To Revise Flashcards
CURB 65 CRITERIA
Confusion Urea >7mM RR >30 BP <90 >_65
Complications of pneumonia
Lung abscess Empyema Sepsis AF Pleural effusion Resp failure Hypotension
Empyema- presentation, ix, rx
Presentation - recovering from pneumonia becomes feverish again
Ix - TAP - pH <7.2, decrease glucose, high LDH
Mx - US guided chest drain + abx
Mx of any condition
A-E if acute
Look at all symptoms and see how to treat each one individually
SIRS Criteria
at least 2 of Temp >38 or <36 HR >90 RR >20 WCC > 12x10^9
Causes of non resolving pneumonia
CHAOS Complication Host Abx Organism Secondary diagnosis
Causes of transudate effusions
Common
- HF
- hypoalbuminaemia
- cirrhosis
Less common
- hypothyroidism
- PE
- Mitral stenosis
Rare
- SVCO
- constrictive pericarditis
Causes of exudative pleural effusions
Common
Malignancy - particularly gynae
Infection - pneumonia, TB, legionella
Less common
Inflammation - RA, pancreatitis, dressler’s
Lymphatic drainage issues
Lights criteria - when to use and what is it
When protein in pleural aspirate is between 25 and 30
Criteria
Exudate if one or more of the following:
Pleural fluid/serum protein >0.5
Pleural fluid/serum LDH >0.6
Pleural fluid LDH > 2/3 of upper limit of normal
Ix to diagnose pleural effusion
US guided pleural aspiration
CXR
Pulmonary effusion CXR
Meniscus
Blunted costaphrenic angles
Tension pneumothorax mx
A-E
Insert large bore IV cannula into 2nd ICS MC line
Chest drain into affected side
Causes of pnuemothorax
Spontaneous
primary - without disease - young thin men, smokers
secondary - with disease eg COPD, Marfan’s, Ehlers Danlos, ppulmonary fibrosis, sarcoidosis
Traumatic
Iatrogenic
- Central line insertion
- positive pressure ventilation
- pacemaker insertion
Pneumothorax rf
Height Male COPD, marfans, ehlers danlos, sarcoidosis Procedure eg central line or pacemaker Smoker - particularly of cannabis Trauma Diving
Rf of PE
SPASMODICAL
Sex: f Pregnancy Age: older Surgery Malignancy Oestrogen DVT Immobility Colossally obese Antiphospholipid antibodies Lupus anti-coagulant
PE - from front door to treament
A-E
Wells Score to determine probability
If highly probable - CTPA
If low probability - D Dimer. If D Dimer high - CTPA. If low - exclude PE
Give interim anticoagulation - rivoroxaban or apixaban first line. If CI, give LMWH
Treatment
Pharmaco - oral anticoags eg warfarin, DOACs (in UHL), LMWH, fondaparinux
Mechanical - IVC filter
Thrombolytic - if large. Streptokinase
Wells Score Categories
Symptoms of DVT
Previous VTE
Immobilisation for 3 days or surgery in the past 4 weeks
HR >100
Cancer
Haemoptysis
An alternative diagnosis is less likely than PE
If >4points PE likely
PE Ix
CTPA Doppler calfs Clotting factors ECG CXR ABG
4 causes of ILD they want us to know about
Extrinsic allergic alveolitis
Usual Interstitial pneumonia (UIP)
Non specific interstitial pneumonia (NSIP)
Sarcoidosis
Signs of ILD
Fine inspiratory respiratory crackles
Clubbing
Symptoms of Extrinsic allergic alveolitis (acute and chronic)
Acute 4-8hrs after exposure
- dyspnoea
- dry cough
- fever, rigors, malaise
Chronic
- increasing dyspnoea
- weight loss
- T1 resp failure
- cor pulmonale
Sarcoidosis definition
Multistystem granulomatous disease of unknown origin
Symptoms of sarcoidosis
GRANULOMA
General - fever, malaise, lymphadenopathy
Respiratory - 90% have dry cough, dyspnoea, chest pain, reduced lung function
Arthralgia
Neurological - Bells palsy, meningitis, SOL
Urinary - increased calcium - renal stones
Low hormones - pituitary - amenorrhoea
Opthalmological - uveitis, sjrogens
Myocardial - restrictive cardiomyopathy secondary to granulomas, pericardial effusion
Abdominal - splenomegaly and hepatomegaly
CXR finding of sarcoidosis
BHL
Ix of sarcoidosis
PFTs ECHO and ECG for cardiac innvolvement CT head for neuro involvement Urinary calcium levels CXR
Treatment principles of ILD
A to E Remove exposure Stop smoking Treatment of infective exacerbations MDT approach Palliation Transplantation
Ddx for resp issues that is apt to think about
covid19
Types of Lung Cancer
Small cell
Non small cell - SCC, Adeno, Large
Differences in presentation between SCLC and NSCLC (SCC and adeno)
SCLC
- smokers
- centrally located near bronchioles
- typically presents as advanced metastatic disease
- associated with cushings
SCC
- smokers
- centrally located
- slow to metastasise
- locally invasive
- PTHrP secreting
Adeno
- non-smokers
- peripherally located
- often presents with metastases
Group symptoms/signs of cancers
Local/organ
General
Metastatic
How to group complications of cancers
Local
Paraneoplastic
Metastatic
Signs of lung cancer
Lungs - consolidation, collapse, pleural effusion
General - cachexia, clubbing, anaemia, lymphadenopathy
Metastatic - bone pain, hepatomegaly, confusion fits focal neurological signs
NSCLS Mx
MDT
Surgical resection - lobectomy, pulmonectomy, wedge resection + adjuvant chemo
Chemo
Chemo + radio
SCLC Mx
MDT
Can do radio but tend to relapse
Palliation and analgesia
Very poor prognosis
Complications of lung cancer
Local
- SVCO
- RLN palsy
- phrenic nerve palsy
- Horner’s syndrome (pancoast cancer)
Paraneoplastic
- hypercalcaemia
- SIADH
- Cushings
- Acanthosis Nigricans
Metastatic
- pathological fractures
- hepatomegaly
- addisons
- confusion, fits, focal neurology
Presentation of TB
Fever with drenching night sweats
Haemoptysis
Weight loss
Productive cough with purulent sputum
TB risk factord
- TB contact
- travelled to a high risk TB country or born there
- immunocompromised
Anti - TB therapy plus side effects and initial ix
Rifampicin - hepatitis and rashes, can cause orange secretions
Isoniazid - hepatitis and rashes, peripheral neuropathy
Pyrazinamide - hepatitis and rashes, arthralgia
Ethambutol - retrobulbar neuritis
LFTs need close monitoring
