Emergency & acute med 3 Flashcards
(169 cards)
1
Q
Common causes of seizures? 9
A
- epilepsy (incl poor compliance to meds)
- drugs (incl recreational)
- alcohol withdrawal
- low sodium or blood sugar
- infection (meningitis, encephalitis)
- high fever (esp in kids)
- head injury / raised ICP (?SAH)
- brain tumours / mets
- pregnancy related - eclampsia etc (consider in women of child-bearing age)
2
Q
If someone presents after a seizure, what questions should you ask them? (before 2, during 5, after 4)
- important PMH/FHx to ask? 2
- What to ask if had seizure before / known epilepsy?
A
BEFORE
- Any aura? Changes in smell, taste, headaches, - is this familiar to the patient?
- any triggers? what were you doing?
DURING
- Does it sound tonic-clonic? Were they jerking? describe it (need collateral if poss)
- LOC?
- Tongue biting (tip or side)
- Incontinence
- how long did it last?
AFTER
- Are they sleepy? Drowsy? Confused? Dizzy? Nauseous?
- for how long afterwards
- Headache
- Weakness
- any other injuries?
1) Have you ever had this before?
2) Any FHx of epilepsy
3) What was DIFFERENT from previous seizure? (eg length, type of seizure etc)
3
Q
What is the difference between:
- simple and complex seizures?
- partial and generalised seizures?
A
Simple = NO LOC Complex = LOC
partial = focal deficit generalised = whole brain
4
Q
Types of partial seizure? 3
A
SIMPLE PARTIAL SEIZURE
- Awareness is unimpaired, there is focal motor, sensory of autonomic symptoms and no post-ictal symptoms
COMPLEX PARTIAL SEIZURE
- Awareness of the period has been impaired. Focal symptoms during an aura. These most commonly arise from the temporal lobe and if there is an aura then this is supportive of this.
Common to have post-ictal confusion in seizures of the temporal lobe but recovery is more rapid in seizures arising from the frontal lobe
PARTIAL SEIZURE WITH SECONDARY GENERALISATION
- 2/3 of patients who have a focal seizure will have a generalising transformation which typically presents as convulsions
5
Q
Types of primary generalised seizures? 4
A
PRIMARY GENERALIZED SEIZURES
ABSENCE SEIZURES
Brief pauses where the person stops what they are doing/saying for ten seconds or less and then starts again (make sure you ask about these in the history). These will commonly present in childhood
TONIC-CLONIC SEIZURES
L.O.C. Limbs stiffen (tonic) and then jerk (clonic) in turn. You can have one without the other: there is usually a considerable post-ictal period with confusion and dizziness
MYOCLONIC SEIZURES
Sudden jerk of the limb or the face or the trunk. The patient may fall to the ground or have a violently disobedient limb
ATONIC SEIZURES
Sudden loss of muscle tone and fall to the ground (no LOC)
6
Q
Triggers of seizures in known epileptics? 7
A
- poor medication compliance
- lack of sleep
- stress
- missing meals
- alcohol or recreational drugs
- illness / infection
- flashing lights (only 3% of people w epilepsy)
(also menstrual cycle can affect too)
7
Q
Management of someone having a seizure in the ED:
- Approach?
- positioning and initial 2 interventions?
- when to give medication and options of what to give 1st line?
- 2nd line medication?
- 3rd line medication?
- 4th line medication?
- when to alert anaesthetist? 2
- bloods? 5
- what to make sure to do as part of ‘exposure’? 2
- what other meds to consider giving? 2
A
A-E approach
- recovery position (and remove tight fitting clothing)
- nasopharyngeal airway
- high flow oxygen
WAIT 5 MINS (time it!)
then give either:
- IV lorazepam
- buccal midazolam
- rectal diazepam
WAIT 10 MINS
- give 2nd dose of benzos (don’t give more than 2 doses as can lead to resp depression)
WAIT 10 MINS
- loading dose then infusion of phenytoin
WAIT 10 MINS
- give propofol or thiopentone (neuroprotective)
ALERT ANESTHETIST
- when GCS <8
- when about to give phenytoin
- ABG
- glucose
- FBC
- UandE
- blood cultures, if pyrexial
(other bloods as well probs - could justify most) - check for rashes or fever (meningitis) or head injury signs
- glucose (if hypoglycaemic)
- pabrinex (thiamine - if suggestion of alcohol abuse or malnutrition)
8
Q
What are the 2 definitions of status epilepticus?
A
continuous seizure lasting >30mins
OR
repeated seizures with breaks but GCS stays <15 in breaks
nb it may start tonic clonic then diminish making diagnosis difficult (coma and minimal twitching only )
- can also get non-convulsive status epilepticus - hard to diagnose (need eeg)
9
Q
Who should get a CT head following a seizure?
Which of these should be done as an emergency?
A
Following any ‘first fit’
emergency:
- focal signs
- head injury
- known HIV
- suspected intracranial infection
- bleeding disorder
- conscious level failing to improve
10
Q
What additional test should you do for women of childbearing age who have a seizure?
A
pregnancy test
as may be sign of pre-eclampsia
if pregnancy-related fit = us IV magnesium sulphate
11
Q
If patient has a ‘first fit’ - when are they allowed to be discharged? 4
What is the follow-up? 1
what advice must be given in the interim, before follow up? 1
who must be admitted and not discharged?
A
- normal neuro exam
- normal cardiac exam
- ECG normal
- electrolytes normal
follow up appointment in ‘first fit’ clinic
not allowed to drive until have seen specialist
if multiple seizures, admit
12
Q
Definition of a stroke?
A
Acute onset of neurological deficit lasting >24 hours (if it is less then it is a TIA), of VASCULAR origin.
13
Q
Symptoms/signs of anterior circulation stroke? 6 (also which arteries norm affected)
Symptoms/signs of posterior circulation stroke? 7 (also which arteries norm affected)
A
ANTERIOR = branches of internal carotids - unilateral limb weakness - unilateral numbness / loss of sensation - unilateral facial droop - speech disturbances - cognitive impairment - visual field disturbances
POSTERIOR = branches of basilar artery (so affect the cerebellum!!) - nausea - dizziness / vertigo - memory loss - lack of coordination - ataxia / loss of balance / gait change - limb weakness - sensory deficits bilaterally
14
Q
Stroke: examination:
- approach?
- examinations to do? 5
- what else to assess, for safety?
A
A-E approach (incl GCS)
- Cranial nerve
- UL neuro
- LL neuro
- cerebellar exam
- cardiac exam (carotid bruits, murmurs, AF)
- assess pts swallow, if not okay make NBM
15
Q
Investigations:
- score to use for TIA? 1
- score to use for stroke? 1
- bedside? 1
- bloods? 3
- imaging? 1
- bloods to consider? 1
A
ABCD2 score for TIA
Rosier score for stroke
- ECG (looking for AF)
- FBC
- UandE
- glucose (always exclude hypoglycaemia)
CT head (non-contrast) - whether is emergency or not depends on timing of presentation and other factors
ABG (if sats <94%)
16
Q
Who gets an emergency CT head following a stroke:
- timing of presentation? 1
- other indications? 7
A
If patient presents WITHIN 4 HOURS of symptoms
- as may be able to thrombolyse
- patient is on anti-coagulant
- severe headache at onset
- fever
- neck stiffness
- GCS <13
- unexplained progressive or fluctuating symptoms
- papilloedema
nb pretty much all patients with a stroke get a CT at some point
17
Q
Possible management options for stroke? 3
- who is eligible for each?
A
nb the first two can only be given at places with specialist stroke services!
THROMBOLYSIS (alteplase)
- if can start within 4.5 hours of symptom onset
AND
- if intra-cranial haemorrhage has been excluded by CT
THROMBECTOMY
- if thrombotic stroke of PROXIMAL anterior or posterior circulation confirmed (using CT or MRI angiography)
AND
- presentation within 24hrs
AND
- there is potential to salvage brain tissue, as shown by imaging
ASPIRIN (300mg)
- give to EVERYONE who presents within 24hrs following stroke
AND
- haemorrhagic stroke excluded by CT
- followed by maintenances dose anti-platelet for weeks
- nb give PPI as well if dyspepsia risk factor
18
Q
sub-arachnoid haemorrhage:
- description of headache?
- other symptoms? 6
- What PMHx and FHx to ask about?
A
- SUDDEN onset (biggest clue!)
- very severe
- feels localised to back of head
- feels like being hit over back of head with something
- LOC (15% only present with this!)
- neck pain
- photophobia
- VOMITING
- drowsiness and confusion
- unilateral eye pain can occur
nb in 25% of cases, exertional activities precede the event
1) pmhx HTN?
2) Any FHx of aneurysms or strokes?
19
Q
Sub-arachnoid haemorrhage:
- which examinations to do? 4
- what is most common exam finding?
- what important to look at in the obs? 3
- why?
A
- cranial nerve exam
- UL neuro
- LL neuro
- cerebellum exam
oculomotor nerve palsy (characteristic of a berry aneurysm in posterior communicating artery)
- increase in BP
- bradycardia
- irregular breathing
= cushings triad / response
= sign of raised ICP
20
Q
Sub-arachnoid haemorrhage:
- approach?
- bedside investigations? 2
- bloods? 4
- imaging? 1
- what to do if imaging normal? 1
A
A-E approach
- fundoscopy
- ECG (ischaemic changes)
- glucose
- FBC
- UandE
- CLOTTING
- emergency head CT
if CT normal, do an LP after 12 hours - looking for xanthochromia in the CSF
21
Q
Sub-arachnoid haemorrhage management:
- what to keep monitoring? 1
- immediate medication? 4
- which teams to involve? 2 (when?)
