STEMI - Acute - >persistent ST segment elevation (1 small square) in 2 contiguous leads (except V2/3) - >new LBBB with symptoms - does not require elevated troponins - Consider posterior STEMI - >ST depression in V1-3 - Old findings - >ST segment at isoelectric - >small R - >pathologic Q (1/3 corresponding R) - >inverted T wave Non-STEMI - >diffuse ST segment depression - >depression in focal area likely STEMI with reciprocal changes - >elevated troponins without ST elevation UA - >unstable/new/severe/frequent angina - >no trops - >only transient ECG changes

Hx - pain (OPQRST) - >Onset is gradual - >Precipitated by exercise/Palliated by rest/NO - >Quality is discomfort/crushing/tightness etc - >Radiates to epigastrium/scapula/jaw/throat/arms - >Site is diffuse, should not be able to point with one finger - >Time longer than 20 minutes - associated symptoms - >most commonly SOB - >palpitations - >nausea/vomiting - >diaphoresis/clamming - >syncope/presyncope - absence of pain - >older age - >women - >diabetics Consider risk factors - Non modifiable - >male - >old - >family Hx men established CAD - Modifiable - >overweight/obesity - >metabolic syndrome - >physical inactivity - >dyslipidaemia - >diabetes - >hypertension - >smoking - >cocaine use (acute and chronic) - >renal dysfunction Exam - evidence of hypoperfusion - >hypotension - >tachycardia - >altered mental status - >pale, cool, clammy skin - evidence of heart failure - >JVP elevated - >crackles - >S3 gallop - >MR murmur Immediate Tests (confirm ischaemia) - ECG - >confirms STEMI diagnosis - >assessment for reperfusion immediately after - High sensitivity troponin - >baseline with repeat within 3 hours - >confirms STEMI/non STEMI if symptomatic with rise/fall with one >99th centile Consider non ischaemic chest pain (PPP GRAMMA) - ddx - >pneumothorax - >pericarditis - >PE - >GORD - >Ruptured viscus - >Aortic dissection - >Myocarditis - >Musculoskeletal - >Anxiety - safe discharge - >consider HEART score Secondary tests - Glucose - >hyper/hypoglycaemia common - FBC - >anaemia (anti-platelet therapy) - >leukocytosis (acute phase reactant) - Electrolytes and CMP - >arrhythmias - Creatinine/eGFR - >baseline for angiography contrast - >baseline for medications - CXR - >rule out ddx Consider - ABG - >signs of shock of pulmonary oedema - Echo - >MI complications

General management - ACCU transfer/early cardio consult - 2x IV canula - O2 - Cardiac monitoring + serial ECGs - Routine bloods - CXR - Pharmacological management (THROMBINS2) - >Thionopyridines (clopidegrel) - >Heparin/enoxaparin - >RAS (ACEI/ARB) - >O2 - >Morphine - >Beta blocker (bisoprolol/metoprolol) - >Invasive treatment (PCI) preferred - >Nitoglycerine - >Salicylate (aspirin) - >Statin - Balance ischaemic and bleeding risk - >GRACE = ACS mortality - >CRUSADE = bleeding risk in ACS Common pathway - Dual anti platelet - >aspirin 300mg oral/dissolved - >clopidegrel 300-600mg - Anticoagulation - >enoxaparin 1mg/kg SC - >give initial 30mg IV bolus then SC if for fibrinolysis - >additional dosing not required for PCI - >use UFH if severe kidney disease (different pathway) - Consider - >abciximab (high risk/at time of PCI) - >or bilalirudin (if high risk of bleeding) STEMI - Choice of reperfusion method - >PCI if available within 90mins of presentation - >if not, fibrinolysis within 30mins of presentation - >if fibrinolysis contraindicated, transfer to PCI - >unsuccessful thrombolysis - Fibrinolysis contraindications - >symptoms >12hrs - >BP 180/110 - >recent trauma/surgery - >GI bleeding in past month - >Stroke/TIA in 3 months - >Prior ICH - >known malignancy/vascular lesion/coagulopathy - Fibrinolysis treatment - >tenectoplase preferred (bolus regime) - >alteplase (bolus plus transfusion) NSTEMI - Approach - >CA guided revascularisation (PCI or CABG) - >no fibrinolysis - Risk stratified treatment - >very high risk = CA within 2hrs - >high risk = CA within 24hrs - >intermediate risk = CA within 72hrs - >low risk/no symptoms = guided by provocative testing

Triggers (Don't PANIC) - Drugs - >corticosteroids - >cocaine - >simpathomimetics - >SGLT-2 - >atypical anipsychotics - Pregnancy - Acute illness - New diagnosis (common) - Infarct - Compliance Symptoms - polyuria/polydypsia - fatigue/weakness - nausea/vomiting - abdo pain Signs - hypotension/tachycardia - hypothermia - kussmaul breathing - fruity breath - altered mental status (GSC) - dry mucous membranes/slow cap refill - pulmonary oedema may occur - evidence of infection

Investigations - Glucose - >greater than 11.1 for criteria - >can be euglycaemic - >usually above 45 in HHS - VBG - >high anion gap metabolic acidosis - >K plasma osmolality (>320mmol/L in HHS) - Ketones - >dipstick tests acetoacetate/capillary tests D-beta-hydroxybutarate level 3x higher - >capillary ketones >3.0 - FBC - leukocytosis is common (very high =?infection) - EUCs - >urea/creatinine high (dehydration) - >Pseudohyponatraemia (minus 1.6mmol/L per 5.6mmol/L) - >K normal despite total body depletion - >Cl low - CMP - >low or normal Consider testing for ddx's