Visual acuity assessed before ethambutol
Pyridoxine given whilst on isoniazid as prophylaxis against peripheral neuropathy
RIPE for 2 months followed by RI for 4 months
Mx principles of TB
negative pressure side room
ziel nielsson stain of sputum
Causes of bronchiectasis
Post infective
- whooping cough
- TB
Immune deficiency
- hypogammaglobulinanaemia
Genetic Mucocilliary Clearance issues
- CF
- Kartageners syndrome
Secondary Immune Deficiency
- RA
- HIV
Toxic Insult
- gastric aspiration
Also Allergic Bronchopulmonary Aspergillosus
Ix of bronchiectasis
Immunoglobulin levels Rheumatoid factor Cystic fibrosis gene screening Aspergillus IgE Auto antibodies
Definitive = High Contrast CT
Definition of a bronchiectasis exacerbation
A patient with bronchiectasis who presents with a deterioration of 3 or more of the following over 48hrs
- cough
- sputum volume and consistency
- Sputum purulence
- Breathlessness
- fatigue
- haemoptysis
What are pts with bronchiectasis at increased risk of
Recurrent infections
What conditions is ABPA associated with
asthma
bronchiectasis
CF
Ix of ABPA
Raised aspergillus IgE as well as total IgE
What type of pathogen is aspergillus fumigatus
Fungi
Mx of ABPA
Steroids
How is Cf diagnosed
Newborn screening
Sweat chloride test
CF genotyping
How does CF often intially present
Meconium ileus in newborns
Intestinal Malabsorption
Recurrent chest infections
Most picked up by newborn screening
Common CF complications
Recurrent chest infections Malabsorption Distal Intestinal Obstruction Syndrome Infertility CF related diabetes
Mx of CF
Lifestyle factors which I know Chest physio Mucolytics Pancreatic enzyme replacement Long term antibiotics ADEK replacement and nutritional support Long term monitoring of CF diabetes
Pathophysiology of asthma
IgE release
Eosinophils
Inflammation
Increased goblet cells so increased mucus
Symptoms of mild asthma
PEFR >75
no symptoms of severe asthma
Symptoms of moderate asthma attack
PEFR 50-75%
No symptoms of severe asthma
Symtpoms of severe asthma
PEFR 33-50% O2 < 92% Cant complete full sentences Increased RR >25 HR >110
Symptoms of life threatening asthma attack
PEFR <33
Normal pCO2
Cyanotic, hypotensive, confused, increased respiratory effort, near or full silent chest, exhaustion, arrythmias
Near fatal asthma attack
Increased pCO2
Mx of asthma
A-E approach
Give O2 if less than 92%
5mg Neb Salbutamol
40mg oral prednisolone
If severe:
Neb 500 micrograms ipatropium bromide
Back to back salbutamol every 15 mins
If life threatening or near fatal
IV aminophylline
IV salbutamol
Urgent ITU or anaesthetist review
What drugs can trigger asthma
Aspirin and betblockers
COPD pathophysiology
Chronic bronchitis and emphysema
hyperplasia of mucous glands
Loss of cilial function
Chronic inflammation and fibrosis of small airways
Obstructive spirometry
FEV1:FVC = <0.7
Inwards ‘L’ shape spirometry curve - cant insert pic hence this is just description
3 main causes of COPD
- smoking
- occupational exposure/pollution
- alpha 1 antitrypsin disorder
how to mx an acute exacerbation of COPD
- A-E
- O2 levels between 88 and 92
- Nebs - salbutamol and ipatropium
- Steroids - prednisolone 30mg stat and then for 7 days
x - Abx if infective cause -
- IV aminophylline
- consider NIV if acidotic and type 2 resp failure
Talk about LTOT
specific criteria eg must be non smoker, O2 must be safe in house
has to be used for at least 16hrs a day for survival benefit
lose independence and reduced activity levels
aims of pulmonary rehabilitation
break the cycle of exercise and breathlessness. Avoid exercise that makes you breathless increasingly makes you more breathless
Causes of Type 1 resp failure (CO2 <6kPa)
V/Q mismatch
- pneumothorax
- early asthma
- PE
- PHT
Diffusion failure
- Fluid (pulmonary oedema, pneumonia, infarction, blood)
- Fibrosis
Causes of Type 2 Resp Failure (paCO2>6kPa)
V/Q mistmatch
Alveolar hypoventilation
- Obstructive - asthma, COPD, bronchiectasis epiglottitis
- Restrictive - CNS sedation, cervical cord lesion, fluid and fibrosis
Sx and signs of hypercapnia
- headaches
- peripheral vasodilation
- confusion - coma
- flap
- bounding pulse
A-a gradient and normal value
Normal = <4
Greater than 4 means something wrong with lungs
PAO2 - PaO2
PAO2 = PIO2 - (PaCO2/0.8)
Causes of ARDS
Pulmonary
- pneumonia
- aspiration
- inhalation injury
Systemic
- sepsis
- pancreatitis
- DIC
Scale used to assess sleepiness in OSA
Epworth sleepiness scale
Mx of OSA
Weight loss
Sleep decubitus rather than supine
Mandibular advancement devices
CPAP - opens collapsed airways and improves V/Q mismatching
Should notify DVLA
Can use BiPAP if severe OSA with CO2 retention
Ix of Infective endocarditis
3 blood cultures at least an hr apart - gold
FBC, CRP, ESR, U+E(septic emboli)
Urine dip - haematuria - septic emboli
ECHO
ECG - long PR interval - perivalvular abcess
Most common IE organisms and people at risk of these
Strep viridans - Dental practice or long prosthetic
Staph aureus - IVDU
Staph epidermidis - short prosthetic
Abx for IE
Strep - benpen
Staph - fluclox
Pen allergic - vancomycin
Monitoring of IE
2 ECGs a week
1 ECHO a week
2 bloods a week
6 weeks of abx
Sign of fast AF
non palpable pulse bc loss of diastolic filling
Mx of persistent AF
Rate control
1st - beta blocker
2nd - diltiazem or verapamil
Mx of paroxysmal AF
Rhythm control
1st line - amiodarone
Amiodarone long term ADR
- pulmonary fibrosis (BANSMe)
- hypothyroidism
When do you use warfarin and when use DOAC for AF? (Given the chadvasc score warrants its use)
Warfarin for valvular AF
DOAC for non-valvular
Mx of following situation
<48hr hx of acute AF
haemodynamically unstable
A-E
Emergency cardioversion - amiodarone or flecanide
Drugs used for different tachycardias
SVT - adenosine
VT - amiodarone
AF - amiodarone