A
- monitor O2 sats - give O2 if low
- analgesia
- anti-emetic
- NIMODIPINE (as soon as SAH confirmed - repeat every 4 hrs, prevents vasospasms)
- MANNITOL (if evidence of increased ICP)
- neurosurgical team (once diagnosis confirmed by CT)
- anaesthetist (if GCS <8 or very agitated)
22
Q
Syncope: definition?
symptoms of vasovagal syncope? (before 5, during 2, after 1)
what other question if it really important to ask in the context of syncope?
ideally what other type of history should you obtain in a pt with syncope?
A
sudden TRANSIENT LOC with SPONTANEOUS complete recovery
BEFORE - feel unwell / nauseous - feeling warm - light-headed - palpitations - blurred vision / dots in vision DURING - short LOC - no side-tongue biting, may be tip of tongue or myoclonic jerks, esp if person can't get supine AFTER - fast recovery - within 5 mins
WHAT WERE YOU DOING AT THE TIME? (exertional syncope is not a good sign)
get collateral hx - if possible!
23
Q
Examination for syncope:
- what sort of exams should you do? 2
- what other specific features should you look for? 3
- what causes of syncope must you not miss? 6 (acronym and how to exclude each)
A
- full cardiac exam
- full neuro exam
- signs of tongue biting
- incontinence
- any injuries
A PEARS
ACS
- ecg and troponin
PE
- risk factors, wells score
Ectopic pregnancy
- ask about abdo pain and vaginal bleeding in women of CBA
Aortic dissection
- BP in both arms
Ruptured AAA
- abdo pain, feel for expansile pulsatile mass in abdomen
SAH
- signs of meningeal irritation
24
Q
Syncope investigations:
- bedside? 2
- bloods? 3
A
- ECG
- lying and standing BP
- glucose
- FBC (anaemia big cause)
- UandE
25
Who to admit to cardiology following syncope? 6
- abnormal ECG (compare to previous)
- heart murmur
- evidence of new heart failure
- LOC of exertion
- aged over 65 with no prodrome
- FHx of sudden death or inherited heart condition
26
Who can you safely discharge following a syncope? 4
- full recovery
- likely vasovagal
- no new ECG signs
- no other signs or worrying features
nb if frequent episodes, may consider referral to neuro or cardio
27
Risk factors for falls in the elderly:
- biggest two risk factors?
- conditions affecting mobility and balance? 5
- other co-morbidities? 2
- other risk factors? 3
= aged over 65
= one or more falls in last 12 months
- arthritis
- diabetes
- incontinence
- stroke
- parkinsons disease
- cognitive impairment
- visual impairment
- polypharmacy and / or certain medications
- fear of falling
- physically frail
28
Which groups of medications increase your risk of falls (esp in elderly)? 8
- opiates
- benzodiazepines
- antipsychotics
- anticonvulsants
- antihypertensives
- antidepressants
- diuretics
- alcohol use!!!
29
Two tests to assess people's risk of falling?
what does each involve?
TIMED GET UP AND GO
- person has to get up from chair (without using arms), walk 3m, turn around, return and sit back in chair
- should take <12-15secs
- can do it with normal walking aid
TURN 180 deg TEST
- person has to stand up and step around until they are facing in opposite direction
- risk of falls if person takes >4 steps
30
Who should be offered a multi-factorial falls risk assessment, ie in specialist falls service? 3
anyone >65 who:
- has had 2 or more falls in last 12 months
OR
- present for medical attention following a fall
OR
- cannot perform, or perform poorly on timed up and go test and/or turn 180 test
31
Possible interventions to reduce falls in elderly? 7
- medication review
- OT review / home hazard assessment
- physio review / strength exercises
- optimise eyesight / glasses
- give walking aids
- wear sensible shoes
- reduce alcohol intake
32
amphetamine overdose:
- most common causative drug in the UK?
- little bit of pathophysiology
- early symptoms? 8
- late symptoms? 2
MDMA (aka ecstacy)
-> release of serotonin, cathecholamines, DH secretion -> abnormal thirst and excessive oral intake -> hyponatraemia and cerebral oedema
- euphoria
- agitation
- delirium
- sweating
- palpitations
- fever
- vomiting
- abdo pain
= seizures
= reduced consciousness
33
Amphetamine overdose, what to ask when doing patient hx or collateral history? 5
- substances ingested
- volume
- route
- timing
- alcohol as well?
34
Amphetamine overdose:
- findings in obs? 3
- other examination findings? 3
- tachycardia
- hypertension
- pyrexial
- sweating
- DILATED pupils
- hyperreflexia
35
Amphetamine overdose, serious complications to look out for? 5
- seizures
- metabolic acidosis
- rhabdomyolysis / AKI
- stroke
- MI
36
Amphetamine overdose: investigations:
- bedside? 2
- bloods? 4
- ECG (looking for ACS)
- urine dipstick (for blood)
- ABG/VBG (acidosis)
- FBC
- UandE (hyponatraemia and AKI)
- glucose
37
Management of amphetamine overdose:
- approach?
- bedside to do? 2
- medication to consider? 2
- who to inform? 1
A-E assessment
treatment is primarily supportive, no reversal agent available!
- try to cool patient - MAIN AIM!
- restrict fluid intake and give saline hypertonic (2.7%) drip if have hyponatraemia
- activated charcoal (if < hour since ingestion)
- consider benzo to manage agitation and reduce fever
inform ICU if need help!
38
Opioid overdose main symptoms / signs? 3
- low RR (<8)
- decreased GCS
- pinpoint pupils
39
What questions to ask during a collateral history of opioid overdose? 6
- what ingested?
- when?
- how much?
- anything else taken? (esp alcohol or benzos)
- recreational or prescribed?
- intentional or accidental?
40
Investigations / management of opioid overdose:
- approach?
- bedside intervention? 1
- medication to give? 1
- things to be aware of when giving this medication? 2
- what to do before discharging? 2
A-E approach
- give oxygen to correct hypoxia / hypercapnia
NALOXONE
1) in addicts, giving it can precipitate withdrawal symptoms: abdo cramping, nausea, diarrhoea, agitation
2) half-life is shorter than opioids so may need to give more than one dose or set up an infusion
nb if it is someone with chronic pain that is over opiated then may be better to just wean them off as naloxone will make their pain come back!!
either mental health risk assessment if intentional / recreational (incl capacity assessment)
OR
medication review if prescribed / accidental
41
paracetamol poisoning:
- early symptoms? 3 (incl time frame)
- mid symptoms? 2 (incl time frame)
- late symptoms? 5 (incl time frame)
```
EARLY <24hrs
- nausea and vomiting
- sweating
- abdo discomfort
(nb often get no symptoms though - anything more than N+V is suggestive of liver damage)
```
MID 24-72 hrs
- RUQ abdo pain (liver capsule stretching)
- more N + V
```
LATE 3-5 days
= symptoms of liver failure
- jaundice
- coagulopathy (bleeding / bruising)
- encephalopathy (confusion, drowsy, agitated, seizures)
- low glucose, can -> coma
- anuric, renal failure
```
42
Taking a history of someone who took a paracetamol overdose:
- medical questions? 7
- psych questions? (6 before, 3 during, 9 after)
- number of tablets taken (and dose)
- when taken (essential!)
- over how long
- anything else taken alongside, other tablets / alcohol
- comorbidities (esp affecting the liver) and mental health history and norm alcohol consumption
- previous deliberate self harm
- DHx (esp anything affecting p450 system)
BEFORE
= any precipitant? (eg argument with partner)
= planned or impulsive?
= where got pills from? stockpiling?
= write a note?
= any precautions against discovery (locking doors, closing curtains, waiting till knew be alone, going somewhere remote)
= was alcohol used?
DURING
= was patient alone
= what was intention? to kill? to harm?
= did you think it would kill you?
AFTER
= what did they do straight after?
= did call anyone? how get to a+e? who were they found by?
= how felt when help arrived?
= do you regret it?
= do you still feel suicidal?
= what would you do if went home today?
= if you were to feel like this again, what would you do?
= what might prevent you from doing this again? anything to live for? (protective factors)
= will they accept treatment?
43
Investigations for paracetamol overdose:
- bedside? 1
- bloods to consider? 6 (WHEN to do each)
- ECG (may be tachycardic)
- LFT
- VBG
- Clotting
- U+E
- blood glucose
^do all of these on admission to get baseline
- PARACETAMOL LEVELS
(do after 4 hours of ingestion)
44
management of paracetamol overdose:
- what to consult? 1
- what to give if < 1 hour since OD? 1
- what medication give? 1
- what is dose dependant on? 1
- how do you calculate if need to give medication? 1
- who do you always give the medication to? 5
- how do you give the medication and over what period? 3
- other medication to consider giving?
TOXBASE (esp paracetamol graph)
activated charcoal if < 1 hour
acetylcysteine (aka pabrinex)
dose is dependant on weight
take paracetamol blood level 4 HOURS after ingestion
- then plot against paracetamol curve - if blood plasma is ABOVE curve then treat - if not then don't need treatment
ALWAYS GIVE TO (ie don't wait the 4 hours):
- any clinical signs of liver damage
- any NEW deranged LFT/clotting (if chronic, discuss with toxbase)
- staggered overdose
- uncertain time of overdose
- overdose was over 8 hours ago
```
First infusion
- over 1 hour
second infusion
- over 4 hours
third infusion
- over 16 hours
21 hours in total, the reassess
```
(dose depends on weight)
GIVE ANTIEMETIC IF NAUSEOUS!
45
What dose (per kg) is deemed a significant paracetamol overdose, likely to cause harm?
what is the definition of a 'staggered overdose'?
over 75mg/kg in less than an hour
any overdose taken over longer than 1 hour = staggered
46
What should you always do before discharging someone that has taken a deliberate paracetamol overdose? 2
What section of the mental health act allows you to detain someone in hospital against their will? for how long?
get mental health team to do a risk-assessment
safety net them for harmful symptoms:
- abdo pain
- N+V
- jaundice of skin or white of eye
- confusion or drowsiness
- difficulty passing urine
section 5.2
- hold someone in hospital for 72 hours!
