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ACRONYMSLactic acidosis LLTIPSL eukaemiaL ymphomaT hiamine defI nfectionP ancreatitisS mall bowel syndromeInhibitorsS odium valproateI soniazidC holamphenicolK etoconazoleF luconazoleA lcohol bingeC iprofloxacinE rythromycinS ulphonamidesC imetidineO meprazoleM etronidazole+ warfarinInducersC arbemazepineR ifampicinA lcoholismP henytoinG riseofluvinP henobarbS ulphonylureas+ folic acidCauses of DIC = VHOTMISSV ascularVasculitis, large aneurysmH epaticFailureO bstetric Amn fl emb, HELLP, abruption, septic abortionT raumaBurns, rhabdo, thermia, fat emb, brain inj, decr O2M alignancyAdenoCa, lymphoma, promyelocyticI mmuneTransfusion, anaphylaxisS epsisGram –ive, viral haemorrhagicS hock / snakesARDS, pancreatitisCauses of ARDS = VHOTMASTV ascularfat, clot, air embolismH epaticFailureO bstetricAmniotic fluid embolism, eclampsiaT raumaSevere HI, multiple #, >8iu blood transfusion in a dayM OFARF, DICA ltitudeHAPES epsisPneumonia, pancreatitis, G-ivesT oxSmoke, metals, NO, NH3, chlorine, SO2, aspirin, HC, paraquat, opioids, cocaine, nitrofurantoinCauses of pancreatitis: GETSMASHEDG allstones (35-40%)E TOHT raumaS corpian bite / toxinM umps, EBV, HIV, coxsackie, parasiticA utoimmune (SLE, Sjogrens, vasculitis)S teroidsH yperCa / lipidsE RCP (5% risk)D rugs (5%; sulphonamides, thiazides, valproate)TTP = FARTNF everA anemia (haemolytic)R enal failureT hrombocytopeniaN euro SxEnhanced elimination = PAM PACAAT PALAATUrinary alkalinisationP henobarbA spirinM ethotrexateMDACP henobarbA spirinC olchicine (DECONTAMINATION > RESUS)A nticonvulsants (carbamazepine, phenytoin, Na valproate)A mitripA manita mushroomT heophyllineHaemoDP henobarbA spirinL ithiumAnticonvulsants (Na valproate, carbamaz)A lcoholT heophyllineCI for thrombolysis = ABC CHAMPAbsolute CIA ortic dissection / active bleedingB errycarditisC NS (ICH ever / ischaemic CVA in past 6m / OT in past 2m)Relative CIC oagulopathy / cavitatory lung disease / CPRH TN (>180 / >110)A llergy, age >80yrsM ajor trauma in past 2mP regnancy / PUD / procedures in past 3wSimple febrile convulsion = FATGIDSF ever >38.5A ge 6m – 5yrsT ime <15minsG eneralised 1YI ntracranial pathology absentD eficit absentS ingle seizure per episode of feverAGMA: CATMUDPILERSC O, cyanideA lcoholic ketoacidosisT ouleneM etformin, methanolU reaemiaD KAP araldehyde, paracetamol ODI soniazid, ironL actic acidosisATissue hypoxiaB1Systemic disordersB2Drugs/toxinsC Hereditary metabolicE thylene glycol, ETOH XSR haboS alicylates, starvationNAGMA: USEDCARP U reterostomyS mall bowel fistulaE xtra ClIncr KD iarrhoea KA (resolving) IureticsMay incr KC arbonic anhydrase inhibitorsA ddisonsIncr KR TAP ancreatic fistulaIncr K with type 4Metabolic alkalosis: GRORORECl sensitiveG I lossesR enal lossesPost-diureticO ther Contraction alkalosisPost-hypercapniaCFCl insensitiveNormal BPR enal lossesBartter, Gitelman, diuretic efeeding alklosisO verdose of baseMilk alkalki, NaHCO3 therSevere hypoK/MgHigh BPR enal lossesLiddle, diuretic, RAS, CRFE ndocrineConns, Cushings, steroidsProlonged QRS and QTC: PAACCTTA ntihistamines DiphenhydramineA ntimalarials Quinine, chloroquineT ype Ia/c Procainamide, quinidineT CAC ocaineC arbamazepineP henothiazinesChlorprom, stemetilProlonged QRS only: PLATP ropanololL AA mantadineT ype IVDiltiazem, verapamilProlonged QTc only: LMAO AT SSL ithiumM ethadoneA ntipsychoticsHaloP, risperidone, quetiapine, droperidolO ‘sOP’s, ondansetron, omeprazoleA ntibioticsErythromycin, clarithromycin, tetracyclineT ype III / IVAmiodarone, sotalol, Ca antS umatriptanS SRI Amitriptyline And ethylene glycol!IMPORTANT TRIALSCVISIS2: 1988; 17,000; aspirin vs SK vs aspirin + SK vs placebo in MIAspirin+SK > aspirin / SKAspirin = SKAspirin alone + SK alone > placebo3% decr AR mortality, 25% decr RR mortalityISIS1 + 3: beta-blockers in MI50% decr infarct size, reinfarct, mortality30% decr ICHDecr short term mortality with TL; decr cardiac ruptureWorsens Sx with large infarct / LVFCLARITY-TIMI / COMMIT: clopidogrel in MIImproved hospital and 30/7 outcomeCURE: clopidogrel + aspirin vs aspirin in MI20% decr death / MI / CVA in 3-12/12 in clopidogrel+aspirin vs aspirin alone1% incr bleeding rateSYNERGY: heparin + aspirin vs aspirin in MIDecr reinfarct / mortality by 33% in heparin+aspirin vs aspirin aloneGUSTO: thrombolysis in MI5% decr AR mortalityPIOPED: investigation of PE diagnosisClinical assessment and VQ scan established diagnosis in only minority of patientsCTPA:83% sens, 96% spec, 92-96% PPV, 10% inconclusiveVQ:98% sens, 10% spec, >50% inconclusive+ive (13%)88% likelihood of PE; 96% PPV if mod/high pre-test probIntermediate15-30% likelihoodLow prob4-12% likelihood-ive (14%)<5% likelihood; NPV 96%NSNINDS:tPA vs placebo for NIHSS scores / mortality / probability of favourable outcome in CVA600 patients; multiple centre RCT; industry sponsored; poorly matched50% treated <90mins; no control over post-TL trtimproved outcome at 3-12/1213% absolute increase in minimal / no disability3% decr mortality: 17% mortality tPA (21% placebo)6% ICH tPA (0.6% placebo) – 50% were fatalECASS:tPA vs placebo for TL <6hrs600 patients; multiple centre RCT; industry sponsored; post-hoc analysis; well matchedtPA no significant improvement in outcomes; increased mortality27% ICH tPA (17% placebo)ECASS II: tPA vs placebo for TL <6hrs800 patients; multiple centre RCT; industry sponsoredNo statistically significant change in outcome; increased ICHECASS III: tPA vs placebo for TL 3-4.5hrsMultiple centre RCT; industry sponsoredBetter NIHSS score at 90/7 tPA and decr mortality; but incr ICHCAST + IST: aspirin in CVA prevention post-TIA20-30% decr risk of CVATOXSalt Lake Study: HBO in CO poisoningGood study; high FULow no. suicides, high no. chronic exposurePoorly matched groups, corrected for in analysis20% decr cognitive sequelae at 6/52 and 6/12 (25 vs 45%, 20 vs 38%)Alfred Study: HBO vs 48hrs 100% O2 in CO poisoning50% lost to FU; only severely poisoned studied, poor methodsNo benefitIDEarly goal directed therapy (Rivers et al, NEJM, 2001): RCT; severe sepsisImproved survival 16% compared to controlMay not be applicable to Australasia as have lower mortality rates than USAEndpoint: CVP 8-12CVO2 >70%MAP 65-90UO >0.5ml/kg/hrIf low MAP / CVP500ml (10ml/kg) N saline Q5-10minly + watch for improved / worsened CV statusIf MAP not achievedCommence NAD + insert CVL/ALEndpoint: PWP 15-18MAP 90-110HR 80-120If CO not achieved (ie. CVO2 <70%, UO low, incr lactate) - CONTROVERSIALCommence dobutamine (controversial; may decr BP and incr HR)Aim HCt >30% (transfuse; controversial)Aim Hb >7APC in sepsis: 6% decr mortality (controversial)Use if severe sepsis with dysfunction of >2 organ systems / APACHE >2524mcg/kg/hr INF for 96hrsCORTICUS (NEJM, 2008): hydrocortisone in septic shock No improved survival or reversal of shock, but did speed up reversal of shock in those who did survive11% decr mortality if relative adrenal insufficiencyControversial – recommended if septic shock requiring vasopressors200-300mg hydrocortisone per daySAFE study (NEJM 2004): saline vs albumin in ICU in critically ill patients RCT, double blindedNo significant difference in mortality, survival time, organ dysfunction, duration of mechanical ventilation / dialysis, hospital / ICU LOSDecr mortality in albumin in severe sepsis (statistically insignificant)Incr mortality in albumin in traumaDopamine vs NAD in shock (NEJM, 2010)No significant difference in outcomeDopamine: Incr adverse events, incr mortality in cardiogenic shockLow dose dopamine for renal protection (Lancet, 2000)Not recommendedNAD + dobutamine vs adrenaline in septic shock (Lancet, 2007): No differenceRSBiPAP in COPD (Bronchard et al): Decr mortality; NNT 10 (no effect on mortality when CPAP for CCF)Decr ETT; NNT 5Decr hospital and ICU LOSRESUSCRASH-2 trial (2010, The Lancet): tranexamic acid 1gLarge RCT trial of effects of tranexamic acid on death and transfusion requirement in trauma patients with, or at risk of, significant haemorrhageDecr death if given <3hrs of trauma (incr risk if given after >3hrs)CONTROL trial: factor VIIa in blunt traumaIncr mortalityNo improvement of any clinically significant outcomes5% incr VTEOnly as last resort after control of bleeding obtainedPermissive hypotension: if uncontrolled haem and early intervention can control bleedingAim:SBP 60-80, MAP 40CI:Controlled haem, evidence of end organ failure (eg. MI), HIUnclear effects on mortality and organ failure in long termARDS-net: TV 6ml/kg (decr mortality rate 10%, from 40% 30%)Permissive hypercapnia (aim pH >7.2 and adequate PaO2)RR 18-22PIP <30Allow mod hypercapniaTitrate PEEP to FiO2Elevate head of bed 45degProne ventilation improves oxygenation but no survival benefitHACA (Hypothermia after Cardiac Arrest, NEJM, 2002)Cooled for 24hrsAt 6/12Favourable neuro55% vs 40% Ability to live independently and work parttimeDeath40% vs 55%Trend to sepsis, bleeding and pneumonia in hypothermia groupNNT 6-7Melbourne Study (Bernard et al, NEJM 2002)Cooled for 12hrsGood neuro outcome50% vs 25% Discharge to home or rehabMortality50% vs 70%ILCOR Recommendations (2002)If unconscious (absent response to verbal commands; GCS <6; motor <4)Initial rhythm VFOut of hospital ROSC within <60minsTESTS AND SCORESTrauma ScoreGCSRRSBPCRTResp effort<12 = seriousRevised Trauma ScoreGCSRRSBPLow score = badCons: poorly predictive of mortalityCRAMS ScoreCircRespAbdoMotorSpeech<8 = badPros: good for pre-hospital triageInjury Severity