 2
Antiveom x4
Toxi book
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)
Antidotes Lvl 3
Acetamide
Botulism antitoxin heptavalent
Fomepizole
DMPS (oral)
Methionine
Prussian blue
Silibinin / Silymarin
Succimer (DMSA)
Toxi book
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
Antidotes Lvl 3
Antivenom x6
Toxi book
Agkistrodon acutus
Russell’s viper
Tr. Muscrosqumatus + Tr. Gramineus
Scorpion
Sea snake
Stonefish
4 types of mushroom poisoning syndromes
Monograph / Book
- Gastroenteritic (Chlorophyllum molybdites, Russula emetic, Porcini) – 80%
- Hepatotoxic (Amanita exitialis, A. rimosa)
- Cholinergic (Inocybe rimosa, Mycena pura)
- Hallucinogenic (Porcini – VH of micropsia or macropsia)
Amatoxin present in which species
Monograph / Book
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
Toxicokinetic / pathophysiology of Amatoxin mushroom poisoning
Monograph
Toxin: Alpha-amanitin
Interferes RNA polymerase, inhibit protein synthesis, causing cell death
Mainly excrete in urine but also significant amount in bile
Clinical features of Amatoxin mushroom poisoning
Monograph
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
Ix of Amatoxin mushroom poisoning
Monograph
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
Mx of Amatoxin mushroom poisoning
Monograph
- IVF rehydration (most important): aim >150ml/hr // 2-3ml/kg/hr
- 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 - Contact QMH LT unit
- Urgent ERCP nasobiliary drain placement without sphincterotomy, preferably within 2h
- May consider: High dose Pen G, early charcoal HP
Not useful: PO cimetidine, forced diuresis, HF or HD, steroid, thioctic acid
Scombroid food poisoning
Which fish
Book
Scombridae: Tuna, Mackerel, Bonito
Non-scombridae: sardine, mahi-mahi, amberjack, albacore
Usually on spoiled fish skin
Clinical features of Scombroid food poisoning
Book
Symptom onset within minutes to hours after ingestion
Flushing, urticaria, headache, N/V
Bronchospasm, angioedema, hypotension
Self-limiting, resolves within 6-8 hours
Mx of Scombroid food poisoning
Book
- Supportive tx
- IVF for hypotension
- Antihistamine for symptoms
- Bronchodilator for bronchospasm
- Adrenaline seldom needed
- Normal serum tryptase (taken 1-2h from onset) -> exclude food allergy/anaphylaxis
Mad honey poisoning
Which toxin
Book
Grayanotoxin
From Rhododendrons flowers, common in Black Sea area of Turkey and Nepal
Clinical features of Mad honey poisoning
Book
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
Biotoxins for food poisoning
x4
Book
Ciguatoxin (coral fish)
Tetrodotoxin (pufferfish)
Saxitoxin (paralytic shellfish)
Histamine (scombroid)
Short incubation more likely toxin
Long incubation more likely infective
Food type food poisoning of the following
Vibrio parahaemolyticus
Botulism
Clenbuterol
Pesticide
Book
Vibrio – undercooked seafood
Botulism – Canned food
Clenbuterol – Pigs’ offal
Pesticide – vegetables
Toxin causing GI symptoms within 6h
Book
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)
Toxin causing GI symptoms beyond 6 hours
Book
Clostridium perfringens (8-16h, toxin production in gut)
Salmonella, Shigella, Vibrio parahaemolyticus (16-72h)
Amatoxin (>6h)
Toxin causing Early neuro and systemic symptoms (Within few hrs)
Book
Ciguatoxin
Brevetoxin (neurotoxic shellfish poisoning)
Saxitoxin (paralytic shellfish poisoning)
Domoic acid (amnesic shellfish poisoning)
Tetrodotoxin
Nitrites
Organophosphorus insecticide
Toxin causing delayed neuro symptoms >6h
Book
Botulinum toxin
Methanol
Cyanogenic glycosides
Methoxypyridoxine (Ginkgotoxin)
Bongkrekic acid poisoning
Book
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)
Clinical features of Bongkrekic acid poisoning
Book
Onset 1-10h
Abd pain, V/D
Hyperglycemia initially then hypoglycemia
Hypotension, arrhythmia
Liver + renal derangement
Hematochezia, hematuria, oliguria, coma, death
Diagnosis of BA poisoning
Book
Epidemiological link
Demo of BGC by either culture or 16S rDNA sequencing
Demo of BA in food residues
Mx of BA poisoning
Book
Supportive
Dextrose for hypoglycemia
Renal support for renal failure
Ciguatera poisoning in which fish
Book
Groupers, snappers, moray eel, hump head wrasse
Pathophysiology of Ciguatera poisoning
Book
Ciguatoxin produced by dinoflagellate Gambierdiscus toxicus
Concentrated in liver, gonads, viscera
Heat and acid stable
Act on Na channels, increasing their permeability
Clinical features of Ciguatera poisoning
Book
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
Mx of Ciguatera poisoning
Book
Supportive
GI decon if early
IV mannitol 1g/kg over 1h
Gabapentin 400mg TDS
Preventing Ciguatera poisoning
Book
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?)
Clenbuterol poisoning
Book
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
Cyanogenic glycoside poisoning
Book
Causes cyanide poisoning
Food involved: kernel of fruits of Prunus specieis, e.g. apricot, peaches, pears, apples; bitter almond; cassava; bamboo shorts; young sorghum
Clinical features of cyanogenic glycoside poisoning
Book
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
Mx for cyanogenic glycoside poisoning
Book
Supportive and symptomatic for mild cases
Antidote for cyanide if severe
Haff’s disease
Book
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
Clinical features of Haff’s disease
Book
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
3 forms of Mercury
Book
Elemental
Inorganic
Organic
Considered as different toxins
Which form of mercury poisoning is most common in HK
Book
Inorganic mercury poisoning from adulterated facial whitening cream / Chinese med
Source of elemental mercury
Book
Sphygmomanometer, thermometer, fluorescent light tube, compact fluorescent light bulb
Toxicokinetic/dynamics of elemental mercury
Book
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
Clinical features of elemental mercury poisoning
Book
Occupational
Cough, chills, fever, SOB
N/V/D, metallic taste
Interstitial pneumonitis, ARDS if severe
Ix of elemental mercury poisoning
Book
CXR for acute inhalation / suspected aspiration
AXR for ingestion
X ray of body parts in SC/IV
Whole blood, 24h urine mercury
Mx of elemental mercury poisoning
Book
Environmental decontam, do not use vacuum cleaner
Supportive care for acute inhalation
Ingestion – FU X ray
Sources of Inorganic mercury poisoning
Book
Skin whitening cream adulterated with inorganic mercury
Certain Chinese meds, e.g. cinnabar
Ayurvedic medicinal products
Mercurochrome
Ix of Inorganic mercury poisoning
Book
- Whole blood mercury: reflect intense, acute inorganic mercury exposure, less reliable after redistribution to tissues
- Spot urine mercury (need to adjust for Cr conc.)
- 24h urine mercury (correlate roughly exposure severity and neuropsychiatric symptoms; confirm exposure and monitor chelation therapy)
- Renal biopsy (membranous glomerulonephritis and minimal change disease most common for nephrotic syndrome in inorganic mercury poisoning)
- CBC, LRFT, AXR
Mx of Inorganic mercury poisoning
Book
Source identification + exposure termination
GI decon (GL/AC if early; WBI)
Supportive tx, adequate hydration
OGD if significant corrosive effects
Chelation therapy
When to start chelation therapy for inorganic mercury poisoning
Book
Clinical features + elevated mercury level
Oral succimer (DMSA- Dimercaptosuccinic acid) for subacute/chronic inorganic
Dimercaprol (BAL - British anti-Lewisite) for acute inorganic
Sources of organic mercury
Book
Seafood
Clinical features of organic mercury
Book
Neurological toxicity
Chelation therapy not useful in organic mercury poisoning
Arsenic poisoning, which one more toxic
Trivalent vs Pentavalent
Inorganic vs Organic
Book
Trivalent arsenic more toxic than pentavalent
Inorganic arsenic more toxic than organic
Ix for Arsenic poisoning
Book
24h urine arsenic
Speciation of arsenic (differentiate organic and inorganic arsenic)
Mx of Arsenic poisoning
Book
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
Chelation for Arsenic poisoning
Book
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
Salicylate found in
Book
Aspirin
Cortal (aspirin + caffeine)
Methyl salicylate (e.g. Wintergreen oil)
Salicylic acid (keratolytic agent for corn)
Pharmacokinetics of salicylate
Book
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
Pathophysiology of salicylate
Book
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
Clinical manifestation of salicylate poisoning
Book
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
Classical acid-base abnormality for salicylate poisoning
Book
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
Toxic/Fatal dose of salicylate
Book
Toxicity: >150mg/kg
Fatal: >500mg/kg
Serum salicylate limited role
Book
Monitor serial salicylate level, check Q2-4h till 2-3 consecutive falling levels
Focus on clinical status, symptoms, acid-base status
Electrolyte disturbance of salicylate poisoning
Book
Increase AG
Hypergly – increase gluconeogenesis, glycogenolysis
Hypogly – depletion of easily mobilized glucose stores
Relative CNS hypoglycemia
HypoK
Urine alkalinization is impaired if hypoK
Tx of salicylate poisoning
Book
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
Indication of serum/urine alkalinization for salicylate poisoning
Book
Symptomatic patients with supratherapeutic salicylate level
Serum salicylate >40mg/dL (>2.9mmol/L)
How to give NaHCO3 for salicylate poisoning
Book
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
When to HD / HF for salicylate poisoning
Book
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
Delta gap
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
Delta ratio
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
MEN 1 / 2A / 2B
1: Pituitary adenoma, Parathyroid hyperplasia, Pancreas tumor
2A: Parathyoid hyperplasia, Medullary thyroid carcinoma, Pheochromocytoma
2B: Medullary thyroid carcinoma, Pheochromocytoma, Mucosal neuroma, Marfarnoid habitus
PRISMA
Preferred Reporting Items for Systematic reviews and Meta-Analyses
Emphysematous cholecystitis USG sign
Champagne sign (gas in GB)
Toxicology Mx triangle
EE / Specific Tx
Antidote
Decontamination / Exposure termination
Supportive Mx / Monitoring
Toxicological causes of status epilepticus
SF ppt
- Sympathomimetic poisoning
- Withdrawal of: ethanol, benzo, sedatives/hypnotics
- Bupropion
- Oral DM meds
- CO poisoning
- Isoniazid, gyromitrin
- Theophylline
Mechanism of Theophylline induced seizure
SF
Theophylline is adenosine antagonist
and Adenosine is CNS inhibitory neurotransmitter
Metabolic effects of Theophylline poisoning
SF
- HypoK (surrogate marker for Theo toxicity)
- Hypergly (increase catecholamines)
- Resp alkalosis (hyperventilate)
- Lactic acidosis (seizure, hypovolemia from repeated vomiting)
- Hyperthermia (increase metabolic activity, increase muscle activity)
Mx of Theophylline induced seizure epilepticus
SF
Lorazepam 4mg
Phenobarbital 10mg/kg IV or Propofol 1-2mg/kg IV
Phenytoin contraindicated
Cause of death in Theophylline poisoning
SF
Cardiac toxicity (tachyarrhythmia, hypotension)
Status epilepticus
Specific end organ toxicity for toxic alcohol
Methanol / Ethylene glycol / Diethylene glycol
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
Absolute CI of Physostigmine
x2
Monograph
TCA poisoning
New onset QRS prolongation
Relative CI of Physostigmine
Monograph
- Asthma
- Underlying cardiac disease
- Perpheral vascular disease
- Mechanical intestinal/bladder obstruction
- Concomintant use of depolarizing muscle relaxant
NRP first step
3 things to consider after birth
- Term gestation?
