4th July 2017



4th July 2017Fellowship session notesInvestigations – bedside-labs-radiology-others(subparts to investigations – e.g for a pleural tap it comprises – Microscopy/gram stain/biochem/culture/LDH etc)Differentials – Surgical sieve – VITAMIN DICComplications – A-B-C-D-E –Infective/Metabolic/Nearby StructuresCause – Consequence - ComplicationsQ1 – Pleural Effusion Radiological abn assoc with- DissectionWide med/apical cap/pl effn/double ring sign/displaced bronchus/- Pleural effusionmeniscus/obscuration of the heart border or diaphragm/opacification/Lights criteria for EXUDATELDH ratio > 0.6 (or 2/3 the upper limit for serum)Protein ratio >0.5Protein >30g/LTests within a teste.g pleural fluid – cytology/MCS/protein/LDHList of tests to establish a diagnosis – What is the diagnosis – how do I prove that diagnosis.Q2 - MigraineMigraine Protocol eTG Aspirin – NSAID – panadolDomperidone – Metoclop – StemetilPreventionQ3 Decompression SicknessJoints and skinNeurological – Patchy, cord, bladderStaggers – Inner EarChokes - APOOther issues related to rapidly enlarging gas – ears/sinuses/PTX/teeth/AGEQ4 HHS formerly known as HONKBlood results – approachWhat is going onWhat can I calculateExplain each parameterBIG PICTURE FIRST – every word is in there for a reason.TAKE 30 secs to analyse the Question.OLD T2?marked hyperglycaemia?hyperosmolality > 350 mosm/L?elevated Cr/Urea ratio?low corrected Na+-corrected Na+ = (glucose (mmol/L) /3.5 + measured [Na+])?acidosis absent or mild-minor lactic acidosis may be present?disseminated intravascular coagulationFluids?CVP monitoring may be necessary?0.9% saline to correct circulating volume if hypotensive?use 0.45% saline to slowly?replace water deficit over 2-3 days?add 5% dextrose once glucose falls below 14 mmol/LInsulin?patients are usually sensitive to insulin?0.05 – 0.1 Units/kg/hour as infusion titrated to produce a slow fall in blood glucosePotassium?deficits are variable but replacement will be required?insulin therapy will result in intracellular movement of K+?hence replacement should generally begin early?monitor levels hourly until stabilised in the normal rangeTreat precipitating causeHeparin?for thromboembolic preventionPoor prognostic factors?hypernatraemia?renal failure?mortality ranges from 15% - 45%-usually due to age and underlying conditionsBlood urea:creatinine ratio?commonly used to attempt to differentiate renal from pre- and post-renal causes of renal impairment?little evidence for its use?low sensitivity and specificity for prerenal causes due to the-large number of unmeasurable factors that affect urea and creatinine concentrations-multi-factorial nature of many cases of renal impairmentNormal ratio?= urea (mmol/L) / creatinine (mmol/L)-NB urea and creatinine in (mmol/L- not??mol/L)?usually approximately 100Abnormal ratios?> 100 suggests prerenal disease?50-100suggests acute kidney injury?< 50 suggests-renal cause-chronic diseaseQ5 Heart BlocksP rateQRS rateAssociatedHOW WIDE IS THE QRS?Steps – think real life – don’t forget consent – Q6 DROWNINGOrlowski scale?age < 3 years?estimated submersion > 5 minutes?no attempted resuscitation in the first 10 minutes after rescue?coma on arrival at the ED?metabolic acidosis on arrival with pH < 7.10?outcome-90% chance of good recovery if < 3 of the above present-5% recovery if > 3 presentOther prognostic factors?on arrival in ED?good prognosis-spontaneous respiration and heart beat?poor prognosis-resuscitation duration > 25 minutes-VT or VF on initial ECG-fixed dilated pupils-cardio or respiratory arrestCRITICAL DRUGSA-B-C-D-others DrugsSedationParalysisO2BP Management – inotropes/antihypertensivesBrain Management – mannitol/analgesia/sedationGlycaemic drugsInfection ManagementCRITICAL COMPLICATIONSA-B-C-D-E-InfectionObstructionHypoxia/ARDSHypotension Seizures/cerebral oedemaGlucoseElectrolytesPneumoniaQ7 Orbital FracturesAssociated InjuriesCHI – SAH/SDH/Epidural/Eye – entrapment, ION, Orbital Comp, traumatic mydriasisNeck – Cspine injuryOther Facial bones – nasal inc septal haematoma/zygomaQ8 Paed ElbowAnt humeral/radiocapetellar/fat padsGRUMGaleazzi – Radial # (Prox RU J dislocation)Ulnar # - Monteggia (Radial head dislocation)C1Capitellum (lateral)R3RadiusI5Internal/Medial EpicondylT7Trochlear (medial)O9OlecranonE11External/Lateral EpicondylQ9 Mass Casualty PreparationAny Prep Question- Notification - **CALL**- Space – Triage Seive/Sort Reception area – staffed by a senior nurse/doctorFor resus – cohorting –moving pts to ward – discharging pt – clearing coridoorsDecant to outpts- People – Role allocation as per disaster planED – Nurse TL/teams/DEM/Outside of ED – specialties/theatres/paeds/radiology/labs/blood bank etcFrom HomeAction cards/disaster plan cards/role labels or tabbards etc- Equipment and DrugsABC stuffFluidsVentsMIMMSProblemsSpace – lack of particularly ICU/theatresPeople – fatigue/lack of staff/rostering ongoing if called in all staff/Equipment and Drugs – Running out of things/lack of trolleys/ventilators/BloodMEDIA Pelvic Injury Complications- Bleeding – venous plexus or arterial- Urinary – uretheral injury or bladder perforation, retention, haematuria- Neurology – LL neuro/cauda equine- Bowel - perforation of rectum- Fat embolusANGIO and EMBOLISE – if tjhink bleeding arterial which is more likely when persistently hypotensive with a pelvic injuryPACKING – damage control – particularly when there is assoc intraabdominal injuriesEX FIX - MTP complications - REACTORReactions e.g. mismatchElectrolytes e.g Hyper K, Low CaAcid-Base – Met alkCoagulopathy Temperature - hypoOverload - APORespiratory – TRALI/ARDSQuestion 12Think of an organic cause then think what would be positive in the history for that cause (meningitis/drugs/head injury)Try to cover all aspects of HxHPC – Site/onset/character/relieving/assoc/timing/exac/severityPMH –RF for organic presentations e.g age/prior sepsis/CVA etcMeds – newly startedFH?SH – IVDU etcHISTORYSuddenAssoc with physical sx – feversVisual (as opposed to auditory hallucinations)Drugs or alcoholTraumaPast Hx- risk factors for organic disease e.g conditions causing hypoxia/immunosurp/malignancyAltered conscious state sieveBlood product exposure/needlestickIdentify people – recipient and donorIf STAFF – cover their work/provide supportRisk assessmentSamples – inc consent, Hep B/C/HIV/HTLV1/LFTsProphylaxis – abx/vaccines/PEP/TetanusInformation -written and verbal – sex – giving blood etxFollow up – Occ health or otherwiseSystems review/audit/risk manQ13 – ABGWhat can you calc?A-A GradAGWinters (met acidosis)0.7 (bic) + 20 +/-5 (met alk)1, 2 HCO3, 4, 5 for RESP ACID/ALKDelta Gap/RatioEVEN IF HAVE AN alkalosis –Calculate the AG – if AG is high then you know you also have a met acidosis as well as a met alkQ14 AnaemiaLoss - Bleeding/IDADestruction - HaemolysisLack of production – Marrow failure/B12/Folate/Chronic diseaseQ15 AsthmaA – Not able to maintain own airway – through lack of LOC/CO2/hypoxiaB – Silent chest/no effort/apnoea/refractory hypoxia despiteC – BradycardiaD – Coma/lack of responsivenessINTUBATION PROBLEMSA – Difficult airwayPrep well/plans A to C, Use VL- Failure to secureBack up intubator- Airway traumaCare, stylet inside ETT, watch teethB- HypoxiaPreOx/HFNP/Sit up/Ramp- Hypercarbia – acidosis – arrest due to pHBag during induction if already hyperCO2/low Ph- R main stemEarly ETT check/CXR- PTXLow as