Goals - restore circulating blood volume - inhibit lipolysis, gluconeogenesis and ketogenesis - address precipitating factors - re-establish normal physiology and electrolyte balance Issues - acidosis - dehydration - hypokalaemia (hyper) Monitoring - continuous cardiac monitoring - regular BP - hourly - >BG - >ketones - >VBG (particularly pH and K) Fluids IV -resuscitate, restore, maintain Insulin IV - goal - >treat acidosis, not hyperglycaemia - infusion - >0.1unit/kg/hr - >don't drop BG >5mmol/L/hr (cerebral oedema) - target - >glucose 10-15mmol/L - maintain insulin infusion - >start 5% glucose infusion Potassium - indication - >serum level once urinary flow is established Resolution - pH >7.3 - bicarb >15 - ketones during illness/reduced fluid intake - advise when sick - >check BG and ketones often - >maintain hydration - >present to medical attention early

Red flags on history - sudden and severe onset - precipitated by exertion or trauma - altered mental status - seizure - visual disturbance - pain down into neck or around eye - systemic symptoms - >fever - >vomiting - >dizziness - concurrent head infection - no past hx - family hx of SAH - medications - >anticoagulants/NSAIDs - >COCP - >simpathomimetics Red flags on exam - Cushings triad - Fever - >inflammation or bleeding - HTN - Toxic appearance - Altered mental status - Focal neuro signs - Meningismus - Eye - >papilloedema - >red eye - >visual deficits - >CN IV/VI palsy Investigations - CT or MRI - >non con - >neck/cerebral angiography - LP (if imaging negative) - >high opening pressure = pathology - >RBC dilution across 4 tubes/xanthochromia - >biochemical analysis - FBC - >anaemia? - >thrombocytopaenia? - Coags - EUCs - >hyponatraemia (SIADH)

Emergency (NEW) Flashcards by Michael Joubert

ACS definitions

STEMI

Acute
> persistent ST segment elevation (1 small square) in 2 contiguous leads (except V2/3)
> new LBBB with symptoms
does not require elevated troponins
Consider posterior STEMI
> ST depression in V1-3
Old findings
> ST segment at isoelectric
> small R
> pathologic Q (1/3 corresponding R)
> inverted T wave

Non-STEMI

> diffuse ST segment depression
> depression in focal area likely STEMI with reciprocal changes
> elevated troponins without ST elevation

> unstable/new/severe/frequent angina
> no trops
> only transient ECG changes

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ACS evaluation

pain (OPQRST)
> Onset is gradual
> Precipitated by exercise/Palliated by rest/NO
> Quality is discomfort/crushing/tightness etc
> Radiates to epigastrium/scapula/jaw/throat/arms
> Site is diffuse, should not be able to point with one finger
> Time longer than 20 minutes
associated symptoms
> most commonly SOB
> palpitations
> nausea/vomiting
> diaphoresis/clamming
> syncope/presyncope
absence of pain
> older age
> women
> diabetics

Consider risk factors

Non modifiable
> male
> old
> family Hx men <55, women <65
> established CAD
Modifiable
> overweight/obesity
> metabolic syndrome
> physical inactivity
> dyslipidaemia
> diabetes
> hypertension
> smoking
> cocaine use (acute and chronic)
> renal dysfunction

Exam

evidence of hypoperfusion
> hypotension
> tachycardia
> altered mental status
> pale, cool, clammy skin
evidence of heart failure
> JVP elevated
> crackles
> S3 gallop
> MR murmur

Immediate Tests (confirm ischaemia)

ECG
> confirms STEMI diagnosis
> assessment for reperfusion immediately after
High sensitivity troponin
> baseline with repeat within 3 hours
> confirms STEMI/non STEMI if symptomatic with rise/fall with one >99th centile

Consider non ischaemic chest pain (PPP GRAMMA)

ddx
> pneumothorax
> pericarditis
> PE
> GORD
> Ruptured viscus
> Aortic dissection
> Myocarditis
> Musculoskeletal
> Anxiety
safe discharge
> consider HEART score

Secondary tests

Glucose
> hyper/hypoglycaemia common
FBC
> anaemia (anti-platelet therapy)
> leukocytosis (acute phase reactant)
Electrolytes and CMP
> arrhythmias
Creatinine/eGFR
> baseline for angiography contrast
> baseline for medications
CXR
> rule out ddx

Consider

ABG
> signs of shock of pulmonary oedema
Echo
> MI complications

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ACS management

General management

ACCU transfer/early cardio consult
2x IV canula
O2
Cardiac monitoring + serial ECGs
Routine bloods
CXR
Pharmacological management (THROMBINS2)
> Thionopyridines (clopidegrel)
> Heparin/enoxaparin
> RAS (ACEI/ARB)
> O2
> Morphine
> Beta blocker (bisoprolol/metoprolol)
> Invasive treatment (PCI) preferred
> Nitoglycerine
> Salicylate (aspirin)
> Statin
Balance ischaemic and bleeding risk
> GRACE = ACS mortality
> CRUSADE = bleeding risk in ACS