ScoreHead+neckAbdo+pelvisChestFaceExtremitiesExternal<9 = minor>25 = severe>35 = very severeCons: doesn’t account for age / co-morbidities; retrospective; bad for penetratingNew Injury Severity ScoreJust 3 worst injuries of abovePros: better mortality predictionCHADS2: 1 for CCF / HTN / Age >75yrs / DM2 for CVA / TIA / thromboembolism0 = aspirin = 2% risk/yr of CVA1.5%/yr ARR 1Y prevention; 2.5%/yr ARR 2Y20% decr risk CVA1 = aspirin / warfarin = 3% risk2 = warfarin = 4% risk60% RRR2.5%/yr ARR 1Y prevention, 8.5%/yr ARR 2Y1%/yr =haemorrhage3= 6%4= 8%5 = 12%6= 18%ABCD2 score:1 for Age: >60yrs2 for:BP: >140/90Clinical: speech disturbanceunilateral weaknessDuration: 10-60mins >60minsDM0-3 = 1% 2/7 risk = 15% 1/52 risk = do CT head and carotid USS within 48-72hrs; OP FU4-5 = 4% 2/7 risk = 20-25% 1/52 risk= admit6-7 = 8% 2/7 risk = 25-30% 1/52 rsikStroke screening tools: ROSIER scale, FAST, CPSS, LAPSS, MASSStroke assessment scale: NIH: correlates with infarct vol, weighted to ant circulation, allows comparison over time, measures level of impairmentTIMI risk score>0.5mm ST deviation>2 angina in past day>3 cardiac RF>50% prev stenosis>65yrsAspirin in past weekIncr cardiac markers = 5% risk death / MI / urgent revasc at 2/522 = 8%3= 13%IntermediateEarly invasive therapy good4= 20%5 = 25%High6-7= 40%Pros: not dependent on physiology; validated; applicable to allCons: doesn’t weight RF’s; 0 score still has 2% riskGrace ScoreST changes Estimate of in-hospital and 6/12 mortalityAgeBiomarkersHRSBPCrKillip classCardiac arrestPros: more preciseCons: more difficult; RF’s not involvedDuke Criteria 2 major2x +ive blood culture of typical MO >12hrs apartStaph aureus, strep bovisIntracardiac massStrep viridians, enterococcusPeriannular abscessHACEKPartial dehiscence of prosthetic valveNew regurg on echo1major, 3 minorIVDU / congenital heart disease5 minorT >38Vascular phenomena (organ emboli, mycotic aneurysm, splinter haem, Janeway)Immunological phenomena (GN, Osler’s nodes, Roth spots)+ive blood culture / echo not fitting major criteriaModified Jones Criteria2 majorCarditis / new murmur66%Chorea10-30%Migratory polyarthritis60-70%Erythema marginatum10%Subcutaneous nodulesUncommon1 major, 2 minorPMH RFT >38Incr titre of antistrep abIncr ESR / CRP >30Long PRArthralgiaSMART-COPS BP <90Predicts deterioration, need for ICU/vasopressorsM ultilobar0-2 = low riskA lb <353-4 = mod riskR R5-6 = high risk (33%)T achy >125>7 = high risk (50%)C onfusion92% sens, 62% specO 2P H <7.35CORBC onfusionPredicts deterioration, need for ICU/vasopressorsO 2 <90%>1 = severeR R >3080% sens, 68% specB P <95CURB-65C onfusionPredicts 30/7 mortality / ICU admissionU r >70 = 0%0 – 1: can send homeR R >301 = 1%2: borderline B P <902 = 7.5%>65yrs3 = 20%4 = 40%5 = 60%Pneumonia Severity IndexHistoryNH res, CCF/CVA/CRF, Ca, liverOET, HR >125, RR >30, BP <90IxBSL >14, Hct <30, PaO2 <60, Ur >11, Na <130, pH <7.35Pleural effusionPredicts mortality; class I – V; admit class III and over; 30% mortality class VNYHA CCF:ISx on abnormal exertionIISx on ordinary exertion10%/yr mortalityIIISx on less than ordinary exertion20%/yr mortalityIVSx at rest40-50%/yr mortalityKillip ClassificationINo CCF5% mortalityIIBibasal rales + S315-20% mortalityIIIFrank pul oedema40% mortalityIVCardiogenic shock80% mortalityBrugada’s VT criteriaAbsent RS in any precordial lead100% specRS >100 in any precordial lead>95% specAV dissociation (<25% sens)Notched QRS (40% sens, >75% spec)Fusion beatsCapture beatsWellen’s VT criteriaRBBBV1L sided incr rabbit ear in V1V6RS ratio <1QS waveLBBBV1RS >60msR wave >30msNotched downslope of SV6RS ratio <1Any Q waveOther VT criteriaQRS >120-140RBBB + QRS >140LBBB + QRS >160Concordance of QRS20% sens, 90% specLAD/RADWell’s Criteria for DVT 1 for RF’sCa <6/12 Recent POP / decr movement Bedridden >3/7 / major OT <4/52LegTender veinsEntire leg swollenCalf swelling >3cm compared to oppositePitting oedemaCollateral superficial veins-2 foralternative diagnosis more likely0-2 = low risk>2 = high riskWell’s Criteria for PE1 forhaemoptysis RED = in PERCCa1.5 forHR >100 Bedridden >3/7 / OT <4/52PMH PE/ DVT3 forSx of DVTPE most likely diagnosis0-1 = 3-4% risk2-6 = 20% risk7+ = >60% riskSubjective; extensively validatedRevised Geneva Score1 for>65yrs2 forhaemoptysis; OT/leg # in 1/12; active Ca3 forHR 75-94; unilat leg pain; prev DVT/PE4 forLeg pain on palpation / unilat oedema5 for HR >95= 8% risk4-10 = 28% risk11+ = 74% riskMore objective; less validatedPERC CriteriaEpiDAge <50yrsSens 97.5%HistoryNo haemoptysis Spec 22%No OT / trauma in 1/12PMHNo PMH PE/DVTDHNo OCPOEHR <100SaO2 >95%No unilateral leg swellingSADPERSONSPSYCH EXAMADDMISA ppearanceD isorders of thoughtD isorders of perceptionM ood and affectI nsightS CognitisionASA CLASS:1 = healthy, no medical problems2 = mild systemic disease3 = severe systemic disease, but no incapacitating4 = severe systemic disease that is constant threat to life5 = moribund, expected to live <24hrs irrespective of operationE = emergencySAN FRAN SYNCOPE RULEHistorySOBPMHPMH CCFOESBP <90 at triageInvestigationNot in SRNew ECG changesHct <301 = 12% serious outcome <1/52; 95% sens, 60% spec; similar to physician judgement but 10% more sensMMSE10 pointsOrientation9 pointsLanguage (objects, if and but, paper, close eyes, sentence, pentameter)5 pointsAttention + calculation (serial 7’s / world)3 pointsRecall (recall registration words)3 pointsRegistration (3 words, rpt back)>25 = normal21-25 = mild<20 = cognitive impairment<9 = severeGCSEye1None2To pain3To voice4Open spontaneouslyVerbal1None2Sounds3Inappropriate words4Disorientated5AppropriateMotor1None2Decerebrate (extension)Pons3Decorticate (flexion)Midbrain4Withdraws5LocalisesForebrain6Obeys commandsSGARBOSSA CRITERIAConcordant STE >1mmUp UpDiscordant STE >5mmUp DownConcordant STD >1mmDown DownOTTAWA ANKLE RULESPain near malleoli+ inability to WB 4 steps immediately and in ED Tender post / inf lat / medial malleolus100% sens, 40% spec; decr XR by 30%OTTAWA FOOT RULESPain in mid-foot+ inability to WB 4 steps immediately and in ED Tender base 5th MT and navicular100% sens, 80% specOTTAWA KNEE RULESPain in knee+ inability to WB 4 steps immediately and in ED >55yrs Tender head of fibula / patella Active knee flexion <90deg100% sens fo significant #, 50% spec; decr XR by 25%NEXUS CRITERIANeuro deficitSens 99.6%ETOHXtra injuriesUnconsciouns / decr LOCSore on palpationCANADIAN C SPINEHigh risk:OLD>65yrsNEURO SXParaesthesiaMECHANISM: fall >1m / >5 steps / axial load / >100kmph / rollover / ejection / >55kmph / death at scene / bike collision / motorized rec vehicleINJURIES: sig closed HI, neuro Sx, pelvic #, multiple limb #Low risk:Rear endedSitting in EDAmbulatory at any timeDelayed neck painNo tendernessCANADIAN CT HEADHigh risk:OLD>65yrsNEURO SXGCS <15 2hrs postVomiting >2xINJURIESOpen / depressed skull #BSF Med risk:MECHANISM: fall >1m / >5 steps / car v ped / ejectionAmnesia >30minsRule Of NinesAdultChild 1yr oldLeg18% each13.5% (+0.5% per yr each)Arm9% eachSameTorso18% front, 18% backSameHead9%19% (- 1% per yr)Perineum1%Neck1%Ranson’s CriteriaOn arrivalA ge >55yrsA ST >250L DH >350-700B SL >10W BC >16@ 48hrsP aO2 <60H ct drop >10%C a <2 U r rise >5B E >4E stimated fluid sequestration >6L0-2 = 1% mortality3-4 = 15% mortality4-5 = 40% mortality6-7 = 100% mortalityGlasgow Scoring System A ST >200A lb <32L DH >600B SL >10W BC >15P aO2 <60C a <2U r >15>3 = severeApache ScoreAgePhysiologyT, MAP, HR, GCSpH, Na, K, Cr, AA gradient, PaO2WBC, HctChronic HealthChronic organ insufficiencyImmune compromiseARFDone at admission only >7 = severe = 11-18% mortality65% sens, 76% specLight’s Criteria: 1+ ofPleural chol : serum chol>0.3Pleural protein : serum protein>0.599% sens for exudatePleural LDH : serum LDH>0.665-85% specPleural chol>1.1Serum alb - pleural alb>1.2Pleural LDH >2/3 upper limit of normal for serum LDHExudateTransudateProtein>30<30WBCHighLowComplicated parapneumonic effusion/empyema:pH <7.2 or 0.15-0.3 less than serumGlu <2.5LDH >1000LoculatedOngoing sepsis despite ABxEmpyemaTurbid with WCC >1000MO on gram stainTransudateExudateIncreased hydrostatic pressureCHFConstrictive pericarditisSVC obstructionMalignancy – primary or metastatic; 38% lung, 17% breastInfectionPneumoniaViral, fungal, mycobacterial, parasiticContiguous infectionPE (80%)Decreased oncotic pressureCirrhosisNephrotic syndromeHypoalbuminemiaConnective tissue diseasesSLE, RAInflammationUremiaPancreatitisSarcoidosisHemothoraxIatrogenic / otherPeritoneal dialysisIatrogenic / otherPost-cardiac surgery Post-radiotherapyDrugs – amiodarone“Classic” exudates that can be transudatesMalignancyPE (20%)SarcoidosisHypothyroidismSeverity of Asthma MildPEFR, FEV1 >75%SaO2 >95%ModPEFR, FEV1 >50-75%SaO2 90-95%HR 100-120PhrasesSeverePEFR, FEV1 <50%SaO2 <90%HR >120WordsExtremis Can’t doSaO2 <90%HR >140/lowCan’t doSeverity of COPDMildFEV1 <80%ModFEV1 <60%SevereFEV1 <40%DRUG DOSES I FORGETO+GTocolysis: Salbutamol 100mcg/hr and increase until contractions stop Nifedipine 20mg stat rpt Q30min if ongoing 20mg TDS MgSO4 20mmol over 30minsGTNCI: >34/40, fetal distress, placental abruption, infection, pre-eclampsiaDelay delivery by 24-48hrs in 80%Betamethasone11.4mg IM Q24h x2; if <34/40; decr risk of ARDS by 50%AntiD: 250iu if <13/40, 625iu IM if >13/40PPHOxytoxcin 10iu IV stat 40iu over 4hrs or Ergometrine 250-500mcg IV/IMMisoprostol 500-1000mcg PR or Intramyometrial 250-500mcg PGF2aMgSO4 in eclampsia: 40mmol over 15mins 20mmol rpt x2 Q15min if seizing 10-30mmol/hr INFMonitor Mg levels and for SE’s (lethargy, decr reflexes, flushing)CaGlu is antidoteBP:Hydralazine 5-10mg IV over 5-10mins rpt Q20min 5-60mg/hr INFNifedipine: 10mg PO rpt Q30min 10mg PO Q4hrlyLabetalol 20mg 40mg 80mg to max 200mg 1-2mg/hr INFMethylodopa: 250mg PO Q6hNitroprusside: 0.1-5mcg/kg/min INFPID:Sexy:Ceftriaxone 250mg IM stat (clinda if penicillin allergy)Azithromycin 1g PO single dose ORDoxycycline 100mg BD 2/52 (roxy if BF)Metronidazole 400mg BD 2/52Severe:Ampicillin 2g IV Q6h IVGentamicin 5mg/kg OD IVMetronidazole 500mg BD IVTOXToxic dosesACEiCan have 2-3x dose and it’s fineETOH2-5g/kg coma>4mmol/L 0 order kineticsWithdrawal:5-10mg PO6-8hrly10-20mg PO1-2hrly5mg IVstatRpt up to 20mg in 30minsThen Q30minlyWernickesThiamine 500mg IVEthylene1ml/kg lethalETOH if >3mmol/LETOH 1g/kg in 5% dex 150mg/kg/hrAim ETOH 20-30mmol/L / 100-150mg/dLHaemodialysis if >4-8mmol/L (until <3mmol/L)CNS CV renalPyridoxine 100mg IVThiamine 100mg IVNaHCO3Meths0.5-1ml/kg lethalMost potent cause of incr OGETOH as above until <6mmol/LHaemodialysis if >15mmol/LPyridoxine and thiamine as above+ folate 50mg IVIso4ml/kg comaIncr OG as above, but minimal AGMA despite high ketosisHaemodialysis if >65mmol/LETOH not usedCarbamazepineDelayed onset 2Y to anticholinergicNa blockade SO TREAT AS TCA ODCharcoal, MDAC, NaHCO3 (cardiotoxicity), haemodialysisNa val>200mg/kg comaBlood probs: decr plt/WBC (BM failure) decr BSL/Ca/phos incr NH/LFT (liver failure) incr Na/MetHb, AGMACharcoal, MDAC, WBI if SR, haemodialysis (>1-1.5g/L)Phenytoin100mg/kg risk of comaNa blockade (IV)Charcoal, MDACType I antihisAnticholinergic, anti adrenergic, anti serotonin, Na and K blockadeNaHCO3, MgSO4, inotropes, benzos for seizuresOlanzapine>300mg comaAnticholinergic, anti adrenergicClozapineAnticholinergic, seizures, agranulocytosis, myocarditisQuetiapine>3g severeNa and K blockade, seizuresRisperidoneAnticholinergic, Na and K blockade, anti serotonin, EPSEChlorprom>5g severeAnticholinergic, EPSE, seizuresHaloperidolNa and K blockade, EPSE, seizuresThioridazineAnticholinergic, Na and K blockade (severe)Na channelCitalopram, venlafaxineQuetiapine, haloperidolRisperidone, thioridazinePropanololAspirin>300mg/kg severe>500mg/kg fatalCharcoal, MDAC, WBI if SRNaHCO3 if symptomatic / level > 2.2 / pH <7.1HaemoD if can’t UA / UA doesn’t work / level >4 despite trt / level >4 chronic / level > 6 acute / severePropanololAs per TCAHypoG, hyperKVerapamil>15mg/kg toxicHyperG, hypoK, ketoacidosis, lactic acidosis, AGMANifedipine>2mg/kg toxicTCA>10mg/kgOlanzapine40-100mg mod>300mg comaQuetiapine>3g severeChlorprom>5g severeNa valproate400-1000mg/kg severe>1g/kg MOFCarbamazepine20-50mg/kg mod>50mg/kg severeAspirin150-300mg/kg mod>300mg/kg severeColchicine>0.5mg/kg mod>0.8mg/kg severeParaquat20-40mg/kg death in 5/7-wks>40mg/kg death in 1-5/7>50mg/kg death in <3/7Isoniazid>10g>15g fatalFe20-60mg/kg mod60-120mg/kg severe>120mg/kg lethalLi>40mg/kgEthylene glycol2ml/kgMeths30ml of 40%Isopropanol2.5ml/kg of 70%Propanolol>1gDigoxin>10mg (>4mg in children)Diltiazem5mg/kg (>10tabs in adults, >2 tabs in children)Verapamil16mg/kg (>10tabs in adults, >2tabs in children)Theophylline>110mmol/lTrt:Syrup of ipecac 15-30mlGastric lavage: 200ml (10ml/kg) warm waterCharcoal: 25-50g (0.5-1g/kg)WBI: 2L/hr (25ml/kg/hr)Intralipid: 1ml/kg 20% over 1min 10ml/hr INFMDAC: 50g (1g/kg) PO 25g (0.5g/kg) Q2hUrinary alkalinisation: 1mmol/kg NaHCO3 IV bolus 2.5-25mmol/hr OP Pralidoxime 1-2g in 100ml N saline slow IV over 15mins 0.5-1g/hrEndpoint: plasma cholinesterase >10%Atropine 1-2mg double dose Q2-3min until dry secretionsFeDesferrioxamine 5-15mg/kg/hr (can cause hypotension)Indication: >90mmol/L, 60mmol/L + Sx, severe toxicityEndpoint: Sx gone, Fe normal, AGMA normal, urine normalCyHydroxycobalamin 5g in 100ml N saline over 15mins rpt if no improvementEndpoint: improved LOC, CV status, metabolic acidosisSafeDicobalt EDTA 300mg in 20ml dex over 1-5mins rpt if no improvementEndpoint: as aboveBad SE’s esp if not poisonedAmyl nitrite 300mg over 2-3mins INHNa thiosulphate 12.5g IV over 10mins rpt if neededEndpoint: as aboveSafeLeadSuccimer 10mg/kg PO TDSDimercaprol 3-4mg/kg IM Q4hNa Ca EDTA 25-75mg/kgIsoniazidPyridoxime 5g IV over 3-5mins (or same dose as isoniazid) rpt Q15min until seizures ControlledMorphineNaloxone2/3 of wake up dose INF per hourDOA 20-60minsMetHbMethylene blue 1-2mg/kg IV over 5mins rpt at 1hr if neededDigibind: Acute:mg ingested x 0.8 x 2 = no ampoulesChronic:(mmol/L level x kg) / 100 = no ampoules ?NG????CaGlu in HFl poisoning:60ml 10% IV if systemic10ml 10% up to 40ml with KY TOP Q15min then 6x/day0.5-1ml/cm 10% SC (not in hands / feet) – not diluted10ml 10% with 40ml N saline + heparin IV regional - large10ml 10% with 40ml N saline IA regional over 4hrs (gold standard)1.5ml 2.5% in N saline NEBCa antagonist poisoning: 60ml 10% CaGlu over 15mins 20ml/hr INFEndpoint: Ca >25mg glucagon stat 1-5mg/hr1iu/kg actrapid in 50ml 50% dex 0.5-1iu/kg/hr actrapid in 10% dex1ml/kg 20% intralipid over 1min 0.5ml/kg/min INFDystonic reaction(EPSE) DBBenztropine 1-2mg IV rpt at 15mins if needed 1mg PO TDSSSSCCyproheptadine 8mg PO TDS Chlorpromazine 50-100mg IVNMSNBBromocriptine 2.5mg PO TDSDantroleneMHMDDantrolene 1mg/kg IV 1mg/kg QID IVFe OD stages0-3hrs 3-12hrs 12-48hrs 2-5/7 weeksGIVariceal haem:Octreotide: 50mcg stat IV 50mcg/hr INF for 48hrsTerlipressin: 2mg IV Q6hGastro:Paedialyte 25ml/kg/hr for 4hrsLiver failure:Mannitol 0.3-0.4g/kgLactulose 20g PO / 300ml PRAppendicitis1g Ampicillin QID + 5mg/kg gentamicin OD + metronidazoleCholecystitis1g ampicillin QID + 5mg/kg gentamicin OD (+ metronidazole if gallstones)GastroNorfloxacin 400mg (10mg/kg) PO BD 5/7 – E coli, Yersinia, salmonella, shigellaDoxycycline – choleraMetronidazole 400mg (10mg/kg) PO TID 7-10/7 – C diff, giardiaVancomycin 125-250mg PO QID 10/7 – severe C diffErythromycin 500mg (10mg/kg) PO QID 5/7 – campylobacter H pyloriPantoprazole 40mg BD + amoxicillin 1g BD for 5/7 pantoprazole 40mg BD + amox + clarithromycin 500mg BD for 5/7SBPCeftriaxone 2g IV OD / cefotaxime 2g IV TDSCeftazadime / cefazolin / vanc intraperitonealRSAsthmaSalbutamol10mcg/kg (500mcg) over 2mins rpt at 10mins 1-20mcg/kg/minMgSO425-50mg/kg IV over 20minsAminoP6-10mg/kg (500mg) over 1hr 0.5-1mg/kg/hr infusionCVEsmolol 500mcg/kg bolus 50-100mcg/kg/min infusion (thyroid storm)HTN:GTN 1-20mcg/min titrated up 5mcg ever 5mins max 200mcg/minMETHBLabetalol 10-20mg 40mg 80mg 1-10mg/hr infusionEsmolol 500mcg/kg bolus 50mcg/kg/min titrated to max 300mcg/kg/minNa nitroprusside 0.1-10mcg/kg/minCYANIDEHydralazine 5-10mg IV over 5-10mins 5mg/hr INFAF: Amiodarone 2-5mg/kg over 10mins 50% reversion in 24hrs, 90% in 48hrsFlecainide 2mg/kg over 30mins 200-300mg PO60% reversion in 3hrs, 80% in 8hrsDigoxin 500mcg IV 250mcg Q4-6h up to 250mcg/dayVerapamil 1mg rpt to 10mg IVMetoprolol 5-10mg over 2minsMIAspirin: 300mgClopidogrel: 300mg for TL, 600mg for PCIUFH: 60Iiu/kg 12iu/kg/hr INF aiming APTT 1.5-4x normalLMWH: 0.75-1mg/kg SC BD (give 30mg IV bolus if <75yrs)Metoprolol: 50mg PO BDReteplase: 10iu IV over 2mins 2nd dose 30mins laterSK: 1.5million IU over 1hrPE:UFH: 80iu/kg IV 18iu/kg/hr INFLMWH: 1mg/kg SC BDr-tPA: 10mg IV bolus 90mg IV over 2hrsSK: 250,000iu IV over 30mins 100,000iu/hr for 24hrsIE:ampicillin 2g IV Q4hFluclox 2g IV Q4h (not needed if subacute)Gent 5mg/kg IV ODIf prosthetic / IVDU:ceftriaxone + vanc + gentRF:penicillin 10mg/kg BD for 10/7SVT:adenosine 6, 12, 18 (0.1mg/kg, 0.2mg/kg, 0.3mg/kg); reverts 90%; 15% recurVerapamil 5mg IV slowly; 80% reversion, 95% with 10mgFlecainide 2mg/kg IV over 30-45minsTdP:20mmol MgSO4 over 1-2mins 10-20mmol/hrVT:Amiodarone 150mg IV over 5-10mins 600mg/24hrs30% effective in 1hrProcainamide 100mg IV 50mg/min until reversion75% effectiveSotalol 1.5mg/kg over 3mins65% effectiveLignocaine 1.5mg/kg IV over 5mins20-30% effectiveProductDoseEffectRbc2u (15ml/kg)Hb 20g/l, Hct 6%Plt (single)1u (5ml/kg)Plt 50,000/mclFFP4u (15ml/kg)1 unit = 3-5%Cryoppt10u (1u/5kg)Fibrinogen 75mg/dLNSSeizure: midaz 0.15mg/kg IV/IN/IMphenytoin 18mg/kg over 30minsPhenobarb 18mg/kg over 30minsLevetiracetam 20mg/kgNa valproate 20mg/kg over 3-5minsThiopental 2-5mg/kg 2-5mg/kg/hrMigraine:paracetamol, nsaid, aspirinMaxalon, chlorprom, stemetilsumitripchlorprom12.5-25mg IVEffective in 85%SE: decr BP, sedationStemetil12.5mg IVEffective in 80%SE: phlebitis, akthesiaMaxalon 110mg IV70-80% effectiveDroperidol2.5mg IV slow80-100% effectiveSE: QT prolongationSumitriptan100mg PO / 6mg SC60-75% effective; use in mod-severeCI: vascular disease, preg, HTN, MAOISE: MI, HTN, arrhythmia, chest pressure, dizzinessDihydroergotamine: 1mg IV over 3mins Q8h85% effectiveCI: preg, sepsis, vascular disease, HTNSE: vasoC, ischaemiaLignocaine:DOA 40mins (2-5hrs with adrenaline)5mg/kg plain, 7mg/kg with adrenalineUse phentolamine to reverse adrenaline effectToxicity: dizziness, tinnitus, perioral tingling, decr LOC, agitation, nystagmus, muscle twitches, seizures, decr BP, arrhythmiaPrilocaine:6mg/kg plain, 8mg/kg with adrenaline; 3mg/kg for Bier’s blockBupivacaine:DOA 6hrs2mg/kg plain, 3mg/kg with adrenalineSE: most cardiotoxicEMLA:prilocaine + lignocaine; onset 45mins; effective in 65% childrenSE: local allergy 5%; vasoC; CI <6/12 as systemic absorption + risk of MetHbAnGEL cream:amethocaine; onset 20minsSE: local reaction 15%TAC:tetracaine adrenaline cocaineSE: less effective <4yrs; CI’ed in places where adrenaline CI’ed; toxicity if used on MM’s (so use lower dose)LAT/ALA:lignocaine + adrenaline + tetracaine; cheap; as effective as TAC; less toxic; onset 20- 30minsThrombolysis