- Good tone?
- Breathing or crying?
Apgar score
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
NRP initial steps
not: Term gestation / Good tone / Breathing or crying
Warm
Dry
Stimulate
Poisition airway
Suction if needed
Ventilation corrective steps
MR SOPA
NRP
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)
Chest compression in NRP
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
Adrenaline dose for NRP
Volume expander dose
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
Sepsis 1 hour bundle
- Measure blood lactate; retake if >2 mmol/L q2-4h till normal
- Blood culture
- Broad spectrum antibiotics
- Crystalloid fluid 30ml/kg (if hypotension or lactate >4)
- Maintain MAP >= 65mmHg (may need vasopressor i.e. noradrenaline)
Refractory shock: + IV hydrocortisone
SIRS criteria
(Systemic inflammatory response syndrome)
Temp >38 or <36
HR >90
RR >20 or PaCO2 <32mmHg
WBC >12 or <4
Delayed sequence intubation (DSI)
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
ATP in central line
reduce dose to 5mg
as ATP is rapidly used up peripherally, central injection -> higher dose
Cormack-Lehane scoring system for laryngoscopy
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
Post intubation hypotension
(AH SHITE mnemonic)
- Anaphylaxis, acidosis
- Heart (Cardiac tamponade, pulmonary HT)
- Stacking of breath
- Hypovolemia
- Induction agents
- Tension PTX
- Electrolyte disturbances
Estimated body weight for age 1-10y
(Age + 4) x 2
Antidote for Rivaroxaban and Apixaban
Andexanet alfa
Brugada syndrome types
litfl / ppt
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
J wave (Osborn wave)
litfl
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)
Hypothermia ECG changes
litfl
Osborn wave!!
- Sinus bradycardia
- Prolong QTc
- AV block
- Supraventricular arrhythmias
- ?U waves
U wave ECG
litfl
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
Delta wave
litfl
Slurred upstroke in QRS complex
In pre-excitation syndromes such as WPW
Epsilon wave
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
Portal venous gas vs Pneumobilia
PV gas: peripheral
Pneumobilia (CBD gas): central
HIV PEP regime
COC
Truvada 1 tab daily + Raltegravir 400mg Q12H
*Truvada = Tenofovir 300mg + Emtricitabine 200mg
SE of HIV PEP
COC
Truvada
- GI intolerance, headache
- rare: renal insufficiency, Fanconi syndrome, lactic acidosis, hepatic steatosis
Raltegravir
- GI intolerance, headahce
- fatigue, sleep disturbance
- rare: rhabomyolysis
SAH scores / classification systems
- Hunt and Hess scale
- World Federation of Neurosurgical Societies grading system
- Modified Fisher scale
qSOFA score
quick Sequential Organ Failure Assessment
for inpatient mortality in sepsis
- Altered mental status: GCS <15
- RR >= 22
- SBP <= 100
Trifascicular block
Bifasicular block + 1st degree HB
Bifasicular block
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
Cardiac axis
litfl
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
Bohler angle
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
Gissane angle
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
Status epilepticus toxicology cause
Isoniazid
Theophylline
OHA (hypogly)
Bupropion
Tetramine
SMFA
CO
Hydrazine
Camphor
Lignocaine
OP
DDx of RUQ gas
ppt
- Pneumobilia
- Portal venous gas
- Emphysematous cholecystitis
- Chilaiditi sign
- Liver abscess with gas forming organism
X ray view for SCJ dislocation
Serendipity view (40 degree cephalic tilt)
Mechanism of injury of SCJ dislocation
Fall on outstretched hand or a direct blow to shoulder
Tourniquet test for Dengue fever
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
Dengue fever classication
Dengue without warning signs
Dengue with warning signs
Severe Dengue fever
Warning signs for Dengue fever
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
Criteria for severe Dengue
- Shock
- Fluid accumulation with resp distress
- Severe bleeding
- Severe organ involvement
Liver: (AST/ALT >=1000)
CNS: impaired consciousness
Heart / other organs
Dengue without warning signs diagnosis
Endemic area, with fever + 2 of:
- Nausea/vomiting
- Rash
- Headache, eye pain, myalgia, joint pain
- Leukopenia
- Tourniquet test +ve
Clinical signs for acute appendicitis
ppt
- Psoas sign
- RLQ pain with hyperextension of R hip - Obturator sign
RLQ pain with internal rotation of R hip (Knee flexed) - Rovsing’s sign
RLQ pain with palpation of LLQ
Volkmann ischemic contracture
From compartment syndrome of upper limb
Claw-hand deformity of hand
classical in supracondylar # in pedi
Coiled spring sign
Sign of Intussusception in contrast enema
Steinstrasse
means “stone street” in German
Complication of ESWL; develop after 1 day to 3 months, most common in distal ureter
Alvarado Score
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
Sever’s disease
Calcaneal apophysitis
Fracture C2 odontoid process classification
Anderson and D’Alonzo classification
Calcaneal # classification
Sanders classification (for CT)
Bidirectional VT (BVT) cause
litfl
- Severe digoxin toxicity (most commonly)
- Familial catecholaminergic polymorphic VT (CPVT)
- Aconite poisoning
Alternating QRS axis with each beat
Rigler triad in GS ileus
- Pneumobilia
- SB obstruction
- Ectopic calcified GS, usually in the right iliac fossa
Medical Control Officer (MCO) role
LDD
Command (take charge of the appropriate response)
Control (deploy and utilize resources)
Communication (obtain info from various sources)
Coordination (liase with other involved parties)
Overall command of medical service
Coordinate the medical and first aid services e.g. AMS, St John
Communicate with HODO (HA head office duty officer) and the respective receiving AEDs on situation update, casualty condition and conveyance
Advise on casualty destination and diversion
?Set up Triage point and Casualty clearing station (CCS)
-Uphill, upwind, upstream
Decision for stand down
Mobile Casualty Treatment Center (MCTC)
Prep course:
- On site medical commander and liason officer
- Liasion (E-team, AED, HADO, AIO)
- Diversion of patient
- Dispatch 2nd EMT
*AIO = Ambulance Incidence Officer
Bouveret syndrome
GS causing GOO
REBOA
3 zones
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
CXR sign for pneumothorax (supine CXR)
deepseek
- Deep sulcus sign
- Double diaphragm sign
- Sharp mediastinal contour
- Increased radiolucency
B lines lung USG
Comet tail artifacts
- Reverberation artifacts, appears as hyperechoic vertical lines without fading
- APO / consolidation
- no PTX (high negative predictive value)
Wallenberg syndrome
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
Thinner hypoK reason
ppt
Contains Toluene
causes type 1 renal tubular acidosis
NAGMA, hyperchloremic, hypoK, inappropriately high urine pH >5.5
Rasmussen aneurysm
ppt
Cx of pTB
Pulmonary artery aneurysm adjacent or within a tuberculous cavity
Osgood-Schlatter disease
ppt
Traction apophysitis of proximal tibial tubercle at insertion of patellar tendon
In adolescents, overuse condition
Tongue blade test for mandibular #
Bite the wooden tongue depressor then twist
high NPV
Physical signs for mandibular #
- malocclusion
- trismus
- chin paresthesia
- sublingual hematoma, floor of mouth ecchymosis
Guardsman #
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
Facial nerve palsy grading system
House-Brackmann Facial Paralysis Scale
Reverse Bennett fracture-dislocation
fracture-dislocation of 5th MC base
unstable due to unopposed extensor carpi ulnaris (ECU) pull on the fracture fragment
required CRIF/ORIF
Gas gangrene microorganism
Clostridium perfringens
Gunshot wound
Entry vs Exit
ppt
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
Hill-Sachs lesion
Cortical depression in humeral head (caused by glenoid rim)
In posterolateral aspect
Bankart lesion
Abruption of antero-inferior aspect of glenoid labrum
Humeral head strikes the inferior margin of glenoid
+/- bony avulsion
Endpoint of pre-oxygenation in AED
SpO2 >= 95% for 2-3 mins
Pediatric assessment triangle
Appearance
Work of breathing
Circulation to skin
CMV / SIMV ventilator
Synchronized Intermittent Mandatory Ventilation
Continuous/Controlled Mandatory Ventilation
Why deep seedation for AECOPD intubated in AED
Deep sedation to prevent hyperventilation and then breath stacking and auto-PEEP
Insp hold for high airway pressure
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
Sepsis bundle name
Surviving Sepsis Campaign hour-1 bundle
XR line for SCFE
Klein’s line
Line drawn along superior border of femoral neck, should intersect on lateral aspect of superior femoral epiphysis
AP view
Positive -> Trethowan’s sign
CPR coach
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
XR signs for posterior shoulder dislocation
- Lightbulb sign
Internal rotation of humerus - Rim sign
AP view, the distance between the anterior glenoid rim and the medial humeral head is increased (typically >6 mm) - 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
Associated injuries of posterior shoulder dislocation
ppt
- Tuberosity or surgical neck #
- Reverse Hill-Sachs lesion or reverse Bankart lesion
- Glenolabral injury
- Rotator cuff injury
Classically caused by: Epilepsy, Electricity, Ethanol
CMCJ dislocation XR line name
- Chmell’s oblique MC line
- Broken zigzag line sign
Confirmation of ETT placement
ppt
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
Winter’s formula
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
Scores for thyroid storm
- Burch–Wartofsky Point Scale (BWPS)
- Japanese Thyroid Association Criteria
Forceful dorsiflexion, MVC
Driving pedal
neck of talus
Test for pancreatitis
Urine trypsinogen-2 test
Radial head # classification
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)
Radial head # nerve injury
Posterior interosseous nerve (PIN)
- check thumb extension
associated injury: ulnar coronoid process #, LCL tear (also MCL?), interosseous membrane injury, elbow dislocation, Monteggia #
Status epilepticus toxicological cause cofactor therapy
IV pyridoxine (B6) 50-70mg/kg
Ethylene glycol
Ginkgo seed poisoning
Gyrometra/false morel Monomethylhydrazine mushroom poisoning
Tetramine
Hydrazine (fuel)
San Francisco Syncope rule
CHESS
Hx of CHF
Hematocrit <30%
Abnormal ECG/cardiac monitor
SOB
SBP <90 at triage
Other rules: Canadian syncope risk rule, Boston syncope rule
Terrible triad of elbow injury
- Elbow dislocation (posterior)
- # Radial head (or neck)
- # Coronoid process of ulna
Instability, recurrence
Pelvic # classifications
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
VT vs SVT with abberancy
list 3 criteria
Vereckei criteria (aVR): dominant R in aVR… etc.