Common pathway

Dual anti platelet
> aspirin 300mg oral/dissolved
> clopidegrel 300-600mg
Anticoagulation
> enoxaparin 1mg/kg SC
> give initial 30mg IV bolus then SC if for fibrinolysis
> additional dosing not required for PCI
> use UFH if severe kidney disease (different pathway)
Consider
> abciximab (high risk/at time of PCI)
> or bilalirudin (if high risk of bleeding)

STEMI

Choice of reperfusion method
> PCI if available within 90mins of presentation
> if not, fibrinolysis within 30mins of presentation
> if fibrinolysis contraindicated, transfer to PCI
> unsuccessful thrombolysis
Fibrinolysis contraindications
> symptoms >12hrs
> BP 180/110
> recent trauma/surgery
> GI bleeding in past month
> Stroke/TIA in 3 months
> Prior ICH
> known malignancy/vascular lesion/coagulopathy
Fibrinolysis treatment
> tenectoplase preferred (bolus regime)
> alteplase (bolus plus transfusion)

NSTEMI

Approach
> CA guided revascularisation (PCI or CABG)
> no fibrinolysis
Risk stratified treatment
> very high risk = CA within 2hrs
> high risk = CA within 24hrs
> intermediate risk = CA within 72hrs
> low risk/no symptoms = guided by provocative testing

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DKA evaluation

Triggers (Don’t PANIC)

Drugs
> corticosteroids
> cocaine
> simpathomimetics
> SGLT-2
> atypical anipsychotics
Pregnancy
Acute illness
New diagnosis (common)
Infarct
Compliance

Symptoms

polyuria/polydypsia
fatigue/weakness
nausea/vomiting
abdo pain

Signs

hypotension/tachycardia
hypothermia
kussmaul breathing
fruity breath
altered mental status (GSC)
dry mucous membranes/slow cap refill
pulmonary oedema may occur
evidence of infection

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DKA labs

Investigations

Glucose
> greater than 11.1 for criteria
> can be euglycaemic
> usually above 45 in HHS
VBG
> high anion gap metabolic acidosis
> K <3.5?
> plasma osmolality (>320mmol/L in HHS)
Ketones
> dipstick tests acetoacetate/capillary tests D-beta-hydroxybutarate level 3x higher
> capillary ketones >3.0
FBC
leukocytosis is common (very high =?infection)
EUCs
> urea/creatinine high (dehydration)
> Pseudohyponatraemia (minus 1.6mmol/L per 5.6mmol/L)
> K normal despite total body depletion
> Cl low
CMP
> low or normal

Consider testing for ddx’s

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management DKA

Goals

restore circulating blood volume
inhibit lipolysis, gluconeogenesis and ketogenesis
address precipitating factors
re-establish normal physiology and electrolyte balance

Issues

acidosis
dehydration
hypokalaemia (hyper)

Monitoring

continuous cardiac monitoring
regular BP
hourly
> BG
> ketones
> VBG (particularly pH and K)

Fluids IV
-resuscitate, restore, maintain

Insulin IV

goal
> treat acidosis, not hyperglycaemia
infusion
> 0.1unit/kg/hr
> don’t drop BG >5mmol/L/hr (cerebral oedema)
target
> glucose 10-15mmol/L
maintain insulin infusion
> start 5% glucose infusion

Potassium

indication
> serum level <5.5
> once urinary flow is established

Resolution

pH >7.3
bicarb >15
ketones <0.6
patient alert
tolerating oral fluids

Education

review precipitating events
discuss symptoms and triggers of DKA
teach self management
> during illness/reduced fluid intake
advise when sick
> check BG and ketones often
> maintain hydration
> present to medical attention early

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Upper GI bleed evaluation

DDx

peptic ulcer
malloryweis
varices
portal hyptersive gastropathy
angiodysplasia
neoplasia
erosive
> oesophagitis
> gastritis
> duodenitis

Typical upper GI bleed
> haematemesis
> coffee ground
> melena
Typical features
> epigastric pain = peptic ulcer
> dysphagia/GORD = oesophageal ulcer
> emesis/epigastric pain/hiatus hernia = MWT/BS
> jaundice/distension = gastropathy/varices
> dysphagia/cachexia = malignancy
> melena w/o vomitting = distal to pylorus
Severity screen
> orthostatic presyncope
> confusion
> angina/palpitations
Past hx
> previous UGI bleed
> varices
> liver disease
> peptic ulcer
> malignancy
> coagulopathy
> renal disease/aortic stenosis/HHT (angiodysplasia)
> AAA (aortoenteric fistula)
Meds
> NSAIDs
> anticoagulants/antiplatelet
> doxycycline
> iron/bismuth
Social
> alcohol
> smoking
> IV drug use

Exam

hypovolaemia
> tachycardia
> hypotension (orthostatic/supine)
> pale/cool, clammy peripheries
> delayed cap refil
stigmata of chronic liver disease
evidence of acute abdomen
> perforation
PR exam
> melena/haematochezia

Investigations

Blood group/cross match
FBC
> Hb normal early/lowered by fluid resusc
> microcytic/iron deficiency = chronicity
EUCs
> urea:creatinine >30
Coags
LFTs
Upper endoscopy once stable
Consider CT abdo

Candidate for outpatient management?