for CVA:tPA 0.9mg/kg 10% as bolus, 90% over 60minsGBSIVIG 2g/kg for 5/7MGCrisisEdrophonium 1 1 2mg IV slow pushNeostigmine 0.5-2mg IV TrtPyridostigmine 60-90mg PO Q4hPred 100mg/dayENVIRONMENTALAMS/HACE:Acetazolamide 250mg PO BD Same dose prophylaxisDexamethasone 8mg stat 4mg Q6h PO/IM/IV4mg PO BD for prophylaxisHAPE: Nifedipine 10mg SL stat 20-30mg SR BDSame dose prophylaxisORTHOSeptic arthritis:2g IV fluclox QID1.2g IV penicillin QID+ gent if <6yrs / IVDUBier’s block3mg/kg 0.5% prilocaineInflate cuff 100mmHg over SBPIDOndansetron0.15mg/kg IV/PODecr LOS, IV use, vomiting, hospitalizationNo effect on readmissionHerpes simplex:Acyclovir 200mg 5x/day for 5/7 or 400mg TDSHerpes zoster:Acyclovir 400mg 5x/day for 10/7Neonatal / encephalitis: 10mg/kg IV TDS for 2/52Kawasaki disease:IVIG 2g/kg over 12hrsAspirin 30-50mg/kg/day until fever gone 3-5mg/kg OD for 6-8/52OMAmox /aug 15-25mg/kg TDS POCefaclor 10mg/kg QID POEpiglottitisCeftriaxone 25mg/kg for 5/7 (+/- vanc)Ludwig’s anginaBenpen 1.2g IV Q6hr or Clinda 450mg IV Q8hMetronidazole 500mg IV BDNec fascMeropenem 1g IV TDS + clindamycinFournier’sCeftriaxone 2g IV + metronidazole 500mg IV + gentamicin 5mg/kg IVMeningitis10mg (0.2mg/kg) dexamethasone IV Q6h for 4/7 within 1hr of ABx halves incidence of audio/neuro complications decr risk mortality in adultsRifampicin 10mg/kg BD x4 for contact prophylaxis / ceftriaxone IM / ciproBrain abscessFluclox 50mg/kg Q4h + cefotaxime 50mg/kg QID + metronidazole 7.5mg/kg TDS<3/12Unknown source Amoxicillin 50mg/kg QID (covers listeria and Grp B strep in <3/12)+ cefotaxime 100mg/kg stat 50mg/kg QIDor ceftriaxone 100mg/kg IM if no IV access+/- 10-20mg/kg acyclovir TDS>3/12Unknown sourceCefotaxime 100mg/kg stat 50mg/kg QID<3/12MeningitisAmoxicillin 50mg/kg QID+ cefotaxime 100mg/kg stat 50mg/kg QIDor ceftriaxone 100mg/kg IM if no IV access>3/12MeningitisCefotaxime 100mg/kg stat 50mg/kg QIDIf suspect pneumococcus: vancomycin 12.5mg/kg QIDIf suspect listeria: keep amoxicillinAdultMeningitisCeftriaxone 2g + benpen 1.8g<3/12PneumoniaAmoxicillin 50mg/kg QID+ cefotaxime 100mg/kg stat 50mg/kg QIDor ceftriaxone 100mg/kg IM if no IV access>3/12PneumoniaAmoxicillin 30-50mg/kg TDSWell pneumoniae Amoxicillin 30mg/kg TDS PO 5-7/7Complicated pneumoniaAugmentin 30mg/kg TDS (or cefuroxime 30mg/kg TDS)Unwell pneumoniaFluclox 50mg/kg QID+ cefotaxime 50mg/kg QID or clindamycinAtypical pneumoniaRoxithromycin 4mg/kg PO BD<3/12UTIAmoxicillin 50mg/kg QID+ gentamicin 5-7.5mg/kg OD (if CNS not excluded, use cefotaxime)>3/12UTIGentamicin 5-7.5mg/kg OD (or cefuroxime)If well, ceftriaxone then discharge on augmentinGastroNa <1203% saline at 1ml/kg/hrNa 120-1500.45% saline + 2.5% dex over 24hrsNa 150-1600.45% saline + 2.5% dex over 48hrsNa >1600.45% saline + 2.5% dex over 72hrsPer stool10ml/kgPer vomit2ml/kgNG rehydration25ml/kg/hr (or 100ml/kg over 4hrs) or5ml/minENDOCRINEDKA1L N saline 1L over 1hr 1L over 2hrs 1L over 4hrs 1L over 10hrsChange to 0.45% saline + 5% dex once BSL <15Aim decr glu by 5/hr, osm by 1-2/hrAdd KCl once K <5 and UO – 10mmol/hr if K 4-5, 30 if 3-4, 40 if <3If BSL decreasing too fast, used 0.45% saline + 10% dexActrapid 0.1iu/kg/hr (max 6iu/hr) 0.05iu/kg/hr once BSL <12NaHCO3 if pH <7, HCO3 <5, severe hyperK0.5-1g/kg mannitol if cerebral oedema5-10ml/kg 3% saline over 30mins if cerebral oedemaThyroid stormEsmolol 500mcg/kg 50mcg/kg/min infusion (if concern of COPD/CCF)Propanolol 0.5-1mg/min to max 10mgPropylthiouracil 900-1200mg PO loading 300mg/dayHydrocortisone 100mg IVGUPriapismTerbutaline5-10mg PO500mcg SCPseudoephedrine60-120mg POAdrenaline 1:100,0002-3mlMETABOLICHyperKSalbutamol5mg nebs rpt Onset 15-30minsDOA 2-4hrsCa resonium15-30g PO Q4-6h Onset 1-2hrsDOA 4-6hrs10iu actrapid in 50mls 50% dex Onset 15-30minsDOA 2-4hrNaHCO31mmol/kg over 15-3mins Onset 5-30minsDOA 1-2hrsCa Glu10-20ml of 10% over 5mins Onset 1-3minsDOA 30-60minsHypertonic (3%) saline25-100ml/hr (1-2ml/kg/hr) via CVLIndication:Coma, seizure, decr LOCEndpoint:Na >125 / Sx resolvedRESUSCooling32-34deg for 12-24hrs passively rewarm over 8hrs at 0.25-0.5deg/hr30ml/kg 4deg N saline over 30minsPaeds resusAdrenaline10mcg/kg including in neonatesAmiodarone5mg/kgMgSO40.1-0.2mmol/kgNaHCO31mmol/kgAtropine20mcg/kg (min 100mcg, max 1mg)SuxNeonate: 3mg/kg; child: 2mg/kgNaloxone0.1mg/kgNUMBERS I FORGETRESUSCardiac arrest:no CPR: no long term survival if time to shock >8minsCPR: no long term survival if time to shock >12minsDefib: 95% success if <30secs; 25% success if 2minsOut of hospital: 35% survive to hospital, 5% survive to dischargeIn ED: 70% survivalETCO2 is 5 less than arterial; correlates well with coronary perfusion p and survival from cardiac arrest; if <10mmHg, survival unlikelyCardioversion:0.8% risk of VF with sync cardioversion; 15% risk of asystole with VFPropofolConsresp depression in 50-60%Apnoea in up to 20%Ventilation needed in 1.5% (intubation in 0.02%)SBP drop by >20 in 15%Pain on injectionNo analgesiaMyoclonic jerks + hypertonicity (rare)Propofol-infusion syndrome (rare)ProsOnset 20secs; offset 9minsAmnesia, bronchoD, anticonvulsant, antiemeticKetamineConsHTN, incr HRSalivation, bronchorrhoea, tearingLaryngospasm 1-2.5%Transient resp dep if rapid IV adminVomiting 8%Incr ICPMovement; ataxia during recoveryDysphoric and emergence phenomenaCIURTI, LRTI, CF, <3/12, incr ICP, glaucoma, penetrating eye inj, HTN , CCF, aneurysm, porphyria, thyrotoxicosis, IHDProsCatatonia, amnesia, analgesiaPreserveation of resp and airway reflexesBronchoDOnset 40secs (8mins IM); offset 10mins (30mins IM)NOConsLittle sedationOnset 5mins; rapid offsetVomiting 5-10%Dysphoria 1%Apnoea 1-2% children <2yrs – resolves when stop gasDizzinessMild CV depressant, pul vasoCCIPneumothorax, bowel obstruction, severe, HI, severe COPD, decompression illness, recent drive, FiO2 >0.5 needed; intoxicated; decr LOC; prolonged use in pregnancyProsNo resp depressionAnxiolysis; analgesiaSuxCIBurns (9-66 days from inj, if >20% TBSA)Neuro conditions (10/7 – 6/12 from SC inj, UMN lesion, peri nerve inj, peri neuropathy, tetanus, muscular dystrophy, CVA)Congenital neuropathy Crush injMalignant hyperthermiaConsIncr IGp, IOp, ICPMuscle fasciculationsHyperK (3-5mins after injection; lasts 10-15mins; by <1)ThioConsNo analgesiaHypotension, arrhythmiasApnoea, trismusPhlebitis, emergence deliriumProsAmnesia, anticonvulsantOnset 40secs; offset 10-30minsEtomidateConsNo analgesiaMyoclonus in 20%VomitingPain on adminResp depressionEmergence phenomenaAdrenocortical suppression and seizures if infusionProsNo CV depressionOnset 15secs, offset 10minsFentanylConsChest wall rigidity if >5mcg/kgHypotension if BP maintained by sympathetic toneDecr HR, resp depressionProsOnset <1min; offset 30-60minsLess hypotensive as no histamine releaseAnalgesiaPAEDSPaediatric FormulaeWeight (>1y)(Age + 4) x2Weight (<1y)[Age (months) + 9] / 2ETTAge/4 + 4?Neonate 3mm 6/12 3.5mm 12/12 4mmETT lengthAge/2 + 12 to lipsAge/2 + 15 to noseNeonate 10cm6-12/12 12cmBP(Age x 2) + 85 Neonate = 60mmHgVentilation rateInfants 20/min 1-8y 15/min >8y 12/minDefib4J/kgCardioversion0.5J/kg, 1J/kg, 2J/kgNG and IDC2 x ETTChest tube4 x ETT or 2 x NGBronchiolitisRSV in 40-70%Adenovirus rare but causes more severe diseaseRapid Ag test 85% sens, 99% spec40% are admittedCroupParainfluenza I 50%CHANGES IN ELDERLY15% decr TBW, 40% decr ECF, decr CI, incr SVR, decr ability to incr HRDecr muscle, incr fat, decr plasma proteins, decr bone densityDecr pul compliance, incr diaphragmatic breathingDecr GFRDecr 1st pass, decr p450, decr GI motility and gastric acid secretionDecr immunitySTATISTICSPrecisionMeasure of accuracy of testFalse negativeFN = 1 – sensFalse positiveFP = 1 – spec SensTP / (TP + FN)TP rate = fraction of people known to have disease who test positiveSpec TN / (TN + FP)TN rate = fraction of people known to be disease free who test negativeAccuracy(TP + TN) / NProportion of all test results that are correct (sens and spec)PPVTP / (TP + FP)The probability a positive test actually signifies presence of diseaseNPVTN / (TN + FP)The probability that a disease will not be present if the test is negativeNSReflexes:C5-6BicepsC7-8TricepsC8FingerL3-4KneeL5-S1AnkleS1PlantarCVA:75%50% unknown80% anterior25% lacunar20% posterior20% embolic80% MCA territory5% atherosclerotic2% dissection (10-25% if young/middle aged)10% mortalityThrombolysis <3hrs (<6-12hrs in MI)NIHSS 4-25 for TL; <1/3 MCA involvement; plt <100; PT <15; <80yrs2% decr mortality if <90mins; benefits at 3-12/12; NNT 83% risk of death from TLTrt BP >220/120 (BP >185/110 if for TL)Aim 10-15% decr in 24hrsICH:25%50% ICH, 50% SAH80-90% 1Y: putamen > thalamus > pons > cerebellum, brainstem, BG; central on CT10-20% 2Y: peripheral on CT40% mortalityOT if <1cm from surface + <60yrs Cerebellar haem >3cmHydrocephalus / marked mass effectEndarterectomy if:>80% stenosis (50% decr RR disabling CVA / death)70-80% stensosis (25% decr RR)TrtBP >190/120 Aim160/90 / MAP 110SAH:70% ruptured Berry aneurysm: <50% aneurysms rupture; <50% AVMs have symptoms15% perimesencephalic50% mortality from initial bleed; 33% good recovery; 33% severe neuro deficitWarning bleed in 50%LOC in 66%CT head 97.5% sens at 12hrs; 95% 12-24hrs; 85% 1-2/7; 75% 2-3/7; 50% >1/52LP >100,000 RBCRebleed 20% (50% mortality); vasospasm 30% (30% mortality)TrtSBP >180/120Aim pre-haem BP / SBP 120 – 180 / MAP 110CVNorms: CO 5.5L/min; SV 70ml; EF 65%; EDV 130mlInfective endo: native:mortality 25%; worse acute; better subacuteStaph aureus in normal (30% in normal, 66% in IVDU) Prosthetic:mortality 50% Strep