Brugada criteria
Pava criteria (lead 2): R Wave Peak Time > 50ms
Mangled limb test
Arterial pressure index (aka Ankle brachial index)
> =0.9 maybe salvageable limb
<0.9 = compromised arterial flow
<0.5 likely limb loss
Massive hemothorax definition
- Blood loss > 1.5L or 1/3 of blood volume
- Blood loss >200 mL/h (3 mL/kg/h) for 2-4 hours
Need for thoracotomy
Classification of traumatic aortic injury
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
RUSH exam USG
protocol
Rapid Ultrasound for Shock and Hypotension
HIAMP ED
Heart
IVC
Aorta
Morison’s pouch
Pulmonary (PTX)
Ectopic pregnancy
DVT
Lunate vs Perilunate dislocation
ppt
Lunate dislocation: Lunate does not articulate with capitate or radius
Perilunate: Lunate remains aligned with radius
Mechanism of Lunate dislocation
FOOSH, forceful dorsiflexion (extension) of wrist
Cx of Lunate dislocation
- Median n. entrapment
- Chronic pain
- AVN of lunate
Classification of Lunate dislocation
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
Terry-Thomas sign
Increase in the scapholunate space (3-4mm)
Indicates scapholunate dissociation (often with rotary subluxation of the scaphoid) due to ligamentous injury
Triquetral avulsion # mechanism
Fall on outstretched arm with wrist extended and ulnar deviation; or extreme flexion
seen dorsal to proximal row of carpal bone
Snowboarder’s #
lateral process of talus
MOI: external rotation + dorsiflexion + axial load
QTc calculation formula
- Bazett’s formula: QT/ √RR
- Fridericia’s formula: QT / cubic root of RR
- Hodges formula: QT + 1.75 x (HR-60)
- 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
Erythema multiforme
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
Erythema nodosum
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
Morel Lavallee Lesion
- 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
NICE traffic light system
For <5y
Identify likelihood of serious illness
Components
Color
Activity
Respiratory
Circulation and hydration
Others
AVM grading scale
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)
Syndrome associated with telangiectasia and AVM
Hereditary hemorrhagic telangiectasia
(aka Osler-Weber-Rendu syndrome)
Clinical findings suggesting spinal cord injury in unconscious trauma patient
ppt
- Paradoxical breathing or abd breathing (if loss of diaphragm innervation)
- Priapism
- Flaccid paralysis
- Flaccid anal sphincter
- Persistent bradycardia and hypotension (neurogenic shock)
- LL flaccid but normal UL tone (paraplegia)
?Areflexia JCM
Parkland formula
4ml x BW (kg) x TBSA (%)
Half in first 8 hours; half in next 16 hours
Count from injury time
*3ml in children
Clinical prediction rule for septic arthritis in children (vs transient synovitis)
ppt
Kocher criteria
- NWB
- T >38.5
- ESR >40
- WBC >12
Scale for patient agitation or aggression
ppt
Overt aggression scale
component
- Verbal aggression
- Physical aggression against self // object // people
RVOT VT ECG features
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
AVNRT ECG features
No visible P waves
Pseudo R’ waves (retrograde P waves) in V1-2
Normal axis, narrow QRS
Tx: ATP
AF with WPW ECG features
Irregular, HR >200
Wide and polymorphic QRS complex
Normal axis
Tx: Procainamide, synchronized cardioversion
Avoid nodal blockers
Left posterior fascicular VT ECG features
Regular wide complex
QRS 100-140ms
RBBB
LAD
Capture beat
*originate from LV -> RBBB (delayed RV activation)
Tx: Verapamil, synchronized cardioversion
Cutaneous larva migrans
Parasite infection (hookworm)
Cannot penetrate through dermis
Self limiting
Neurocysticercosis
Parasitic CNS infection
caused by Taenia Solium (pork tapeworm)
*larval stage (cysticercus)
Wrist TFCC full name
Triangular fibrocartilage complex
Ulnar wrist pain
Clicking or point tenderness between pisiform and ulnar head
*Piano key test
Difficult BVM
ROMAN
Radiation (H&N) / Restriction (poor lung compliance)
Obstruction / Obesity / OSA
Mask seal / Mallampati / Male
Age >55y
No teeth
Difficult extraglottic device
RODS
Restricted mouth opening
Obstruction / Obesity
Disrupted / Distorted airway
Stiff lungs
Difficult cricothyrotomy
SHORT/SMART
Surgery
Hematoma / Mass
Obesity / Access
Radiation
Trauma
SALAD technique
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
CVC endovenous placement confirmation
NLTH
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
Spondylolysis
Stress # in pars interarticularis
most common in L5
Myopericarditis vs Perimyocarditis
Myoperi
- acute pericarditis with elevated TnI, normal LVEF
Perimyo
- acute pericarditis with elevated TnI, reduced LVEF
Cause of Myopericarditis
statpearls
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
Young patient syncope, important ECG diagnosis for sudden cardiac death
x7
ppt
- Brugada syndrome
- HCM
- Long QT syndrome
- Arrhythmogenic RV dysplasia (ARVD)
- WPW syndrome
- Early repolarization syndrome
- Catecholaminergic polymorphic VT
Potential life-threatening marine animal exposure
ppt
- Pufferfish
- resp failure - Paralytic shellfish
- resp failure - Freshwater crayfish
-rhabdo, ARF - Large reef-dwelling fish (Ciguatera)
- CVS collapse, resp failure - Sea snake
- myotoxic, neurotoxic, rhabdo, muscle paralysis, resp failure - Jellyfish (box jellyfish)
- cariopulmonary arrest, anaphylaxis - Blue-ringed octopus
- tetrodotoxin, muscle paralysis, resp failure - Cone snail (cone shell)
- muscle paralysis, resp failure - Stonefish
(Hot water immersion 45oC)
Lokelma
Sodium zirconium cyclosilicate
Bind K in GIT -> increases fecal K excretion
Risk of anti-thyroid drug
ppt
- Potential teratogenicity (CBZ > PTU)
- Agranulocytosis (PTU > CBZ)
- Hepatotoxicity
Agitation / Sedation scale
ppt
Richmond Agitation and Sedation Scale (RASS)
Ramsay sedation scale
DOPES
Displaced ETT
Obstruction
PTX
Equipment failure
Stacked breaths
DOTTS
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
CI for permissive hypercapnia
Cerebral edema, increased ICP, seizure
prep: Severe metabolic acidosis, CVS instability
Cat scratch disease organism
Bartonella henselae
DC vs AC electrical injury
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
CI of delayed sequence intubation
ketamine 1-2mg/kg IV
- Inability to breathe spontaneously
- Inability to protect own airway
Medical Cx of molar pregnancy
ppt
- Thyrotoxicosis
- Hyperemesis gravidarum
- Early onset pre-eclampsia
Sheehan syndrome
Postpartum pituitary gland necrosis
Asherman syndrome
Intrauterine adhesion/scarring after surgery of uterus
Amenorrhea, recurrent pregnancy loss, IU adhesions
Cupola sign
pneumoperitoneum
seen on supine X ray - air beneath central tendon of diaphragm in midline
Mechanism of lightning injury
ppt
EM book
- Direct strike (5%)
- Side flash (30%)
- Contact (15%)
- Ground current (50%)
Book also:
5. Upward streamer
6. Ball lightning
7. Blunt trauma
Delayed Cx of lightning injury
ppt
Psy:
- memory, concentration impairment
- depression, personality change
ENT:
- hearing loss
CVS:
- delayed pericarditis
Skin
- delayed SCC
Eye
- cataract
- optic neuritis
Strychnine poisoning
book
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
FAST-ED scale for stroke
Field Assessment Stroke Triage for Emergency Destination scale
Etomidate
inhibit 11 beta hydroxylase
which is responsible for the final conversion of 11-deoxycortisol to cortisol
Button battery severe outcome predictors
- Lodged in eso
- > 20mm
- <6y
- multiple button batteries ingestion
Triad for Aconite poisoning
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
Penetrating neck injury
Hard signs of vascular injury
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
Penetrating neck injury
Soft signs of vascular injury
- Dysphonia
- Dysphagia
- Non-expanding hematoma
- Subcutaneous or mediastinal air
- Minor hemoptysis or hematemesis
Transcutanous pacing
Anterolateral leads placement better as closer to apex
No capture despite high mA: Hair shave, avoid air/fluid like PTX/pericardiac effusion, correct electrolytes
Acute mountain sickness (AMS)
Tx
Tx: Acetazolamide, O2, Dexamethasone, HBOT, Descent
Cardinal feature = headache
High altitude cerebral edema (HACE)
Tx
AMS with mental state change or ataxia
Tx: Dexamethasone, Acetazolamide
High altitude pulmonary edema (HAPE)
Tx
Tx: O2, rest, HBOT, descent, Nifedipine, Tadalafil, Sildenafil
Prevention: Nifedipine
Doppler USG sign for testicular torsion
Whirlpool sign
DDx of Testicular torsion
Torsion of appendix testis (blue dot sign on PE)
Acid/Alkali injury necrosis type
Acid ingestion: coagulation necrosis
Alkali ingestion: liquefactive necrosis
Gamekeeper’s thumb
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)
Cx of Basal skull #
- Meningitis, CNS infection
- CSF fistula
- Cavernous sinus thrombosis
- Pneumocephalus
CSF rhinorrhea
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
Hamate # classification
Milch classification
1: hook of hamate
2: body (2a: coronal; 2b: transverse)
ACJ injury classification
Rockwood classification
3 ligaments: Acromio-clavicular (AC); Coraco-clavicular (CC); Coraco-acromial (CA)
Inferior shoulder dislocation associated injury
Axillary artery
Mangled limb definition
A limb with an injury to at least three out of four components
1. soft tissue
2. bone
3. nerves
4. vessels
Open fracture classification
Gustilo-Anderson classification
Type 1: wound <1cm
2: wound 1-10cm
3A: >10cm
3B: bone exposure
3C: vascular injury
Galeazzi fracture-dislocation
MUGGER
Radius (distal 1/3) + DRUJ dislocation
Monteggia fracture-dislocation
MUGGER
Ulnar (proximal 1/3) + radial head dislocation
Terrible triad of shoulder injury
Shoulder dislocation
Rotator cuff tear
Brachial plexus injury
Boutonniere deformity
rupture of central slip of extensor tendon at PIPJ
Tourniquet for bleeding name
Combat application tourniquet
Bleeding not detected by FAST scan
Retroperitoneal bleeding
External bleeding
Long bone fracture/bleeding
<200ml
intra-capsular
Damage control resuscitation
3 components
Permissive hypotension
Hemostatic resuscitation (early transfusion, prevent acidemia)
Damage control surgery
Damage control surgery
litfl
Limited surgical interventions to control haemorrhage and minimize contamination until the patient has sufficient physiological reserve to undergo definitive interventions
Inhalational burn injury signs
- Facial burn
- Singed eyebrow / facial hair
- Soot over nasal cavity
- Oropharyngeal swelling
- Hoarseness of voice
- Stridor
- Carbonaceous sputum
Severe burn scores
- Modified Baux score
Age + TBSA of full thickness burn + 17 (if inhalational injury)
>140 = non survivable - Abbreviated Burn Severity Index (ABSI)
Age, sex, TBSA (%), presence of full thickness burn, inhalational injury
Pott puffy tumor
Forehead swelling due to frontal bone osteomyelitis with associated subperiosteal abscess
Rare complication of sinusitis
Orbital # common location
Lamina papyracea
aka orbital lamina of the ethmoid bone
forms medial wall of orbit
Penumbra
Reversibly injured brain tissue around the ischemic core which is the target for the treatment of acute stroke
NF USG
STAFF
Subcutaneous thickening
Air
Fascial Fluid
Mount Fuji sign in CTB
Tension pneumocephalus
NAI ordinance
Cap 213
Protection of Children and Juveniles Ordinance
Children <14y; Juveniles 14-18y
Kleihauer-Betke test
Check on maternal blood
Determine the amount of HbF that has passed into the maternal circulation
Atracurium vs Cisatracurium
Atracurium has histamine release - not to use in asthma
Dynamic hyperinflation
Sepsis definition
Life-threatening organ dysfunction as a result of dysregulated host response due to an infection
Septic shock
Sepsis III definition of SEPTIC SHOCK:
Infection causing vasopressor requirement to maintain a MAP > 65 mm (despite fluid resuscitation)plusa serum lactate >2 mM.