Process of looking through ECG for tachycardias
Rate Rhythm Sinus or not V1 - LBBB or RBBB, VT Concordance
2 types of SVT
AVNRT
ANRT - only one we need to know is WPW. Seen by short PR and delta wave
Features of VT on ECG
Concordance Broad QRS complex AV dissociation - p waves all over the place Capture and fusion beats Regular
If irregular likely to be AF w/ BBB or pre excited AF
Causes of VT
IM QVICK
Iatrogenic - digoxin, anti arrhythmics Myocarditis QT increased Valvular issues Infarction Cardiomyopathy K low K
Treatment for torsades de pointes
Magnesium sulfate
Mobitz 1 vs Mobitz 2
1 is increasing PR interval followed by dropped QRS
2 is same PR interval followed by dropped QRS
Causes of bradycardias
DIVISIONS
Drugs - Anti arrythmics (type 1a - amiodarone) - Beta blockers - Calcium channel blockers - Digoxin Ischaemia/inferior infarct Vagal hypertonia Infections Sick sinus Infiltration O - hypOthermia, hypOthyroidism, hypOkalaemia Neuro - increased ICP Surgery or septal defect
Hr <40 treatment
500 micrograms IV atropine
htn stages
1 >140/90
2 > 160/100
3 >180/110
HTN targets
<80 yrs <140/90
>80yrs <150/90
Differential of paroxysmal hypertension associated with headaches and sweating
Phaechromocytoma
What is a hypertensive crisis
an increase in BP which if sustained over a few hrs will cause end organ damage (LV failure, encephalopathy, aortic dissection, renal failure, unstable angina)
Mx of a hypertensive crisis
A-E
IV: 1 sodium nitroprusside - needs arterial line BP monitoring 2 GTN 3 Labetalol 4 esmolol
Heart murmurs sounds
Aortic stenosis - luuuub dub
Aortic regurge - lub tahh
Mitral regurge - durrr durr
Mitral stenosis - lub durr
Mx of oesophageal ca
Most have mets on diagnosis so majority are palliative - median survival is 4mo after dx
Some can go for an ivor lewis oesophagectomy - prognosis 5% survive 5years
Achalasia pathophys
Degeneration of myenteric plexus
reduces peristalsis
LOS fails to relax
What di 3-5% of pts with achalasia go on to develop
Oesophageal SCC
Ix for achalasia and sign shown
Barium swallow - bird bea sign
OGD to exclude malignancy
How does the dysphagia in achalasia present
liquids then solids
H Pylori Triple therapy
PPI + Clarithromycin + Amoxicillin/metronidazole
Where are gastric and duodenal ulcers most likely found
Gastric - lesser curve if stomach antrum
Duodenal - 1st part of duodenum
What is the rockall score used for
Predict risk of re bleeding in upper GI bleeds
Symptoms and signs of gastric cancer
Sx
- usually presents late
- epigastric pain
- fevers, w/l
- dyspepsia
- dysphagia
Signs
- epigastric mass
- anaemia
- virchows node
- sister mary josephs node
- ascitis
- acanthosis nigricans
Mx of gastric cancer
Mostly palliative due to late presentation
Medical - analgesia, PPI
Surgical - pyloric stenting or bypass
Curative surgical - endoscopic resection, partial or total gastrectomy
What is Zollinger Ellison and presentation
gastrin secreting tumour (gastrinoma)
Dyspepsia with chronic diarrhoea (bc of inactivation of pancreatic enzymes)
When to refer someone with GORD
If: >65 Failed to respond to medical treatment Haematemesis/malena Weight loss Anaemia Progressive symptoms Dysphagia
Surgery for GORD
Nissen fundoplication
Pathophys of Barrett’s oesophagus
Trauma to oesophagus
metaplasia -> dysplasia -> adenocarcinoma
Two types of hiatus hernia and which should you always treat even if asymptomatic
Rolling (15%) and sliding (80%) and mixed (5%)
Rolling should always be treated as risk of strangulation
Difference between rolling and sliding hiatus hernias
Rolling - gastro oesophageal junction remains in abdomen and part of stomach rolls out in tk the chest
Sliding - gastro oesophageal junction herniates into chest
Haematemesis Differential Acromym
VINTAGE Vascular - varices Inflammatory - PUD Neoplasia - oesophageal or gastric Trauma - Mallory Weiss, Boehaaves syndrome Angiodysplasia and HHT Generalised bleeding disorders - warfarin, thrombolytics Epistaxis
Rectal Bleeding Differentials Acronym
DRIPING Arse
Diverticular disease Rectal haemorrhoids Infection - shigella, E coli, campylobacter Polyps Inflammation - IBD Neoplasms Gastric upper GI bleeding Anal fissure/ Angiodysplasia + HHT+ ischaemic colitis rse
5 stages of fracture healing
Haematoma formation
Inflammation
Proliferation - of osteoblasts and fibroblasts
Consolidation - woven bone to lamellar bone
Remodelling
What factros can extend healing time of fractures
Adult
Smoker
Diaphysial
Open
3 key principles of fracture mx
Reduce
Hold
Rehabilitate
Benefits of reduction
- Tamponade bleeding
- reduce inflammation
- reduced neuropraxia risk
- reduced ischaemia risk
classification of open fractures
Gustillo-Anderson 1 - <1cm, clean 2 - 1-10cm clean 3A >10cm, adequate skin coverage 3B >10cm, inadequate skin coverage 3C - any open fracture with vascular injury
Mx of open fractures
6A’s Analgesia Anti sepsis - copious fluid irrigation, debridement, cover with betadine soaked bandages Assess - NV status, soft tissues Anti-tetanus - give vaccine Abx - broad spec eg co amox Align - align and splint
Complications of fractures generally
Immediate
- bleeding
- neurovascular damage
Short term
- compartment syndrome
- infection
- fat embolism
Long term
- malunion
- post traumatic OA
- growth disturbance
- complex pain syndromes
Seddon classification of nerve injuries
Neuropraxia - temp loss of conduction with loss of axon continuity
Axonotmeses - disruption of nerve axon. Get wallerian degeneration. recovery is possible
Neurotmesis - disruption of entire nerve fibre. Surgery needed, recovery not usually complete
What palsy can an anterior shoulder dislocation cause
axillary nerve
what palsy can a fracture of humeral shaft cause? deformity?
radial nerve - waiters tip
what palsy can an elbow dislocation cause? deformity?