possible pressures- Hard to ventilateUse ICU vent/paralyse- Stacking/DHIAwareness/low and slow/long exp times/watch the graphs/permissive hypercarbia/low rates- AnaphylaxisChoose agents carefullyC –HypotensionPush dose pressors/Adrenaline/Fluid loadCVS collapse due to increase pulm pressuresLow as poss pressuresQ16 – Comp SyndromePain out of propPulselessPallorPerishingly coldParaesthesiaParalysisDelta pressure = diastolic blood pressure (DBP) — intracompartment pressureA delta pressure <30 mmHg is suggestive of compartment syndromeComp >20 = badComp >30-40 = necrosis soonQ17 – Missed FractureDealing with a complaint- Deal with any immediate clinical issues- Agree to respond in given timeframe / contact complainant- Gather info from all sources- Review process- Feedback to staff and patient- M&M/Riskman- Educate- AuditTop End Cheat Sheets 4th JULY Abdominal pain in Pregnancy and Preterm LabourQuestion – a x week (third trimester) pregnant lady presents with abdominal pain, give a differential diagnosis and supportive history/exam featuresConditionHistoryExaminationPregnancy related Pre-Term labourContractions painPROMCervical dilatation >3cmCervical EffacementPROMVaginal spotting or SHOWBraxton Hicks ContractionsNon-sever menstrual cramp like pain (DUNN)30-60 second contractions with irregular intervalsAbsence of effacement and dilatationPlacental AbruptionBleedingHypertonic, high frequency contractionsUterine tendernessNon pregnancyRenal ColicSevere colicky LOIN to groin painRenal angle tendernessAppendicitisClassicalFocal tenderness/peritonismMay be displaced superiorlyUTIDysuriaPretty much any reasonable cause of abdo pain but beware. The patient in the question is pregnant for a reason. Stick to pregnancy related if you’re not specifically asked or they want < 3. If they want load you’re gonna have to stick some non pregnancy related ones in thereWhat investigations would you order/perform?Bedside USS/Foetal HR for foetal well-beingCTG monitoring – foetal distressFoetal Lie and position – gestational age, presentation/risks of ongoing labourUltrasound – Cervical length- >3cm excludes pre-term labour- <1.5cm strongly predictive pre-term labourFoetal fibronection (vaginal swab)- 98% negative predictive value for delivery within 7 days - Used to minimize potentially dangerous/expensive interventionG+H reasonableHb maybeYou suspect pre-term Labour how would you treat this?TocolysisNifedipine 20mg PO Repeat if contractions persist at 30mins then 3hrly PRN (max 160mg 24Hrs)If fails prepare for labourNifedipine is the preferred option for tocolysisSalbutamol infusion 2.5mcg per minute titrate up until contractions slow, continue for 24 hours then titrate downIndomethacin Causes adverse foetal an neonatal effectsIndicated in < 28 weeks only50-100mgProgesterone pessary – used as prophylaxis of pre-term birth in ladies with short cervix < 2cmSteroids – Lung mmaturationBetamethsone 11.4mg stat and at 24hrs IMMagnesium – Neuroprotection4g over 20mins1g/hr thereafterGBS +ve or unknown – prophylactic antibioticsActive pre-term labour onlyPenicillin 3g IV stat1.2g Q4hrly for 48HrsTocolysis – Contraindications- Gestation > 34 weeks- Gestation <24 weeks- Placental Insufficiency/abruption- eclampsia- Foetal distress or death in Utero- Chorioaminionitis- Advanced labour (cervix >4cm) SyndromeDiagnostic criteriaFever at least 5 days +At least 4 ofExtremity changes – Erythema, oedema, desquamationBilateral conjunctivitisPolymorphous rashCervical LymphadenopathyChanges in lips and oral cavity – (Pharyngeal oedema, dry/fissured or swollen lips, strawberry tongue\The above establishes the clinical diagnosis they go on to have echo demonstrating coronary