viridans in abnormal (50-60%)Mitral in normal; triscuspid in IVDUAF:2/3 cardiovert within 24hrs40% due to IHD 0.1% risk if lone AF <60yrs1.5% if low risk and anticoagulated4.5% if low risk and uncoagulatedPost-cardioversion: 55% in SR @ 1yr90% success <48hrs, 50% success >48hrs1-5% risk of embolismWarfarin: 2.5%/yr ARR 1Y, 8.5%/yr ARR 2Y60% RRR CVA1%/yr haemorrhageAspirin:1.5%/yr ARR 1Y, 2.5%/yr ARR 2Y20% decr risk CVASyncope:1% ED visits; 5% hospital admissions; 2% incidence >80yrs40% unknown20% vasovagal10% cardiac (exertional = HOCM, AS)10% postural (abnormal = decr SBP >20mmHg, or SBP <90)situationalcarotid sinus sens (abnormal = decr SBP >50mmHg, or ventricular pause >3secs)pacemaker failureECG finds cause in 5%; blood tests in 2.5%MI: Prox LADMortality 70%aVRAnt-septalMortality 10%V1CHB, RBBB, Mobitz IILateralVentricular ruptureInferiorMortality 5%RV in 1/3; CHB; papillary muscle ruptureRVMortality 25-30%CHBCirculation balanced 60-65%; R dominant 20-25%; L dominant 10-15%15-30% silent15% with initial normal ECG’s develop criteria on serials10% incr sens if RV and post leads12% in hospital mortalityIrreversible damage in 20-40mins1/3 have no RF’sRisk stratification:40% V low <2% chance of MI / death in 6/1255%Low2-10% chance30% reclassified as high risk5% High>10% chanceNormal ECG + trop: 1% risk MINormal ECG + trop + <40yrs, no PMH, no RF 0.1-0.2% risk MITrop T99% sens75-90% specDetectable 2-12hrsDuration 14/7Trop I95% sens82-95% specDetectable 2-12hrsDuration 7/7Tot CK90% sens90% specDetectable 4-8hrsDuration 4/7CKMBHigherHigherDetectable 4-8hrsDuration 2/7CKMB mass95% sens99% specReperfusion in general:2.5% decr AR mortality47% decr RR mortality5-10% incr improvement of LVEFPCI:6-7% dec AR mortality, 90% reperfusion rate<1hr since SxAvailable <60mins1-2hr since SxAvailable <90mins3-12hr since Sx and offsiteAvailable <120mins>12hrsIf unstableLarge infarct: anterior / RV / inferior plus significant ST depression / LBBBCardiogenic shock / severe CCF (Killip >3) and <75yrsCI to thrombolysisAs rescue therapy if TL failsBest if: >70yrs, late, large, anterior / RV, CCF, prev CABGTL: 5% decr AR mortality, 60-80% reperfusion rateToo late for PTCA / PTCA not available>30mins pre-hospital transfer time<6-12hrs since Sx (<3hrs in CVA)tPA best if: <75yrs; decr BP; indigenous; >4hrs delay; ant MI; CI to SK2% decr AR mortality compared to SKAspirin: 1Y prevention for AMI: not recommended2Y prevention for AMI:decr ARR serious vascular events 8% 6.7%decr ARR CVA 2.5% 2%decr ARR coronary evetns 5% 4%In unstable angina:50-70% decr MI / deathIn MI (ISIS2): 3% decr AR mortalitysame as reperfusion therapy 25% decr RR mortalityClopidogrel: In MI (CURE):20% decr mortality (with aspirin)1% incr bleeding rateHeparin:In MI:33% decr mortality (with aspirin)GTN:In MI: 35% decr mortality BB:In MI:50% decr mortality, infarct size, reinfarct rate30% decr ICHStatins:30% decr coronary events over 5yrs15% decr CVAPE:10% mortality rate5x incr risk during pregnancyDVT in 30-50% patients50% no RF’s, 15-30% trauma, 10-25% Ca, 5-15% immobilizationSOB most common SxD dimer ELISA95% sensQualitative80-85% sensUSS leg 60% sens, 93% specTTE60-70% sens, 90% specTOE80-97% sens, 88-100% specThoracic USS75% snes, 95% specCXRAbnormal in 70-85%ECGAbnormal in 70-90%Risk stratificationHigh = massive40-50% PA occluded>15% short term mortalityMod = submassive RV dysfx3-15% short term mortalityLow = non-massive No RV dysfx3% short term mortalityTL indications in PE:CV compromise / cardiac arrest likely 2Y to PEPE <5/7>40% pul vascular occlusionRV dilation / hypokinesis / RVSP >40mmHgSignificant co-morbidities: COPD, CCF, prev PEFloating thrombusHR:SBP >1Incr tropECG showing RV strainSevere hypoxiaPericardial tamponade: 15-60ml normal200ml tamponade200-250ml must be present to be seen on CXR2L can be tolerated if slow accumulationPulsus paradoxicus = decr SBP >10-20mmHg on inspirationCancer most common cause of chronic; SOB most common SxEcho:>2cm effusion depthRA / RV / LA collapseDilated IVC with lack of collapsePericarditis:25% Idiopathic25% CaECG abnormal in 90%Pericardial effusion in 40%Incr trop in 50%CCF:If Sx 2yr mortality 35%, 6yr mortality 65-80%ACEi: 40% decr mortality; decr re-hospitalisationBB:decr disease progression / hospitalization; incr survival / cardiac performanceMorphine:10% incr mortality, hospital LOS, need for ventilationCPAP:decr need for intubation / ICUNo change in hospital mortality / LOSDiuretics:No study has ever shown benefitHTN:Mild140-15990-99Mod160-179100-109Severe>180>110Malignant>180>120+ evidence of end organ damageAim<110or 25% reduction in 12-24hrsWPW:95% orthodromic, 5% antidromicECG changesK>10VF, asystole, sinus arrest, brady, CHB9Sine wave7-8Loss of P waves Wide QRS, S+T waves mergeIdioventricular rhythm, BBB6.5-7Small P waves, ST depressionBlocks6-6.5Long PR, long QT5.5-6Peaked T waves3.5 – 5 NormalDecrLong PR, T wave flat/inverted, ST depressionU waves (mimic long QTc)VF, VT, atrial arrhythmiaCaIncrShort QT; peaked wide T waves; J wavesDecrLong QTcMgIncrLong PR, wide QRSCHBDecrLong QTcTdP, AF, SVTdsdRSNIV: Decr need for intubation by 25% overallCPAP decr need for intubation by 90% in APO Incr survival to dischargeDecr ICU LOS, intubationLess evidence in pneumonia, ARDS, asthma, children25% don’t tolerateIndication:type II resp failurepH 7.25-7.35paO2 <60 on FiO2 50%paCO2 >50RR >24Incr WOBType I resp failureRR >30CPAPImproved compliance, FRC, VQDecr preload + afterload incr CODecr intrapul shuntingBiPAPDecr WOB, afterloadPneumothorax:1Y:50-85% re-expansion rate without intervention0.1% risk non-smoker, 12% smoker2Y:30-65% re-expansion rate without intervention>70% smokers30-50% recurrence rate; 20% recurrence within 1yrCXR 90-95% sens; sliding lung 95% sens, comet tail >95% sensO2 4x incr reabsorptionAsthmaPaCO2 >40 = bad = likely ifPEFR <200 / <30% predictedFEV1 <1L / <25% predictedCXRWill detect 100-300ml fluid on PA/AP 75-100ml on lateral decubitus 800-1000ml on supineUSS100% sens for >100ml; can detect 5-50mlDecr pneumothorax from 15% to 5% when used to guide drainagePleural effusionRemoving >500ml/hr will cause re-expansion pul oedema if >1.5L removedDrain if deeper than 1cm on USSO+GPre-eclampsia: >160/>110 x1 or >140/>90 x2 + >300g/24hrs + generalized oedema orother end organ damage In 5-7% pregnancies30% recurrence in next pregnancyFetal and maternal mortality 2%Trt >170/110Aim <160/110EclampsiaFetal mortality up to 30%Beta-hCG:Urine:>20iu/L95-100% sens; <1% false negativesBlood:>5iu/LSens 100%+ >50% in 2/7 suggests viable pregnancy (decr from 12/40 onwards) + <50% in 2/7 suggests ectopic - <35% in 2/7 suggests ectopic - >35% in 2/7 suggests miscarriageFundus height:12/40Symphysis pubis16/40Half way20/40UmbilicusTVUS:4.5-5/40Gestational sac5.5-6/40Yolk sac6/40Fetal pole and cardiac activityBadEmpty gestational sac with diameter >18-20mmGestational sac >16mm / CRL >6mm without cardiac activityTVUS zone1500-2400Works from 5/40TAUS zone3000-6000If >6/40 and nothing seen TVUSEctopicIn 2% pregnancies25-30% ectopic pregnancy rate in subsequent pregnancies80% ampullaryPID: 10% infertility after 1st episode, 20% after 2nd, >50% after 3rdChanges in pregCVCan lose 30% blood vol before decr BPUterus decr CO 10-30% when compresses40% incr CO; 15-20 incr HR by term; 10-15 decr BP and MAP in 2nd trimester but normalizes by 20/40; decr DBP>SBP; 20% decr SVR; 50% incr plasma vol; 100x incr uterine blood flow; split S1; loud S3; SM; LADHaem20-30% incr RBC vol; 30% incr RBC mass; decr Hct; incr WBCRS20-30% incr O2 consumption; 40% incr TV; 25% incr MV; 20% decr FRC; 25% decr RV; no change in VC / RRGI2-3x incr ALP; decr alb 5GU50% incr GFR and CrCl; glycosuria in >50%APHIn 2-5% pregnancies30% placenta preaeviaPainless profuse PV bleedingBright redNon-tender soft uterusMaternal shock (mortality 0.03%)Fetus OKUSS 95% sens20% placental abruptionPainful PV bleeding or may be concealed (1-2L)Dark red bloodTender tense large uterusMaternal shock (<1% mortality)Fetal shock (15-35% mortality)USS 25% sensUterine rupturePV bleedingPalpable fetal parts; small uterusHigh maternal morbidityHigh fetal morbidityVasa praeviaPainless small amounts PV bleedingMother OK75% fetal mortalityPPH1Y>500ml in 1st 24hrs / >1L after CSMassive = >50% circulating blood vol in <3hrs / >150ml/min2-5% of SVDTone, trauma, tissue, thrombin2YFrom 24hrs – 6/52Perimorbid CSImmediate70% survival10mins15% survival20mins2% survival with poor outcomeRENAL / URORenal stone: 90% opaque 70% CaPhos (O), 15% struvite; 10% urate (L); 1% cysteine (partially O) CTKUB: 97% sens and spec IVP: 80-85% sens, 95% specUSS: 65-93% sens, 90-95% spec AXR: 50% sensRenal failureMildGFR 60-90ml/minModGFR 30-60SevereGFR <30FailureGFR <15CAPD>100 WBC>50% neutrophilsUsually staphNa deficit(135 – Na) x 0.6 x kgH20 deficit((Na – 140) / 140) x 0.6 x kgGIUpper GI bleeding:60% PUD (25% duodenal ulcer, 20% gastric ulcer, 25% gastritis)20% Mallory Weiss tear7-10% Variceal: most common cause of rebleedPUD: 30% duodenal, 15% gastricH pylori most common cause; ELISA IgG 85% sens, 80% spec; Urease 90-95% sens; Faecal Ag >90% sens and spec; trt success 85%NSAID’s 2nd (20% have Sx)Duodenal = 90-95% have H pyloriGastric = NSAID (70% have H pylori)H pylori: 10-20% get PUDbleeding stops spontenously in 80%5-6% mortality20% haemorrhage, 20% penetration, 5% perf, 2% GOOGORD:omeprazole help Sx in 80%; H2 better at helping Sx than omeprazole20-50% have H pyloriVarices:bleeding stops spontaneously in 20-30%10-15% haemorrhage/yr25-40% mortality (15-20% 