- mental health has to assess their capacity in this time!
47
What is the main side effect of the treatment for paracetamol overdose?
anaphylaxis reactions with acetylcysteine (aka pabrinex)
| up to 30% of people who receive it
48
Tricyclic antidepressant overdose:
- normal drug caused by?
- signs and symptoms? 10
amitriptyline
basically anti-cholinergic effects (so fight or flight)
- tachycardia
- hypertension
- dry mouth
- dilated pupils / blurred vision
- urinary retention
- ataxia
- jerky limb movements
- increased muscle tone
- increased reflexes / plantar response
- decreased GCS
49
Taking a history of someone who took a tricyclic antidepressant overdose:
- medical questions? 7
- psych questions? (6 before, 3 during, 9 after)
- number of tablets taken (and dose)
- when taken
- over how long
- anything else taken alongside, other tablets (esp aspirin)/ alcohol
- comorbidities and mental health history and norm alcohol consumption
- previous deliberate self harm
- DHx
BEFORE
= any precipitant? (eg argument with partner)
= planned or impulsive?
= where got pills from? stockpiling?
= write a note?
= any precautions against discovery (locking doors, closing curtains, waiting till knew be alone, going somewhere remote)
= was alcohol used?
DURING
= was patient alone
= what was intention? to kill? to harm?
= did you think it would kill you?
AFTER
= what did they do straight after?
= did call anyone? how get to a+e? who were they found by?
= how felt when help arrived?
= do you regret it?
= do you still feel suicidal?
= what would you do if went home today?
= if you were to feel like this again, what would you do?
= what might prevent you from doing this again? anything to live for? (protective factors)
= will they accept treatment?
50
Investigations for tricyclic antidepressant overdose:
- bedside? 2
- bloods? 1
- 12-lead ECG (prolonged PR or QRS, heart block, ventricular dysrhythmias)
- cardiac monitoring
- ABG (for acidosis)
51
Management of tricyclic antidepressant overdose:
- approach? 1
- medication to consider? 5 (+ when to do so)
- who should you contact?
A-E assessment
OBSERVE CLOSELY
- nb treatment is mainly supportive, treat things as you find them!
- consider activated charcoal (if < 1 hour since)
- consider sodium bicarbonate (if acidotic)
- consider intralipid
- correct hypotension and arrythmias
- give lorazepam or diazepam if seizure
CONTACT TOXBASE!! for help!
52
What is antidote to benzodiazepine overdose?
when not to give?
flumenazil
(give as part of A-E approach)
don't give if mixed overdose (ie with other drugs too)
53
What is antidote to beta-blocker overdose?
glucagon
- give as part of an A-E approach
54
What resource should you always consult in case of poisoning or overdose of any substance?
What medication can sometimes be used to 'absorb' toxins?
TOXBASE!
intralipid
55
What is the two stage test for assessing capacity?
What things can you do to help someone have capacity? 6
1) Does the person have an impairment of their mind or brain, whether as a result of a mental or physical illness, or external factors such as alcohol or drug use?
2) Is a person able to:
- UNDERSTAND the info relevant to the decision
- RETAIN the info
- WEIGH UP the info as part of the process of making the decision
- COMMUNICATE their decision, verbally or otherwise
- ensure information is easy to understand
- use different types of communication (verbal, non-verbal etc)
- can someone else (carer, family) help with communication
- particular times of day when pts understanding is better
- particular locations where pt may feel more at ease
- can the decision be delayed until they regain capacity?
capacity is TIME and DECISION specific
56
What is the acronym for people at risk of suicide?
SAD PERSONS
- Sex: male
- Age <19 or >45
- Depression or hopelessness
- Previous attempts or psych care
- Excessive alcohol or drug use
- Rational thinking loss
- Separated / divorced / widowed / single
- Organised / serious attempt
- No social support
- Stated future intent
57
Doing a self-harm risk assessment following deliberate self harm:
- what to ask about the current episode? (6 before, 5 during, 10 after)
- extra Qs if overdose? 6
- extra Qs if cutting? 6
(see other cards on what else to put in risk assessment)
BEFORE
- precipitant?
- planned or impulsive?
- final acts? (note, will, terminating contracts)
- precautions against discovery? (locking doors, closing curtains, waiting till knew be alone, somewhere remote)
- alcohol used?
- what did you think / hope would happen?
DURING
- what did you do?
- where were you?
- were you alone?
- what was going through your mind?
- did you think it would kill you?
AFTER
- what did you do immediately afterwards?
- did you call anyone?
- how did you get to A+E? who found by?
- how did you feel when help arrived?
- any regret now?
- still feel suicidal?
- if go home today, what would you do?
- if feel like this again, what will you do?
- protective factors? anything to live for?
- will they accept treatment?
IF OVERDOSE:
- what taken? anything else?
- dose? number of pills?
- when did you do it? over how long?
- where get from?
- what take pills with?
- what did you think that amount of pills would do?
IF CUTTING
- where are cuts?
- number of cuts?
- how deep are cuts?
- how did you feel whilst cutting?
- how did you feel when you saw blood?
- what were you hoping the cutting would do?
58
Doing a self-harm risk assessment following deliberate self harm:
- what to ask about any previous episodes? 3
- psych hx qs? 2 what to do if no hx?
- PMHx qs? 3
- DHx qs? 3
- FHx qs? 2
- SHx qs? (3 major sections, with qs for each)
(see other cards on what else to ask about current episode in risk assessment)
- any self harm in the past? when?
- what methods?
- gain any help as a result?
PSYCH Hx
- any mental health conditions?
- any previous admissions to hospital or psych hospital?
IF NONE:
- screen for:
---- depression (anhedonia, low mood, fatigue)
---- psychosis (are thoughts ever not your own? heard voices?)
---- alcohol dependency
---- anorexia
PMHx
- any relevant to current episode (eg bleeding disorders, liver problems)
- chronic pain?
- others?
DHx
- allergies
- regular meds
- OTC? herbal? (incl st johns wart)
FHx
- any family members attempted or completed suicide?
- any mental health conditions in close fam members?
SHx
LIVING SITUATION
- who with?
- where?
- good support?
- manage ADLs?
- any children? (ask about them)
OCCUPATION
- job?
- if none, how coping financially? any debt?
ALCOHOL and DRUGS
- how much alcohol?
- pattern of drinking?
- any recreational drug use?
- what? how often? how much? who with?
59
What 3 safeguarding questions should be asked following an episode of self-harm in someone with children?
- are they being neglected?
- do they witness episodes?
- does parent have any thoughts of harm towards children?
60
symptoms of meningitis:
- three symptoms of meningism?
- other symptoms? 10
- additional symptoms in infants? 3
= headache
= photophobia
= nuchal rigidity (aka neck stiffness - can't do neck flexion)
- nausea + vomiting
- FEVER
- irritability
- drowsy / reduced GCS
- cold hands and feet
- pale skin
- non-blanching skin rash (late sign)
- muscle or joint pain
- SOB
- seizures
infants
- refuse feeds
- stiff or floppy body
- bulging fontanelle ('soft spot')
nb rash only if it's caused by neisseria meningitidis
nb may start as flu-like illness in elderly or immunocompromised
61
What are most cases of meningitis caused by?
what's more serious?
Which 3 age groups are most likely to get meningitis?
normally viral
- bacteria, esp meningococcal, are rarer but more serious!
1) infants and young children
2) young adults
3) older adults
62
What are the two special tests on examination which you can do to look for meningitis?
how good are they?
KERNIG'S SIGN
- with the pt supine and thigh flexed to 90 deg
- attempts to straighten or extend leg met with resistance
BRUDZINSKI'S SIGN
- flexion of neck cause involuntary flexion of knees and hips
not very sensitive
- only present in 20-50% of cases
- but worth doing as about 90% specific
63
investigations and management of suspected meningitis:
- approach? 1
- bedside investigations to do? 2
- bloods to do? 7
- imaging to consider? 1
- medications to give immediately? 2
A-E approach
- fundoscopy
- LP (only if no signs of raised ICP)
- ABG
- blood cultures
- FBC
- U+E
- LFTs
- glucose (need this to compare to LP glucose)
- CRP
- clotting screen (do this! as can't do LP without!)
- CT scan (if suspect raised ICP)
1) IV empirical antibiotics
2) IV steroids
nb if septic shock, do bufalo
64
Suspected meningitis:
- Which empirical abx should be given to everyone?
- which age groups should have additional empirical abx?
- empirical treatment in penicillin allergy?
- what should be given in out of hospital (eg GP) before transfer to hospital if possible?
EVERYONE
- cefoTAXime - "pay your TAXes so kids don't die of meningitis"
AGED < 3 months OR > 50 years
- check local guidelines but add in something like ampicillin or amoxicillin
PENCILIN ALLERGY
- chloramphenicol
PRE-HOSPITAL
- IM benzylpenicillin
nb once get lumbar puncture and blood cultures back then can switch abx to most suitable or switch to anti-viral/supportive care if is viral
65
What are the two main contraindications for doing a lumbar puncture?
- raised ICP
| - coagulopathy (hence why do clotting)
66
Space-occupying lesion:
- socrates description of the headache?
- other possible neuro symptoms? 5
- other symptom? 1
headache
- persistent (had for long period of time)
- always on same side
- dull / achey
- MADE WORSE BY lying down OR straining OR bending forward OR coughing
- associated focal neurological symptoms
- vision changes
- weakness
- sensation changes
- seizures
- personality changes (get collateral hx)
= vomiting (dt raised ICP)
67
Space-occupying lesion
- examinations to perform? 3
- bedside tests? 2
- blood tests? 3
- imaging? 1
- cranial nerve
- UL neuro
- LL neuro
- FUNDOSCOPY
- ECG
- FBC
- U+E
- glucose
CT head
68
initial management of space occupying lesion:
- who to refer to?
