Stress fracture - metatarsals
Can occur from running or significant walking
can be hairline fracture with no displacement.
tx. review 7-10 days. analgesia and << activity. Possibly x-ray.
painful, unilateral red swollen eyelids
px often systemically unwell
managment for sprains
Ice 20 mins every two hours. elevate << swelling.
Increase in pain 48 hours after injury. Takes 6-8 weeks to heal.
What is diagnosis of DKA based on?
Diabetic ketoacidosis is a serious complication of Type I DM.
Diagnosis based on
diabetes (blood glucose >11 mmol/L)
ketones (urine or blood)
acidosis (pH <7.30 venous blood)
Which part of the orbit do the cranial nerves IV, III, VI pass?
Superior orbital fissure
What is the cause of most URTI?
common cold virus
What is Kussmaul breathing?
Deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure.
Scaphoid fracture management
Cast if suspected (scaphoid backslab)
Refer to review clinic in 10-12 days
What passes through the optic canal?
Le Fort Fractures
Signs/ symptoms fractured mandible
pain/ restricted movement
missing teeth, numbness, teeth not meeting properly
Sublingual haematoma; often indicative of fractures.
When to use Equinus cast
Ruptured achilles tendon
It transmits the infraorbital artery and vein, and the infraorbital nerve, a branch of the maxillary nerve
Can be palpated during an examination.
foot bones 1
When would you use a collar and Cuff sling?
- gravity assist
- eg. impacted head of humerus (refer if impacted head)
Foot bones 4
management of corneal abrasion
remove FB with damp cotton bud/ bevel of needle (with slit lamp)
review 2-3 if not improving.
Acute-angle closure glaucoma
acutely painful red eye.
Px usually > 60, other symptoms; headache, nausea, blurred vision and haloes around lights.
EM tx of hypoglycaemia
50ml of glucose 50% if IV access available.
otherwise 1 mg glucagon
(as PAs 10% glucose IV okay)
non-emergency; dextrose, then more complex carbohydrates.
Two main types of conjunctiva based anatomically
- palpebral conjunctiva lines the lids
- bulbar conjunctiva is over the eyeball
Types of wrist fracture
Smith's - surgery
Colle's (often due to FOOSH). Tx in A & E
Symptoms of hypoglycaemia
confusion, sweating, fatigue and feeling dizzy.
maybe pale, weak, blurred vision, tachycardia, unconsciousness
an injury to the spine in which the vertebral body is severely compressed.
- severe trauma, such as a motor vehicle accident or a fall from a height.
foramen and fissures of the orbit
organism; bacterial tonsilitis
group A beta haemolytic streptococcus
elbow fracture - what will you find on x-ray?
The sail sign.
Never a posterior fat pad unless there is a fracture.
Battle's sign, also mastoid ecchymosis, is an indication of fracture of middle cranial fossa of the skull, and may suggest underlying brain trauma.
Anterior compression/ Open book
Look at SI joint and pubic symphysis
Common causes of hypotension (6)
- nitrates (GTN)
- many anaesthetic agents
What's a common symptom of a fractured orbit?
due to obstruction of rectus muscles, or suspensory ligament is not fixed.
Foot bones 3
Diagnositic symptoms of DKA?
+ Kussmaul breathing
What drug can be used for emergency treatment of acute-angle closure glaucoma
NB. causes miosis
Good vision 20/20
bilateral - basilar skull fracture
Bilateral hemorrhage occurs when damage at the time of a facial fracture tears the meninges and causes the venous sinuses to bleed into the arachnoid villi and the cranial sinuses
What can cause mydriasis?
What nerve supplies the lateral rectus muscle?
long nerve makes it prone to injury.
which extraoccular muscle attaches nasally?
Foot bones 2
Bones of skull
What is a Salter-Harris Fracture?
A fracture that involves the epiphyseal plate.
collapse of a vertebra.
Trauma or a weakening of the vertebra (compare with burst fracture). This weakening is seen in patients with osteoporosis
Wedge deformities, with greater loss of height anteriorly than posteriorly
Tender points for knee - ottawa
> 55 yrs
can't weight bear
can't flex 90 o
sudden foot inversion can cause....
avulsion fracture of the base of the 5th metatarsal.
(tightening of peroneus brevis tendon)
tx. support bandage if can weight-bear
backslab is unable to weight-bear
- red, watery eye, often bilateral.
- VA is usually normal.
- bacterial or viral
Infectious, topical treatment,
NB> check for FB, abrasion before diagnosing conjunctivitis
What is the signifance of a lack of consensual pupillary response?
- problem with motor connection
- could be; oculomotor nerve or Edinger-Westphal nucleus
dentritic ulcer - not common
presents as red eye with FB sensation.
seen with fluoroscein , caused by herpes-simplex virus
Orbital cellulitis; an emergency and requires intravenous (IV) antibiotics.
