Fellowship written Flashcards

Question

Late cx of blood transfusions (days to weeks)

Answer 1

Infection - hep B/C, HIV, CMV Bacterial - syphilis, yersinia Delayed haemolytic ransfusion reaction - jaundice, alloimmunisation TRALI Transfusion related GVHD post transfusion purpura Transfusion reaed immune modulation

Answer 2

1. Febrile non haemolytic transfusion reaction 2. TRALI 3. Acute haemolytic transfusion reaction 4. Transfusion transmitted bacterial infeciton

Answer 3

Staph epidermis Strep viridans

Answer 4

1. Staph aureus 2. Coag negative staph 3. Streptococci

Answer 5

1. Severe AR 2. Cardiogenic shock/severe HF 3. Aortic valve dehiscience 4. Relapsing prosthetic valvle endocarditis 5. Fungal endocarditis 6. Peri-valvular abscess 7. Major embolic complications

Answer 6

CSF: albumin-cytological dissociation high protein low WCC MRI - no spinal cord pathology, may show enhancement of anterior spinal nerves EMG/nerve conduction - peripheral demyelination Anti-ganglioside antibodies raised

Answer 7

Immune - ADEM (acute disseminated encephalomyelitis), GBS Tumours e.g. GBM, astrocytoma Post infectious cerebellar ataxia (varicella, EBV, enterovirus) ` Toxins e.g. alcohol, antihistamines Trauma e.g. post concussion NAI - ICH, concussion CVA Meningitis/encephalitis Functional neurological disorder

Answer 8

Campylobacter jejuni influenza EBV CMV Mycoplasma pneumoniae Enteroviruses

Answer 9

1. Hypoxia SaO2 <92 2. Tachypnoea 3. FVC <15mL/kg (15-20mL/kg - monitor in ICU) 4. Fatigue - inc O2 requirementts 5. Unable to clear secretions 6. Unable to lift head/neck off bed 7. Hypoventilation e.g. TV <5mL/kg, low MV <5L/min 8. Unable to trigger breaths on NIV 9. Refractory hypoxaemia with FiO2 >60% 10. PEEP >10 cmH20

Answer 10

1. Haemolysis e.g. RBO/Rh incompatibility 2. Transfusion reactions 3. Hereditary blood disorders eg. sickle cell, thalassaemia 4. Liver failure 5. Overdose e.g. cephalosporins 6. Gilbert's disease 7. Tumour lysis

Answer 11

Cholecystitis Pancreatic cancer Pancreatitis

Answer 12

1. Airway burns - singed nasal hair 2. Early intubation anticipating airway oedema 3. Deep facial burns causing oedema 4. Respiratory distress, stridor, SOB 5. Hypoxia SaO2 <90% on >FiO2 0.60 6. Decreased GCS <10 7. Circumferential chest wall burns, unable to ventilate 8. Dysphonia 9. Severe pain, - planned analgesia

Answer 13

Hydroxycobalamin Sodium nitrite Sodium thiosuflate

Answer 14

1. RAPD 2. Reduced colour vision 3. Optic disc oedema 4. Reduced VA <6/12 5. Papilloedema 6. Pain with eye movements 7. Central scotoma

Answer 15

Wong-Baker faces scale FLACC (Face, legs, activity, cry, consolability)

Answer 16

Risk stratification for UGIB for outpatient vs inpatient mx - Malena - Syncope - Liver disease - CV failure - SBP - BUN - Hb - HR >100 - Male

Answer 17

Balloon inserted into aorta, inflates during diastole to increase coronary artery perfusion Cx - distal ischaemia, reduced perfusion of distal limbs/organs - pump failure - Traumatic aortic rupture - Arterial thrombus - Haemorrhage on insertion - AV fistula

Answer 18

Increases SV and afterload during systole, reduced LV workoad and O2 demand Cx - Bleeding - pericardial effusion - Infection - Thromboembolism - Device failure - RH failure - VT - Thrombus

Answer 19

high riding testicle horizontal lie absent cremasteric reflex pain not relieved with elevation of scrotum wide based gait swollen tender testis

Answer 20

MRI brain - demyelination changes LP - normal protein, IgG elevated, oligoclonal bands no organisms on culture