- medication to consider? 2
- neurosurgery
- analgesics
- dexamethasone (if cerebral oedema)
basically not managed in the acute setting - just keep stable until can be transferred
nb if present with a seizures then manage these in normal way - benzos etc
69
Temporal arteritis:
- features of headache?
- other places where in pain? 3
- other symptoms? 6
- condition it's associated with? 1
- who should it be considered in? 1
headache
- unilateral
- pulsatile
- jaw claudication (pain on chewing)
- scalp tenderness (worse when brushing hair)
- myalgia
- shoulder girdle stiffness
- weight loss
- general malaise
- night sweats
- low grade fever
- reduced or loss of vision (late sign - act fast!)
associated with polymyalgia rheumatica
should be considered in anyone OVER 50 with new onset headache or change of headache pattern (almost non-existent if <50)
70
temporal arteritis:
- signs on examination? 3
- bedside test to do? (and signs you find on this)
- area over the temporal artery may be Tender, Erythematous and Pulseless
FUNDOSCOPY
- pale papilloedema
- ischaemic disc is pale, waxy, elevated
- splinter haemorrhage
71
temporal arteritis initial investigations:
- bedside? 1
- bloods? 2
fundoscopy
- ESR (will be raised at >40 - though a normal ESR doesn NOT exclude temporal arteritis)
- FBC (may be anaemia)
nb do biopsy as well as gold-standard investigation but don't wait for this before starting management
72
initial management of temporal arteritis:
- medication given and roughly what dose?
- who to refer to urgently?
200mg IV hydrocortisone OR 40mg PO prednisalone
- don't learn exact doses - just know that it is HIGH-DOSE steroid stat!
then URGENT referral to opthalmology (or neurology)
73
Venus sinus thrombosis:
- what is it?
- sinus most commonly occurs in?
- three different presentations? (depend on location: 4,4,5)
- two conditions that must be excluded?
```
acute thrombosis (blood clot) in the dural venous sinuses (which drain blood from brain)
- aka cavernous
```
SAGITTAL = most common
- headache
- vomiting
- seizures
- visual changes
TRANSVERSE
- headache
- mastoid pain
- focal CNS signs
- seizures
```
SIGMOID
- headache
- oedematous eyelids
- proptosis
- painful opthalmoplegia
- fever
(this often spreads from facial pustules or folliculitis)
```
TO EXCLUDE
- meningitis
- SAH
Nb often presents with stroke-like symptoms and so is misdiagnosed! - but don't get headache with stroke (unless SAH)
nb these are WORST HEADACHE EVER
74
Groups of causes of / risk factors for venous sinus thrombosis:
- prothrombotic states? 6
- others? 3
HYPERCOAGUABLE
- pregnancy
- post-partum (up to 3 months)
- malignancy (+ chemo drugs)
- haematological conditions (eg polycythaemia vera, sickle cell, TTP etc)
- clotting disorders (eg factor V leiden)
- dehydration
OTHER
- sinus INFECTIONS (or facial or orbital)
- head injury
- recent LP
nb infections are a big cause (known as septic venous sinus thrombosis) - always ask about recent infections in head and neck and any current symptoms
75
Investigations for venous sinus thrombosis:
- bedside? (1 to do, 1 to consider)
- bloods? 3
- imaging to exclude other things? 1
- imaging to confirm diagnosis? 1
- fundoscopy (papilloedema)
- consider LP (elevated opening pressure, inflam cells if septic)
- FBC (raised WCC if septic)
- U+E (dehydration)
- blood cultures (if suspect septic)
- plain CT (to rule out SAH if sudden onset pain - won't visualise thrombus though!)
- MR or CT venogram is for diagnosis (which one you use depends on location of clot, may do both)
nb further down the line may consider antiphospholipid or factor V leiden blood tests to find out cause (ie thrombophillia screen) - but sometimes cannot find one
76
venous sinus thrombosis management:
- medication to give?
- medication to consider? 2
- who to refer to?
IV unfractioned heparin
if septic:
- antibiotics
- consider steroids
refer to neuro
77
Croup:
- symptoms that normally precede?
- croup symptoms? 4
- age group most common in?
- what norm the cause?
coryzal symptoms norm precede
- barking cough
- stridor
- hoarse voice
- low grade temp
kids age 6 months - 6 years (though can happen to anyone)
(epidemics spring + autumn)
norm parainfluenza virus
78
Examination to do for croup? 1
Signs to look for in croup that indicate the severity? 5
score which encompasses these and used to judge severity?
- respiratory exam! esp looking for any signs below and obs (also beware of the newly drowsy pt)
WESTLEY CROUP SCORE
- STRIDOR
(none, only when upset /agitated, at rest)
- SUBCOSTAL RETRACTIONS
(mild, moderate, severe)
- AIR ENTRY
(norm, mild decrease, marked decrease)
- SPO2 <92% ON AIR
(no, with agitation, at rest)
- LEVEL OF CONSCIOUSNESS
(norm, altered)
score various things for different bits but basically goes into mild, moderate and severe
ALSO LOOK for other signs of resp failure: cyanosis, tracheal tug, nostril flare etc
79
management of croup:
- medication for all? 1
- who needs to be admitted?
- other medication if severe? 1
- other interventions if severe? 2
nb croup is a clinical diagnosis (just do exam + obs)
ORAL DEXAMETHASONE (for all)
anyone scoring >3 on Westley scale (ie moderate or severe) needs to be admitted - eg stridor at rest
if severe: nebulised ADRENALINE! (nb not salbutamol!)
also consider:
- oxygen (if low sats)
- intubation (if impending resp failure)
80
What is the definition of diarrhoea? (ie how many loose stools in what timer period)
THREE or more loose / liquid stools in 24 HOURS
81
If someone presents with acute diarrhoea, what are your top differentials? (5 common, 3 uncommon)
= acute gastroenteritis (incl noro, food poisoning etc)
= IBD (also coeliac)
= IBS
= medications
= c.diff (following abx - nb this is effectively gastroenteritis)
less common
= ischaemic bowel
= radiation injury
= overflow diarrhoea
82
acute diarrhoea:
- questions to ask about stool? 5
- GI associated symptoms to ask about? 3
- systemic symptoms to ask about? 4
STOOL
- consistency? (bristol)
- how many times / frequency?
- mucus?
- blood?
- constipation? (get before overflow)
ASSOCIATED:
- abdo pain (socrates)
- nausea + vomiting? (consistency, freq, blood)
- urinary symptoms (blood, freq, colour - dehydrated)
SYSTEMIC: AW FS FIN
- APPETITE (also ask about fluid intake)
- WEIGHT LOSS
- fatigue
- sleep
- FEVER
- itch
- NIGHT SWEATS
83
acute diarrhoea:
- pmhx to ask? 3
- fhx to ask? 1
- dhx to ask? 4
- shx to ask? 6
PMHx
- had this before?
- any crohn's or UC or IBS?
- any food intolerances?
FHx
- any crohn's or UC or IBS?
DHx
- any allergies (incl food intolerances)
- any recent changes / additions?
- any recent abx (c. diff)
- any laxatives
SHx (ASd OHa DoT)
- alcohol
- smoking
- occupation (looking for food/health occupations - should be 48hrs clear before go back to work)
- home situation - ANYONE ELSE ILL? contact tracing
- diet (any changes)
- Travel (any recent)
84
acute diarrhoea:
- what examination to do?
- what two parts not to forget?
GI exam
- PR
- hydration status (ask them about fluids, thirsty, urination etc - look at mucus membranes, sunken eyes, cap refill etc)
85
investigations for acute diarrhoea:
- bedside to consider? 2
- bloods? 2
- MRSA screen
- stool sample / microscopy (maybe occult blood?)
- FBC
- U+E
(maybe LFT)
86
management of acute diarrhoea:
- bedside for all? 2
- meds to consider? 2
- if C. Diff? 1
- fluids (oral or IV)
- rehydration salts (if need)
- antiemetics (if N+V)
- paracetamol (if pain, fever)
C. DIFF
- PO/IV metronidazole or PO vancomycin
- (also stop offending abx)
87
OTITIS MEDIA
- localised symptoms? 4
- systemic symptoms? 3
- what may precede it?
- age group most common in?
- ear ache
- tugging at the ear
- deafness (if sudden + discharge, may indicate perforation)
- discharge (means it's perforated - always ask!)
- irritability
- lethargy
- fever
may be preceeded by a resp tract infection
most common aged 3-6 years (can be any age though)
88
OTITIS MEDIA:
- examinations to do? 2
- what can you see on each?
1) OTOSCOPY
tympanic membrane
- evidence of inflammation
- loss of light reflex
- bulging
if perforated
- visualise perforation
- purulent discharge
may also be erythema in external auditory canal
2) MASTOID
- look for associated swelling / erythema over mastoid (implies secondary mastoiditis)
89
OTITIS MEDIA
- how diagnosis made?
- bedside investigation to consider?
- bloods to consider?
otitis media is a clinical diagnosis
- can do ear swab
- can do blood cultures is pt systemically unwell
90
OTITIS MEDIA
- medication for all?
- medication to consider? (who to give to - 3)
- who to refer? 4 (and who to refer to)
- additional advise for perforation? 2
- oral analgesia
consider oral abx (5 days amox - clarithro if pen allergic) if:
- systemically unwell (ongoing fever with discharge / perforation)
- mastoiditis
- duration over 4/5 days
nb if perf alone but not systemically unwell then don't
ENT referral
- recurrent
- non-healing perforation
- significant hearing loss
- mastoiditis
if perforation
- no swimming or bath for about ?4 weeks
- GP follow-up
91
TONSILLITIS
- localised symptoms? 3
- systemic symptoms? 3
- most common age groups?