6/52 mortailty)20-30% recurrence (most common cause of rebleed in upper GI bleeding)SB tube: 50% recurrence; controls bleed in 80%; 30% complication rateSclerotherapy: 40% complication rateLigation / sclero: stops bleeding in 80%Octreotide: stops bleeding in 80%TIPS: controls bleeding in 90%Lower GI bleed20% bleeds; 5-10% mortality80% stop spontaneously60% due to diverticular disease; 10-20% no cause; 12% angiodysplasia; 2% Ca90% GI FB’s pass sponteanously; 80% are paeds; cricopharyngeal narrowing at C6 most common site of obstruction in paeds, distal oesophagus most common in adultSBP: WCC >500-1000; neut >250; low glu; high protein; G stain and culture 70% sensEnterobacter (63%; eg. E coli (30%), klebsiella (10%)) > strep pneumonia, enterococci, anaerobes (5%), staph aureus (10%), pseudomonas (5%)10% >1 MO30% ascitic patients develop SBP in 1yrAges for diseases:<1/12Nec enterocolitis<3/12Volvulus / malrotation, feeding intolerance, incarcerated hernia, testicular torsion2-6/12Pyloric stenosis6-18/12Intussusception18-24/12Kawasaki disease1-3yrsCroup (most 18m)1-7yrsEpiglottitis (most <2yrs)4-6yrsHSP5-8yrsBacterial tracheitisAbdo USS:90% sens for 250ml96% sens for 500ml95% specAscites:Transudate<30g/L proteinCCF, cirrhosis, constrictive pericarditisExudate>30g/L proteinCa, infection, venous obstruction, pancreatitis, lymphatic ObstructionBloodCa>300 WBC?infectionLactateSBPAmylasePancreatitisLiver failure:Jaundice seen when bil >4070% unconjugated = 2, 30% conjugated = directFulminant>75% mortalityOnset of encephalopathy within 2/52AcuteOnset of encephalopathy within 8/52Bad prognosis:Hep C/D/E, idiosyncratic drug reactionGood prognosis:Hep A, paracetamolAdults50-70% paracetamol20% no cause13% idiosyncratic drug reaction8% Hep B (more in developing world)<5% Hep A4% Hep CPaeds <1yrs40% metabolic25% other15% neonatal haemochromatosis15% viral hepatitisPaeds >1yr45% unknown25% Hep C/D/E10% Hep A10% drug related5% Hep BAppendicitis20% fetal loss in preg30% retrocaecal, 30% pelvicAnorexia most common Sx; pain migrates to RIF in 50%50-75% have classical SxMcBurney’s point = 1/3 way from ASIS/umbilicus; appendix is medial and inf to pointUSS 80-90% sens, 90-100% spec – diameter >6cm, target sign, wall thickness >2mmCT + MRI 90-95% sens, 95% specAcceptable negative laparotomy rate 10-20%BiliaryGallstones present in 10-20%; symptomatic in 20%Ca is most common cause of CBD obstructionCholecystitis >90% gallstones, 10% acalculus (anaerobes and coliforms)Bacteria present in 50% cholecystitis (75% G-ive, 15% G+ive, anaerobes rare)Acalculus cholecystitis >50% mortality70% cholesterol stones (radiolucent); 30% pigment stones (radio-opaque)Murphy’s sign 85-95% sens, 85% specUSS 90-95% sens, 95% spec for gallstones90% sens, 80% spec for cholecystitis – GB >4x8cm, wall >4mm, CBD >10mmCTLower sensDiverticulitisOccurs in 10-25% people with diverticular diseaseUsually anaerobes and G-ive rodsSignificant bleeding usually R sided; 5-15% bleedCT97% sens, 100% specVolvulisSigmoid 2/3, elderly; sigmoidoscopy 90% success rate, but 90% recurrenceCaecal 1/3, young; mortality 10-40%ObstructionSBO >2.5cmLBO >5cm>5 AF levels abnormalAXR 75-80% sens, 50% specUSS95% sens and specCT90% sens, 95% specElderly AP10% mortality; 40% initially misdiagnosedCholecystitis most common causeHerniasInguinal:75%; 2/3 indirect, 1/3 direct; 3%/mth strangulation; cough impulse above and medial to symphysis pubis; most common inc in womenIndirect: lat to inf epiG art; frequent strangulationDirect: med to inf epiG artFemoral:20%/mth strangulationMed to inf epiG art; below and lat to pubic tubercleIschaemic colitis>50% mortalityPancreatitisMortality 2-10%ETOH most common cause; gallstones most common cause in womenBacteria present in 20% (50% in cholecystitis)CRP >150 at 48hrs is predictor of severityLipaseIncr earlier (in 4-8hrs), for longer (1-2/52)95% sens and specDoes not correlate with severityAmylaseIncr later (2-12hrs), for shorter (1/52)80-90% sens (less sens with ETOH), 75% specDoes not correlate with severityCT80-95% sensGURenal colic90% stones radio-opaque (25% gallstones)90% pass spontaneously70% Ca phos / oxalate (radio-opaque)10-15% struvite – infective staghorn10% urate (radiolucent)1% cysteine (partially radio-opaque)Narrowest part is VUJ : 1-5mm4mm = 90% pass5mm = 80% pass5-8mm = 15% pass>8mm = 5% passHaematuria absent in 5-10%; gross haematuria in 30%CT KUB 97% sens and specAXR 50% sensUSS may miss if <5mm / mid-ureterENTOMIncr cure rate by 10%, decr duration fever by 1/7No effect on rate of complicationsPharyngitisDecr duration Sx by 0.5 days, decr severity Sx, decr infectious period from 2/52 to 1/7Decr risk RF by 70%Decr risk OM by 70%Decr risk quinsy by 85%Decr risk sinusitis by 50%No effect on risk of post-strep GNLudwig’s angina50% failure rate for RSITOXConcerning dosesMetformin >10gDigoxin >10mg (>4mg in children)Fe>60mg/kg>60mmol/L (>90mmol/L is high risk)LithiumParacetamol>200mg/kgAspirin>300mg/kg>2.2mmol/L for alkalinisationDecontaminationCharcoal: 45% decr absorption at 30mins, 40% at 1hr, 15% at 2hrsSyrup of ipecac: decr absorption 30% if in 1st hrGastric lavage: 25% decr absorption if at 30mins, 10% if at 1hrFe ODMarkers of toxicity: WCC >15, BSL >8, AGMAMETABOLICNa deficit (mmol/L) = (0.6 x kg) x (desired Na – actual Na) 90% DM is type IIHONK: pH >7.3, HCO3 >15, AG normal, BSL >600, ketones +, osm >320DKA: pH <7.3, HCO3 <15, AG high, BSL >250, ketones +++, variable osmHONK: N saline resus replace with 0.45% saline over 48-72hrs add 5% dex when BSL <15DKA: N saline resus replace with N saline over 24hrs 0.45% saline + 5% dex when BSL <15HONK: 0.05iu/kg/hr DKA: 0.1iu/kg/hrHONK mortality: 15-45% DKA mortality: 5-15%TRAUMAHyphema: rebleeding in 3-5/7 in 30%FAST: 96% sens for >800ml FF90% sens for >250ml FF95% spec100% sens, 96% spec for need for laparotomy in hypotensive patientinsufficient sens to rule out significant inj in stable patientUSS chest:90% sens, 95% spec for haemothoraxSliding lung sign 95% sens, 90% specAbsent comet tails >95% sens, 60% specUSS AAA: ED doc 90-100% sens, >95% spec for >3cmUSS IVC: normal 15-20mm with 5mm decr during inspHypovolaemia: <14mm, with >40% collapse on inspirationHypervolaemia: >20mm, without any insp collapseBurns:MinorModMajorFull<2%2-10%>10%Partial<15%15-25%>25% (-5 if <10 / >50yrs)Burns unit>10% TBSA adult>5% TBSA child>5% full thicknessSpecial areasBrooke-Parkland:2-4ml/kg/% burn (+maintenance if child)1st half in 8hrs, 2nd half in 16hrsAim UO 0.5-1ml/kg/hrPenning’s criteria:C110mmC25mmC3-47mm<50% width C4 in childrenC5+20mmHaemothoraxSmall<350mlMod350-1500mlLarge>1500ml (>15ml/lg)Massive>300ml/hr for 2hrs>600ml/6hrs>4ml/kg/hrThoractomotyStable>200ml/hr for >2hrs>1500ml overallUnstable>100ml/hr for >2hrs>1000ml overallCompartment syndrome: 1-10mmHgNormal<15mmHgSafe20-30mmHgCause damage>30mmHgEmergency fasciotomyBoehler’s angle: <20deg = fractureDPL:1L (10ml/kg) saline; 98% sens; 1% complication rate; 15% false +ive>20ml frank blood>100,000 RBC/ml if blunt>5000 RBC/ml if penetrating>500 WBC/ml if <3hrs since injbile / foodORTHOJt aspirate: NormalWCC <200, <25% PMNInflammWCC 2000-50,000; >50% PMNSepticWCC >25,000; >85% PMNSeptic arthritis:15% mortality50% staph, 40% grp A strep in adultsENVIRONMENTALHeat stroke T >40, altered LOC, anhydrosis, MOFMortality 10-50% Decr T by… Incr T by…Blanket0.5-2deg / hrIce packs0.04-0.08deg / minIce/warm water immersion0.15-0.25deg / min4-10deg / hrEvaporative 0.3deg /minHumidified O21-1.5deg / hrGastric lavage 0.5deg / minPeritoneal lavage2-4deg / hrThoracic lavage3-6deg / hrHaemodialysis2-3deg / hrCPB7-10deg / hrHypothermia: Severe <28; mod 28-32; mild 32-35check pulse for 60secs (instead of 10)1x shock + drugs withhold until >30deg then 2x interval between drugs until 35 degHeat IVF to 42 degUse 5% dex as energy substrateRapid rewarm to 30deg then slower45% survive with normal function, 15% with severe brain inj100% good outcome if GCS >8 at 2hrs>90% if GCS >3 at 2hrsGood prognosis:witnessed <5mins to retrieval<5mins submersionGCS >5 on scene<10mins to CPR<10mins to first resp effort = <10% significant neuro deficit<30mins to spontaneous breathingSaO2 >94%ROSC pre-hospital / no resp arrestPupillary response / motor response to pain on arrivalCold waterBad prognosis:above +male<3yrs >10-25mins submersion>25mins resusFixed dilated pupils at 6hrsGCS 5 on arrival = 80% risk death / severe deficitVT/VF on initial ECG / asystoleMetabolic acidosis pH <7.1 on arrivalAltitudeHigh >1500m (4900ft)AMS begins >2500mHAPE begins >3500mMost can acclimitise up to 5500mChangesIncr RR, HCO3 diuresis, pul HTN, incr lung volIncr SV, incr BP, incr CO, peri vasoCIncr RBC (days-wks), incr EPO (hrs), incr 23DPGBurns>20% fluid shifts, recommend IVF + IDC + NGT>40% recommend stress ulcer prophylaxis>50% potentially fatal>60% decr CO>80% full thickness unsurvivable50deg 5mins55deg 30secs60deg 5secs70deg 1secAdmit burns unit:Partial thickness >20%Partial thickness >15% if chemicalPartial thickness >10% if <10yrs / >50yrsFull thickness >5%Other major burn criteriaAGEOccurs within 5-20mins of ascent, or in waterDCS50% within 1hr, 90% within 6hrsElectrical>1000V = threshold for severe injVertical = 20% mortalityHorizontal = 60% mortalityLightning = 10-30% mortality1mAmp tingling2-10mAmp pain10mAmp paralysis / tetany100mAmp – 1Amp VF, rest arrest, burns>10Amp asystoleLow volt AC VF, rhabdo, ARF, deep tissue burnsHigh volt AC / DC / lightning asystole, superficial burnsIDNeedlestick inj:Transmission:Hep B: E+ive, 40%; E-ive 