In contrast to orbital cellulitis, patients with periorbital cellulitis do not have bulging of the eye (proptosis), limited eye movement (ophthalmoplegia), pain on eye movement, or loss of vision.
Bones of the hand
Tests for diabetes
urine or blood test for ketones
pH (venous fine)
What can cause sudden loss of vision?
central retinal artery occlusion
vitreous detachment/ haemorrhage
+ full neurological examination for cv event
what could be triggers for hypoglycaemia attacks?
infections; UTI, pneumonia
physiological stressors including cold, status epilepticus.
What's the function of the choroid?
Dark pigmentation to prevent internal light reflection, supplies blood to the retina
Bones of the wrist
orthostatic hypotension values
20 mmHg drop of systolic pressure
20 beats per minute increase in HR
(remember two min delay between position changes)
What is the most common cause of hypotension?
+ what drugs commonly cause hypotension
alpha/ beta blockers
Giant cell arteritis
painless visual loss, px usually >60.
Scalp tenderness, jaw claudication, headache.
Blindness if not prompt treatment.
bilateral, often related to hay-fever.
Chemosis (oedema of the conjunctiva) is a classic sign.
Patient - time
Continuous low pitched, rattling lung sounds that often resemble snoring.
Obstruction or secretions in larger airways.
Chronic obstructive pulmonary disease (COPD), bronchiectasis, pneumonia, chronic bronchitis, or cystic fibrosis.
Rhonchi usually clear after coughing.
Common cause of metatarsal fractures?
stress fractures; don't need trauma history
drainage of aqueous humour
Formed in the anterior portion of the ciliary process in the posterior chamber of the eye.
Drains into the scleral venous sinus (Schlemm's canal)
Blockage = glaucoma
General advice for facial fractures
no nose blowing
knocked out teeth; keep in saline or milk. 1-4 hour window to reimplant.
Bites; Augmentin antibiotic
Greenstick fracture of the orbital floor or medial orbital wall resulting in ischemic entrapment of an extraocular muscle.
• Typically children
• Minimal external signs of trauma mask the severity of the orbital injury.
Commonly due to sports injuries.
What is the anatomical signifiance of the central artery of the retina?
It runs WITHIN the optic nerve.
It's an end artery, a branch of the ophthalmic artery.
Why avoid amoxicilin with tonsillitis?
in case causative organism is Epstein-Barr virus (glandular fever); rash
What are the EM physiological side effects of NO insulin causing hypoglycaemia? (3)
>>> sugar in blood, none in cells.
Breakdown of fats and proteins; ketones and acidosis
leads to dehydration, Potassium loss and acidosis.
Dehydration because water follows excretion of sugar (osmotic diuresis)
What's the risk if injury close to bone?
sling for elbow fracture?
Broad arm sling,
and backslab up to the shoulder.
Management of Otitis media
analgesia. 80% improve spontaneously.
>48hrs require antibiotics
Hamstring injury management
crutches and refer to fracture clinic
Toes - x-ray or not?
If associated wound present, or injury is with the great toe.
Signs of scaphoid fracture?
- tenderness at anatomical snuff box.
- pain when pressing thumb proximally
IMP. Danger of avascular necrosis
Eye conditions not to miss
- acute-angle closure glaucoma
- peri-orbital cellulitis
- giant cell arteritis
Which bone is boxer's fracture?
What is a haematoma block?
Analgesic technique used to allow painless manipulation of fractures while avoiding the need for full anesthesia.
This procedure is normally only appropriate for fractures of the radius and ulna.
Broad arm sling and let heal.
Jones fracture is a break between the base and middle part of the fifth metatarsal of the foot.
tx. cast, 6 weeks rest.
Signs/ symptoms of fractured zygomatic arch
swelling/ bruising - periorbital
pain, numbness, diplopia, reduced eye movements
altered pupillary reflexes, facial flattening/ symmetry
- look at jaw from behind and put fingers on zygomatic arches. Compare for differences.
Why rehydrate gradually with DKA?
to avoid rapid intracellular osmotic/ sodium shifts that may cause fatal CNS oedema.
Remember: with DKA and polydipsia, rapid fluid shift from intracellular compartments.
Refer to orthopaedics ; other injuries likely.
- Swelling of the outer portion of the upper lid, with possible redness and tenderness
- Pain in the area of swelling
- Excess tearing or discharge
- Swelling of lymph nodes in front of the ear
Common causes include mumps, Epstein-Barr virus, staphylococcus, and gonococcus.
What is Argyll Robertson (AR) pupil and what's the most important cause (and very specific)?
bilateral small pupils that reduce in size on a near object (i.e., they accommodate), but do not constrict when exposed to bright light
+ diabetic neuropathy
What is a big danger of px with long-standing diabetes and neuropathy?
MI or abdominal conditions such as infection or pancreatitis may be painless. Maybe osteomyelitis in the feet..