Answer 21

PAINED - Paracetamol - Allopurinol/amiodarone - Iron/isoniazid - Nitrofurantoin - Epilepsy drugs - carbamazepine/phenytoin/vaproate - Deathcap (amanita phalloides) paracetamol Iron isoniazid Allopurinol Amiodarone Deathcap mushrooms (amanita phalloides) Nitrofurantoin Anticonvulsants: Carbamazapine Phenytoin Sodium valproate Metabolic causes - Acute fatty liver of pregnancy - Wilson's disease Vasculopathy - Ischaemic hepatitis - Portal vein thrombosis

Answer 22

Local - Quinsy - Neck abscess - Otitis media - Lemierre's syndrome (IJV inflammation and clot) - Lymphadenitis - mastoiditis - sinusitis Systemic - Sepsis - Pneumonia - Meningitis - cerebral abscess - Post strep arthritis - Mediastinitis - glomerulonephritis - toxic shock syndrome

Answer 23

Bradycardia <100 for > 5 mins Absent/reduced baseline variability Late decelerations with reduced variability Baseline foetal tachy HR >160 No decelerations Sinusoidal variability pattern

Answer 24

Pleural protein: serum protein >0.5 Pleural LDH: serum LDH >0.6 Pleural LDH >2/3 upper limit of normal serum LDH

Answer 25

Infection e.g. empyema Malignancy e.g. primary lung ca, mets Lymphomas PE RA Pancreatitis Dressler's syndrome SLE Pulmonary infarction Transudative Heart failure Ascites Pe Nephrotic syndrome

Answer 26

Na channel blockers - TCAs, hydroxychloroquine Beta blockers CCBs theophylline Sulfonylureas Recreational - amphetamines, MDMA Opiates - methadone, morphine, oxycodone

Answer 27

Dissection, aortic aneurysm Primary lung cancer Lung abscess TB Sarcoidosis Lymphoma (HL/NHL) Thymoma Thyroid mass - neoplasm, retrosternal goitre Teratoma Neuroblastoma Germ cell tumour

Answer 28

Pemberton's sign - flushing/erythema of face with arms above head Cough Dysphagia Distended neck veins Facial/neck oedema Dysphonia/hoarse voice Facial telangiectasias Proptosis Altered GCS Inc collateral veins to anterior chest wall Inability to lie flat

Answer 29

Balanced transfusion of blood products 1:1:1 Prevent acidosis, aim pH >7.2 Prevent hypocalcaemia iCa >1.1 Target to ROTEM parameters Prevent hypothermia, temp >35 Avoid excess crystalloids (dilutional coagulopathy) TXA IV access - improve flow rate with RICC line Direct control of haemorrhage Correct coagulopathy Permissive hypotension, MAP 60, SBP 80

Answer 30

1. Cardiac massage & internal defib 2. Direct control intrathoracic bleeding 3. Drain pericardial effusion; relieve tamponade 4. Cross clamp aorta - inc perfusion to coronary arteries and brain 5. Cross clamp pulmonary hilum to prevent air embolus

Answer 31

propranolol hydrocortisone PTU Lugols' idodine Carbimazole

Answer 32

hypotension bradycardia apnoea hypoglycaemia seizures

Answer 33

1. Postural hypotension >20 2. Postural tachy >30 3. Signs of dehydration e.g. lethargy, tachy, hypotension 4. Rapid weight loss >15% in 3-6 months 5. HR <50 6. Resting BP <80 7. Hypothermia 9. Uncontrolled purging, exercising

Answer 34

Metabolic disorder post prolonged starvation and refeeding of nutrition, causing electrolyte abnormalities post insulin refeeding triggers redistribution of electrolytes from extra to intracellular space Hypophosphataemia Cx - VT, VF, QTc prolongation, torsades - Cardiac failure - pericardial effusion

Answer 35

- Head up 30dg - Maintain normocarbia paCO2 35 - BP control BP <130/80 and SBP> 110 - Sedation/paralysis to control ICP - propofol/midazolam, vecuronium - Seizure prophylaxis keppra 2g - IV mannitol 0.25-5g/kg or hypertonic salinle 3% 3mL/kg over 10 mins

Answer 36

1. Severe resp failure refractory to maximal ventilation settings e.g. pneumonia 2. ARDS 3. Status asthmaticus 4. Traumatic pulmonary contusions 5. Bridge to lung transplant 6. GVHD 7. Drowning