60/60 sign
Pulmonary acceleration time <60 ms (normal >130)
Pulmonary arterial systolic pressure (TR jet gradient) <60 mmHg
Pre-eclampsia medication dosage
- MgSO4 4-6g in 100ml NS over 15 mins; infusion 2g/h
- Labetalol 20mg IV bolus, repeat in 10 min interval
- Hydralazine 5mg IV
(Nicardipine infusion 5mg/h uptodate)
Oral meds
Labetalol 100mg BD
Nifedipine 10mg BD
Methyldopa 250mg TDS
Treatment threshold: BP 160/110
NRP adrenaline dose
IV: 0.02mg/kg
ETT: 0.1mg/kg
Scrub typhus
organism and vector
Orientia tsutsugamushi
Mites
Ix
USG
Doppler USG
QE
Patrick
EM book
Prep course ppt
KWC ppt
JCM
PIC
COC Guidelines
Keraunoparalysis
can be caused by lightning strike
transient weakness affecting the lower limbs more commonly and automatically reverses in a matter of few hours
Major incident managment
METHANE
Major incident declared
Exact location
Time
Hazard
Access
Number of patients
EMT / Emergency services required
Major incident response - 4Cs
Communicate
Coordinate
Command
Control
Hazmat agents
Pulmonary
Vesicant
Blood agent
Nerve agent
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
Types of data
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
Stat tests
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
CONSORT
Consolidated Standards of Reporting Trials
- provides checklist for essential items to be reported in RCTs
Cronbach’s alpha
Assess reliability
> 0.9 = excellent
<0.7 = questionable
Number needed to treat (NNT)
1/ Absolute risk reduction (ARR)
ROC curve
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)
Power of study
1 - beta
i.e. “1- type 2 error”
Applicability
5 Killer Bs
- Biology: any difference in ethnics or disease severity
- Barrier: the availability in our local department or locality
- Bargain: the benefit, compared to the risk, cost and any competitors
- Belief: the degree of acceptance in local community, or in local professions
- Burden: the prevalence of the disease in the locality, amount of patient load
Pre-test probability
= Prevalence
Pre-test odds
= pre-test probability / (1-pre-test probability)
Post-test odds
= pre-test odds x likelihood ratio
Power of study
3 factors affecting
LAW
- Sample size
(larger sample size larger power) - Effect size
(for same power, needs larger sample size to detect smaller difference) - alpha value
(higher alpha value -> more likely to have stat sig result -> reject null hypothesis)
Vertical line of RR =1
The line of no effect
Concept on thinking to start conducting a study
FINER
Feasible
Interesting
Novel
Ethical
Relevant
PICO / PEO
Patient
Intervention
Comparison
Outcome
Patient
Exposure
Outcome
Study design level of evidence
LAW
RCT >
Cohort (prospective > retrospective) >
Case control (nestsed > others) >
Cross-sectional >
Retrospective case series
Elements of validity in RCT
RAMBO
Randomization
Ascertainment (Intention to treat analysis + FU adequacy)
Blinding
Measurement objective
Intention to treat vs Per protocol analysis vs Sensitivity analysis
LAW
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
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
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)
3 pillars in EBM
LAW
Validity
Result
Applicability
Simpson’s paradox
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
Bonferroni correction
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
Sensitivity
Specificity
Prevalence
Accuracy
Positive predictive value (PPV)
Negative predictive value (NPV)
Positive likelihood ratio (PLR)
Negative likelihood ratio (NLR)
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
Probability and odds equation
odds = p / (1-p)
probability = odds / (1+odds)
Pre-test probability
Pre-test odds
Post-test odds
Post-test probability
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
Estimation of post-test probability from pre-test probability
Fagan’s nomogram (Likelihood ratio nomogram)
Spectrum bias
Subjects included in a study are not representative of the population, leading to clinically significant differences in post-test probabilities.
Verification bias
Patients with negative results are not evaluated with the gold standard test
Causality criteria
Bradford Hill criteria (9 criteria)
- Strength
- Consistency
- Specificity
- Temporality
- Biological gradient
- Plausibility
- Coherence
- Experiment
- Analogy
Funnel plot
For systematic review/meta-analysis
Scatterplot of treatment effects
Detects bias / heterogeneity
Assymetrical -> publication bias (but not only cause)
Fixed effect model vs Random effect model
For meta analysis
Fixed effect model: use if no sig heterogeneity
Random effect model: use if moderate/high heterogeneity
Wider confidence interval
Forest plot
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
Test for heterogeneity
- Eyeball test (look at forest plot)
- Cochran’s Q test (Chi square test, p value)
- I2 test
Prognosis use which study
Cohort study
Statistical tests to test for any difference between 2 or more survival curves
- Cox proportional hazard model
- Log rank test
Trauma scores
Anatomical
1. Abbreviated injury scale (AIS)
2. Injury severity score (ISS) - 9 regions each 6 gradings; sum of square of 3 highest regions; score 1-75
3. New ISS (NISS)
Physiological
4. Pediatric trauma score (PTS)
5. Revised trauma score (RTS) - GCS, SBP, RR
6. APACHE score (Acute physiology and chronic health evaluation)
7. GCS
Combined
8. Trauma score - Injury severity score (TRISS)
9. Kampala trauma score (KTS)
Score for predicting massive transfusion
ABC score (Assessment of blood consumption) <2: unlikely; 3: 45%; 4: 100%
- penetrating injury
- SBP <90 in AED
- HR >120 in AED
- FAST +ve
TASH score (Trauma associated severe hemorrhage)
- Sex
- Hb
- BE
- SBP
- HR
- FAST +ve
- Clinically unstable pelvic #
- Open or dislocated femur #
PWH score (Rainer score) >=6
- SBP <90 (3)
- HR >120 (1)
- GCS <= 8 (1)
- Displaced pelvic # (1)
- CT/USG +ve for fluid (2)
- BE >5 (1)
- Hb <= 7 (10) / Hb 7-10 (1)
Shock index (HR/SBP)
>0.9 = higher risk of massive transfusion
Risk factor of Ovarian hyperstimulation syndrome (OHSS)
- Young age
- Low BMI
- PCOS
- Previous OHSS
- Elevated estradiol level
OHSS avoid what PE
Avoid pelvic examination -> trauma to ovary -> induce rupture of cysts
Cx of OHSS
- Ovarian torsion
- Ruptured ovarian cyst
- Thromboembolism
- Pericardial effusion, CHF
- Renal failure
- ARDS
Features of severe pre-eclampsia
qe
- Headache
- Blurring of vision
- Altered mental status
- Plt <100
- Pul edema
- dLFT ALT > 2x ULN
Signs of imminent delivery
qe
- Regular uterine contractions of 1-2 min interval
- Increase in bloody show
- Irresistible urge to bear down
- Crowning of baby’s head or breech presentation part appear in vulva
- Bulging of perineum
- Dilatation of anal sphincter
- Bowel movement
Shoulder dystocia
HELPER4
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
Active management of third stage of labor (AMTSL)
ALSO
- Oxytocin 10U IV bolus over 1-2 min (or IMI; IV preferred) with delivery of infant ASAP
- Delayed cord clamping for 1-3 mins
- Continuous, gentle cord traction (Brandt maneuver)
- Transabdominal uterine massage after placenta delivers
Medications for uterine atony / PPH
ALSO
- Oxytocin 20IU IMI, or 10U IV over 10 mins then infusion
- Syntometrine 1 ampoule IMI (5u Syntocinon + 0.5mg ergometrine) - caution for pt with HT
- Carboprost 0.25mg IMI - caution for pt with asthma, sig renal/hepatic/cardiac disease
- Misoprostol 600 mcg SL (PR, PV PO)
- Tranexamic acid 1g over 10 mins
Fitz-Hugh–Curtis syndrome
Uncommon Cx from pelvic inflammatory disease
Perihepatitis, by perihepatic adhesions
RUQ pain, referred pain to R shoulder
Rhesus hemolytic disease of the newborn
Give Anti-D immunoglobulin
Do Kleihauer-Betke test to determine amount of fetal Hb in materal circulation
Special consideration of resuscitation for pregnant women
ABC
A
- Anticipate difficult airway
- Apply apneic oxygentation technique to prolong safe apneic time
- Apply cricoid pressure to reduce risk of aspiration (laxed LES)
- Use ETT of 1 size smaller due to airway edema
- Use laryngoscopy with short handle for larger breasts
B
- Baseline resp alkalosis; normocapnia may imply impending resp failure
- Increase O2 consumption by 20%; rapid decrease in PaO2 leads to hypoxia
- Decrease tidal volume (TV) and functional residual capacity (FRC)
C
- Manual lateral uterine displacement to relieve aortocaval compression
- IV access set above diaphragm to bypass aortocaval compression
- Fetal monitoring beyond 20-24 wk ges
- Remove fetal monitoring device before defib
- Early fluid and blood products resuscitation; avoid vasopressors
Emergency contraception
- Levonorgestrel 1.5mg PO once (within 72h)
-progestogen - Ulipristal 30mg PO once (within 120h)
- selective progesterone receptor modulator - Copper IUCD insertion (within 120h)
Croup treatment
- Dexamethasone 0.6 mg/kg PO/IM/IV
- Nebulized adrenaline 1:1000 solution 0.5 mg/kg (max 5mL)
Pyloric stenosis
USG findings
Target sign
Cervix sign
3.1415
Pyloric muscle thickness >3mm
Pyloric transverse diameter >14mm
Pyloric muscle length (longitudinal) >15mm
IO sites for pedi
qe
- Proximal humerus: 2cm above the surgical neck at greater tubercle
- Proximal tibia: 1-2cm inferior and medial to tibial tuberosity
- Distal tibia: 3 cm proximal to most prominent part of medial malleolus
- Iliac crest
- Distal femur: anterolateral surface, 3 cm above lateral condyle
- Sternum
Pink needle: <6m
Blue needle: >6m
Yellow needle: >40kg
Test for rash of meningococcemia
Glass test
- does not fade against pressure
Pedi status epilepticus drug dose
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
Hypoglycemia for children treatment dose