- pain on swallowing (dysphagia)
- sore throat
- cough
systemic (Aw Fs Fin)
- APPETITE
- weight loss
- FATIGUE
- sleep
- FEVER
- itch
- night sweats
most common in school age children
92
TONSILLITIS:
- examinations to do? 2
- investigations to consider? 3
- criteria for determining between bacterial or viral? 4
- examine back of throat
- examine lymph nodes
- throat swab (if severe)
if think glandular fever:
- FBC
- paul-bunnel test (mononuclear spot test)
CENTAUR CRITERIA (more likely to be bacterial - if 3+ give abx)
- fever >38
- tonsillar exudate
- absence of cough
- cervical lymphadenopathy
93
TONSILLITIS:
- medication for all?
- criteria for determining if get abx? 4
- which abx to give?
- which abx to avoid?
- analgesia for all (paracetamol and ibuprofen)
CENTAUR CRITERIA (more likely to be bacterial - if 3+ give abx)
- fever >38
- tonsillar exudate
- absence of cough
- cervical lymphadenopathy
penicillin or clarithromycin
(don't use amoxicillin - as gives a rash if have comorbid glandular fever)
94
TONSILLITIS:
| - potential complications? 3 (describe symptoms of most common of these)
PERITONSILLAR ABSCESS (quinsy)
- pain localises to one side (bilateral abscess is v rare)
- swelling on one side
(needs IV benpen and aspiration + drainage)
OTITIS MEDIA
RETROPHRAYNGEAL ABSCESS
95
taking a Hx from patient with acute lower back pain in the ED?
- what are the four severe conditions that cause low back pain which you are trying to rule out in the ED? 4
- what are the 3 commonest causes of back pain in the ED?
- what pneumonic for HPC? 8
- additional Qs specific to low back pain within this pneumonic? 17
- leaking aortic aneurysm
- cauda equina
- metastatic disease
- cord compression
common
- mechanical back pain
- nerve root compressions (incl sciatica)
- medical referred from elsewhere (renal colic, pancreatitis etc)
96
taking a Hx from patient with acute lower back pain in the ED?
- what pneumonic for HPC? 8
- additional Qs specific to low back pain within this pneumonic? 17
SOCRATES
Site
Onset
- any precipitating? (injuries, heavy lifting, falls, new exercise/activity)
Character
Raditation
- shoulder blade? loin to groin?
```
Associated symptoms
= neuro
- weakness
- altered sensations
- incontinence
- saddle anaesthesia
= systemic (AW fS FiN)
- appetite
- weight loss
- sleep (waking up in night?)
- fever
- rigor
- night sweats
```
Timing
- how long been going on for?
- worse in eve or morning?
Exacerbating + relieving factors
- movement effect?
- effect of painkillers?
Severity
- 1-10 (ask if changed over time, before/after analgesia etc)
97
taking a Hx from patient with acute lower back pain in the ED?
- PMHx? 5
- DHx? 3
- SHx? 7
- systems review? 1
- PMHx of back pain? how is this different?
- previous or current malignancies?
- any surgeries?
- other medical conditions? (osteoporosis, OA, HIV etc)
- risk factors for AAA (HTN, connective tissue, had screening)
- ALLERGIES?
- analgesia? what using?
- steroids?
SHx (ASD OHA Dot)
- alcohol
- smoking
- any IVDU (perispinal abscess - ask about if have fever)
- Occupation (really important!)
- home situation (who there etc)
- ADLs (how managing)
- Diet + EXERCISE (what norm do)
DO A SYSTEMS REVIEW
98
examination for low back pain in ED:
- examinations to consider doing (depending on hx)? 3
- special tests for nerve root irritation? 2
BACK EXAM
- look (scoliosis, deformity, weight loss)
- feel
- move
- gait
LL NEURO EXAM
- ***look up acronym
- inspect
- tone
- power
- reflexes
- sensation
- proprioception
- coordination
ABDO EXAM
- looking for AAA (pulses, perfusion, expansile mass)
- PR (if suspecting cauda equina)
lumbar root irritation
= straight leg raise*
lumbar disc prolapse + entrapment
= crossed straight leg raise***
also don't forget obs!! - esp temp for infective cause and HR, RR etc for AAA
can do urineanalysis if suspecting renal colic / infection
99
management of mechanical back pain in the ED:
- medications? 1
- advise? 2
- who to refer to?
- analgesia (paracetamol + nsaids, if not CI)
- keep moving (avoid bed rest)
- expect 4-6 week recovery
- GP follow up (or physio)
100
Symptoms of cauda equina syndrome? 5
- low back pain
- LL bilateral parasthesia
- LL bilateral weakness
- bowel or bladder incontinence or changes
- saddle anaesthesia
101
symptoms of ankle sprain?
normal mechanism of injury? (ie direction)
normal ligament sprained?
- pain
- swelling
- redness
- reduction in range of motion
normally INVERSION injuries (ankle roles so the sole of foot faces inwards)
-> pain + tenderness around LATERAL malleolus as is often ANTERIOR TALOFIBULAR LIGAMENT that is damaged (ATFL injury)
102
Ottawa ankle rules:
- what are these used to determine?
- what are the rules? 5
- which groups of people may these rules not apply to? 4
used to determine who needs an xray following an ankle injury (ie signs that indicate fracture is more likely than a sprain)
Any tenderness on palpation of any of:
1) lateral malleolus (posterior edge or tip of)
2) anterior malleolus (posterior edge or tip of)
3) 5th metatarsal (base of)
4) navicular
OR
an inability to weight bear BOTH immediately after the incident AND in the emergency department for FOUR STEPS (nb limping is still weight bearing)
have a lower threshold for x-ray if pt:
- is intoxicated or uncooperative
- has other distracting painful injuries
- has diminished sensation in legs
- has gross swelling which prevents palpation for bony tenderness
nb palpate the entire distal 6cm of fibula and tibia to assess for tenderness
nb hearing a 'snap' or 'crack' not necessarily indicative of a fracture
nb in study guide only need to "be aware" of ottawa ankle rules
103
Questions to ask pt presenting with ankle pain following injury:
- HPC? 8
- additional Q? 1
- PMHx? 1
- DHx? 2
- SHx? 2
SOCRATES
- site (get them to point)
- onset (mechanism of injury, when happen)
- character
- radiation (up leg?)
- associated symptoms (pins and needles, changes in sensation, ANY OTHER INJURIES)
- timing
- exacerbating / relieving (pain relief, weight bearing)
- severity (1-10, before/after analgesia, then vs now)
ABLE TO WEIGHT BEAR IMMEDIATELY AFTER INCIDENT?
- any previous injuries to ankle?
- any allergies?
- any blood thinners?
- occupation
- ADLs
104
Examination of ankle in suspected sprain / fracture?
- look? 4
- feel? 7
- move? 5
- special test for achilles? 1
- what rules used to assess need for x-ray?
LOOK
- deformity
- swelling
- broken skin
- pale
FEEL
- temperature
- PULSES
- sensation
```
bony landmarks
= medial malleolus
= lateral malleolus
= 5th metatarsal
= navicular
```
MOVE
passive and active:
- dorsiflex / plantarflex
- inversion / eversion
- adduction / abduction
- wiggle toes
- walk (CAN WEIGHT BEAR 4 STEPS?)
Simmonds test
= pt kneel on chair / bed, squeeze calf muscle, foot should plantar flex same on both sides - if reduced on injured side then achilles tendon tear / rupture
ottawa ankle rules
105
management of ankle sprain:
- in short term? 4
- medication?
- what to recommend re recovery?
RICE
- rest
- ice
- compression
- elevation (above level of heart)
analgesia (paracetamol +/- nsaids)
start remobilising as soon as possible, maintain ROM
if no x-ray needed, advise to come back after 5 days if struggling to weight bear
106
wrist fracture:
- most common type? which bone affected?
- most common mechanism of injury?
- other two types of wrist fracture? what caused by?
Colle's fracture of distal radius
- DORSAL ANGULATION of the distal radius bone fragment
- normally caused by a FOOSH
smith's fracture
= PALMAR ANGULATION of distal radius bone fragment
- less common
- caused be fall onto palmar flexed wrist
scaphoid fracture
- norm caused by FOOSH
- often mixed on x-ray
- tenderness on ASB palpation
- tenderness on telescoping of thumb
107
wrist fracture:
- who particularly at risk?
- what question important to ask in history about pmhx? 1
- elderly particularly at risk (also people with OA)
ask if any known problems with joints or bones - eg osteoporsis, any type of arthritis etc
108
wrist examination for fracture:
- look? 2
- feel? 6
- move? 15
LOOK:
- scars
- deformities (either from fracture or from OA/RA)
FEEL:
- PULSES
- sensation (3 nerves)
- full length of ulnar
- full length of radius
- bones in hand and wrist
- ANATOMICAL SNUFF BOX
MOVE:
- dorsiflex wrist
- palmarflex wrist
- abduction wrist
- adduction wrist
- pronate wrist
- suppinate wrist
- spread fingers (against resistance)
- make fist (and squeeze fingers)
- okay sign / pincer grip (with resistance)
- flex thumb
- extend thumb
- abduct thumb
- adduct thumb
- opposition thumb (bring to bottom of pinky)
- TELESCOPE THUMB W PRESSURE
109
wrist fracture:
- investigation? 1
- what should you look for if spot a distal or radius fracture?
xray
- two views (plus scaphoid view if suspect this)
look for fracture of other forearm bone! - remember polo!
110
wrist fracture:
- medication management? 1
- management for all? 1
- other management if displaced? 1
- other management if not displaced? 2
- analgesia
- give sick note or discuss occupation etc
grossly displaced
= manipulation under anaesthesia (MUA) or open reduction and internal fixation (ORIF)
not displaced
= cast
= elevate with sling
advise patient to keep moving:
- fingers / thumb
- elbow
- shoulder
111
Hip fractures:
- most at risk?