5% (2-30% risk)Hep C:2-10% (<2% risk)HIV:0.3% Gloves decr by 50%Prophylaxis decr seroconversion by 80%Full 4/52 course tolerated by 35%HIV transmission:0.8% anal receptive3-15% prev in homos0.6% shared IVDU1% prev in IVDU0.3% needlestick0.1% vag / insertive anal<0.1% prev in heteros<0.1% MM exposureHep B transmission15% sexHep C transmission15% sexHIV:PCP occurs in 60%MalariaFalciparum>90% within 2/12; more resistanceVivax50% within 2/12; most common; can be delayed monthsMost common cause of fever in travellerDengue4-10/7 incubationRisk of SBI:<4w and well<5%<4w + ill13-21%<4w + bronchiolitis: 3-10% so do septic screen<6w15% overallHeight of fever irrelevant this young6w – 3m well<5%6w – 3m ill13-21%4w – 2m + bronchiolitis: 3-5% so do urine6w – 3m6-10% overall if any fever3m – 6m<1%6m – 2yrs<1% (incr if higher fever)Overall <2yrs3%Seizure + well0.3% SBISeizure + ill15-18% SBIUTI (paeds)3-8% with no source have UTI<3/1230% systemic sepsis>3/125% systemic sepsis85% E coli, 6% proteusNitrites40% sens, 99% specWBC50-90% sens and spec (dipstick 75% sens)Bacteria50-90% sens, 10-90% specMSSU>5-10 WCCCatheter>1-5 WCCSPA>0 WCCMeningitis (paeds)5% mortalityFND in 15% (30% pneumococcus)Decr LOC 15% (more pneumococcus)Seizures 30%Meningitis60% strep pneumoniaFND prominent16% N meningitides14% grp B strepCSFBacterialWCC 200-10,000PMN 100-10,000MMN <100Pro >1Glu lowViralWCC 100-700PMN <100MMN >100NNPartial TrtWCC 200-5000PMN 10-100MMN >100EitherEitherTBWCC 100-500PMN high earlyMMN high latePro >1Glu low lateProtein incr 0.01 per 1000 RBCOpening pAdult 7-18cm22-25G, 12cm8-18yrs7-20cm22-25G, 6cm1-8yrs1-10cm2cmSIRS = >2 ofT <36 or >38HR >90HR >160 infants, HR 150 childrenRR > 20 or PaCO2 <32RR >60 infants, RR >50 childrenWCC <4 or >12 or >10% bandsOrgan dysfxSBP <90 / 40 below normal / MAP <60BE < -5Lactate >2UO <30ml/hrFiO2 >0.4 or PEEP >5Cr >160Decr LOCSevere sepsis= SIRS + organ dysfxLactate good for risk stratification: >2 = 4% mortality, >4 = 28% mortalityIncr mortality by 8%/hr for delay in ABxSeptic shock= severe sepsis + uncorrectable hypotensionUnknown sourceFluclox + gentRSCeftriaxone + azithromycinGIAmpicillin + gent + metronidazoleUTIAmpicillin + gentSkinFlucloxFebrile convulsion4% incidence; 35% recurrence3% go on to epilepsy (same as general population)Nec fascMortality 25-35%Clostridium perfringens most common causeB fragilis and E coli in Fournier’sKawasakiIVIG 2g/kg IV over 12hrsAspirin 30-50mg/kg/day until fever gone 3-5mg/kg OD for 6-8/52ENDOCRINEDM:Type I10% DM90% immune mediated; 10% unknown50% concordance in twins>80% loss islet cells for features of DMType II80% DM100% concordance in twinsMODY2-5% DMDKAFetal mortality 30-50%; mortality 5-15% (1% in children); 70% mortality if cerebral oedemaAcetoacetate on ketostix urine testB-HB on blood; more in alcoholic ketoacidosisB-HB converted to acetoacetateAcetone on breath test5-10L fluid deficit; 5-10mmol/kg Na deficit; 3-5mmol/kg K deficitDERMATOLOGYEM minorNo MM involvedEM major1MM involvedSJSEpidermal detachment <10% BSA>1MM involvedMortality 10-15%TENEpidermal detachment >30% BSAMM often involvedMortality 25-35%TSSToxicT >38.9ShockSBP <90SRash desquamation; involvement 3+ systemsSSSSNo MM involvementFACTS I FORGETDISCHARGE PLANNINGDiagnostic certaintySHPredictors of early readmission – reliance on others, assistance neededSymptom controlPO intakeMental stateTest mobilityTime of dischargeCommunicationCheck contact detailsOrganise OP FUDischarge medicationStatutory requirements (eg. Work certificate)Discharge info and letterTransportationDERMATOLOGYKawasaki diseaseFever >5/7 + 4/5 of100%MM involvement: cracked lips, strawberry tongue90%Bilat conjunctivitis with perilimbic sparing80%Polymorphous generalized rash99%Peripheral redness and oedema85-95%Cervical lymphadenopathy60-98%Do echo at 2/52 6/52 1yrMI is leading cause of death; mortality <1%MeaslesFever >38Rash – erythematous maculopapular1 of: cough / coryza / conjunctivitis / Koplick spotsMortality 10-15%; 50% due to pneumoniaENVIRONMENTALPIBFunnel web, mouse spiderAll snakes inc seaCone shellBlue ringed octopusRedback20% envenomation rateFemale bite Severe pain (in mins/delayed), erythema, sweating, piloerection lactrodectism (severe pain, sweating, piloerection) maybe weakness, N+V+AP 2 vial AV IM (serum sickness 10-15% for all AV)Funnel web10-25% envenomation rateMale bite pain + fang marks within 30mins, autonomic storm NCPO, spasms, paralysis, coma PIB, 1 vial AV rptMouse spider<5% envenomation rateMod localNon-specific general PIB, funnel web AVWhite tailLocal painRecluse spiderBlue ulcer necrotizing arachnidism, metHbBlack houseNecrotising arachnidismBox JellyImmediate severe painCardiotoxicity collapse in water cardiac arrest, arrhythmia, HTN /decr BPMuscle spasms + paralysis vinegar, 1-6 vials AV, MgSO4CarybdeidMild localIrukandji Syndrome on beach sympathetic storm HTN, CCF, NCPO, collapseSevere generalized pain vinegar, MgSO4, anti-HTNBlue bottleSevere local in water hot waterBlue ringedParalysis collapse on beach PIBStone fishSevere pain hot water, 1-3 vials AV, ABx, ADTSea snakeParalysis in 2-6hrsMyolysis + ARF PIB, 1-3 vials AVBrown snake60% snake deaths, 70% snake bitesCardiotoxicitiy early collapseEarly severe coagulopathyThrombotic microangiopathy ARF PIB, 2 vials AVTiger snake25% snake deathsCardiotoxicity early collapseEarly coagulopathyLate neurotoxicity, severe myolysis, ARF PIB, 2 vials AVBlack snakeMarked localCoagulopathy, neurotoxicity, myolysis, ARF PIB, 1 vial AVTaipan10% snake deathsEarly collapse, coagulopathy, neurotoxicity, myolysis PIB, 1-3 vials AVDeath adder5% snake deathsEarly neurotoxicity PIB, 1 vial AVIDLive attenuatedBCGAvoif if immunosuppressedMMRVZVPolioNotifiable diseaseCampylobacter, chlamydia, gonorrhea, hep A+E, flu, legionella, listeria, MMR, syphilis, salmonella, VZVTRAUMABrown SequardIpsilateral motor, position, vibratoryContralateral pain, TCentralUpper > lower bilaterallyAnteriorBilat motor weaknessHuman bites:Staph aureus EikenellaDog bitesStaphylococcus Streptococcus Haemophilus speciesEikenella Pasteurella Proteus Klebsiella speciesEnterobacter speciesCapnocytophaga canimorsus – overwhelming sepsis in immunocompBacteroides Moraxella Corynebacterium Neisseria Fusobacterium Prevotela Porphyromonas Cat bites – 60-80% get infectedStaphylococcus Streptococcus Pasteurella Actinomyces Propionibacterium Bacteroides Fusobacterium Clostridium Wolinella Peptostreptococcus speciesBartonella cat scratch disease regional lymphadenopathy after 7-12/7Marine assocStaph, strepG-ive rods esp VibrioTetanus ProphylaxisHxCleanDirtyTdTIGTdTIG<3 or unknown?No??Immunised≤ 5yNoNoNoNo5-10 yNoNo?No>10 y?No?NoHBsAg+HBsAg-UnknownUnvaccinatedHBIg (400iu IM) + vaccVaccVaccVacc + responder (anti-HBs >10)No RxNo RxNo RxVacc + non- responder (anti-HBs <10)HBIg (400iu IM) + vaccBoosterIf hi-risk,?Rx as HSourceMxHIV -Nil elseLikely/confirmed +PEP 4/52 (ideally <24-36h) 2 drugs standard?3 drugs if hi-riskUnknownUsually no PEP 2 drugs if hi-riskO+GSafe in preg:cephalosporins, azithromycin, nitrofurantoin, penicillinsMaxalon, ondansetron, stemetil, promethazineHeparinNot safe in preg:fluroquinolones (ie. Ciprofloxacin), sulphonamides (eg. Cotrim), tetracyclines (eg. Doxy), gent, metronidazoleOral hypoglycaemicsWarfarin, thrombolysisNSAIDs, aspirinStemetilPhenytoinAmiodarone, ACEi, AII receptor antagonistsLithiumMost common cause of vulvovaginitis: bacterial vaginosisGIH pylori:PUD:PUD in 20%; most common cause; duodenal > gastricNSAIDS:PUD:Symptoms in 20%; endoscopic evidence in 50%; 2nd most common cause; gastric > duodenalOmeprazole: GI bleed:Decr LOS, active bleeding at endoscopy, need for OTNo effect on transfusion, recurrence, mortalityPUD:Heal earlierH2 antagonists:GORD:Better at treating Sx than omeprazolePUD:Heals 85% duodenal in 4-8/52, 70% gastric in 8/5280% relapse at 1yr if no maintenanceMisoprostolFor NSAID related diseaseSucralfateBetter in smokersBismuth cmpdsFor H pylori related diseaseOctreotide:Varices:Decr active bleeding; transfusion need by 33%; as effective as sclerotherapyGastroscopy:GI bleed:Decr rebleeding by 60%, mortality by 45%, emergent OT by 65%SB tube:Varices:Controls bleeding in 70-90%50% recurrence; 25-30% complication rateBanding/sclera:Varices:stops bleeding in 80-90%40% complication rate for sclerotherapyTIPS:Varices:Stops bleeding in 90%; 25% decr 1yr mortality, 50% decr rebleedingAngio+embo:Varices:Stops bleeding in 80%Complications:PUD:Haem 20% (most common), penetration 20%, perf 5%, GOO 2%HepatitisAcutePreviousChronicCarrierImmuneAIgM anti HAV No No IgG anti HAVHAV RNA .BIgM anti HBcAg5-10% 1-10%HBsAgAnti HBsAgHBsAg >6/12HBsAg IgG anti HBsAgHBeAgAnti HBeAgHBeAg (phase 2)HBV DNAIgG anti HBcAgIgG anti HBcAgAnti HBeAg (phase 3)Hep B DNA .CHCV RNA75-85% (less in kids)0.2-1%- IgG anti HCV .DHDV RNA5-10% co, 80% superLow-IgM anti HDVIgG anti HDV .EHEV AgNoIgM anti HEVIgG anti HEV IgG anti HEVHAEMATOLOGYClotting probs retroperitoneal bleeding, intra-articular bleeding, delayed bleedingPlt probs mucocutaneous bleeding = gum, petechiae, purpura, epistaxis, GI/GU bleed, menorrhagia, bruisingDIC incr DD, decr plt (most common lab finding), incr INR, decr fibAbsoluteRelativeBleedActive bleeding or diathesis Sig closed HI <3/12?Face trauma <3/12Recent bleed <4/52 Surgery <3/52?Active PUD Anticoagulant use Non-comp vasc punc site CPR >10minICHPrior ICH?Ischemic CVA <3/12 Cerebral vasc lesion Malig lesion 1° or 2°Severe/poorly controlled HT HT >180/110 on presentation Ischemic CVA >3/12 DementiaOtherAortic