diseases and have other similar diseases excludedArthritis urethritis and hepatitis may occurFever persists 1-2 weeksBloods show v high ESR/CRP leukocytosis, normochromic normocytic anemiaComplications Myocarditis7% have ECG changes1% have AMI20% have conduction defects (particularily infants)Coronary artery aneurysm, usually detectable on ECHO+ (according to this weeks answers) Pericarditis/effusion Valve dysfunctionArrythmiaCardiac failure/LV dysfunctionTreatment Aspirin 100mg/kg/dayIV Immunoglobulin 2g/kg – needs to start <10 days from onset to prevent coronary aneurysmDifferentials (of pediatric rash) in this particular question they haven’t really given any description or other clinical symptoms/signs so it could be almost anything. Noone knows anything about rashes do they? I’d go for a list of common (or high risk uncommon) causes, picking from different broad aetiology groupsHeres a list from the BMJ and then a flowchart for distinguishing between typesCommon? HYPERLINK "" \l "expsec-2" Roseola infantum (sixth disease)?Erythema infectiosum (fifth disease)?Epstein-Barr virus infection?Atopic dermatitis? HYPERLINK "" \l "expsec-13" Seborrhoeic dermatitis?Irritant contact dermatitis? HYPERLINK "" \l "expsec-17" Pityriasis rosea?Impetigo? HYPERLINK "" \l "expsec-21" Tinea corporis?Scabies?Insect bites or stings?Child abuse?Cutaneous candidiasis?Cutaneous herpes simplex? HYPERLINK "" \l "expsec-593240" Molluscum contagiosumUncommon?Varicella-zoster? HYPERLINK "" \l "expsec-5" Rubeola (measles)?Cytomegalovirus infection?Hepatitis B?Hepatitis C?HIV seroconversion?Rubella (German measles)?Hand-foot-and-mouth disease?Allergic contact dermatitis?Psoriasis? HYPERLINK "" \l "expsec-18" Mastocytosis?Folliculitis?Rocky Mountain spotted fever?Lyme disease?Simple drug eruption?Chemotherapy?Stevens-Johnson syndrome/toxic epidermal necrolysis?Drug reaction with eosinophilia and systemic symptoms (DRESS)?Erythema multiforme?Systemic hypersensitivity syndrome? HYPERLINK "" \l "expsec-31" Meningococcaemia?Scarlet fever?Staphylococcal scalded skin syndrome?Toxic shock syndrome?Syphilis?Gonorrhoea?Bacterial endocarditis?Food allergy?Leukaemia?Idiopathic thrombocytopenic purpura?Kawasaki disease?Juvenile arthritis? HYPERLINK "" \l "expsec-44" Henoch-Schonlein purpura?Systemic lupus erythematosus?Rheumatic fever?SarcoidosisSalicylate ToxicityRisk assessment < 150mg/kg = Minimal symptoms150-300mg/kg = Moderate, tachypnea, tinnitus, vomiting>300mg/kg = Severe – Metabolic acidosis, altered mental state, seizures>500mg/kg = Potentially lethalWeird stuff- Enteric coated forms form large tablet masses (bezoars) in the stomach delaying absorption- Kinetics change from first to zero order in overdose- High urinary pH promotes excretionInvestigations- Don’t ever forget BSL, paracetamol level and ECG in a tox question- ABG/VBG – HAGMA with Resp alkalosis - Lower than expected CO2- UEC – to detect and correct hypokalemia prior to urinary alkalizationDecontamination> 150mg/kg Activated charcoal 50g PO up to 8 hrs following acute overdose >300mg/kg – secure airway, 50mg Charcoal via NG, repeat at 4 hrs if levels continue to riseEnhanced eliminationUrinary AlkalinisationCorrect hypokalemia first2mmol/kg IV Bicarb bolusBicarb infusion aiming urinary pH >7.5Potassium supplementation Continue until clinical and lab evidence of intoxication improving Haemodialysis – rarely required if decontamination and urinary alkalinisation are performedLevels > 4.4mmol/L despite decontamination/eliminationSevere toxicity (neuro, pH, renal failure)Acute levels >7.2mmol/L (4.4 in chronic toxicity or elderly patient) ................
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