Answer 37

1. Massive PE with cardiac arrest 2. Bridge to heart transplant or LVAD 3. Anaphylaxis 4. Severe cardiac failure 5. Cardiac, aortic trauma 6. Witnessed cardiac arrest 7. severe myocarditis 8. drug overdose with severe cardiotoxicity 9. Severe sepsis with cardiogenic faillure 10. Cardiac/major vessel trauma

Answer 38

1. Prolonged CPR >60 mins 2. Age >75 3. Significant comorbidities e.g. neurological injury, end stage malignancy 4. If deemed futile - irreversible cardiac/respiratory failure non candidates for transplant 5. Advanced care directive NFR 6. Major ICH 7. Severe bleeding risk e.g. active bleeding 8. Unknown time of OOHCA e.g. unwitnessed arrest

Answer 39

IV methylpred 1g daily for 3days then PO pred 40-60mg daily for 4 weeks then taper MTX 10mg weekly up to 25mg with folic acid Aspirin 100mg daily Analgesia

Answer 40

Overcrowding: insufficent resources to meet needs of ED pts causing longer wait times, treatment delays and poor quality of care. Often due to access block Access block: poor care/inability to provide care due to pts unable to access hospital bed within reasonable time frame (8 hours) due to lack of inpatient capacity or lack of integration between ED and inpatients

Answer 41

1. Reduced quality of clinical care = poorer outcomes 2. Increased wait times 3. Increased violent incidents 4. Decreased patient satisfaction 5. Increased staff stress 6. increased medical errors/near misses

Answer 42

1. ED flow coordinator 2. Rapid assessment areas, fast track areas for pts that do not require stretcher 3. Assessment areas at triage to allow initial assessment by senior for disposition planning 4. Senior staff completing rapid assessment and determining disposition prior to junior staff assessing pt 5. ED scribes 6. Direct admissions for stable transfers

Answer 43

1. 24 hour hospital coordinator to facilitate pt flow 2. SSU for pts likely to be discharged within 24h to free up inpatient beds 3. Hospital bed occupancy at 85% to allow for emergency admissions and surges 4. Early morning discharges in anticipation of PM admissions 5. Early senior decision making of inpatients to facilitate discharge 6. Early identification of pts that can be transferred to private 7. Week/out of hours discharges 8. Transient lounges

Answer 44

1. Duration >15 mins 2. Not returning to baseline within 1 hour 3. Focal neurological symptoms at onset 4. Recurrence within same illness 5. Hx of developmental delay/regression 6. Age <6 months 7. Signs of CNS infection

Answer 45

1. FHx 2. Neurodevelopmental problems 3. Prolonged/focal febrile seizures 4. Febrile status epilepticus

Answer 46

1. Return to baseline 2. Underlying illness managed 3. Serious bacterial infection excluded 4. Parental education on first aid and mx of future seizures 5. Appropriate f/up and safe environment, pts understand when to bring child back

Answer 47

1. Best available evidence 2. Clinical expertise 3. Patients' values

Answer 48

1. Confirmation bias – data interpreted in a way that confirms researcher’s hypothesis 2. Recall bias – pt does not remember events accurately = incorrect results 3. Observer bias – researcher’s expectations/beliefs influences the experiment, distorting the data 4. Sampling bias – individuals not chosen randomly, don’t represent population 5. Selection bias – selection method is biased, not randomised and doesn’t represent population 6. Reporting bias 7. Attrition bias 8. Detection bias

Answer 49

1. High risk animals - bats, cats, rats 2. Deep puncture wounds, cannot be irrigated well 3. Inmunocompromised 4. Delayed presentation >12 hours 5. Bites to hands/face/neck/genitals/joints

Answer 50

1. Pneumothorax 2. Interstitial fluid e.g. APO 3. Infection - consolidated lung 4. ILD 5. Pleural effusions 6. Pulmonary fibrosis 7. Atelectasis

Answer 51

CO binds with stronger affinity to Hb than O2, shifting O2 dissociation curve to left Hence, SaO2 may appear normal, but PaO2 is much lower = tissue hypoxia The SaO2 from pulse oximeter appears much higher than on ABG Pulse oximeter does not differentiate b/w COHb and O2Hb hence unreliable.