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)
3 narrow points for esophagus button battery ingestion
- Upper esophageal sphincter (cricopharyngeus - C6)
- Aortic arch constriction (T4)
- Lower esophageal sphincter (T10)
Auto-AED use in Pedi
1 years old cutoff for pedi mode
<1y - manual defibrillator
1-8y - pedi mode
>8y - adult mode
Defib dose Pedi
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
Chikungunya fever
Chikungunya virus
Vector = Aedes aegypti; can also be Aedes albopictus
Fever and debilitating joint pain
Can cause GBS
Symptoms similar to Dengue
Malaria parasites / vectors
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
Severe malaria definition
Presence of P. falciparum parasitemia + 1 of
- Impaired consciousness
- Multiple convulsions
- Acidosis
- Hypoglycemia
- Severe anemia
- Renal impairment
- Jaundice
- Pul edema
- Sig bleeding
- Shock
- Hyperparasitemia
- Prostation (generalized weakness)
Tx of malaria
Severe: IV artesunate 2.4mg/kg over 1-2 minutes
Alternative: Quinine IV + Doxycycline PO
Hereditary angioedema enzyme deficiency
C1 esterase inhibitor deficiency
Tx: C1 inhibitor concentrate, FFP, Icatibant, Ecallantide
Given transamin if on ACEI
Cerebral venous sinus thrombosis (CVST) signs
Plain CT:
1. Dense clot sign
2. Cord sign (hyperdensity of sinus)
CT venogram:
3. Empty delta sign
Risk factor for Cerebral venous sinus thrombosis (CVST)
- Thrombophilia (Protein C or S deficiency; lupus anticoagulant, antiphospholipid syndrome)
- Estrogen (preg, OCP, tamoxifen)
- Smoker
- Female
- Age <50
- Malignancy
- Parameningeal infections
- Trauma
Cause of Young stroke
qe
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
Waterhouse–Friderichsen syndrome
Bilateral adrenal gland failure due to hemorrhage
Caused by sepsis, meningococcemia
Purple Urine Bag Syndrome
Female, constipation on LT foley
E coli, proteus, klebsiella
Tumor lysis syndrome electrolytes
HyperK, HyperPO4, Hyper-uricemia
HypoCa
ARF due to CaPO4 and uric crystal formation in renal tubules
Hyperviscosity syndrome
Symptom triad
- Mucosal bleeding
- Visual change
- Neurological deficit
Hyperviscosity syndrome
Common cause
- Waldenstrom macroglobulinemia (type of B-cell lymphoma)
- Multiple myeloma
- Leukemia
Dressler syndrome
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
Tx of Torsades de pointes
Polymorphic VT; QTc prolongation in SR
- Prompt defib if hemo unstable
- MgSO4 1-2g IV over 15 mins
- Temp transvenous overdrive pacing at 100bpm
- Isoproterenol IV if triggered by pauses/bradycardia
Echo findings in hypertrophic cardiomyopathy (HCM)
- Asymmetrical septal hypertrophy
- Systolic anterior motion of the mitral valve (SAM)
- Dynamic LVOT obstruction
Wilson’s disease
Kayser-Fleischer ring
Low serum ceruloplasmin level
High serum copper
High 24hr urine copper
Tx
Chelator: D-penicillamine, Trientine
Denver criteria
Determine whether CT angiography of the neck is indicated
To detect blunt cerebrovascular injury (BCVI) with trauma patients
Anterior Atlanto-dens interval (ADI) cutoff
<3mm in adults
Posterior shoulder dislocation reduction method
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.
3 in 1 protocol for pelvic fracture
- Pelvic external fixation
- Retroperitoneal pelvic packing
- Angiographic embolization
Hip dislocation classification
Thompson-Epstein system (based on X ray)
Stewart-Milford system (based on functional hip stability)
90% hip dislocations are posterior
Posterior hip dislocation
Reduction techniques
- Allis technique
- Stimson technique
- Captain Morgan technique
- Whistler/Rochester technique
- 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
Neurogenic shock above which level
T6
Triad: hypotension, hypothermia, bradycardia
Spinal shock resolution first clinical indicator
Return of bulbocavernosus reflex
Spinal cord injury classification
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
Pilon #
Distal tibia involving articulating surface
High energy trauma
Pre-hospital stroke scale
FAST-ED
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
Alcohol driving limit
blood/breath/urine
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
Stonefish toxin name
Stonustoxin
abbreviation of STOnefish National University of Singapore + toxin
Early sign of LA toxicity
qe
- Tinnitus
- Perioral numbness
- Visual disturbance
- Agitation*
- Confusion*
- Arrhythmia
- Convulsion
*web
Cyanide source
- Fire victims (combustion of nitrogen-containing materials e.g. wool)
- Electroplating
- Bitter almond intake
- IV nitroprusside
4 indications for antidote in cyanide poisoning
- Cardiac arrest
- Impaired GCS <=13
- Hypotension
- Lactate >10mmol/L
Indication of HBOT in fire victims
- Syncope / LOC
- Severe metabolic acidosis pH <7.1
- Evidence of end organ damage (coma, seizure, cognitive deficits, MI)
- COHb >25% // 15% in preg / children
Heavy metal posioning associated conditions
qe / book
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
Plants toxin matching
qe
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
Food toxin matching
qe
- Pufferfish - Tetrodotoxin
- Shellfish - Paralytic/Neurotoxic/Amnesic/Diarrhetic/Azaspiracid shellfish poisoning
- Coral reel fish - Ciguatoxin
- Bitter almond / Bamboo shoot / Cassava / Apricots - Cyanide (Cyanogenic glycoside)
- Ginkgo seed - Ginkgotoxin (Tx = Pyridoxine B6; can cause status epilepticus)
- Crayfish - Haff’s disease (rhabdomyolysis)
- Sprouting potato - Solanine (GI upset)
- Choi sum - OP
- Canned food - Food botulism
- Spinach - Methemoglobinemia
- Starfruit - Neurotoxin (Caramboxin), oxalate (AKI/Neurotoxicity)
- Lychee - Hypoglycin A (hypoglycemia, encephalopathy) / Methylenecyclopropylglycine (MCPG)
- Pig’s offal - Clenbuterol (B2 agonist)
- Tuna - Scombroid
- Uncooked green bean - Phytohemagglutinin (GI upset)
- Hairy crab - Dioxin
- Sushi - Anisakiasis
- False taro (Alocasia) - Ca oxalate crystal
Orbital compartment syndrome USG sign
Guitar pick sign
Carotid blowout syndrome (epistaxis after RT HN cancer)
Types
qe
Type 1: Threatened
Type 2: Impending
Type 3: Acute
Involves ICA/CCA
Tx: Endovascular embolization / stenting; Surgical ligation
Forms of elderly abuse
COC
- Physical
- Sexual
- Psychological
- Neglect
- Abandonment
- Financial exploitation
Indicators of potential elder abuse from history
COC
- Unexplained injuries
- Past history of frequent injuries
- Elderly patient referred to as “accident prone”
- Delay between onset of medical illness or injury and seeking of medical attention
- Recurrent visits to ED for similar injuries
- Using multiple physicians or EDs for care
- Non-compliance to medications or appointments
Psychological or behavioral signs of elderly abuse
COC
- Apprehension
- Withdrawal
- Depression
- Being passive
Screening tools for elder abuse
COC
- Elder Abuse Assessment Instrument (EAAI)
- Senior Abuse Identification tool (Senior AID)
- Elder Abuse Suspicion Index (EASI)
- Vulnerability to Abuse Screening Scale (VASS)
Warning signs of elder abuse
Physical abuse
Sexual abuse
COC
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
Warning signs of elder abuse
Psychological abuse
Neglect
COC
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
Child abuse
Indicators relating to physical harm/abuse
physical vs behavioral
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
Child abuse
Indicators relating to sexual harm/abuse
physical vs behavioral
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
Child abuse
Indicators relating to neglect
physical vs environmental vs behavioral
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
Child abuse
Indicators relating to psychological harm/abuse
physical vs behavioral
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
PEP for STD
COC
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
Psychological and counselling support services in HK for rape case
COC
- CEASE Crisis Center
- RainLily
Risk factors for escalating violence in Intimate partner violence
COC
- Isolation
- Threatens to kill
- Presence of a weapon
- Pathological jealousy
- Use of drugs/alcohol
- Children at home
Score for mortality of unstable angina / NSTEMI
TIMI Risk Score for UA/NSTEMI
Score for chest pain in AED
- predicts 6-week risk of major adverse cardiac events in patients with chest pain
HEART Score for Major Cardiac Events
Hx
ECG
Age
RF
TnI
Tx for HT crisis from pheochromocytoma
- Phentolamine
- Phenoxybenzamine, Terazocin, Prazocin
Avoid BB as unopposed alpha action
Coracoid process # classification
- Ogawa classification
- Eyres classification
Medications hypoK if taken excessive amounts
JCM
- Diuretics
- Laxatives
- Steroids
- Insulin
- Abx (penicillin, ampicillin, amphotericin B)
Composition of staghorn stone
JCM
Struvite
(magnesium ammonium phosphate)
Tripod fracture components
aka Zygomaticomaxillary complex fracture
(Lateral orbit + Zygoma + Maxilla)
- Zygomatic arch
- Inferior orbital rim, and anterior and posterior maxillary sinus walls
- Lateral orbital rim
Pericarditis Tx
- Aspirin / NSAID
- Colchicine
- Glucocorticoid (Prednisolone)
Risk factor of posterior reversible encephalopathy syndrome (PRES)
- HT
- Eclampsia
- Vasculitis (SLE)
- Kidney disease
- Chemo/cytotoxic drugs
- Post organ transplant
Xanthogranulomatous pyelonephritis (XGP)
Rare form of chronic pyelonephritis
Chronic granulomatous disease resulting in a non-functioning kidney
Specific imaging features
Staghorn stone
CT: Bear’s paw sign
Penetrating neck injury
Procedures to avoid
JCM
- BVM (dissect air into neck)
- C-spine immobilization (unless direct cord injury)
- Wound exploration at AED (may dislodge clots)
- CVC insertion
- R/T insertion
Dystonia / Oculogyric crisis Tx meds