glasgow blatchford score
> mortality risk increases with every point

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Upper GI bleed management

Unstable

Secure airway
> nasal cannula
> low threshold for intubation
Gain IV access
Fluid resuscitation
> start immediately
Transfusion
> may be required despite high Hb
> avoid overtransfusion in variceal bleeding
> FFP/platelets after 4 PRBCs
Monitor
> telemetry/ECG’s
> pulse ox
> serial BPs

General management of stable patient

Keep NBM
Fluid rescus
PRBs
> restrictive (<7) approach preferred
> lower mortality compared to liberal (<9)
> no difference in MI (including past MI)/CVA/AKI
FFP
> give before endoscopy if INR >2
Platelets
> consider before endoscopy if thrombocytopaenic
Medications
> IV esomeprazole 80mg
> consider IV octreotide or vasopressin
> IV erythromycin 30mins prior to endoscopy
> IV ceftriaxone 1g if cirrhotic
> consider with-holding anticoagulants/antiplatelets
Upper endoscopy
> interventions depend on pathology

Variceal bleeding

Natural hx
> mortality rate approx 15%
> 50% spontaneous resolution
> 1/3 rebleed in short term
> 2/3 rebleed in long term
Initial therapy
> IV octreotide 50mcg bolus then 50mcg/hr transfusion
> consider vasopressin
> balloon tamponade after intubation
Urgent endoscopy
> after resuss/within 12hrs
> band ligation/sclerotherapy
> successful in approx 90%
Consider alcoholism complications
> monitor serum electrolytes
> check thiamine
Consider cirrhosis complications
> hepatic encephalopathy
> secondary infection
> electrolyte abnormalities
> renal failure

Mallory Weiss

Natural hx
> mortality rate approx 5%
> rebleeding in <10%
Initial therapy
> IV ondansetron 10mg once daily
> consider IV ocreotide 25-50cg bolus and transfusion
Urgent endoscopy
> after resuss/within 12hrs
> haemoclip
> adrenaline + haemoclip/sclerotherapy/band ligation
> successful >90%

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thunderclap headache ddx

Always Remembering Several Critical Differentials is A Painful Thorn In My Side

Aneurysm rupture
> thunderclap headache after trigger/maybe sentinel bleed
> vomiting/nuchal rigidity/LOC/seizures
Reversible cerebral vasoconstriction syndrome
> recurrent TCH over days to weeks
> similar triggers to aneurysmal rupture
> may develop neurological deficits due to stroke
Spontaneous intracranial hypotension
> postural headache after trauma/CSF drain
> nuchal rigidity/nausea/vomiting sometimes
Cluster headache
> eye/temple pain lasting up to 3 hours
> red eyes/ipsilateral lacrimation/rhinorrhea/horners
Dissection (cervical artery)
> stroke/TIA/neck or head pain
> partial horners (no anhidrosis)/tinitus/bruit
> trauma/connective tissue disorder
Acute angle glaucoma
> blurred vision/halos/red eye/dilated pupil
Posterior reversible encephalopathy syndrome
> HTN/seizure/visual symptoms/insidious headaches
> white matter oedema
> sometimes UMN signs and focal deficits
Thrombus (venous)
> VTE risk factors/neuro deficits across arterial territories
Ischaemic stroke

-Meningitis

Spontaneous intracerebral haemorrhage
> HTN/anticoagulated/older
> gradual focal neuro signs (putamen/post int capsule)
> headache/vomiting/meningism/stupour

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Headache evaluation

Red flags on history

sudden and severe onset
precipitated by exertion or trauma
altered mental status
seizure
visual disturbance
pain down into neck or around eye
systemic symptoms
> fever
> vomiting
> dizziness
concurrent head infection
no past hx
family hx of SAH
medications
> anticoagulants/NSAIDs
> COCP
> simpathomimetics

Red flags on exam

Cushings triad
Fever
> inflammation or bleeding
HTN
Toxic appearance
Altered mental status
Focal neuro signs
Meningismus
Eye
> papilloedema
> red eye
> visual deficits
> CN IV/VI palsy

Investigations

CT or MRI
> non con
> neck/cerebral angiography
LP (if imaging negative)
> high opening pressure = pathology
> RBC dilution across 4 tubes/xanthochromia
> biochemical analysis
FBC
> anaemia?
> thrombocytopaenia?
Coags
EUCs
> hyponatraemia (SIADH)

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Aneurysmal SAH management

Consider complications (Bloody Hot CHIPS)

> Bleeding (mortality increased to approx 70%)
> Hydrocephalus
> Cardiac (arrythmia/trops/takasubo)
> Hyponatraemia
> Ischaemia (delayed due to vasospasm)
> Pressure (increased ICP)
> Seizures

Transfer

> to ICU
> tertiary institute
Grading
> Hunt and Hess

Core supportive measures

Blood pressure
> withold management unless severe/stuporous
Vasospasm
> Nimodipine 60mg oral immediately
Analgesia
> paracetamol
> opioids
Monitor
> neurological status every 1-2hrs
> transcranial doppler daily

Additional measures

Anti-thrombotic reversal
> antiplatelet = desmopressin
> warfarin = IV vit K + FFP
> UHF = protamine
> DOACs= some have direct inhibitors
Euvolaemia
> prevent hypovolaemia and stroke
> avoid raising BP
> correct hyponatraemia
Definitive treatment
> surgical clip/coiling

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Meningitis evaluation and management

ddx (MASES PTSD)