Ulnar nerve - claw hand
what palsy can a hip dislocation cause? deformity?
sciatic nerve - foot drop
what palsy can a fracture of neck of fibula cause? deformity?
Fibular nerve - foot drop
common organisms causing septic arthritis
Neisseria gonnorhoea
Staph aureus
Strep pyogenes
ddx of septic arthritis
OA flare
haemarthritis
reactive arthritis
lymes disease
Ix of septic arthritis
Synovial fluid aspirate prior to abx - look for leucocytes, gram stain, microscopy and culture
2 x blood cultures at different times
Routine Bloods
X ray
Length of abx course for septic arthritis
2 weeks of IV then 2-4 weeks of oral
Complications of septic arthritis
OA
Osteomyelitis
Mx of compartment syndrome
Fasciotomy
Analgesia
Remove tight bandages, splints, casts
Monitor renal function for signs of rhabdo - high CK, or for reperfusion injury
Grade Classification used for OA
Kellgreen and Lawrence
What is a segond fracture? what is it pathognomonic of?
avulsion of lateral proximal tibial. ACL
difference in surgical methods for outer third and inner third of meniscus
outer third often sutured as good blood supply
inner third often trimmed
types of meniscal tears
longitudinal - bucket handle
Transverse - parrot beak
Degenerative
Vertical
Complications of knee arthroscopy
DVT Damage to: - Saphenous vein and nerve - popliteal vessels - perineal nerve
Complications of MCL injury
Saphenous nerve damage
Joint instability
What is the ITB
aponeurosis of the tensor fascia lata and the gluteus maximus
Rf of ITB syndrome
Repetitive flexion and extension eg runners
Bowleggedness
Special tests for ITB syndrome
Nobles - lie supine, finger on lateral femoral epicondyle. pt extends leg, pain at 30 degrees
Renne - pt stands, finger on lateral femoral epicondyle, pt squats, pain at 30 degrees as this is when ITB crosses over
Surgical mx for ITB syndrome
ITB release - but only if symptoms and loss of function for greater than 6 months
What condition to be aware of when looking at patella for a fracture
bipartite patella - failure of medial and lateral facets to fuse so held together by fibrocartilage
Mx of patella fracture
Conservative
- ensure early extension
- wear brace or cylinder cast
Surgical.
- ORIF with tension band wiring
How does ORIF with tension band wiring work for patella fractures
converts tensile force applied to patella during extension into a compression force
Complications of patella fractures
Reduced ROM
post traumatic OA at the patellofemoral joint
Which tibial plateau is injured more frequently
lateral due to varus force
Which nerve can be damaged in a tibial plateau fracture
common fibular nerve
What will you see on xray of tibial plateau fracture? what other scan is usually required?
Lipohaemarthrosis
CT
The presence of fat in a joint indicates what
an intraarticular fracture
Classification of tibial plateau fractures
Schatzker
Criteria to receive conservative mx for a tibial plateau fracture . What is the mx
uncomplicated
- articular step <2mm
- no ligament injury
- no tibial subluxation
Non or partial weight bearing in a high knee brace for 8-12 weeks
Physio
Analgesia
Criteria to receive surgical mx for tibial plateau fracture and what is it
Complicated fracture
- articular slope >2mm
- tibial subluxation
- ligament injuries
Compartment syndrome
Open fracture
ORIF - metaphyseal gap filled in with bone graft or substitutes
When may ORIF be unsuitable and what would you do instead
highly comminuted fractures/polytrauma
significant soft tissue injury
Do external fixation
why is risk of compartment syndrome and open fractures greater along the tibial shaft
Bc there is a lack of significant soft tissue envelope
Mx of tibial shaft fracture
Realign stat Monitor for compartment syndrome Above Knee back-slab If stable - sarmiento cast If unstable - surgery - intramedullary nailing or ORIF with locking plates Fibula fractures tend to be left alone
Causes of sensironeural hearing loss
acoustic neuroma labrynthitis presbyacusis noise related drug induced
conductive hearing loss causes
ear wax acute otitis media otitis media with effusion foreign body cholesteatoma otosclerosis
Causes of vertigo
BPPV Labrynthitis Menieres Vestibular neuritis benign vestibulopathy
External ear
Otitis externa
Malignant otitis externa
Rinnes and webers
If lateralises to the right
- right conductive
- left sensorineural
Conductive BC>AC
Sensorineural AC>BC
Normal AC>BC
Acoustic neuroma presentation
Unilateral hearing loss Unilateral Tinnitus Symptoms of increased ICP Vertigo May present with facial nerve palsy
Ix of acoustic neuroma
webers and rinnes
Audiograms
MRI head
Labrynthitis presentation
Sudden onset unilateral hearing loss, tinnitus and vertigo
Nystagmus, vomiting
Recent hx of URTI
Mx of labrynthitis
vestibular suppressants eg prochlorperazine (also anti emetic)
BPPV presentation
Episodes of vertigo after turning head - lasts seconds
Nystagmus, nausea
BPPV ix and mx
Dix-Hallpike then Epley manoeuvre
Suggested cause of menieres
Too much endolymph
Presentation of menieres
Episodes of vertigo, tinnitus, hearing loss lasting mins to hrs
Aural fullness, muffled sound
Nustagmus, nausea
Mx of menieres
Vestibular supressant - prochlorperazine Betahistidine Low salt diet Thiazides Hearing aids Surgery
Presbyacusis presentation
bilateral hearing loss
Lose high frequency first - eg female voice, might have TV really loud
Old
Mx of presbyacusis
Social - eg flashing lights instead of doorbell, telephone amplifiers
Hearing aids or cochlear implants
Ix for hearing loss problems
Otoscope
Rinnes and Webers
Audiogram
MRI head
Pathophys of noise related hearing loss
Damage to stereocilia in the cochlear
Ototoxic drugs
Gentamicin
Furosemide
How to identify which ear on otoscopy image
Cone of light is on the same side as the ear
The malleus points away from direction of ear
What causes otitis media with effusion
Negative pressure in the ET tube
Presentation of otitis media with effusion (glue ear)
Developmental delays - speech and learning
Not very responsive to sound
Otoscopy of glue ear
Yellow retracted TM, air bubbles
Mx of glue ear
leave for 3 months as most self resolving
If >3 months - grommets
Acute otits media pathogens
Bacteria - moraxella, haemophillus, pneumococcus
Viral
Mx of acute otitis media
Most likely viral so wait at least 48hrs before giving abx
Fluid, rest, analgesia
Safety Net
Complications of acute otitis media
Mastoiditis then meningitis
Cerebral abcess
Cholesteatoma pathophys
trapped squamous epithelium erodes into the bones
Causesnof cholesteatoma
Recurrent infections paired with ET dysfunction
Mx of cholesteatoma
Semi urgent referral
or urgent if signs of nerve palsy
Presentation of cholesteatoma
Otalgia
Smelly otorrhoea
Rf for cholesteatoma
recurrent infections
down syndrome
Male
low socio economic status
Complications of cholesteatoma
Facial nerve palsy