- other risk factors? 3
- features of HPC? 8
- apart from hip pain, also suspect hip fracture in elderly people who present with? 2
elderly people
- if young person, suspect high energy injury, eg RTA
- osteoporosis
- osteomalacia
- increased falls risk
SOCRATES
- site in hip
- onset - injury / mechanism
- character
- radiation - can go to hip
- associated symp - weight bearing (may be able to)
- timing
- exacerbating / relieving (weight bearing, effect of analgesia)
- severity
Suspect hip fracture in a elderly person who presents with:
- Sudden inability to weight bear
- Knee pain
112
suspected hip fracture examination:
- look? (feature you often see) 1
- feel? 5
- move? 6
- other systemic things to look for in someone with suspected hip fracture? 2
- leg may be shortened and EXTERNALLY rotated
FEEL
- pulses
- sensation
- hip
- greater trochanter
- knee
MOVE
- extend hip
- flex hip
- abduct hip
- adduct hip
- externally rotate hip
- internally rotate hip
(don't forget!! this is what normally elicits the most pain in hip fracture)
LOOK FOR
- hypothermia
- dehydration
(esp if long lie! - high risk of rhabdo)
113
hip fracture investigations:
- bedside? 1
- bloods? 5
- imaging? 1
- ECG (arrythmias can cause falls)
- FBC
- U+E
- LFTs (give abx in surgery)
- glucose
- cross-match
- hip xray
114
hip fracture management:
- medication for all? 1
- initial management to consider? 1
- who to refer to?
- two broad locations of fracture and what done about each?
- management following surgery?
- analgesia
- IV fluids (if needed)
refer to ortho
intracapsular
= hemiarthroplasty
extracapsular
= hip screw
(nb if traumatic and acaetabular fracture then need full joint replacement)
weight bearing asap following surgery
115
shoulder dislocation:
- most common type?
- normal mechanism of injury?
- what should you always ask re pmhx?
almost always anterior dislocation (ie humeral head is displaced anterior to joint space)
normally forced external rotation / abduction of the shoulder
ever dislocated shoulder before?
116
shoulder dislocation, examination:
- what to consider giving before examination?
- look? 1
- feel?
- what commonest complication, how to examine for this?
consider giving analgesia prior to exam
LOOK
- visible deformity of joint
FEEL
- PULSES
- sensation (esp regimental badge area)
- palpate bone around shoulder joint
MOVE
- abduction shoulder
- adduction shoulder
- flexion shoulder
- extension shoulder
- internal rotation shoulder
- external rotation shoulder
(do these passively)
nb unlikely to be able to do any of these movements
COMMONEST COMPLICATION
= damage to AXILLARY NERVE
- look for sensation in REGIMENTAL BADGE AREA (upper lateral arm)
117
shoulder dislocation:
- investigation?
- what also looking for?
x-ray shoulder
- also looking for associated fractures - most commonly in greater tuberosity of humerus
118
shoulder dislocation management:
- medication to give?
- medication to consider?
- definitive management?
analgesia
consider sedation
reduction of shoulder
- nb multiple methods to do this
119
red flags in history of back pain:
- age? 2
- onset? 1
- radiation? 1
- associated symptoms? 6
- timing? 2
- duration? 1
- exacerbating factors? 1
- pmhx? 3
- shx? 1
(and what each of these things could indicate)
- age <18 (tumour, infection, congenital etc)
- age >50 (tumour, AAA)
- following trauma (fracture)
- pain radiating below knee (herniated disc or nerve root compression)
- fever / chills / night sweats (infection, malignancy)
- weight loss (infection, malignancy)
- incontinence (cauda equina)
- saddle anaesthesia (cauda equina)
- reduction in sensation in LLs (cauda equina)
- reduction in power in LLs (cauda equina)
- unremitting pain, even when supine (tumour, infection, AAA, kidney stones)
- night pain (tumour, infection)
- pain >6 weeks (tumour, infection, rheumatological)
- pain worse with coughing, sitting or valsalva (herniated disc)
- cancer (MCSC)
- recent surgery (infection)
- immunocompromised (infection)
- IVDU (infection)
120
red flags in physical examination of back pain:
- obs? 1
- percussion? 1
- neuro exam? 2
- special tests? 2
(and what each of these things could indicate)
fever (infection)
point tenderness to percussion (fracture, infection)
- perianal / perineal sensory loss (cauda equina, SCC)
- major motor weakness in LLs (cauda equina, SCC)
- anal tone laxity on PR (cauda equina, SCC)
- positive straight leg raise test (L5 or S1 herniated disc)
121
atrial fibrillation:
- symptom most patients get?
- other symptoms? 3
most patients are asymptomatic
- palpitations (heart racing or galloping)
- dizziness (rare)
- dyspnoea (rare, norm dt heart failure)
- valvular heart disease (eg hx of rheumatic fever)
- heart failure
- ischaemic heart disease (eg hx MI, angina)
- hypertension
- hyperthyroidism
- acute infection
- shock (septic, hypovoloemic)
- drugs / alcohol use
122
Atrial fibrilation
- cardiac risk factors / causes to ask about? 4
- other risk factors / causes to ask about / assess for?
CARDIAC
- valvular heart disease (eg hx of rheumatic fever)
- heart failure
- ischaemic heart disease (eg hx MI, angina)
- hypertension
NON-CARDIAC
- hyperthyroidism
- PE
- acute infection
- shock (septic, hypovoloemic)
- hypokalaemia
- hypothermia
- drugs / alcohol use
123
Which examination to perform for AF?
Possible findings? 5
full cardiac exam
- irregularly irregular pulse (norm with tachycardia)
if HF cause / sequlae
- raised JVP
- peripheral oedema
- fine bilateral basal crackles
- potential additional heart sounds
124
Investigations for atrial fibrillation:
- bedside? 2
- bloods? 3
- imaging to consider? 2
- 12-lead ECG
- cardiac monitoring
- FBC (infection)
- U+Es (electrolytes)
- TFT (hyperthyroid)
(obvs blood culture if suspect infection)
- consider echo
- consider CXR if heart failure signs
125
management of AF:
- medication for all? 1
- to consider in all pts? 1
- when to consider emergency electrical cardioversion? 4 (what medication to give in addition?)
- medication used for chemical cardioversion?
- if symptoms <48hours? 1
- if symptoms >48hours? 1
- if asymptomatic?
- LMWH for all
- treat underlying cause
```
consider emergency electrical cardioversion if signs of:
- shock
- syncope
- acute cardiac failure
- new ischaemia
(do this with sedation!)
```
chemical cardioversion:
- flecainide
- amiodarone
if symptoms <48 hrs
- consider electrical or chemical cardioversion
if symptoms >48 hrs
- at risk of cardiac thromboembolism
- use rate control instead (rhythm control possible after 3-4 weeks of anticoagulation or can echo to see if cardiac thrombus)
rate control drugs: bisoprolol, metoprlol, digoxin, verapamil
if picked up incidentally (ie aymptomatic) then use chads2-vasc score - if high, anticoagulate and observe
nb this is similar initial management for atrial flutter, secondary management may be catheter ablation though
126
supraventricular tachycardia:
- what is it?
- four main electrical disorders which can cause it?
when there is an abnormally fast ventricular rhythm in the heart due to improper electrical activity in the atria (ie can follow on from AF etc)
- atrial fibrilation
- atrial flutter
- paroxysmal supraventricular tachycardia
- wolf-parkinson white
(they all either come from the atria or the AV node)
127
supraventricular tahcycardia:
| - possible symptoms? 7
- palpitations
- chest pain
- feeling faint
- SOB
- sweating
- SYNCOPE
- IN SHOCK
128
```
supraventricular tachycardia
investigations:
- bedside? 2
- bloods? 3
- imaging to consider?
```
- 12 lead ECG
- cardiac monitoring
- FBC
- U+E
- troponin
- consider echocardiogram
129
supraventricular tachycardia management:
- bedside procedure for all? 1
- bedside management to consider? 2
- four indications for immediate synchronised DC shock? 4 (and what to do if this doesn't work)
- management if don't have indications for immediate shock? (two pathways)
- where to look for detailed management?
gain IV access
- give O2 if hypoxic
- correct any electrolyte abnormalities
indications for immediate synchronised DC shock:
- shock
- syncope
- myocardial ischaemia
- heart failure
if stable, broad or narrow tachycardia?
BROAD:
- irregular = seek help
- regular = amiodarone or treat as narrow
NARROW:
- irregular = probs AF, anticoagulate and control rate
- regular = vagal manouveres + carotid massage then ADENOSINE in repeated boluses (6, 12, 12 etc)
ALS guidelines for SVT!! (on resus app)
130
What things can cause sinus tachycardia (ie as a physiological response):
- general? 6
- specific conditions? 4
- pain
- anxiety
- dehydration
- hypovolaemia
- anaemia
- hypoxia
- heart failure
- PE
- hyperthyroidism
- malignant hyperthermia
find and treat the cause, not the sinus tachy itself
131
ventricular tachycardia:
- definition? (incl sizes / rates on ECG)
- possible symptoms? 8
broad complex tachycardia originating from a ventricular ectopic focus
- rate >100
- QRS complex >3 small squares
any symptoms of IHD or haemodynamic compromise
eg:
- chest pain
- palpitations
- SOB
- dizziness
- syncope
- symptoms of heart failure
- anxiety / agitation
- lethargy / coma
132
Investigation for ventricular tachycardia:
- bedside? 2
- bloods? 8
- imaging to consider? 2
- 12 lead ECG
- cardiac monitoring
- ABG/VBG
- FBC
- U+E
- Magnesium
- Phosphate
- Calcium
- troponin
- digoxin level (if on)
- consider cxr (if HF)
- consider bedside echo
DON'T DELAY MANAGEMENT FOR ANY OF THESE!