Meningitis
> bacterial
> aseptic
Abscess
Subdural empyema
Encephalitis
SAH
Petechial ddx’s
Trauma
Septicaemia
> meningococcus
> varicella
> pneumococcal
Drugs
> sulfur containing
> antibiotics
> anticonvulsants

Initial evaluation

concurrent primary survey + history to confirm
key issues
> shock
> hypoxia
> hypoglycaemia
> hyponatraemia
> seizures

Investigations

Consider CT before LP if signs of raised ICP
Lumbar puncture
Blood cultures
> useful if LP is delaying treatment
Glucose
FBC
EUCs
CMP
CRP
Coags

Initial management

dexamethasone 10mg (0.15mg/kg) IV before antibiotics
> ideally before antibiotics
cefotaxime/ceftriaxone 2g (child 50mg/kg) IV
> as soon as possible
> should not be delayed by investigations
Maintenance fluids for euvolaemia
ICP
> sit bed at 45 degrees
> if raised = consider monitoring/osmotherapy/sedation

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Anaphylaxis evaluation and management

ASAP Fluids, Ventilation, Adrenaline

anaphylaxis
shock
asthma attack
panic attack
foreign body aspiration
vasovagal reaction
acute exacerbation COPD

Immediate response

remove allergen
lay flat
call for help
prepare IM adrenaline
collapsed
> assess pulse and breathing
> ALS pathway

A
-examine lips, tongue, pharynx
-assess for obstruction
->stridor/angioedema = upper 
->wheeze = lower
-ladder of interventions
->low threshold for intubation
->oxygenation is priority 
-ask patient to speak
->change to voice with angioedema 
B
-high flow O2 via hudson/non rebreather
C
-IM adrenaline
>10mcg/kg (up to 0.5mg)
->min dose = 0.1mg (<1yr old)
->outer thigh
->repeat every 5 mins
-not responding after approx 2 doses
->prepare adrenaline infusion
->contact ICU
->fluid boluses
->consider IV glucagon in beta blocker patient 
-any signs of shock 
->1-2L boluses adult
->20mL/kg bolus child
-D
->serially assess
-E
->any more allergens?

Resistant to treatment

transfer to ICU
adrenaline infusion
fluid boluses
upper airway obstruction
> nebulised adrenaline
lower airway obstruction
> nebulised salbutamol

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anaphylaxis post acute care

Treatment

consider H2 antihistamines (ranitidine/cimitadine)
> itch
consider corticosteroids (methyprednisone)
> biphasic
> limited evidence

Observation

at least 4 hours
longer if
> severe
> hx of biphasic
> risk factors for fatal anaphylaxis
> remote or isolated
biphasic reaction
> overal risk approx 5% (higher in kids)
> up to 3 days later
consider tryptase for follow up

Discharge (SAFE)

Safety net
> recurrence in 20%
> patient education
> provide anaphylaxis action plan (ASCIA)
Allergen avoidance
Follow up with immunologist
> diagnosis revised in up to a third
> confirm allergen
> immunotherapy for stinging insects
> address co-morbidities
Epinephrine
> prescribe 2x auto injectors
> urge patient to fill immediately
> education on proper use

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Undifferentiated shock

When to suspect (Red flags)

hypotension
> SBP <90/MAP <65/orthostatic
> not always present (compensated shock)
tachycardia
oliguria
abnormal mental status
cool, clammy, cyanosed skin
cap refill >3 seconds
metabolic acidosis
lactic acidosis
tachypnea

Initial response

secure airway
support breathing
gain IV/IO access (x2)
> fluid bolus (adults=500mL, paeds=10mL/kg)
> draw blood for lab
risk stratify
> brief hx and exam

Risk stratified response

life threatening condition suspected
> begin empiric life saving therapies
> do not delay for results lab studies
patient stable but undifferentiated
> focused hx and exam
> ECG
> CXR
> ultrasound (RUSH) or echo
> lab studies

Lab studies for undifferentiated

ABG
FBC
EUC
LFTs
Coags and D dimer
Troponin and BNP
Lactate

Empiric treatment

IV fluid boluses
> adults = 20mL/kg up to 1L then ICU
> paediatrics = 10mL/kg up to 40mL/kg then ICU
> smaller if cardiogenic suspected
Inotropes/pressors
> only use when fluid resus has failed (can worsen hypovolaemic shock)
> norad or metaraminol (pressor choice doesn’t matter)

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Septic arthritis evaluation

Study These Flashcards

Clinical manifestations

acute onset
single joint (polyarticular does occur)
> red
> hot
> swollen
> painful (any amount of active/passive movement)
> tender
> loss of ROM
large joint
> usually lower limb (including sacroiliac)
> knee and hip most common
systemically unwell
fever
neonate
> intolerance of handling/posture changes
> pseudoparalysis of limb
children
> refusal to walk
> consider referred pain
consider
> hx of trauma
> rashes
> recent antibiotic use
> recent or concurrent illness (haematogenous/reactive)
> immunisation status
> family hx of rheumatological disease/IBD

Investigations

FBC
> leukocytosis common
CRP/ESR
> elevated
aspiration before abx (into blood culture bottle)
> cell count = high WCC with neutrophils
> culture = moderate sensitivity
> gram stain = increased sensitivity/rapid results
> polarised microscopy = crystals may co-occur
xray
> usually normal
> excludes ddx’s (fracture/osteomyelitis)
ultrasound
> very high sensitivity
> used to guide aspiration