meningitis
cerebral abscess
What is otosclerosis
fusion of the ossicles, most commonly stapes to oval window
Common organism of otitis externa
pseudamonas
RF for otitis externa
Moist environments eg swimmers
immunocompromised
hearing aids
Presentation of otitis externa
Otalgia - tragus and in mastoid area behind ear
otorrhoea
complicatons of otitis externa
osteomyelitis
temporal bone destruction
Malignant otitis externa and who is it more common in
Otitis externa with its complications + facial nerve palsy
Common in diabetics and CF patients
Mx of acute sinusitis
Send to hospital if has complications
Otherwise wait 10 days, self care measures
If no improvement - corticosteroid nasal spray, back up abx,
Complications of acute sinusitis
Cavernous sinus thrombosis Cerebral abcesses Meningitis Periorbital cellulitis Osteomyelitis
when is sinusitis classed as chronic
> 12 weeks
Causes of chronic sinusitis
Kartageners
CF
Facial deformity
Septal deviation
Mx of chronic sinusitis
Nasal douching
Corticosteroid spray
Antihistamines
Macrolides
Arteries we need to know in the nose
Sphenopalatine
Posterior and anterior ethmoid
Kesselbachs area and littles area
Causes of epistaxis
Trauma HTN idiopathic HHT/angiodysplasia Coagulation disorders Malignancy Unilateral polyp
Mx of epistaxis
A+E if bleeds for >30mins Anterior packing Silver nitrate Cautery Posterior packing Electrocautery in Surgery
Red flag nose
unilateral bleeding
Red flag ear
unilateral tinnitus
unilateral hearing loss
Mx of allergic rhinitis
antihistamines
steroid nasal spray or oral pred if severe
Nasal irrigation
septoplasty
Septal haematoma mechanism
blunt force trauma
blood between periosteum and perichondrium
reduce blood supply to cartilage
Can end up with saddle nose (or cauliflower ear if pinna haematoma)
Mx of septal haematoma
drain blood
tamponade
pathogens causing tonsillitis
Group A strep
EBV
Viruses eg influenza
Score to determine if tonsillitis caused by Group A Strep
FeverPAIN score
Abx for bacterial tonsilitis
phenoxymethylpenicillin
Epiglottits presentation
4Ds Distress - respiratory Drooling Dysphasia Dysphonia
Soft stridor compared to croup which is harsh
Mx of epiglottitis
try and calm them
sedation
intubation
ceftriaxone - as most common cause is haemophillus
complications of tonsillitis
peritonsillar abscess - quinsy
Bells Palsy mx
steroids
eye drops
antivirals eg acyclovir
Becks triad - what is it and what is it for
Cardiac tamponade Acutely unwell person with - raised JVP - hypotension - muffled heart sounds
What ECG anomaly can thiazide diuretics such as indapamide cause as a result of their side effect profile
flattened t waves as a result of hypokalaemia and hypocalcaemia
common adverse effects of thiazides
dehydration postural hypotension hypokalaemia, hypocalcaemia, hyponatraemia gout impaired glucose tolerance impotence
criteria for Hyperosmolar Hyperglycaemic State (HHS)
hypovolaemia
hyperglycaemia >30
serum osmolarity >320
calculating serum osmolality
2xNa + glucose + urea
Causes of dactylitis
spondyloarthropathies eg psoriatic and reactive arthritis, systemic sclerosis
Sickle cell disease
Rare - TB, sarcoidosis, syphillis
how long are provoked PEs treated for
3 months
what is the first line abx for c diff
oral vancomycin
What is the main antibody test for coeliacs disease
anti-TTG
when do you use rhythm control as first line in AF
if reversible cause, coexistent heart failure or if first onset AF
What tests should adults with suspected asthma have
Both
- fraction of exhaled nitric oxide (FeNO) test
- spirometry with reversibility testing
what abx class can cause torsades de pointes
macrolides
sign of LVH on ecg
large R waves in V5 and V6 (left sided leads) and deep S waves in V1 and V2 (right sided leads)
What is a Bartons fracture
Intra articular fracture of the distal radius with associated dislocation of the radio-carpal joint
Presentation of scaphoid fracture
Sudden onset pain
pain in anatomical snuffbox
Pain on scaphoid tubercle
Invs of scaphoid fracture
Xray
If none seen repeat at 10-14 days
And then MRI if still no evidence
mx of undisplaced scaphoid
thumb plaster and spica splint
BUT
if fracture of proximal pole then surgery as high risk of avascular necrosis
mx of displaced scaphoid #
percutaneous variable pitch screw for compression
complications of scaphoid #
avn
non-union
Presentation of carpal tunnel
pain and parasthesia of lateral 3 and a half digits
Worse at night
Late stages - may get atrophy of thenar eminence
Where is spared in carpal tunnel and why
Palm
Palmar branch exits before enters beneath flexor retinaculum
Ddx of carpal tunnel syndrome
cervical radiculopathy (C6) pronator teres syndrome
Mx of carpal tunnel
NSAIDs
Splint (at night)
physio
steroid injections
surgical
- decompression by cutting flexor retinaculum
what is dupuytrens
contraction of longitudinal fascia
RF of dupuytrens
Male Alcoholic liver cirrhosis T1DM Occupational exposure Age 40-60
Pathophys of dupuytrens
fibroplastic hyperplasia and altered collagen matrix of palmar fascia
Typical progression of dupuytrens
- pitting and thickening
- painless nodules
- cord contracts
- flexion deformity
Test for dupuytrens
Heustons test
Lie palm flat - positive if unable to
Mx of dupuytrens
Therapy
Inject Collagenase clostridium histolyticum (NO STEROIDS)
Surgery
- fasciectomy
What is de quervajns tenosynovitis
inflammation of the tendons of the first extensor compartment of the wrist. (by the thumb)
Presentation of de quervains
pain at base of thumb
grasping movements difficult and painful
Finkelstein’s test positive
Mx of de quervains
splint
physio
Steroid injections
Surgical
- decompression of extensor compatment
What are ganglionic cysts a d where are they found
Synovial fluid filled soft tissue lumps caused by degeneration of joints or tendon sheaths
Found along joints and tendons
Presentation of ganglionic cyst
smooth, soft, fluctuant lump along tendon or joint, transilluminates
May have neuro features if compressing nerve
Mx of ganglionic cysts
Usually sort then selves out
If not and rom severely affected, aspirate or excise
what is trigger finger
finger and/or thumb lock or click when in flexion
pathophys of trigger finger
flexor tenosynovitis - due to repetitive movements = inf;lammation
tenosynovitis at metacarpal head (superficial and deep flexor tendons) = nodal formation, distal to the pulley (A1 pulley ligament most common)
moves proximal to pulley when flexed, but cant move back under it on extension = locked in flexed position
rf of trigger dinger
female
age DM
presentation of trigger finger
painful snapping/clicking on finger extension
ca be bilateral and more than one finger
Mx of trigger finger
splint
activity modification
steroid injections
surgical
-percutaneous trigger finger release under local
What abx can prolong QT interval?