Answer 52

1. CarboxyHb level (COHb) - if high e.g. 50% = severe toxicity, but low 10% with symptoms also indicates toxicity 2. CXR - co-existing pathology 3. ABG - lactate - tissue hypoxia 4. Paracetamol/ETOH screen 5. CTB - globus pallidus lesions- bilat symmetrical regions = severe CO poisoning 6. Troponin for ischaemia 6. UECs, CK - rhabdo, end organ ischaemia

Answer 53

1. Severe toxicity with LOC/syncope/confusion 2. Seizures/coma 3. AMI 4. COHb >25% 5. CV dysfunction, hypotension 6. Severe metabolic acidosis 7. not normalised after 6 hours O2 8. pregnancy

Answer 54

Cognitive impairment Hearing loss Memory loss Depression Impaired concentration & speech movement disorders

Answer 55

Timeframe - Primary is within 24hours - Secondary >24hours, usu. 5-7 days Cause - Primary - related to intra-operative factors e.g. surgical technique, or underlying coagulopathy - Secondary - due to sloughing off of fibrin clot & exposure of underlying tissue causing bleeding - Or due to infection

Answer 56

3mL/kg of 3% NaCl

Answer 57

1: <10% lac or subcapsular haematoma 2: <10-50% of spleen 3: >50% of spleen 4: Laceration with vascular injury and intraparenchymal haematoma. >25-75% devascularisation 5: shattered spleen

Answer 58

1. Cold IVT 2. Evaporative - fans, spray cool water, remove clothing 3. Cold water irrigation of bladder/rectum 4. Ice packs to neck, axillae, groin 5. Intubate/ventilate - paralysis reduces metabolic activity 6. Immersion if patient is stable 7. ECMO

Answer 59

- Congenital heart disease e.g. TOF - Respiratory sepsis - e.g. bronchiolitis - Haematological e.g. methaemoglobinaemia, spherocytosis - Peripheral causes e.g. hypothermia - Sepsis

Answer 60

- Helps distinguish between cardiac vs respiratory causes of cyanosis (VQ mismatch vs shunting) - Measure ABG without O2, then provide high flow nasal 100% O2 for 10 minutes and repeat ABG - If there is a R-L shunt in cyanotic heart disease, SaO2 doesn't improve and patient remains cyanotic - With respiratory disease, SaO2 improves - NB: severe respiratory disease may still cause persistent cyanosis despite O2

Answer 61

With IV access - IV fluid bolus 5-10mL/kg - Phenylephrine 0.01mg/kg - Beta blockers - Morphine decreases catecholamines and infundibular tone 0.1mg/kg Without IV access - High flow O2 1L/kg - Change posture - knees to chest - Manual abdo compression - Avoid distressing child, quiet environment, parents etc

Answer 62

Process to analyse the cause of a system failure during a sentinel event, solve problems & provide recommendations for change. When should it be taken? - As soon as possible after an incident or during audit proess - For high risk, high impact incident with potential harm for patients What are the 4 principles of a RCA investigation? - Focuses on systems and processes rather than individual performance - Fair, thorough, efficient - Focuses on problem solving - Uses recognised analytical methods - Uses scale of effectiveness to develop recommendations 5 major steps of RCA 1. Define incident/problem 2. Map a timeline of event 3. Analyse the critical event 4. Identify root causes and support with evidence 5. Identity ways t address the problem and provide recommendation

Answer 63

- ADEM - Post infectious vestibular ataxia - Reactive arthritis - Meningitis/encephalitis - Cerebral abscess - Cerebral/cerebellar tumour - Drugs e.g. sedative antihistamines/cold & flu tablets - Hyponatraemia SIADH - Stroke - Toxins

Answer 64

0-6 hours: GI sx (N/V/D/cramps) 6-12 hours: Symptoms improve, pt feels better 12-48 hours: Cardiogenic shock and HAGMA, hypertension, multi-organ failure 2-5 days: Fulminant liver failure, coagulopathy, jaundice, coma 2-6 weeks: Liver cirrhosis, GI scarring, strictures

Answer 65

Ingested elemental iron dose <20mg/kg: asympomatic 20-60mg/kg: GI symptoms 60-120mg/kg: systemic toxicity >120mg/kg: potentially lethal