Septic arthritis management

Study These Flashcards

Supportive

analgesia
> opioids inpatient
> NSAIDs and paracetamol on discharge
physiotherapy
> prevent contractures

Antibiotics (guided by gram stain)

gram +ive cocci in clusters (s. aureus)
> flucloxacilin 2g (50mg/kg child) IV
gram +ive cocci in chains (strep) or gram -ive
> cefotaxime 2g (50mg/kg child) IV
no gram stain results
> assume staph aureus

Drainage

needle aspiration
arthoscopic or arthrotomy
> allows irrigation
> preferred for hips and shoulders
repeat drainage may be necessary

Monitor

clinical condition
WCC and ESR/CRP
consider repeat synovial fluid analysis

Chest pain ddx

Study These Flashcards

Life threatening (ED TRAP)
Embolism
Dissection
Tamponade
Ruptured viscus
ACS
Pericarditis
Other/Common (GIMP)
Gastrointestinal
Gastritis/peptic ulcer
Pancreatitis
Cholecystitis
Infective respiratory conditions
Pneumonia
Asthma/COPD exacerbation
Musculoskeletal
Intercostals/ribs
Psychiatric
Panic/anxiety

Hyperkalaemia evaluation

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missed dialysis
prolonged fasting
chest pain/palpitations
abdo pain 
weakness/paresthesias

Acidosis
> infection/shock/ingestion of toxins
Diabetes
> insulin dosing/hyperglycaemia/fasting
Hyporeninaemic hypoaldosteronism
> medication hx
Catabolism
> trauma/seizures/cancer
RTA
> chronic diseases
> urine output
Aldosterone resistance
> medication hx
Sodium delivery
> hypovolaemia
> AKI

Exam

ascending muscle weakness
> beginning with legs, moving to trunk and arms
> progresses to flaccid paralysis
> presence = immediate treatment

Immediate ECG

Morphology
> flattened P waves
> prolonged PR interval
> broad QRS
> short QT
> peak T waves
> tall peaked T waves
shortened QT
Arrhythmias
> sinus brady
> AV block
> RBB/LBB
> VT/VF
> asystole

Glucose
-hyerglycaemia/hypoinsulinaemia 
VBG
-pH
-electrolytes
Repeat electrolytes
-pseudohyperkalaemia 
-hyponatraemia?
Calcium
FBC
-haemolysis
-infective
Urea/creatinine
-AKI
-GFR

Hyperkalaemia management

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Primary survey

weakness, supporting airway
c - cardiac complications

Remove aetiology

Stabilise myocardium

calcium (chloride or gluconate) IV
effects immediate but last 30-60 mins
> can repeat after 5 mins
> monitoring serum calcium level
> doesn’t drop K level
don’t give calcium in digitalis (cardiotoxicity)

Drive K intracellularly

Give fluid before insulin
> reverse dehydration effect
Insulin and glucose IV or nebulised salbutamol
effect within 15 mins
> can drop K by 1mmoL
> lasts 2 hrs

Increase K excretion

IV furosemide
> not as monotherapy/avoid with poor renal function
Gastrointestinal cation exchangers
> bind K and exchange for Na or Ca (zirconium)
> use in acute hyperkalaemia debatable
Haemodialysis
> preferred method/particular with poor renal function
> can be delayed when no vascular access

Seizure evaluation and management

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Epileptic vs non epileptic
Non epileptic
->provoked
->non provoked
->psychogenic

Primary survey

Prior
> triggers
> aura
During
> duration
> awareness
> movements
> injuries
Post
> hemiparesis/aphasia
> post ictal confusion
Past hx
> previous episodes
> medication compliance
> triggers
Family hx
Psychosocial
> work/ADLs
> driving

Exam

alertness and orientation
speech
upper/lower/CN neurological exam
> symptoms = underlying lesion
assess for injuries and infection
look for meningism

Blood glucose
ECG

FBC
Electrolytes and CMP
Urea and creatinine
Toxicology screen (if indicated)
bHCG if female (treatment)

MRI brain
-structural lesion
EEG
->relatively low sensitivity
->if still confused = as inpatient
->otherwise can be done as outpatient
Lumbar puncture
->if infection suspected

Consider serum prolactin

needs to be performed within 20 mins of seizure
> repeat later as baseline
> distinguishing psychogenic from real

No specific management needed
focus on safety

ECI website for seizures

Dizziness evaluation

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sit down
anti-emetic
veg for electrolytes

What do they mean by dizzy?
Time course
> acute prolonged = stroke/vestibular neuritis
> constant for months = psychogenic
> recurrent attacks = meniers/vestibular migraine
Provoking factors
> postural = presyncope or vertigo
> positional without posture = vertigo
> moving head makes it worse = vertigo
> occurs only with walking = balance
Association symptoms
> tilt/drop attack/oscillopsia = vertigo
> hearing loss = peripheral vertigo
> brainstem symptoms (D’s) = central vertigo
> warm/diaphoretic/nausea = presyncope
> palpitations/chest pain/dyspnoea = cardiac presyncope
Prior hx
> cardiac disease/stroke or risk factors
> migraine
> trauma
Medications

Exam

BP + orthostatic
Gait
> peripheral = fall towards lesion
> central = can’t walk/variable lean
Rombergs
> proprioception
Cardiovascular exam
Upper/lower/CN exam
> focal lesion supports central