Macrolides
What bloods need to be routinely monitored in the first 12 months of treatment with Simvastatin
LFTs
How long before an op should warfarin be stopped? What is it substituted with? What should INR be less than?
at least 5 days before, LMWH
INR should be less than 1.4
NSAIDs mechanism of action
COX inhibitors
Inhibits prostaglandin synthesis from arachidonic acid
Aspirin MOA
inhibits production of thromboxane A by inhibiting both COX1 and 2
Thromboxane A usually enables platelet aggregation
What does a transaminase (elevated ALT and AST) in the 10 000s commonly indicate
paracetamol overdose
Side effects of calcium channel blockers
ankle swelling
headache
flushing
moa of heparins (both LMWH and unfractionated)
Both activate antithrombin 3
LMWH
- increase action of antithrombin 3 on factor Xa so greater inhibition
Unfractionated
- increase action o pf antithrombin 3 on factors Xa, IXa, XIa and XIIa so greater inhibition
When is unfractionated heparin often used
used in situations where there is high risk of bleeding as it can be terminated rapidly. Also useful in renal failure
What is adhesive capsulitis
glenohumeral capsule becomes contracted and adherent to the humeral head
Rf of adhesive capsulitis
Woman
40-60
previous contralateral adhesive capsulitis
DM
Presentation of adhesive capsulitis
general shoulder pain that may radiate to biceps
reduced ROM
Stiffness
Tender to touch
Mx of adhesive capsulitis
Medical
- physio
- analgesia
- Corticosteroid injections
Surgical - after months to years of medical mx
- manoeuvre joint under GA
- surgical release of capsule
Complications of peri operative hypothermia
Coagulation - impaired clotting
Infection
Reduced wound healing bc of vasoconstriction
Prolonged recovery from anaesthesia
Components of the different fluids
Hartmanns
- 131 mmol/L Na
- 111 Cl
- 29 HCO3
- 5 K
- 2 Ca
- 9%NaCl
- 154 Na
- 154 Cl
Dextrose
- 278 glucose
Tonicity and compartment movement of the fluids
Hypotonic - hartmanns and NaCl so stay extracellular in vasular and interstitial space
Isotonic - dextrose
Colloid products
FFP
Platelets
Red blood cells
Why would you give FFP and platelets in a DIC pt
Losing them due to clotting
Daily requirements
1mmol/kg/day Na, Cl, K
50-100g per day glucose
25-30ml/kg/day water
Daily urine output
0.5ml/kg/day
What are the categories of a comprehensive geriatric assessment
Medical - problem list, nutrition, meds, co morbidities Functional - baseline Social Psychiatric Environmental
ADR of dextrose
hypokalaemia
in who would you consider a lower does of opioids for pain mx
renal failure as vulnerable to overdose
patients with delirium
Drugs to be stopped before surgery
COCP 4 weeks
Warfarin 5 days
Clopidogrel 7 days
DVT complications
PE Chronic venous insufficiency - lipodermatosclerosis - venous eczema - venous ulcer - hyperpigmentation
PE complications
Death
Type 1 resp failure/hypoxia
RHF
Arrythmias
Steps taken to reduce the stress of an op on body
Oxygenate Avoid hypothermia Maintain BP Nutrition Analgesia
What are people on steroids at risk of post op
Addisonian crisis
Why are pts on steroids at increased risk of addisonian crisis
HPA axis supression
Cant increase steroids according to demand after trauma
So adrenal insufficiency
Symptoms and signs of addisonian crisis
hypotension Fatigued n+v abdo pain myalgia hyponatraemia hypoglycaemia
mx of addisonian crisis
immediate resus with IV hydrocortisone
Mx of diabetes perioperatively
T1DM
- stop sc insulin
- use variable rate
- NBM
- regular monitoring of BM
- first on theatre list
- maintenance fluid - generally 5% dextrose
what effect does stress have on goucose levels
hyperglycaemic
Components of MUST score
BMI
Unintentional weight loss percentage over last 3-6months
Acutely unwell and no nutritional intake for >5 days
What blood type is universal donor and what is universal recipient
Donor - O
Recipient - AB
Difference between G+S and crossmatch
G+S identifies blood group - there is no issuing of blood.