133
Management of ventricular tachycardia:
- approach?
- bedside (1 to do, 1 to consider)
- management for VT with pulse? 1
- management for pulseless VT? 1
- where to look for guidelines?
A-E approach
- get IV access
- give O2 if hypoxic
VT WITH PULSE
- amiodarone infusion
(if pulse goes, DC shock + compressions)
^nb this is under regular broad complex tachycardia in the ALS quidelines
PULSELESS VT
- compressions and DC shock - ie normal ALS
See RESUS app!!
134
Ventricular fibrillation:
- what is happening within the heart?
- presentation / symptoms? 2
ventricles are quivering and so producing practically no cardiac output
- collapse / LOC
- no pulse
135
Ventricular fibrillation investigations / management:
- approach? 1
- what to start immediately? 1
- other things to do during this? 6
- most important blood to take? 1
- medication that give during? 2
- imaging / interventions to consider? 2
- where to look for guidelines? 1
A-E approach
start compression 30:2
- then shock (then follow ALS guidelines, incl rhythm checks)
1) attach defibrillator / monitor
2) intubate with igel / IV
3) Give oxygen
4) vascular access (IV or IO)
5) do ABG (and other bloods)
6) look for reversible features
- adrenaline after 3-5 mins
- amiodarone after 3 shocks
- consider ultrasound
- consider angiography and PCI
RESUS app!
when doing shock:
- remove oxygen devices
- pause compressions
136
What are the 8 reversible causes of cardiac arrest?
4H's 4T's
- Hypoxia
- Hypothermia
- Hyperkalaemia (or other metabolic)
- Hypovolaemia
- Tamponade (cardiac)
- Tension pneumothorax
- Thrombosis (coronary or pulmonary)
- Toxins
137
Give the most common examples of each type of shock:
- hypovolaemic? 3
- cardiogenic? 2
- obstructive? 2
- distributive? 3
hypovolaemic
- haemorrhage
- burns
- pancreatitis
cardiogenic
- post-MI
- malignant dysrhythmias*
obstructive
- tension pneumothorax
- cardiac tamponade
distributive
- septic shock
- anaphylaxis
- neurogenic shock
138
what is an acronym to identify the different stages of shock? 4
HEP B - further you go down, the later the signs of shock (ie BP is the last thing to go)
HANDS
- temp
- sweating
- cap refill
END ORGAN PERFUSION
- conscious level
- urine output
PULSE
- rate
- regularity (rhythm)
- quality (character)
BLOOD PRESSURE
139
What are the four different types of hypoxia? (explain each)
HYPOXIC HYPOXIA:
- reduced capacity for gaseous exchange at the level of the alveoli.
EXAMPLES: pneumonia, pulmonary oedema, asthma, drowning. (also at high altitudes due to the reduced ppO2)
ANAEMIC HYPOXIA:
- reduced haemoglobin function.
EXAMPLES: anaemia, carbon monoxide poisoning, sickle cell disease, due to meds such as aspirin, sulfonamides and nitrites
STAGNANT HYPXIA:
- inadequate circulation
EXAMPLES: heart failure, decreased blood volume, vasodilation
HISTOTOXIC HYPOXIA:
- impaired cellular O2 metabolism. Body's tissues aren't able to use the oxygen that is being delivered to them - it is not a true hypoxia
EXAMPLES: cyanide poisoning, alcohol consumption, narcotics
140
anaphylaxis:
- which type of hypersensitivity reaction?
- pathophysiology?-
- speed between exposure and reaction?
severe type 1 hypersensitivity reaction
Is a generalised immunological response to a stimulant in a sensitised person
effects mediated by IgE, mast cell degranulation. Mast cells contain histamine which has a vasodilatory effect
reaction norm happens within 30 mins of exposure (if ingestion)
- 5-10 mins if IV
(up to a maximum of an hour after exposure)
141
anaphylaxis:
- initial symptoms / signs? 6
- later symptoms / signs? 5
- what to always ask? 2
INITIAL
- urticaria
- angio-oedema
- flushing
- dyspnoea
- wheezing
- rhinitis
LATER
- inspiratory stridor and hoarse voice
- agitation / anxiety
- confusion / disorientation
- dizziness / syncope
- tachycardia
(then signs of shock)
ASK:
1) Have you ever had an allergic reaction? any allergies?
2) Any history of asthma / atopy?
3) what did you eat / touch before?
142
anaphylaxis:
- approach to examination / investigation / management? 1
- initial manoeuvre to do?
- initial medication to give? (dose for adult, how often to repeat)
- blood test to always do? 1
- blood tests to probs do? 3
- other bedside interventions? 3
- other medications to give? 2
- things to monitor? 3
A-E approach
lie patient flat and raise legs
ADRENALINE
- 500micrograms IM (use IV if experienced)
- repeat every 5 mins if no improvement
- SERUM TRYPTASE LEVEL
- ABG/VBG
- FBC
- U+E
- establish airway
- high flow oxygen
- IV fluid challenge 500ml
- chlorphenamine
- hydrocortisone
- pulse oximetry
- ECG
- blood pressure
ALSO ALWAYS CALL FOR HELP!
MUST KNOW ALL THIS!
143
if someone is cold and clammy and in shock? what types of shock are likely to have caused this? and which not?
cold and clammy
- likely cardiogenic or hypovoloaemic
opposite (flushed) in distributive
144
Canadian c-spine rules:
- what are they used for?
- which patients do they apply to?
- what are they? (roughly)
to assess whether someone needs c-spine imaging
for all ALERT (GCS 15) and STABLE trauma pts where c-spine injury is a concern
1) any high risk factor which mandates radiography?
- age >65
- dangerous mechanism (fall from >3 ft, axial load to head, high speed MVC, rollover, ejection, bicycle struck or collision)
- parasthesia in extremities
DO RADIOGRAPHY
2) Any low-risk factors which allows safe assessment of range of motion?
- simple rearend MVC
- sitting position in ED
- ambulatory at any time
- delayed onset of neck pain (ie not immediate)
- absence of midline c-spine tenderness
^ if no to ALL of these, do radiography
^ if yes to any of these -> 3
3) able to actively rotate neck?
- 45 deg left and right
^ if unable, do radiography
^ if able, no radiography
nb if pt is lower than GCS 15 or unstable then these rules don't apply, normally just do imaging
145
Hypovolaemic shock:
- approach to investigation / management? 1
- bedside interventions to do fast? 2
- bloods? 7
- imaging to do at bedside?
- other two bedside interventions?
- bedside investigation to do if young woman?
- intervention to consider if large haemorrhage?
- definitive management if large internal haemorrhage?
A-E approach
1) IV access and 500ml fluid challenge - WARMED! (take blood during cannulation)
2) 15L high flow oxygen
- ABG / VBG (norm do VBG first and then ABG later)
- U+E
- FBC
- glucose
- CROSS MATCHING
- clotting (also INR if on warfarin)
- CRP (exclude septic cause)
1) FAST scan - to identify if / where there is internal bleeding
2) ECG
catheterise (so can measure urine output)
- do pregnancy test if woman of CBA (as could be ruptured ectopic)
massive haemorrhage protocol
- incls packed RBCs and other blood products as well as transaexamic acid
(you give O- until cross match comes back)
emergency surgery (normally open laparotomy)
nb if suspect aortic dissection then do BP on both arms
146
If patient is in shock and has a normal systolic BP but a low diastolic BP (ie a wide pulse pressure) then which type of shock is it likely to be?
what about if a narrow pulse pressure with a normal systolic? 2
what is the normal pulse pressure?
wide pulse pressure
= anapylaxis or sepsis (ie distributive)
^this is dt arterial vasodilation
narrow pulse pressure
= cardiogenic or hypovolaemic
^this is dt arterial vasoconstriction
normal pulse pressure is 35-45 mmHg
147
What is SIRS?
criteria? 4
- definition of sepsis?
- definition of severe sepsis?
- definition of septic shock?
systemic inflammatory response syndrome
at least 2 of:
- temp >38 or <36
- HR >90
- RR >20 (or PaO2 <4.3)
- WCC >12 or <4
sepsis
= SIRS + infection
severe sepsis
= sepsis associated with organ dysfunction, systemic hypoperfusion or hypotension
septic shock
= sepsis with arterial hypotension DESPITE adequate fluid replacement
148
SEPTIC SHOCK
- approach?
- acronym for management? 6 (incl timescale)
- other blood tests to do? 6
- what is the aim in sepsis? what interventions can you consider doing to help achieve this?
- medical management that you can consider?
- what to do repeatedly?
- who to call for help?
A-E approach
BUFALO
- blood cultures (ideally before Abx)
- urine output (norm catheterise)
- fluid challenge (500ml warmed)
- antibiotics (broad - change when you know source of infection)
- lactate (ABG)
- oxygen (high flow)
^complete these within an hour
- FBC
- LFT (for abx)
- U+E
- blood glucose
- clotting
- CRP
Aim is to find source of infection:
- CXR (or chest CT)
- MSU / dipstick urine
- ?LP
- look for infected wounds
- echocardiogram if suspect endocarditis
consider vasopressors
```
REASSESS SITUATION (response to fluids etc - keep monitoring on!!)
- also repeat U+E, blood cultures, ABG etc
```
call for senior / anaesthetist etc
149
AKI:
- what is normally the first sign/symptom?
- other possible symptoms?
- what is the official definition? 2 (with numbers)
first sign is norm reduced urine output
- N+V
- dehydration
- confusion
nb these depend hugely on cause!!