HINTS+ (not for BPPV suspected)

Head impulse
> eye deviation to side of peripheral lesion
> normal in central lesion
Nystagmus
> beat = away in peripheral/towards in central
> central = at rest/with fixation/reversible direction
Test of skew
> vertical misalignment = supranuclear lesion
Hearing test
> loss = central
Otoscope
Dix halpike (canalithiasis of posterior SCC)
> do not use when nystagmus at rest
> nystagmus when lesion in lower ear
> beat superiorly and torsion of upper pole downwards
> opposite direction when sat up
> horizontal with no torsion = probably horizontal BPPV

ECG
glucose

MRI/MRA
->if central lesion cannot be ruled out

ddx hyperkalaemia

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ADH CRAPS

Acidosis (metabolic)
Diabetes
> insulin deficiency
> hyperglycaemia
> fasting on dialysis
Hyporeninaemic hypoaldosteronism
> ACEI/ARB
> NSAIDs
> heparin
Catabolism
> trauma
> rhabdo
> tumour lysis
RTA (voltage dependent)
> UTO
> lupus
> sickle cell
Aldosterone resistance
> spironolactone
Pseudohyperkalaemia
Sodium delivery to distal nephron
> hypovolaemia
> AKI

Initial clinical assessment stroke

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DDX
(Thinking About Stroke Mimics Helps Me Consider Everything They Missed)
-Todds paralysis
-Abscess
-Syncope
-Migraine with aura
-Hypertensive encephalopathy
-MS
-Conversion disorder
-Encephalitis 
-Tumour
-Metabolic encephalopathy (hypoglycaemia)

Time is brain
> concurrent primary survey/history/beside investigations

Before/during/after
> illness/seizures/aura/trauma
Onset
> determine time of onset/last seen well (management)
> acute = ischaemic/gradual = haemorrhagic
Ischaemic factors
> CVD risk factors
Haemorrhagic risk factors
> HTN
> anticoagulation
> sympathomimetics
Haemorrhagic vs ischaemic
> haemorrhagic = nausea/vom/LOC/meningism/seizure

A
-LOC loses protection
-NBM until swallowing assessed
B
-brainstem involvement = lose respiratory drive
->hypoventilation/hypercapnia/cerebral vasodilation/ICP
-risk of aspiration
-monitor SpO2 and supplement if <94 (not higher)
-listen to lungs for stridor/abnormal breath sounds
C
-ECG and telemetry 
->AF
->demand ischaemia 
-BP
-palpate carotid/peripheral pulses
-listen to heart for murmur
D
-serial GCS
-NIHSS score
E
-temperature
-signs of anticoagulation
-hypercholesterolaemia/PVD
-recent surgery
-head trauma
-fundoscopic exam
->papilloedema
->terson
->cotton wool/roth spots/cholesterol
F
-often volume deplete
-IV normal saline resuss and maintenance 
-avoid hypotonic solutions
G
-measure glucose
->hypoglycaemia as ddx
->secondary hyperglycaemia worsens outcome

Initial investigations and management stroke

Immediate empiric management - Positioning - >however comfortable - >flat for ischaemic/45 degrees if aspirating/ICP - >avoid cervical collars etc - O2 - >supplement if <94% - >liberal use increases mortality - BP - >management determined by aetiology - Correct hyperglycaemia - >doesn't improve outcome - Fever - >1g paracetamol may improve outcome - Transfer to stroke unit - >improves outcome - VTE prophylaxis - >cause of 10% mortality - >compression stockings - >early mobilisation - >UFH/enoxaparin if no haemorrhagic change ``` Immediate tests -FBC -EUCs -Trops -Coags -VBG -CT non con ->haemorrhagic/ischaemia/intracerebral lesion ->haemorrhagic = midline shift/bleed volume/subarachnoid -CT perfusion ->ischaemic = estimate penumbra expansion -CT angio (intracranial + aortic arch) ->ischaemic = thrombus ->haemorrhagic = aneurysms/vascular malformations ``` Haemorrhagic management - BP - >treat if hypertensive = labetalol - >aggressive treatment favoured if SBP>220 - ICP - >maintain head at 45 degrees - >mild sedation - >consider monitoring/mannitol/CSF drainage - Anticoag/antiplatelet ceased and reversal - >warfarin = FFP + vitamin K - >UFH = protamine - >aspirin = desmopressin - Surgery - >haematoma excavation for cerebellar or hydrocephalus - >craniotomy for supratentorial bleed is controversial Ischaemic management - BP - >avoid lowering - Endovascular interventions - >stent retrievers (first line)/thrombectomy/thrombolysis - >if evidence of thrombus and within 6hrs - Thrombolysis - >effective within 4.5hrs (aim for <1hr) - >consent (5% haemorrhage -> 50% fatal) - >consult local guidelines for indications/contraindications - >consider severity/goal of treatment/likely outcome - Aspirin 300mg once daily - >indicated for all if non-haemorrhagic confirmed on CT - >delay 24hrs if for thrombolysis - >immediate if not for thrombolysis - Anticoagulation (UFH for 3 months) - >start immediately if venous (even if haemorrhagic change) - >if AF, use 1,3,6,12 rule (TIA/small/moderate/large)