Answer 66

Desferrioxamine Indications - Altered GCS - pH <7.1 - Serum iron conc >90 micromol/L - 60-90micromol/L but iron tablets seen on AXR or patient is symptomatic - Significant symptoms regardless of levels Cx of desferrioxamine - Pulmonary toxicity - Hypotension - AKI (renally excreted) - Toxic retinopathy

Answer 67

Causes - Hyper-extension injury of neck - OA/spinal canal stenosis - Tumour - Syringomyelia Motor weakness upper limbs > limbs Motor weakness distal (hands)> proximal Motor > sensory loss Variable sensory loss Bladder dysfunction Variable reflexes Reduced pain & temp in arms, often hyperaesthesia & normal vibration/proprioception Usu. good outcome

Answer 68

Flexion injury Disc protrusion Post AAA Anterior spinal artery occlusion Examination? Motor weakness/deficits (ventral corticospinal tract) Pain and temperature loss Light touch/proprioception spared (dorsal column) Highly unstable injury - poor prognosis (as opposed to extension teardrop fractures that are stable in flexion but unstable in extension and less severe)

Answer 69

Anti-arrhythmics e.g. sotalol to prevent ventricular arrhythmias Anticoagulation - inc risk of RV thrombus formation due to RV dysfunction ICD ACE inhibitors for tx of heart failure Radiofrequency ablation if frequent arrhythmias

Answer 70

1. Echocardiogram – identifies RV failure, RV dilation, RWMA particularly of RV, thinning of RV myocardium 2. Cardiac MRI – RV dilatation, thinned myocardium – fibrofatty infiltration 3. Histological diagnosis – endomyocardial biopsy 4. CXR – cardiomegaly, signs of RV failure e.g. pulmonary oedema - not diagnostic of ARVD

Answer 71

BP >140/90 on 2 occasions or >160/110 Hyperreflexia Proteinuria AKI Pleural effusions Peripheral oedema RUQ abdo pain Headaches Ix - UEC - AKI - Thrombocytopaenia - DIC - raised INR/APTT, dec fibrinogen - Haemolysis - raised LDH, reticulocytes, dec haptoglobin - LFTs - transaminitis - Increased urate - Hypocalcaemia - Urinary protein

Answer 72

Acetylcholinesterase inhibition causing increased ACh at neuromuscular junction of muscarinic/nicotinic receptors. I.e. cholinergic symptoms Muscarinic: - Diarrhoea, urination - Hypersalivation - Bronchorrhoea - Emesis - Lacrimation Nicotinic: - Fasciculations, agitations, tremor, weakness Life threatening effects: - Bradycardia, hypotension - Bronchospasm - Resp muscle paralysis - Seizures - Coma Antidote: - Pralidoxime IV 2g then infusion 0.5g/hr - Atropine for bradycardia - endpoint: drying of secretions, HR > 80, good AE bilat

Answer 73

1. Prothrombinex 50IU/kg 2. Vitamin K 10mg IV 3. FFP 4 units

Answer 74

Clinical features - Localised pain within mins, increasing intensity over hours - Erythema 10cm around bite - Localised piloerection - Sweating – local or generalised - Lymphadenopathy and regional LN pain within 30 mins - May have mild muscle fasciculation/weakness - N/V, restlessness, tachycardia, HTN Management First aid - Ice/cold compresses - Pressure immobilisation not recommended - Analgesia - Benzos if muscle spasm/anxiety prominent - ADT prophylaxis Redback antivenom - Controversial

Answer 75

Sx - Pain and erythema; trauma from large fangs - Autonomic o Sweating, salivation, lacrimation o Piloerection o Mydriasis, miosis o CV: HTN, tachy/brady, hypotension - Neuromuscular o Paraesthesias (local, distal, peri-oral) o Fasciculations, muscle spasms, paralysis - APO (non cardiogenic) in 30%; major cause of mortality o Due to adrenergic stimulation - Others o Headache, abdo ppain, N/V o Altered GCS o Secondary coagulopathy o Multi-organ failure Mx - Immediate pressure immobilisation - Mx of CV instability, APO - Atropine for salivation/bronchorrhoea Antiemetics - ADT - ICU may be requried - Antivenom - 2 vials; repeat every 30-60mins; often needs 8 viasl