URINE OUTPUT
- < 0.5ml / kg for >6 consecutive hours (8hrs in children + young people)
RISE IN CREATININE:
- > 26umol in 48 hours
OR
- >1.5x baseline in 48 hours
150
What are the three groups of causes of AKI?
| - which is most common?
pre-renal, renal + post-renal
pre-renal is most commons
151
What are the 4 main groups of causes of pre-renal AKI? (list 3 examples for each)
PRE-RENAL CAUSES
- sudden and severe drop in BP (shock) or interruption on blood flow to kidneys from severe injury or illness
HYPOVOLAEMIA
- haemorrhage
- severe vomiting or diarrhoea
- burns
- inappropriate diuresis
OEDEMATOUS STATES
- cardiac failure
- cirrhosis
HYPOTENSION
- cardiogenic shock
- sepsis
- anaphylaxis
HYPOPERFUSION
- renal artery stenosis
- NSAIDs
- ACE-i
152
Causes of intra-renal AKI? 6
INTRA-RENAL CAUSES
- direct damage to kidneys by inflammation, toxins, drugs, infection or reduced blood supply
GLOMERULAR DISEASE
- glomerulonephritis
- haemolytic uraemic syndrome
TUBULAR INJURY
- acute tubular necrosis
- nephrotoxins (aminoglycosides, contrast media, myoglobin in rhabdo)
- acute interstitial nephritis
- vascular disease
also autoimmune (SLE etc) and cancer (lymphoma, myeloma)
153
Causes of post-renal AKI? 5
POST-RENAL CAUSES
- sudden obstruction of urine flow due to enlarged prostate, kidney stones, bladder tumour or injury
- kidney stones
- strictures
- increased prostate size
- extrinsic compression of ureter
- radiation fibrosis
154
AKI:
- questions to ask to determine whether acute or chronic? 3
- questions to determine if infectious cause? 7
- who to consider obstructive cause in? 5 (based on PMHx)
- Hx of comorbidity e.g. DM, HTN
- Previous abnormal blood tests
- Small kidneys on USS <9cm
LUTS
- urgency
- dysuria
- frequency
- hesitancy
- pyuria
- loin pain
- rigors / fever
Hx of:
- single functioning kidney
- renal stones
- anuria
- prostatism
- previous surgery / radiotherapy
155
Main 4 risk factors for AKI?
what else to always ask in drug hx?
- elderly
- pre-existing renal impairment
- HTN
- diabetes
Any recently started medications??
156
AKI signs
- signs indicating hypovolaemia? 5
- signs indicating fluid overload? 5
- what other signs to look for in someone with AKI? 2
- things to remember to palpate / auscultate in AKI? 3
HYPOVOLAEMIA
- low urine output
- poor skin turgor
- dry mucus membranes
- high pulse
- low BP
(invisible JVP)
FLUID OVERLOAD
- gallop rhythm on auscultation
- lung basal crepitations
- high BP
- high JVP
- peripheral oedema (ankles and sacral)
OTHER SIGNS
- rashes
- fevers
(also LUTS - could be from a UTI)
PALPATE
- kidneys
- bladder
AUSCULTATE
- renal bruits
157
Investigations for AKI:
- bedside to do? 2
- bedside to consider? 2
- bloods? 7
- imaging to consider? 2
- dip urine (always - WBC, nitrite, blood, protein, glucose)
- ECG (potassium)
- MSU (if think infective, do if infective features on dipstick)
- PCR (protein creatinine ratio - high suggest glomerular disease, only do if protein on dipstick)
- VBG / ABG (for lactate)
- FBC
- U+E (watch potassium)
- LFT
- clotting
- CRP
- CK (looking for rhabdo)
(- consider blood culture if think sepsis)
- Renal USS
- bladder scan
can consider more advanced tests like bence jones in urine and Auto-antibodies in blood if think myeloma or serum Ig etc - but these are rarely the initial investigations
158
what are the 4 main complications of AKI?
- hyperkalaemia
- acidosis
- pulmonary oedema
- pericarditis
159
Initial management of AKI:
| - acronym? 4 (and what in each section, especially last one has 5 subsections)
STOP (AKI)
SEPSIS
- complete sepsis 6 (bufalo) if it is suspected
TOXINS
- stop / avoid nephrotoxins (drugs and contrast)
OPTIMISE BLOOD PRESSURE
- improve cardiac output (norm w fluid challenges / boluses) and renal output
- only use 0.9% saline (don't use haartmans unless low potassium on U+E)
PREVENT HARM
1) treat complications
- hyperkalaemia
- acidosis
- pulm oedema
- pericarditis
2) identify cause
- eg obstruction, infection, shock, intra-renal
3) review all meds and doses
- refer if renal replacement therapy indicated (see other card for indications of RRT)
4) monitor
- daily fluid balance
- daily volume assessment
- U+Es
- VBGs
5) optimise nutritional support
- adequate calories
- potassium restriction
160
What are the indications of renal replacement therapy in AKI? 5
refer for RRT if have these features AND they are NOT responding to initial medical therapy:
- hyperkalaemia
- metabolic acidosis
- symptoms or complications of uraemia (eg pericarditis or encephalopathy)
- fluid overload
- pulm oedema
161
Acute urinary retention:
- four mechanisms of cause?
- most common cause?
- other common causes? 4 (write which of 4 mechanisms this is)
nb much more common in men
1) INCREASED RESISTANCE TO FLOW: can be at bladder neck smooth muscle, resulting in a dynamic outflow obstruction or a mechanical obstruction (eg urethral stricture or prostatic enlargement)
2) INAPPROPRIATE DETRUSOR MUSCLE INNERVATION, resulting from neuro causes (eg stroke, spinal cord lesions or diabetic neuropathy)
3) BLADDER OVER-DISTENSION (eg with postop pain and alcohol); inability to void leads to bladder distension
4) DRUGS: anti-muscarinic and alpha adrenergic medications
by far the commonest cause
= benign prostatic hypertrophy (1)
- medications (4)
- post op (pain: 3, after spinal: 2)
- alcohol consumption (3)
- urinary tract infection (?)
other common causes incl bed rest, urethral stones, constipation
neuro causes can include spinal cord compression as well as MS, parkinsons, alzeihmers
female specific causes include: organ prolapse, pelvic mass, vulvovaginits and herpes
162
Which medications can cause acute urinary retention:
- group of medications (with 3 examples)?
- other medications? 5
ANTICHOLINERGICS
- decongestants (phenylephrine, pseudoephradrine)
- antihistamines (diphenhydramine, phenergan)
- tricyclic anti-depressants
OTHER
- opioids
- amphetamine
- beta agonists (atropine, isoprenaline)
- hyoscine
- nifedipine
basically anything that blocks the parasympathetic system OR stimulates the sympathetic system could cause urinary retention
163
In patients presenting with acute urinary retention:
- which precipitating factors should be asked about? 4
- what groups of symptoms should also be asked about? 2
- who should you consider urinary retention in, regardless of whether have symptoms?
precipitating factors:
- constipation
- UTI
- excess alcohol
- previous catheterisation? (or uro surgery)
- urinary symptoms (esp haematuria)
- neurological symptoms (cauda equina screen)
in someone with retention caused by BPH they will often describe increasing urinary symptoms prior to retention
ALWAYS CONSIDER acute urinary obstruction in ACUTE CONFUSION in the ELDERLY
164
Acute urinary retention:
- examinations to do? 3
- what are you looking for in each?
- when to do each?
1) ABDO EXAM
- palpate and percuss bladder
- any signs of systemic of renal infection?
- any abdominal massess (eg ovarian or colorectal tumour)
2) EXTERNAL GENETALIA EXAM
- any signs of infection?
- purulent discharge?
- blood?
3) DIGITAL RECTAL EXAM (all, incl women)
- feel for saddle anaesthesia
- anal tone (neuro)
- palpate prostate for size and any cancerous signs
nb ideally put catheter in BEFORE doing DRE as may induce pain if still in retention
165
Acute urinary retention:
- imaging to do? 1
- bloods to consider? 4 (and why)
- initial management? 1
- bedside tests to do following intervention? 2
- who to consider referral to?
```
bladder scan (record how much urine)
- if >1000ml, consider help as high risk post-obstruction diuresis
```
- PSA (if suspect ca, do before catheter or DRE, be careful with, should repeat in few weeks)
- FBC (infection)
- U+E (renal function)
- CRP (infection)
catheterisation
- either urethral or suprapubic if retention dt trauma
(always document size used and ease of catheterisation in the notes)
urine from catheter
- dipstick
- MSU
consider urology referral
166
Testicular torsion
- age group most common in?
- other risk factor?
- most common symptom?
- other common symptom?
age under 25
more common in boys / men with undescended testes - ie cryptorchidism
testicular pain
- sudden onset
- very painful
- constant (though can be intermittent)
- pain can be in upper thigh or lower abdo too
nausea and vomiting are common
167
Testicular torsion
- what find on inspection?
- additional special tests and findings? 2
affected testicle
- red
- swollen
- tender
- may lie higher than unaffected testicle
- may lie horizontal instead of vertical
1) absent cremesteric reflex
2) pain is not relieved upon elevation of scrotum
if been there for a long time, may also have reactive hydroceles or oedema
168
testicular torsion:
- investigations?
- refer to who?
- medical management while waiting for referral? 2
no investigations needed - is clinical diagnosis (don't need USS if typical presentation)
- may want to do bloods to exclude other diagnoses though
refer URGENTLY to uro-surgery
- analgesia (norm IV/IM morphine)
- antiemetics (norm IM/IV ondasetron)
nb if waiting for surgery for long time can try manual de-torsion as a temp holding measure before surgery ('open book' method)
169
Testicular torsion:
- differential diagnoses? 5
- how to rule these out? 3
- testicular appendix torsion
- epididymitis / epidiymo-orchitis
- hydrocele
- varicocele
- strangulated hernia
- bloods (FBC, CRP - normal in torsion, elevated in infection)
- urine dipstick (normally normal in torsion, not in infection)
- USS (with doppler to see blood flow)