DDx palpitations

DDX (AV POEMS) - Arrhythmias - >structural defect (cardiomyopathy/prior MI) - >congenital (long QT/WPF) - Valvular - >mitral valve prolapse - Psychiatric - >anxiety/panic/somatization - Output high - >anaemia/fever/pregnancy - Excessive catecholamines - >stress - >excercise - >pheochromocytoma - Metabolic - >hyperthyroid/hypoglycaemia - Substances - >caffeine - >cocaine/amphetamines/nicotine - >anticholinergics/vasodilators Sepsis Shock

Evaluation arrhythmias

Immediately - ECG - BP - pulse oximetry - glucose Hx - Patient's age - >younger = AVRT or AVNRT - Regularity - >irregular = most common AF - >regular = most common sinus tachy - Duration - >brief/faded after an instant = PVC/PAC - >minutes or longer = more concerning - Character - >skipped beat/pounding = PVC/PAC - Additional features - >pounding in neck = AVRT/AVNRT - >worse when lying down/bending = AVRNT - >syncope/presyncope = VT - Precipitating factors - >stress/emotions = anxiety/long QT/inappropriate sinus tachy/sinus tachy - >feeling of panic = anxiety or arrhythmias - >exercise = long QT/AF/sinus tachy - >awakening = POSA + AF - Past cardiac hx - >previous MI - >congenital heart disease - Non cardiac ddx - >hyperthyroid symptoms - >diabetes/fasting - >psychiatric disorder - >substance use - Strong family hx - >cardiomyopathy - >long QT syndrome Exam - primary survey - >unstable? cardiogenic shock/pulmonary oedema - General appearance - >signs of hyperthyroidism - >fever or anaemia with high output - Pulse - >rate and rhythm - >bradycardia = heart block + PVC - BP - >high = catecholamine excess - JVP - >AV dissociation - Praecordium - >displaced apex beat = dilated cardiomyopathy - Auscultation - >valvular lesion Consider - ambulatory monitoring - >if cause unknown/high risk of arrhythmia - TSH - FBC - Electrolytes and CMP - Echo/cardia MRI - >if structural lesion suspected

Arrhythmia management

Regular and Narrow Tachy - ddx - >sinus tachy/SVT/atrial tachycardia/atrial flutter - Sinus tachy - >treat underlying cause - SVT - >DC cardioversion if unstable - >consider vagal maneuvers then adenosine if stable - Atrial tachycardia - >DC cardioversion if unstable - >if stable, beta blockers/non dihyrdropyridine CCB - Atrial flutter - >treated liked AF Irregular and Narrow Tachy - ddx - >AF/multifocal atrial tachy/atrial flutter variable conduction - AF - >unstable = DC cardioversion - >stable = beta blockers/non dihydropyridine CCB - >consider need for anticoagulation - multifocal atrial tachy/atrial flutter variable conduction - >usually underlying cardiac/pulmonary path - >usually stable - >treatment focused at addressing cause Regular and Wide Tachy - ddx - >VT (until proven otherwise) - VT - >unstable = DC cardioversion - >stable = amiodarone or lidocaine Irregular and Wide Tachy - ddx - >polymorphic VT/VF - Polymorphic VT - >unconscious = DC cardioversion - >baseline long QT (torsades) = magnesium sulfate - >normal baseline QT (post MI) = beta blockers - VF - >ALS Bradycardia - only treat if shocked - >temporary pacing - >atropine given prior - >consider dopamine/adrenaline adenosine - half life in seconds - with flush - raise arm cardioversion -usually with propofol

Fall with postural hypotension evaluation

DDX orthostasis (HAND) - hypovolaemia - age (decreased baroreceptor sensitivity) - neurological - >synucleinopathies (parkinson's/lewy body dementia) - >peripheral neuropathies - drugs - >vasodilators/anti HTN - >tri-cyclics - >diuretics - >antipsychotics - Before - >early morning/heat/meal/prolonged standing - >orthostasis (dizziness/dimming vision/weak) - >mechanical/palpitations/vision/substances - During - >injury/LOC - >length of lie - After - >pain/power/sensation - >confusion/drowsiness - Falls past medical ddx (BADASS FAN) - >balance/dizziness/vertigo - >arrhythmias and heart disease - >diabetes - >arthritis/immobility/de-conditioning/injury - >seizures/strokes - >sight - >fluids/vomiting/diarrhoea - >alzheimers - >neuropathies (burning/tingling/loss of sensation/incontinence) - Medications, medications, medications - >BP altering - >anticoagulant/antiplatelet Exam - Postural BP - >SBP <20, DBP <10 - Autonomic failure - >HR increase <20 - Pulse - >absent sinus arrhythmia - Exposure - >injuries (head/long bones) - Gait - Peripheral neuro exam - >power/sensation/proprioception ECG Glucose FBC EUC

Management falls and orthostatic hypotension

Review medications - reduce dose/cease where possible - consider alternative anti-HTN Advice - sit before standing - no straining on toilet/valsava while exercising - >may need to treat constipation - eat smaller, more frequent meals - toe standing/crossing legs/muscle tensing - stockings to increase venous return Volume expansion - increase salt supplementation - >sleeping head up reduces overnight salt loss - 2L water per day - consider fludocortisone Pharmacological intervention - midodrine - >alpha 1 agonist - >urinary retention/supine HTN/pruritus - pyridostigmine - >AcH inhibitor - droxidopa - >noadrenaline pro-drug - >indicated in neurogenic orthostatic

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