dissection PericarditisPregnancyTOXICOLOGYWBI:SR prepsAgents that don’t bind charcoalFe (>60mg/kg)Li (>40mg/kg)Lead, arsenic, SR verapamil/diltiazem, SR KCl (>2.5mmol/kg), body packers, pharmacobezoarsIntralipid:LAPropanolol, verapamilTCAMDAC:Carbamazepine / phenobarb coma, phenytoin, valproateAspirinTheophyllineQuinineNaHCO3:Phenobarb comaAspirinMethotrexateHaemodialysis:Carbamazepine / phenobarb, valproic acidAspirinTheophyllineMetformin, alcohols Lithium (>6mmol/L acute OD, >2.5mmol/L chronic)Charcoal haemP:Carbamazepine / phenobarb, phenytoinAspirin, paracetamolTheophyllineAmanitaDRUGSNOmax 70:30; onset 4-5mins; MAC 1.02 (weak)Pros: analgesia, amnesia, no decr RR or airway reflexesCons: diffusion hypoxia at high doses; mask intolerance; vomiting 5-10%; dysphoria 1%; apnoea 1-2% <2yrs, 1:300 otherwiseCI: pneumothorax, bowel obstruction, gastric distension, severe HI; severe COPD, decompression illness, >50% O2 needed, decr LOC, pregnancyBLOODSUrIncrRenal failure, CCF, dehydration, catabolism, sepsis, OT, steroids, starvation, GI bleedDecrPreg, severe liver disease, low protein diet, anabolism, Ur cycle defectsCrIncrDecr GFR, incr muscle mass, catabolism, muscle diseaseDecrElderly, decr muscle massUr:CrIncrPrerenal, sepsis, GI bood, dehydration, CCF, RAS, steroids, tetracyclines50-100Renal, acuteDecrRenal, chronic; hepatic failure, muscle trauma, preg, trimethoprimCVJVPRaisedR heart failure, fluid overload, decr HR, SVC obstructionParadoxicalCardiac tamponade, constrictive pericarditisLarge aTricuspid stenosis, pul HTN, pul stenosis, CHB, flutter, HOCM, ASAbsent aAFSystolic waveTRApexTappingMSProlongedASTripleHOCMHeaveLarge RV / LAThrillSevere ASS1LoudMS, TSTachySoftMRLBBB, 1st deg HB, MIS2LoudASHTNSoftARMISplit S1RBBBSplit S2IncreasedPS, MR, VSDRBBBFixedASDReversedAS, coarctationLBBBS3Rapid diastolic filling; CCF, AR, MR, VSD, PDA, MI, maybe physiologicalS4Poorly compliant V; AS, PS, MR, pul HTN, HTN, MIEjection clickASMid-systolic clickMV prolapseOpening snapMSPSMMR, TRVSDESMAS, PSASDLate systolicMV prolapseEarly diastolicAR, PRMid diastolicMS, TSContinuousPDA, coarctation, venous humInspirationIncr R murmursExpirationIncr L murmursHOCMIncr by Valsalva and standing; decr by squatting, hand grip, leg elevation; SMASLoud reverse split S2, S4, ejection click, ESM, large a wave, narrow pulse p, slow rising pulse, sustained displaced apex beat, thrill if severe, LVH on ECGARSoft S2, S3, early diastolic murmur (+/- SM), Corrigan’s sign, Quinke’s sign, Traube’s sign, Duroziez’s sign, water hammer pulse, wide pulse p, Austin Flint murmur, displaced apex beat, LVHMSLoud S1, opening snap, mid diastolic murmur, tapping apex beat, small pulse p, thrill; RAD; RV strain; P mitrale, AFMRSoft S1, incr splitting S2, S3, S4, PSM, small vol pulse, RAD, LV strain, P mitrale, AFMV prolapseMid-systolic click, late systolic murmurAnti-arrhythmics:IAProcainamide, quinidine, disopyramideWide QRS, QTIBLignocaine, phenytoinICFlecainideWide QRS, PRIIBeta-blockersLong PR; HBIIIWide PR, QRS, QTIVCa antagonistsLong PROK in WPW:Flecainide, procainamide, verapamil (if narrow complex)Not OK in WPW:Adenosine, BB, Ca antagonists, digCyanotic heart diseaseTOFTotal anomalous venous drainageTGATruncus arteriosusTricuspid atresiaECGHypothermiaDecr complex size; Osborn wave (esp II, III, aVF, precordial); HB’s; AF, VF, asystole, prolonged PR, long QRS and QT, STEHyperthermiaLong QTc; AF, SVT, RBBBRESPIRATORYCavitating lung lesions:Cancer: SCC; HodgkinsAutoimmune: granulomatosis, sarcoidosis, Wegener’s, RA, progressive massive fibrosisVascular: septic emboli, pul infarctInfectious: Staph aureusKlebsiellaG-ives, anaerobesFungi, aspiration, 2Y TBInfected bullae / cystsTrauma: traumatic cystYoung: bronchogenic cyst, laryngotracheal papillomatosisAbscessStaph aureus (esp if immunocompromised)KlebseillaG-ive, anaerobes (esp if immunocompetent)Fungi (aspergillus, cryptococcal), aspiration, 2Y TBAspirationStaph aureus, strep pneumoniaKlebsiellaG-ives, anaerobesE coli, enterobacter, H influenza, pseudomonasCXR initially normal in 25%; 40% who aspirate get pneumoniaEmpyema/effusionStaph aureus, strep pneumonaie (esp effusion)EmpyemaKlebsiellaPseudomonas, nocardia, TBEffusionG-ives, anaerobesMycoplasma, HibCCF, trauma, PE, Ca (more likely if large), autoimmune, renal failureR = ovarian CaL = pancreatitis, chylothorax, CCFRound pneumoniaStrep pneumonia, staphLegionellaCoxiellaInterstitial lung disease: A-SHITFACEDA typicalsViral, atypicals, radiationDiffuse, tiny, hazeS arcoidosisH istiocytosisI diopathicT umourMets, lymphangitisF ailureA utoimmuneSLE, RA, scleroderma, granulomatosisC ollagen vascular diseaseE nvironmentalAsbestosis, silicosis, coal, farmerD rugsMethotrexate, amiodaronePul fibrosisUpper zone SETCARPS ilicosis, sarcoidosisGround glass, reticularE osinophilic pneumoniaLinear and nodulesT BDirty lookingC oal, CFA spergillosis, ank spondR adiationP CP, pneumoconiosisLower zone BADRASHB ronchiectasisA spirationD rugsMethotrexate, nitrofurantoin, hydralazine, amiodarone, paraquat, smoke inhalationR AA stebestosS clerodermaH amman Rich, histiocytosisHoneycomb BIGHIPSB leomycinI diopathicG ranulomasH istiocytosis I nterstitial pneumoniaP neumoconiosisS arcoidosisPul nodules: CAVIEC ancerAdenomaNeoplasiaMetsColon, breast, renal, testicular, melanoma, TCCAdenoCaCentralSCC, small cellPeriLarge cell, bronchoalveolarA utoimmuneGranulomatosis, RA, Wegener’s, silicosisV ascularAVM, haemartoma, PE, infarctI nfectionRound pneumoniaMiliary TBVaricella pneumoniaFungalHistoplasmosis, aspergillomaE nviroPleural plaquesPleural masses MALLETSM esotheliomaA denoCa, asbestosisL ymphoma, leukaemiaE mpysemaT hymomaS plenosisNEUROLOGYMCAContralat face+arm >leg hemiplegia + sensory lossHonomynous hemianopiaDom: aphasia, agnosia (Broca’s and Wernicke’s)Non-dom: spatial neglect, dressing apraxiaACAContralat leg > arm hemiplegia + sensory loss Disorder of conjugate gazeConfusion, personality changeDom: aphasiaNon-dom: neglect, confusionOpthalmicAmaurosis fugaxPCAIpsilat cranial nerve III deficitContralat sensory lossNO MOTOR LOSSHonomynous hemianopia, quadrantanopiaVertebroBIpsilat cranial nerve deficitContralat body signsCerebellar signsLat med SIpsilat VII, IX, X Horner’s syndrome, ipsilat facial numbness, dysphagia, dysarthriaContralat loss pain and T in bodyNO MOTOR LOSSDisorder of conjugate gazeCerebellar signsWallenbergIpsilat facial loss of pain and T, weaknessContralat loss pain and T in body, weaknessCerebellar signsInt capsuleContralat motor lossNO SENSORY LOSSThalamusContralat sensory lossNO MOTOR LOSSUMN acuteUMN chronicLMNSpinal cordNMJWastingNoneMildSevereToneDecrIncrDecrFasciculationsNoNoYesReflexesIncrIncrDecrLoss at levelNormalIncr below levelPlantarUpUpNoneFatiguableILCOR changesMajor30 chest immediately MinorAED ASAP – now BLS skillChange op Q2minAnnual BLS trainingEmphasis on signs of life rather than vitalNo finger sweepChest compressions only OKPlace hand over centre of chestPrecordial thump de-emphasisedMajorNo interruptions – push hard, push fastCompress chargingChange Q2minNo atropineETCO2 Minor100/minDrug IV/IO not ETTSingle shocks200JUSS for checking heart activityAvoid hyperoxiaHypothermia for surivivorsPrecordial thump for witnessed collapseAngioplasty post ROSCCT head:Lat ventricle 3rd ventricle quadrigeminal cistern, suprasellar cistern 4th ventricle Ring enhancing lesions:MetsRadiation necrosisTuberculomaHaematoma (resolving)AneurysmMultiple sclerosisPrimary brain tumour (glioblastoma, CNS lymphoma, cystic astrocytoma)Abscess toxoplasma, TB cryptococcus, candida Staph aureus, strep prevotella, pseudomonas anaerobes, bacteroidesneurosyphilisSynovial FluidNormalClass IClass 2Class 3Class 4Type of fluidNormalNon-inflammInflammatory*Purulent HemorrhagicAppearanceClearLight yellowClearLight yellowCloudy-opaque Dark yellowCloudy-opaqueDark yellow-greenCloudyPink-redVolume (ml)<3.5>3.5>3.5>3.5>3.5ViscosityHighHighLowLowVariableWbc/L<200200-20003000-100,000>40,000>2000PMNs<25%<25%50%75%30%Gram + cultureNegNegNegUsually positiveNegGlc:serum==<<<=DifferentialsN/ADegenerativeTraumaAVNNeuropathicHPOAEarly inflammRheumatoidGoutPseudogoutReiter’s Ank spondPsoriaticSarcoidIBDSclerodermaRh feverTB, viralPyogenicS. aureusGonococcus(25% G+C only)TraumaFractureBleeding diathesisHemophiliaNeuropathicHemangioma Bleeding neoplasm*pseudogout = pos birefringence; gout = neg birefringence; RA = phagocytic PMN inclusions; Reiters = phagocytosis of leucs by macrophagesCSFParameterNormalBacterialViralTB / FungalPressure cmH2O7-20Very highN / slightly highVery high in TBWcc/mm3<5neonates <30>200up to 20,000<1000<1000Predominant cell typeLymphocytes0 PMNsPMN(10% lymphocytes)Lymphocytes(50% PMN initially)LymphocytesGlucose0.6 x serum0.8 in neonatesLow0.3 x serumNormal or highLow / NProtein15-45 mg/dl90 in infantsHigh > 50Normal or highHighOrganisms080% +ve60% if pretreated080% +ve ZN90% crypto AgAbdominal ParacentesisTraditionally classified as transudate vs exudateMore useful is serum-ascites albumin gradient (SAAG)TransudateExudateSAAGHigh (>11g/l)Low (<11g/l)Protein< 30g/l> 30g/lpH> 7.3< 7.3LDHLowHighGlucoseNormalLowWCC<1000 /l> 1000 /lCausesPortal HT present:CirrhosisHeart failureConstrictive pericarditisBudd-Chiari or veno-occlusive diseaseNon-portal HT etiology:MalignancyInflammatory / InfectionPancreatitisLymphatic obstructionBacterial peritonitis likely if: (ADHB RMO Handbook 2005)Wcc > 500 x 106 / L Predominantly neutrophils ................
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