Cross match identifies if any immune reactions with matched units of blood and then issues x amount of blood bags
When would you halve the dose of prophylactic dalteparin
if eGFR <30
referral criteria for possible colorectal cancer
>40 with unexplained weight loss and abdo pain >50 with unexplained rectal bleeding >60 with any of - iron deficiency anaemia - changes in bowel habit <50 with rectal bleeding AND any of the following unexplained symptoms - abdo pain - change in bowel habit - weight loss - iron deficiency anaemia
Dukes classification for colorectal cancer
A limited to bowel
B extending through bowel wall (beyond the muscularis)
C regional lymph node involvement
D distant metastases
Complications of stomas
Early
- bowel ischaemia/necrosis
- bowel retraction
- parasternal abscess
- poor stoma functtion
- high output
Late
- parastomal hernia
- stenosis
- prolapse
- adhesion leading to BO
- parastomal dermatitis
- bowel dysmobility
- malnutrition
- psychosocial complications
Chronic mesenteric ischaemia presentation
Older people with rf of arterial disease
Diffuse colicky abdo pain worse after eating
Weight loss due to pain as aboid eating
May have diarrhoea and malaena or haematochezia
Abdo tenderness
Epigastric bruits may be present
Indications for liver transplant after paracetamol imduced liver failure
pH <7.3 24 hrs after ingestion
prothrombin time >100s
creatinine >300
grade 3 or 4 encephalopathy
Mx of paracetamol overdose
less than 1 hr - activated charcoal
Otherwise acetylcysteine
(wait 4 hrs after ingestion to get paracetamol level)
extra intestinal features of IBD
Dermatology - erythema nodosum, pyoderma gangrenosum
Ocular - anterior uveitis, episcleritis, conjunctivitis
MSK - assymetrical arthritis
HPB - primary sclerosing cholangitis (more common in UC)
AA amyloidosis
Colonoscopy and biopsy results in UC
continuous inflammation with an erythematous mucose, loss of haustra and pseudopolyps
Biopsy - loss of goblet cells, crypt abscess and inflammatory cells (predominantly lymphocytes)
mx of acute UC
1 - IV corticosteroids
2 - Add IV cyclosporin or consider surgery
3 surgery (indications are toxic megacolon, acute fulminant UC)
1 Ivor Lewis oesophagectomy 2 Nissen fundoplication 3 gastrectomy 4 lap chole 5 whipples pancreaticoduodenectomy 6 Hartmanns
1- oesophageal cancer 2 - GORD/hiatus hernia 3 - gastric cancer, Zollinger ellison 4 - gall stones 5 - pancreatic cancer 6 - diverticulitis, LBO, (resection of rectosigmoid colon)
inducing remission in UC pts first line drugs
5ASA’s – sulfasalazine
2nd line prednisolone
Hyperkalaemia ve early STEMI ECG changes
Both have hyperacute t waves
Hyperkalaemia would be widespread, stemi would be regional
Presentation of a heart attack in a female with poor diabetic control
Atypical
Mild non specifc upper abdo pain
Central autonomic neuropathy so may not get sweating and tachycardia
complications of RCA occlusion
Supplies SAN and AVN so can get bradycardia/heart block
Leads of the ecg and territories
Inferior - 2,3 and avF
Lateral - 1,avL and V5 V6
Anterior - V1-V4
Septal - V1-V2
what can you hear on auscultation of heart in a stemi
4th heart sound
ECHO finding on STEMI
regional wall muscle abnormality - not contracting properly
pulmonary oedema signs on CXR
kerley b lines - horizontal lines at bases
bat wing sign
may have increased cardio thoracic ratio if cardiogenic in cause
mx of STEMI
ROMANCE Reassurance Oxygen Morphine and Metoclopramide Aspirin 300mg PO Nitrates - GTN Clopidogrel/prasugrel Enoxaparin or another LMWH
Then PCI
Then Meds for life Aspiring 75mg ACEi Beta blocker Clopidogrel - for first 12 months Statin
Mx of NSTEMI
GTN action
vasodilates (risk of hypotension)
Venodilates - reduces pre load of heart and increases blood flow to heart
Complications of MI
DREAD Death Rupture eg of papillary muscles oEdema Arrythmias Dresslers - post MI syndrome - get pericarditis about 2 weeks after MI
ECG of pericarditis
global ST elevation - saddle back
PR depression
Signs of cardiac tamponade
Becks triad
- hypotension
- Increased JVP
- muffled heart sounds
Tx of cardiac tamponade
pericardiocentesis
mx of SVT
vagal manoeuvre
Adenosine (up to 3 times)
synchronised DC cardioversion if haemodynamically unstabel and above not worked
causes of VT
MI
Structural heart disease
cause of torsades de pointes
long QT - caused by drugs
digoxin toxicity ecg findings
ventricular ectopics,
AF
Bradycardias
Reverse tick sign
if arrythmia cant be controlled what is the mx
ICD or pacemaker
mobitz type 1 vs 2
type 1 increases
type 2 stays the same - higher risk of going into heart block
Where best to hear murmurs
aortic stenosis - aortic area and carotids
aortic regurge - er s when leaning forward and inspiring
mitral regurge - axilla
Mitral stenosis - apex
Ix of hf
ECHO
ECG
pro-BNP
CXR
pink frothy sputum supign of what…
pulmonary oedema
normal ejection fracture
greater than 50%
cause of raised bnp in copd
cor pulmonale
Score used to classify heart failure
New York
mx of hf
Symptom control
- loop diuretics eg furosemide
- GTN
Reduced mortality
- beta blockers
- ACEi/ARBSx
Which valvular problem can cause AF
Mitral stenosis
side effect of hartmanns solution and when not to use
hyperkalaemia and lactic acidosis
with care in sepsis mx
Rules of fluid resus
give 500ml bolus unless HF/very fail (250ml) or pancreatitis (1L)
Not hartmanns if lactate or hyperkalaemic
Rules of potassium in maintenance fluids
max 40mmol per bag
max 10mmol/hr of KCL
max 80ml a day
target INR pre surgery for pt on warfarin
<1.5
Complications of meningits
Complications of meningits
Septic shock DIC Seizures Coma Subdural effusions Death SIADH
Abscess
Hearing loss
organisms causing menitngitis
Neisseria meningitidis Streptococcus pneumoniae Haemophilus influenza Listeria Measles and rubella
Abx for streps
Group A, viridans - benpen
Pneumonia - amoxicllin, clarithromycin, IV cephalosporin
Abx for MRSA
glycopeptide such as vancomycin
abx for sepsis
meropenem
or as per local guidelines
abx for c diff
metronidazole or vancomycin
sepsis definition
life threatening organ dysfunction caused by dysregulated host response to infection
septic shock definition