- Benztropine (Cogentin) 1-2mg IM/IV
- Diphenhydramine (Benadryl) 25-50mg IM/IV
DDx of Acute painless visual loss
- Retinal detachment
- Vitreous hemorrhage
- CRAO
- CRVO
- Stroke/TIA (amaurosis fugax)
- Ischemic optic neuropathy
Clinical prediction rule for CT brain with HI
- Canadian CT head rule
- New Orleans criteria
- NEXUS CT head instrument
Bedside Ix for raised ICP
USG measuring optic nerve sheath diameter (ONSD)
- measured at 3mm behind eye globe
- repeat few times and take average
- >5mm = ICP >20mmHg
LGL syndrome
Lown–Ganong–Levine syndrome
Pre-excitation syndrome
ECG: Short PR, no delta wave
Coronoid process of ulna
Classification
Regan and Morrey classification
1: Avulsion #
2: # of <50% coronoid
3: # of >50% coronoid
Intussusception USG signs
- Target sign; aka doughnut sign
- Pseudokidney sign
Red currant jelly stool
Neck of talus X ray view
Canale view
(medial oblique axial talus view)
Foot plantarflexed, 15 degree eversion (pronation)
Neck of talus classification
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
Anti-impulse therapy for aortic dissection
Aim HR <60
SBP 100-120
BB: Labetalol, Esmolol
CCB: Verapamil, Diltiazem
Acute non-traumatic headache decision x CT
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
Cause of pneumobilia
radiopedia
- ERCP
- GS ileus (spontaneous biliary-enteric fistula)
- Infection: cholangitis, emphysematous cholecystitis, liver abscess
- Biliary-enteric surgical anastomosis (Whipple, choledochoduodenostomy)
- Incompetent sphincter of Oddi
Cause of portal venous gas
radiopedia
- Ischemic bowel
- Intra abd sepsis / abscess (diverticulitis, cholangitis, cholecystitis)
- IBD
- PPU
Pedi: post UVC, necrotizing enterocolitis
Prevertebral soft tissue thickness at C3 and C7
JCM
C3: 7mm
C7: 18mm
Not measured at C4/5 as variable position of eso and larynx
Radiological measurement of hydrocephalus
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
Unstable C-spine orthosis
Sterno-Occipital Mandibular Immobilizer (SOMI) for stable injury
Halo vest immobilizer for unstable injury
Acute infectious flexor tenosynovitis
Kanavel cardinal signs of flexor sheath infection
x4
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
Necrotizing fasciitis (NF) classification
Type 1: Polymicrobial *most common 80-90%
2: Monomicrobial (Group A streptococcus most common)
3: Vibrio vulnificus
4. Fungal (immunocompromised)
Eczema herpeticum virus
Herpes simplex virus (type 1)
Sudden onset papulovesicular lesions with punched out, crusted ulcers in chronic dermatitis
Hypocalcemia elicited signs
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
Decompression sickness types
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)
Ludwig angina 3 compartments of floor of mouth
- Sublingual
- Submental
- Submandibular
Systematic review (SR) definition
LAW
EEEM 2021
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.
Brain abscess microbe
Streptococcus anginosus
Stroke score for AF name
CHA2DS2-VASc score
GIB score for low risk OP Mx
Glasgow-Blatchford Bleeding Score
Rewarming methods
- Passive external
- Remove wet clothing
- Blanket - Active external
- Bair hugger (active rewarming blanket)
- Radiant heat - Active internal
- Warm saline infusion
- Bladder irrigation with warm saline
- Peritoneal / pleural irrigation
Flail chest definition
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
HAZMAT decontamination
Universal decontamination agent: Hypochlorite solution (0.5% for skin, 5% for equipment)
Copious amount of water equally effective
Lichtenberg figures
Book
Fern-like pattern
Imprints from electron showering on the skin, not true burns
Appear within 1 hour
Disappear in 24-36h
Heat stroke types
Book
- 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 - 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
Acute radiation syndrome
3 classical syndromes
- Bone marrow syndrome (0.7Gy)
- BM destruction, causing infection/hemorrhage - GI syndrome (10Gy)
- Unlikely survive, die within 2 weeks - 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
Adult status epilepticus drug dose
BZD
1. Lorazepam (0.1mg/kg) max 4mg IV
2. Diazepam (0.15mg/kg) max 10mg IV
3. Midazolam 10mg (0.2mg/kg) IMI / nasal (5mg each nostril)
Anti-seizure medication (ASM)
1. Levetiracetam 60mg/kg IV (max 4500mg)
2. Phenytoin 20mg/kg IV **max rate 50mg/min
3. Valproate 40mg/kg IV (max 3000mg)
Refractory SE (requires continuous EEG monitoring)
1. Midazolam infusion 0.2mg/kg IV bolus, then 0.1mg/kg/hr, max 3mg/kg/hr
2. Propofol 1-2mg/kg loading over 5 mins, then repeat 0.5-2mg/kg until seizure stops, infusion at 0.2mcg/kg/min
3. Pentobarbital 5mg/kg over 10 mins, max 50mg/min; 5mg/kg bolus still seizure stops, infusion 1mg/kg/hr
Risk factor of placental abruption
EM book
- Maternal HT
- Previous hx of placental abruption
- Smoking / cocaine use
- Advanced maternal age
- Trauma
- Retroplacental fibroid
- Multiparity
Burn total BSA (body surface area) chart
- Wallace rule of nines
- Lund and Browder Chart
- more precise
ECG South African flag sign
High lateral STEMI
STE in lead 1, aVL, and V2
STD in lead 3
acute occlusion of the D1 (first diagonal) branch LAD
RAPD causes
deepseek
- Optic neuritis
- Ischemic optic neuropathy
- Retinal detachment
- CRAO, CRVO
Pre-transport preparation framework
Prep course
Tai / SF doc
Indications and CI and alternatives
Communication
- patient, relative, receiving facility, transport team, ambulance
- consent
Proper documentation
- interhospital transfer form, condition upon dispatch, en route vitals and Mx
Prepare patient
- head to toe, ensure all equipment, iv lines, tubes and drains and secured and functioning
- vital signs before dispatch
Prepare staff
- Select experienced staff for transport
Prepare equipment / meds
- transport kits, meds, monitoring device, ventilator
- prepare necessary meds: pre-drawn meds, limit to 1-2
Anticipated problems
- predict possible complications and actions
Communication
- patient, relative, receiving facility, transport team, ambulance
- consent
Staff
- Select appropriate staff for transport
- Risk of deterioration, competency
Equipment support
- transport kits, meds, monitoring device
- prepare necessary meds: pre-drawn meds, limit to 1-2
Pre-transport assessment
- head to toe, ensure all equipment, iv lines, tubes and drains and secured and functioning
- vital signs before dispatch
Write up Mx plan of emergency
- predict possible complications and actions
Documentation
- Indication, pt condition upon dispatch, enroute mx and vitals
Bedside echo LVEF estimate
E point septal separation (EPSS)
**>=7mm = reduced LVEF (<30%)
Parasternal long view
M mode over distal tip of the anterior leaflet of MV
Emergency Medical Team (EMT) role
Prep course:
- Triage
- Treatment
- Transfer
Field triage, on scene treatment, decision for diversion of patients to hospitals
Level C PPE
Protective suit and filter type respirator
- Personal protective suit
- A pair of nitrile gloves
- A pair of chemical resistant boots
- Full face mask with vapour or particulate air-filter or Powered Air-Purifying Respirator
- Sealing tape
Level A and B PPE
Level A: Gas-proof protective suit and self-contained breathing apparatus (SCBA)
Level B: Splash-proof suit and SCBA
Physiological criteria for primary trauma diversion / trauma call activation
- GCS <= 13
- SBP <90
- RR <10 or >29
Anatomical criteria for primary trauma diversion / trauma call activation
- Flail chest
- LL # involving 2 or more femur/tibia
- Penetrating trauma to head/neck/torso
- Limb paralysis
- Pelvic #
- Burn 2nd+ degree involving >= 20% TBSA
- Amputation proximal to wrist or ankle
Pneumoperitoneum XR sign
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.
Ix to do
- H’stix
- ECG
- 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
- CXR, AXR, C-spine, Pelvis, LS spine
- USG: E-FAST, Echo (TTE/TEE), DVT, Doppler, Lung, Eye
- CT: brain, contrast, CTA, CT venogram
- MRI
- Urine x pregnancty test, bedside immunoassay, toxicology, c/st; osmo/Na; multistix; protein/creatinine
- Stool x c/st
- NPS x CoV/Flu/Resp virus/Mycoplasma
- Sputum x c/st, AFB, cytology
- Vomitus / GL content x toxin
- POCT blood iStat / GEM: MetHb, CyanoHb, Electrolytes, Lactate
- LP, EEG
- IOP
AIRS full name
Advance Incident Reporting System (AIRS)
Fishbone diagram
Ishikawa diagram / Cause-and-effect diagram
Visual tool to identify and analyze potential cause of a problem
Sentinel events (SE)
醫療風險警示事件
9 categories
Definition: Unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof
- Surgery / interventional procedure involving the wrong patient or body part
[Wrong patient/part] - Retained instruments or other material after surgery / interventional procedure
[Retained instruments/material] - ABO incompatibility blood transfusion
[Blood incompatibility] - Medication error resulting in major permanent loss of function or death
[Medication error] - Intravascular gas embolism resulting in death or neurological damage
[Gas embolism] - Death of an inpatient from suicide (including home leave)
[Inpatient suicide] - Maternal death or serious morbidity associated with labor or delivery
[Maternal death/morbidity] - Infant discharged to wrong family or infant abduction
[Wrong infant/abduction] - Other adverse events resulting in permanent loss of function or death (excluding Cx)
[Others]
Phenytoin why CI in toxicology causes of seizure
Its mechanism is to stop propagation of seizure focus
Poison case -> generalized seizure focus
Toxicology causes of Hypoglycemia
Book
- Insulin
- Oral hypoglycemic agents
- Ethanol
- Salicylate
- BB
- Quinine
Maternal cardiac arrest causes
ABCDEFGH
Anesthetic Cx (loss of airway, aspiration, LAST etc.)