Tx for DKA
(Sickness and vomiting, abdominal pain, muscular weakness)
500ml then another 500ml then another 500ml (saline). MUST ensure patient is rehydrated before giving insulin. 0.1units per kilo per hour.
As sugar moves into cells (insulin taking effect) potassium follows therefore px becomes hypokalaemic. Normal potassium 3.5 to 5.
Watch urine output to check hydration.
Red flag; peds until 22-23 yr old. Can die from cerebral oedema; therefore don’t give insulin until properly hydrated.
What factors cause cause a hypoglycaemic attack?
Too high a dose of medication (insulin or hypo causing tablets)
Otitis media bugs
Cauda Equina - signs and symptoms
- altered sensation perineal area, bowel/ urine/ sexual dysfunction
- PR - loss of tone and sensation
What can cause miosis?
NB> latency of pupillary responses increases with age
What could blood clotting abnormalities and platelet consumption indicate with a septic px?
development of disseminated intravascular coagulation (DIC); clotting factors and platelets are consumed by clot formation in the peripheral circulation.
Fluid challenge and central venous cannula/ measurement of CVP; what's that about?
If CVP doesn't rise or rises transiently and then falls, then px is 'underfilled'.
Sign of poor perfusion of the brain?
poor conscious level
Sign of poor perfusion of the skin?
poor capillary refill time
What could cefuroxime and clarithromycin possibly treat?
+ may need vasopressor drugs to produce peripheral vasoconstriction if px adequately filled (CVP monitoring). Renal output would be poor.
symptoms of septic shock
- warm peripherae, bounding pulse with low diastolic pressure, low JVP
- pyrexia (or hypothermia)
- history and signs of underlying infection
Symptoms of hypovolaemic shock (this includes burns)
symptoms of fluid loss, eg. melaena, haematemesis
cold peripherae; weak, thready pulse, low JVP
skin pallor, dry mucous membranes
symptoms of cardiogenic shock
- chest pain, palpitations, history of IHD, AF
Cold sweaty peripherae; weak pulse, JVP raised, tachycardia
- pulmonary oedema
What's the difference between hemiparesis and hemiplegia?
Hemiparesis ; unilateral weakness
Hemiplegia; complete loss of power on one side
What is Todd's paralysis?
A focal appendage transient weakness after a seizure.
It usually subsides completely within 48 hours.
Todd's paresis may also affect speech, eye position (gaze), or vision.
NB> important to differentiate from ischaemic stroke because seizure is an exclusion criteria for thrombolysis.
What % of px presenting to hospital with strokes, fulfill criteria for thrombolytic tx, and what is the drug?
Actilyse; recombinant tissue plasminogen activator alteplase
What is the risk of thrombolytic tx of ischaemic stroke?
And the incidence?
significant risk of primary intracerebral haemorrhage
1 in 30
In the case of ischaemic stroke, what is the window for treatment?
3 hours from onset of symptoms.
(this includes getting a CT scan!)
Thrombolysis; remember that...
lots of exclusion criteria!!!
- px on warfarin
- previous stroke within three month
- BP >110 diastolic, > 185 systolic
- hypoglycaemic/ hyperglycaemic
Risk factors for CVD?
What are Charcot-Bouchard aneurysms?
Aneurysms in the small penetrating blood vessels of the brain.
They are associated with hypertension.
The common artery involved is the lenticulostriate branch of the middle cerebral artery.
What are the following acronyms?
TACI: Total Anterior Circulation Infarction
LACI: Lacunar Infarction
How effective is prophylaxic treatment of AF with warfarin in preventing strokes?
yearly risk of cerebral embolism reduced from 3% to 1%.
Aspirin, stroke, no CT scan results. What's the story?
No evidence that starting aspirin before CT findings are known adversely affects prognosis.
When is a CT scan URGENT following a stroke?
- if 3 hour window to start thrombolytics
- evidence of head injury
- severe headache at the time of onset of weakness
- GCS score deteriorating
- prior anticoagulation treatment
Are px with carotid artery stenosis at risk of embolic stroke?
Yes, especially if stenosis 70-99% (very high risk). Also: is px well enough to receive tx?
Carotid stenosis diagnosis; doppler
haemorrhagic strokes - TACI or POCI
Stroke tx whilst awaiting CT scan results
Nasogastric tube, IV fluids
Oxygen mask, monitor cardiac rhythm (digoxin if needed)
Possibly catheter to monitor output
Statins (low dose) even if lipid levels normal
TED (thromboembolic disease) stockings
Why don't you treat HT immediately following a stroke?
cerebral autoregulation of blood flow is disturbed and therefore risk of hypoperfusion.
Watershed infarction; there can be an extension of the stroke due to reduced blood supply around area of infarction.
NB. continue with regular BP meds if taken previously.
High BP two weeks after stroke. Which meds?
ACE inhibitors (perindopril - take at bedtime because can become dizzy)