a subset of sepsis with profound circulatory cellular and metabolic abnormalities associated with greater risk of mortality than sepsis alone
Red flags of sepsis
resp rate >25 HR>130 New need for greater than 40% O2 to keep sats over 91% systolic BP <90 or fall of 40 from normal No urine output for 16hrz New onset delirium Non blanching rash Neutropenia or chemo in last 6 weeks
Which malaria organism causes most severe form of malaria
o falciparum
presentation of malaria
abrupt onset of rigors followed by high fever, malaise, severe headache and myalgia
Vague abdo pain, n+v
signs of malaria
jaundice
hepatosplenomegaly
presentation of typhoid
sustained fever rose spots anorexia malaise vague abdo discomfort constipation or diarrhoea dry cough
signs of typhoid
hepatosplenomegaly
rose spots
pulse temperature dissociation
definition/criteria of PUO
temp >38 degrees on multiple occasions
illness >3 weeks
No diagnosis despite 1 week worth of inpatiemt
screening for latent TB
cxr and quantiFERON (measurement of interferon gamma)
can quantiFERKN differentiate between active and latent TB
no
who is screened for TB
healthcare workers
Immigrants from high prevalance countries
HIV positive pts
patients starting on immunosupression
treatment of latent TB
3 months Rifampicin and isoniazid
pts aged >35 are at increased risk of hepatotoxicity so advised against treating TB in these pts unless they have other risk factors eg HIV
Active TB presentation
non resolving cough
unexplained persistent fever
Drenching night sweats
weight loss
gold standard for TB ix
cultures of sputum
paradoxical reaction of TB treatment
increased inflammation as bacteria die causing symptom worsening
If TB is affecting sites where swelling cant be tolerated eg meningeal/spinal/pericardial, then steroids are given at the start of treatment
what further ix should those with miliary tb have and why
CT/MRI head and LP to exclude CNS involvement
where should TB pts be managed
in negative pressure side rooms and staff should use PPE
Baseline ix for pts newly dx with HIV
Confirmatory HIV test
CD4 count
HIV viral load
HIV resistance profile
HLA B*5701 status
Serology for syphilis, hepatitis B (sAg, cAb, sAb), hepatitis C, hepatitis A
Toxoplasma IgG, measles IgG, varicella IgG, rubella IgG
FBC, U&Es, LFTs, bone profile, lipid profile
Schistosoma serology (if has spent >1 month in sub-Saharan Africa)
Women should have annual cervical cytology.
What opportunistic infections are pts with a CD4 count <200 at risk of
PCO
MAI
CMV
what vaccinations should HIV pts recieve
Hep B and pneumococcus
Annual influenza vaccine
Needle stick injury guidelines
bleed wound wash with soap and water May also use antiseptic Contact OH or ED if out of hrs need for post exposure prophylaxis (PEP) will be assessed
broad spectrum abx
Ceftriaxone
Clarithromycin
meropenem
Amoxicillin
best ix for gonorrhoea and chlamidyia
NAAT - urine nucleic acid amplification test
top 2 causes of hypercalacaemia
primary hyperparathyroidism eg parathyroid adenoma
cancers eg lung cancer releasing PTHrP, or bone mets,
causes of hypercapcaemia with a low PTH
cancers
TB
sarcoidosis
why get hypercalcaemia in CKD
renal bone disease
parathyroid gland hypertrophy as a result of tertiary hyperparathyroidism
(Calcium levels start low but eventually raise as PTH levels go crazy)
what diuretic causes raised calcium
thiazides
presentation of hypercalcaemia
stones moans bones groans dehydration, polydipsia
effect of hypecalcaemia on ecg
shortens QT so can get arrythmias
hypercalcaemia mx
large amounts of fluids to rehydrate
Bisphosphonates
which diuretics lower calcium
loop diuretics
ix for hypercalcaemia
calcium
PTH
Parathyroid ultrasound
search for underlying cause - think cancer, kidneys,
causes of hypocalcaemia
autoimmune destruction of parathyroid surgery damage radiation tumour low magnesium prostate cancer (osteoblastic)
causes of low calcium and high PTH (secondary hyperparathyroidism)
poor diet
malabsorption
reduced vit D
early ckd stages
presentation of hypocalcaemia
Parasthesia in hands and lips Chvosteks sign carpo pedal spasm tetany abdo cramping prolonged QT seizures and laryngospasm - complications to prevent Diarrhoe
mx of hypocalcaemia
IV or oral calcium depending on severity
treat caues eg give magnesium or vit d
causes of hyperkalaemia
renal - reduce excretion
- spirinolactone
- ACEi/ARBs
- NSAIDs (can worsen AKI)
- AKI/CKD
increased intake - diet
extracellular shift
- hypoglycaemia
- DKA
- rhabdomyolysis
- tumour lysis
cause of pseudonyperkalaemia
leaving tourniquet on too long or too tight
what type of arrythmia does hyperkalaemia cause
bradyarrythmias
what is classed as severe hyperkalaemia
> 6.5
or with any ecg changes
mx of hyperkalaemia
protect heart - slow 10% IV calcium gluconate 30ml
Drive into cells - 10 units insulin (actrapid) in 50ml 5% dextrose in 100ml bag of saline, or 5mg Neb salbutamol
Clear from gut - calcium resonium
if doesnt work, ITU and haemodialysis
hypokalaemia causes
loops and thiazides vomiting and diarrhoea decreased intake intracellular shift - alkaline, insulin, salbutamol, laxatives hyperaldosteronism
gi complication of low potassium
paralytic ileus
what toxicity can hypokalaemia aggravate
digoxin
causes of hypernatraemia
hyperaldosteronism
dehydration - d+v, sweating, burns
conns syndrome - raised aldosterone
cushings - cortisol can mimic aldosterone in high concentrations
ix using serum and urine osmolality
mx of hypernatraemia
give fluids to dilute sodium
what can happen if correct hypernatraemia to quickly
cerebral oedema
hyponatraemia causes
SIADH SSRIs primary polydypsia thiazides addisons
fluid overload- HF, CKD, liver cirrhosis
epinephrine
IM 0.5mg (1in1000) every 5 mins
Hydrocortisone
IV 100mg
Chlorphenamine
IM or IV 10mg
Atropine
IV 500 micrograms
Aspirin
PO 300mg
clopidogrel
300mg PO prior to PCI
calcium gluconate
IV 30ml 10%
Insulin dextrose infusion
10 units of insulin in 50ml 5% dextrose in 100ml normal saline
diazepam
IV 10mg or PR 10mg
Lorazepam
IV 4 mg
salbutamol
Neb 5mg
prednisolone in asthma
PO 40mg
morphine
PO 10mg or IV 5mg
Given with metoclopramide also 10mg
M+M 10+10
Naloxone
IV 400 micrograms