Bleeding (uterine atony, placental abruption, uterine rupture, trauma etc.)
CVS causes (cardiomyopathy, MI, AD, arrhythmia)
Drugs (anaphylaxis, Mg, opioid, insulin, oxytocin overdose)
Embolic (PE, amniotic fluid embolism, air)
Fever (infection, sepsis)
General non-obs causes -> 5H5T
Hypoxia, Hypovolemia, Hypothermia, H+ acidosis, Hypo/hyperK
Tamponade, Tension PTX, Thrombosis (PE), Thrombosis (AMI), Toxin
Hypertension (Preeclampsia, Eclampsia, HELLP, ICH)
Serious untoward events (SUE)
重要風險事件
2 categories
Definition: Unexpected occurrence which could have led to death or permanent harm
- Medication error which could have led to death or permanent harm
[Medication error] - Patient misidentification which could have led to death or permanent harm
[Patient misidentification]
Penetrating abdominal injury
Stab / gunshot wound
4 regions
- Anterior abdomen
- Thoracoabdominal area
- Flanks
- Back
Pediatric scores for at risk of deterioration
- Pediatric early warning score (PEWS)
- NICE traffic light system
CI for Permissive hypotension
- Traumatic brain injury
- Spinal cord injury
BP aim
- SBP 80-90
- MAP 50-60 ?65
Diabetic ketoacidosis (DKA) diagnostic criteria
- Hyperglycemia: BG >11.1mmol/L or hx of DM
- Ketosis (in blood/urine): BHBA >= 3.0 or urine ketone strip 2+
- Metabolic acidosis: pH <7.3 and HCO3 <18
Pedi ABC compared to adult
Ying
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
Severe asthma cutoff for RR and HR
RR 30
HR 120
Pedi uncuff vs cuff ETT
CS
Uncuff (preferred <8y)
Pros
1. Larger internal diameter for age
(less resistance to airflow, reduced blockage by secretions, easier suction)
2. Minimal mucosal pressure
Cons
1. Leakage of air
2. Aspiration
3. Airway injury by oversized (pressure on cricoid mucosa) /undersized (movement trauma) tubes
Cuff
Pros
1. Smaller external diameter for age
2. Improved ventilation and respiration
3. Reduce aspiration risk
4. Reduce air pollution
5. Less pressure on cricoid mucosa
6. Easier intubation
Cons
1. Smaller internal diameter
2. Airway injury (tracheal rupture, mucosal ischemia)
Ventilator settings for severe pneumonia (ARDS)
CS
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%
Ventilator settings for asthma/COPD
CS
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
Peak and plateau pressure high causes
Compliance problems
- One lung intubation
- PTX
- Atelectasis
- APO
- ARDS
AMPLE history
Allergy
Medication
PMH
Last meal
Event
Cx of massive transfusion
- Coagulopathy
- Hypothermia
- Electrolyte disturbance: hypoCa, hyperK
- Metabolic alkalosis (citrate metabolize to HCO3)
- Transfusion related acute lung injury (TRALI)
- 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
USG jellyfish sign
Atelectatic lung “swimming” within a large pleural effusion
High dose insulin (HDI) therapy dose
Book
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
SE of high dose insulin (HDI) therapy
Book
- Hypoglycemia
- BG Q10-30min, keep >5.6 - HypoK
- K Q1H, keep >2.8 - Exacerbate LV outflow obs in HCM patients
Blood x Mg, PO4 daily
Rebound hyperK after stopping HDI
Mx of BB overdose
Book
- Ensure ABC
- 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
- Glucagon
- bolus 2-5mg IV (50mcg/kg children)
- maintenance: 2-5mg/h in D5 (20-50mcg/kg/h in children), titrate clinically - Calcium
- same as CCB; 1gCaCl or 3g Ca glu - HDI
- 1U/kg bolus, followed by infusion 0.5-2U/kg/h - Inotropes and Vasopressors
- Adrenaline or NA - IV lipid emulsion (ILE)
- Lipid sink for BB with high lipid solubility (propranolol, sotalol)
- reserved for life threatening toxicity / cardiac arrest - Others: Pacing, Intraaortic balloon pump, ECMO
For prolonged QRS in Propranolol poisoning
10. NaHCO3 1-2mmol/kg bolus for QRS >100ms
For prolonged QTc in sotalol poisoning
11. MgSO4 2g IV infusion for QTc >500ms
Enhanced elimination
12. HD/HF for life threatening atenolol/sotalol poisoning
- not recommended in propranolol poisoning
CURB-65 for pneumonia severity
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
Wells’ score for PE
- Clinical S/S of DVT (+3)
- PE is top DDx (+3)
- HR >100 (+1.5)
- Immobilization at least 3 days or surgery in previous 4 weeks (+1.5)
- Previous PE or DVT (+1.5)
- Hemoptysis (+1)
- 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
SILENT (lithium)
Syndrome of irreversible lithium-effectuated neurotoxicity
Irreversible neuropsychiatric sequelae, persistent after cessation of lithium use
- Cerebellar dysfunction predominates
Dialysable drugs characteristics
deepseek
- Low molecular weight
- Low protein binding
- Small volume of distribution (<1L/kg)
- Hydrophilic (pass through dialysis membranes more easily)
e.g. Methanol, Ethylene glycol, Lithium, Salicylate, Theophylline, Metformin, VPA, Phenytoin
PECARN rule
Pediatric Emergency Care Applied Research Network
Predicts need for CT brain in pediatric head injury
Under 2y and over 2y
Shoulder dystocia
ALSO
HELPER4
H: Call for help early
E: Evaluate and explain clinical situation
L: Legs: McRoberts maneuver
P: Suprapubic pressure
E: Enter birth canal posteriorly and assess need for episiotomy
R: Remove posterior arm (follow posterior arm to elbow, flex arm at elbow, sweep forearm across chest and out of vagina)
R2: Rotational maneuvers (Rubin II, Rubin II + Woods screw, Reverse Woods screw)
R3: Roll patient to hands and knees (all 4 position)
R4: Repeat
Complaint management
SF short case
- Open disclosure
- Review the case
- Explained what has happened and post event management
- Report to COS/ Consultant / AIRS
- Staff management
- Education / Root cause analysis
Why aspirin not good for thyroid storm
Displace thyroid hormone from binding proteins
Increase serum free T4 and T3
Sign of placental separation after birth
x3
- Gush of blood
- Lengthening of cord
- Globular and firm uterus
Mx of SE and SUE
prep
Immediate response
1. Assess patient condition and provide care to minimize harm to patient
2. Notify senior staff (e.g. COS) without delay
3. Immediate response plan (worked out by departmental and hospital management staff)
- Disclosure to patient/relatives
- When to notify HAHO
- Public relations issues and media handling
- Appropriate support / staff counselling
Reporting
1. AIRS within 24h
2. Coroner (if applicable)
Ix
1. Root cause analysis (RCA) panel appointment within 48h
SE by HAHO; SUE by respective hospital
2. Final Ix report submission to HCE within 6wk and HAHO within 8wk
FU
1. Implement of action plan (department and HA-wide changes)
2. Learning and sharing
Root cause analysis (RCA)
prep
A comprehensive and systematic medtodology to identify gaps in systems and processes that may not be immediately apparent and which may have contributed to the occurrence of an event
Goals of RCA is to determine
1. What has happened?
2. Why did it happen?
3. What can be done to prevent it from happenening again?
Complaint management
prep
- Ackowledge the complaint in a timely manner
- Apologies of any distress caused (not admission of liability)
- Determine the complaints
- Immediate support for the complainant (call back for re-ax and tx if necessary)
- Undertake to investigate
- Arrange FU
- Internal Ix
- Assess both systematic and individual factors
- Gather info e.g. case notes, individual staff
- Support staff and maintain confidentiality
- Inform administration and stakeholders
- Consider legal implications
- Incident Mx and RCA as appropriate
- Determine what actions need to be taken
- FU with complainant
- Feedback
- Revise existing protocol and implement changes
- Education and learning
- Re-audit
Disaster definition
prep
Any adverse incident in which the demand for emergency medical care is beyond the capacity of a single hospital
START and JumpSTART
Simple triage and rapid treatment (START) triage system
4 steps:
- walking
- ventilation
- pulse / circulation
- mental status
3 components (RPM)
- Respiration
- Perfusion
- Mental status
JumpSTART:
- Difference in “normal” RR for children
- Assess pediatric patients better
- Age cutoff for use 8y/o (infant to 8y/o)
- Five rescue breaths are to be given to apneic children with a pulse; then, they are given a black tag.
- Normal RR are more than 15 or less than 45
- Neurological assessment is done using the mnemonic AVPU (alert, responds to verbal stimuli, responds to painful stimuli, and unresponsive). Any patient who has abnormal posturing to painful stimuli or is unresponsive gets a red tag designation.
BLACK: (Deceased/expectant) injuries incompatible with life or without spontaneous respiration; should not be moved forward to the collection point
RED: (Immediate) severe injuries but high potential for survival with treatment; taken to collection point first
YELLOW: (Delayed) serious injuries but not immediately life-threatening
GREEN: (Walking wounded) minor injuries
MDAC useful in
Book
- Phenobarbital
- Dapsone
- Theophylline
- Digitoxin
- Phenytoin
- Carbamazepine
- Quinine
in general sustained release, drugs that form concretions in GIT
considered for poison with enterohepatic recirculation or pharmacokinetic properties favor gut dialysis
Secondary PPH
Any significant uterine bleeding occurring between 24h and 12 weeks postpartum
Definitions vary between 48h and 6 weeks postpartum
Postpartum hemorrhage (PPH) definition
WHO: Blood loss >= 500ml within 24h after birth
American OG college: Cumulative blood loss ≥1000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process (includes intrapartum loss) regardless of route of delivery
PSA agents
Sedatives choice
Midazolam, Propofol
NLTH PSA
- Midazolam
- Short acting BZD
- SE: Resp depression, apnea; Pedi: Parodoxical reactions including hyperactivity, aggressive behavior and crying in 1-3% pediatric patients - Propofol
- Non-opioid, non-barbiturate sedative agents
- Pros: Rapid onset, short recovery time, easily titrated, antiemetic properties
- No analgesic effect
- SE: Resp depression, apnea, hypotension
- Hypotension mx with IVF folus, phenylephrine bolus
- CI in egg/soybean oil allegy
PSA agents
Sedatives choice
Etomidate, Ketamine, Dexmedetomidine
NLTH PSA
- Etomidate
- Non-barbiturate hypotic agents (GABAA agonist)
- No analgesic effect
- Pros: Rapid onset and rapid recovery, hemodynamic stability usually maintained
- SE: injection site pain, vomiting, transient myoclonus - Ketamine
- Dissociative agent with sedative, analgesics, amnesic properties
- Pros: Maintain protective airway reflexes, spontaneous respiration and cardiopulmonary stability
- SE: vomiting, sympathomimetic effects (HT, tachycardia, transient laryngospasm, apnea, resp depression, rasied ICP, hypersalivation, emergence reaction - undesirable psychological experience like vivid dreams
- CI: <3m old, psychosis, uncontrolled raised ICP/IOP, thyrotoxicosis, airway instability - Dexmedetomidine (Precedex)
- Centrally acting seletive alpha 2 adrenergic agonist
- Potent sedative effects with modest analgesic effects
- Pros: maintain spontaneous respiration and upper airway reflexes
- SE: bradycardia, hypotension / HT
- CI: receiving AVN (digoxin, BB, CCB), high degree HB, severe ventricular dysfunction
IO site anatomy adult
- Proximal tibia
- 2cm medial and below tibial tuberosity - Proximal humerus
- 1cm above surgical neck at greater tubercle - Distal tibia
- 3cm proximal to most prominent part of medial malleolus
CI of Intraosseous (IO) insertion
- Previous IO attempt at same site within 24h
- Fracture
- Overlying skin infection
- Osteogenesis imperfecta (OI)
- Unable to locate bony landmarks
- Vascular injury
Cx of IO
- Extravasation
- Fat / BM embolism
- Compartment syndrome
- Infection
- Growth plate injury
- Lab results not reliable: Na/K/Ca, pCO2, WBC, platelet
Primary survey ATLS
ABCDE
Airway maintenance with restriction of cervical spine motion
Breathing and ventilation
Circulation with hemorrhage control
Disability (assessment of neurologic status)
Exposure/Environmental control
Adjuncts to primary survey with resuscitation
ATLS
- Cardiac monitor
- Pulse oximetry
- EtCO2 monitor, ventilatory rate monitor
- ABG
- Foley to monitor urine output and assess for hematuria
- Gastric catheters decompress distention and assess for evidence of blood
- Blood lactate
- X ray: CXR, pelvis
- USG: Extended focused assessment with sonography for trauma (eFAST)
- Diagnostic peritoneal lavage (DPL)
Penetrating chest injury
Lethal six and hidden six
Lethal 6
1. Airway obs
2. Tension PTX
3. Open PTX
4. Massive hemothorax
5. Flail chest
6. Cardiac tamponade
Hidden 6
1. Thoracic aortic disruption
2. Tracheobronchial disruption
3. Esophageal distruption
4. Myocardiac contusion
5. Pulmonary contusion
6. Diaphragmatic tear
Penetrating chest injury
cardiac box
high risk of injury to the heart and other mediastinal structures
superiorly by the clavicles and sternal notch
laterally by nipple line
inferiorly by costal margins
ROTEM, TEG
ROTEM: Rotational thromboelastometry
TEG: Thromboelastography
RSI meds pros and cons
Etomidate
COC
Etomidate 0.3mg/kg (0.2mg/kg if pretx with opioid)
Pros:
1. CVS stable
2. Ability to reduce cerebral blood flow and O2 consumption
3. Does not cause histamine release
Cons:
1. Adrenocortical suppression
2. Painful on injection
3. Myoclonus
4. Laryngospasm
For trauma, hypotension
RSI meds pros and cons
Propofol
COC
Propofol 1-2mg/kg
Pros:
1. Decrease ICP, cerebral metabolic rate of oxygen, cerebral blood flow (useful in brain injury / ICH)
2. Anticonvulsant properties
3. Bronchodilation (useful in asthma and bronchospasm)
Cons:
1. Hypotension
For seizure, asthma
RSI meds pros and cons
Thiopental
COC
Thiopental 4mg/kg (2mg/kg if hypotensive)
Pros:
1. Decrease ICP and cerebral blood volume (by cerebral vasoconstriction)
Cons:
1. Hypotension (also cause histamine release)
For status epilepticus, CVS stable
RSI meds pros and cons
Ketamine
COC
Ketamine 1-2mg/kg
Pros:
1. Bronchodilatory effect
2. Analgesic, amnesia effect
3. Preserves resp drive (for awake intubation)
4. Increase BP, reduce airway resistance (stimulate sympathetic outflow)
Cons:
1. Laryngospasm
2. Stimulate oral secretion, hypersalivation
3. Emergence reaction (reduced by giving BZD as well)
4. HT
CI:
1. Acute intraocular injury, glaucoma
2. Coronary artery disease, CHF, HT
Use for septic shock, ?asthma
Morphine avoid in asthma
Causes mast cell degranulation -> histamine release -> bronchoconstriction
Succinylcholine CI
COC
Dose: 1.5mg/kg
- Significant hyperK (e.g. with ECG changes)
- Major crush injuries beyond 48h
- Extensive burns more than 48h
- Subacute major nerve or spinal cord injuries (denervation syndromes)
- Muscular dystrophies (e.g. Duchenne muscular dystrophy)
- Hx of malignant hyperthermia
- Previous allergy to succinylcholine
SVCO causes
Malignant causes
1. CA lung
2. Lymphoma
3. Metastases
Non-malignant causes
4. Thrombosis (indwelling CVC, PICC)
5. Aortic aneurysm
6. Restrosternal goiter
7. Mediastinitis (radiation induced, TB, abscess)
DDx Chest pain + Bradycardia
deepseek
Cardiac cause
1. AMI
2. SSS
3. High degree HB
4. Myocarditis
Metabolic cause
5. HyperK
6. Hypothermia
Toxicological cause
7. BB / CCB overdose
8. Digoxin toxicity
9. OP poisoning
Neurological cause
10. Raised ICP e.g. SAH; chest pain from neurogenic pul edema
+/- vasovagal syncope
Endocrine cause
11. Hypothyroidism
Vasopressors vs Inotropes examples
Vasopressors + Inotropes (Inopressors)
1. Adrenaline
2. NA
3. Dopamine
Vasopressors
1. Vasopressin
2. Angiotensin II
3. Phenylephrine
Inotropes
1. Milrinone
2. Isoproterenol
3. Dobutamine
RSI 7Ps
COC
- Preparation
- Pre-oxygenation
- Pre-intubation optimization (fluid resus for hypotension, apneic oxygenation or BiPAP/CPAP for refractory hypoxia; treat tension PTX, pre-tx with fentanyl, lignocaine)
- Paralysis with induction
- Positioning and protection
- Placement with proof
- Post-intubation mx
Opioid pre-tx in RSI
Fentanyl 1-3ug/kg
Alfentanil 0.01mg/kg
Blunts sympathetic discharge and ICP rise associated with DL and intubation
Consider in raised ICP, aortic dissection, ruptured aortic aneurysm, IHD
Lignocaine 1.5mg/kg
Trauma: Indication for laparotomy
prep
- Blunt abd trauma with hypotension, FAST +ve
- Hypotension with abd wound penetrating anterior fascia
- Gunshot wound traverse peritoneal cavity
- Eviseration
- Bleeding from stomach, rectum, genitourinary tract with penetrating injury
- Peritonitis
- Free air, retroperitoneal air, rupture of hemidiaphragm
- Contast CT showing ruptured GIT, intraperitoneal bladder injury, renal pedicle injury, severe visceral parenchymal injury after blunt/penetrating trauma
Ventilator monitor
Pressure
Flow
Volume
Measure intrinsic PEEP
Expiratory hold (need to be intubated)
Post cardiac arrest
Resp / hemodynamic parameters
ACLS
Early placement of ETT
Resp parameters
- 10 breaths / min
- SpO2 92-98%
- PaCO2 35-45mmHg
Hemodynamic parameters
- SBP >90
- MAP >65
Post cardiac arrest
Targeted temperature management (TTM)
ACLS
Improves survival and brain function
Start if patient not following commands
Begin at 32-36C for 24h (by using cooling device with feedback loop)
Bradycardia medication
ACLS
- Atropine 1mg bolus, repeat every 3-5 mins, max 3mg
- Dopamine infusion 5-20ug/kg/min (0.3-1.2mg/kg/h) (50kg: 15-60mg/h)
[200mg in 100ml NS: 2mg/ml: 7.5-30ml/h] - Adrenaline infusion 2-10ug/min (0.12-0.6mg/h)
[4mg in 50ml NS: 0.08mg/ml: 1.5-7.5ml/h]
Extracorporeal CPR (ECPR)
Indications and CI
prep
Indication
1. Good premorbid
2. Reversible diease process
3. Overall goals of therapy are curative
CI
1. Irreversible organ damage
2. Multiorgan failure
3. CI to anticoagulation
4. Severe AR or aortic dissection
ACLS medication dose
Adrenaline (1:10000) IV/IO
1mg every 3-5 min
Amiodarone IV/IO
1st dose: 300mg bolus
2nd dose: 150mg
Lignocaine IV/IO
1st dose: 1-1.5mg/kg
2nd dose: 0.5-0.75mg/kg
DDx sore throat
deepseek
Infective
1. Acute pharyngitis
2. Acute tonsillitis
3. Peritonsillar abscess (quinsy)
4. Acute epiglottitis
5. Retropharyngeal abscess (look for trismus)
6. Ludwig angina
Non-infective
1. Foreign body ingestion
2. Malignancy: CA larynx, lymphoma
3. GERD
4. Carotid artery dissection
Centor Score for Strep Pharyngitis
Used in acute pharyngitis <3d
To Dx Group A streptococcus infection / streptococcal pharyngitis
- Age
3-14 +1
15-44 0
>= 45 -1 - Exudates / swelling on tonsils
0/1 - Tender/Swollen anterior cervical LNs
0/1 - Fever (T>38)
0/1 - Cough
present 0
absent 1
> =2 points for throat culture
FBI site of impaction
- Palatine tonsils
- Tongue base
- Vallecula
- Pyriform fossa
Cx of FBI
Early
1. Mucosal laceration, ulceration, bleeding
2. Abscess formation
3. Deep neck infection (Ludwig)
Late
1. Esophageal perforation
2. Mediastinitis
3. Vascular injury: carotid a erosion, IJV thrombosis
4. Tracheo-esophageal fistula
5. PTX
Risk factor for pre-eclampsia
- Previous pre-eclampsia
- Nulliparity
- Multiple pregnancy
- Chronic HT
- DM / GDM
- SLE
- Advanced maternal age >35y