Answer 76

Confusion O2 satts <90% RR 30 BP <90/60

Answer 77

SBP <90 Multi-lobar infiltration Albumin <35g/L RR >30 if age >50, or >25 if under 50 Tachycardia HR >125 Confusion O2 sat <93% pH <7.35 0-2 points = low risk 3-4 = moderate 5-6 = high 7-8 = very high (33% 30 day mortality)

Answer 78

1. Malignancy - RCC, bladder ca, prostate caa 2. Obstructive renal calculus 3. Glomerulonephritis 4. Polycystic kidney disease 5. Post op e.g. TURP

Answer 79

Drugs - sulfonamides, amoxicillin, OCPs, NSAIDs, salicylates Infectious - strep throat, viral throat infections, TB, Chlamydia, fungal parasites, HSV, viral hepatitis, HIV, salmonella, campylobacter Malignancy - lymphoma, leukaema, sarcoidosis, IBD, pregnancy

Answer 80

1. Haematuria 2. Rhabdomyolysis 3. Myoglobinuria e.g. extreme exercise 4. Jaundice, cholestasis 5. UTI 6. Meds - Fe supplements, rifampicin 7. Food - fava beans

Answer 81

Primary - CLD with ascites - Nephrotic syndrome - Peritoneal dialysis Secondary bacterial peritonitis - Appendicitis - Pancreatitis - Perforated viscous - Diverticulitis All can cause ascites

Answer 82

- Tentacles often seen - red linear rash - Wheels, whip like marks - Tachycardia, HTN - Muscle spasms, paralysis

Answer 83

Pain - intiially not severe No tentacles seen Skin erythema but no wheal Muscle spasms/aches Headache, sweating, agitation SOB HTN Tachy Sweating APO

Answer 84

Risk stratification tool, validated for use in ED post triage 1. LOC/syncope 2. Seizure activity 3. Asymmetrical facial weakness 4. Asymmetrical arm weakness 5. Asymmetrical leg weakness 6. Speech disturbance 7. Visual field defect

Answer 85

1. Time of onset of symptoms <4.5 hours at time of starting treatment 2. Age >18 3. Clinically definite stroke - new persistent focal neurology e.g. speech disturbance 4. Significant deficit NIHSS >4 5. CTB excluded ICH Hospital factors - Immediate access to radiology and interpretation of images - authority by neurologist/ED physiican - access to stroke mx team to give thrombolysis

Answer 86

1. Apology to patient/family/NOK 2. Factual explanation of the event 3. Discussion of potential consequences of event 4. Allow pt to ask questions 5. Explain what steps are taken to manage the event and prevent recurrence

Answer 87

Zone 1: clavicle to inferior border of cricoid cartilage - Trachea, oesophagus, thyroid, subclavian artery/veins, jugular veins, common carotid art, apex of lung Zone 2: Inf border of cricoid to angle of mandible - Recurrent laryngeal nerve (hoarse voice), sympathetic chain (Horner's syndrome), Glossopharyngeal nerve (CN IX) (loss of taste to posterior 1/3 tongue), Vagus nerve (CN X) (dysphonia/dysphagia), hypoglossal nerve (CN XII) (loss of motor fx to tongue) Zone 3: above angle of mandible to base of skull - Lateral pharynx - Carotids - CN VII, XI, X, XI, XII

Answer 88

NaCl 3% 1-2mL/kg/hr via CVC for 2-3hrs Increase serum Na 1-2mmol/hr for 3-4 hours and <12mmol/24h aim UO >0.5m/hr

Answer 89

1. High chance of mortality/morbidity 2. Concerns for neglect / NAI 3. Court order 4. Other parent consents 5. Parent does not have capacity e.g. mental healtlh

Answer 90

1. Malignancy e.g. bony mets 2. HyperPTH e.g. parathyroid adenoma 3. multiple myeloma 4. AKI 5. Drugs e.g. Vit D for OP 6. Dehydration e.g. gastro Calcium supplements Hyperparathyroidism Iatrogenic - e.g. thiazides, lithium, Vit D Malignancy/MM Parathyroid disease e.g. cancer etc Sarcoidosis

Answer 91

1. Raised ICP e.g. papilloedema 2. Overlying cellulitis/infection 3. Recent seizure within 1 week 4. Known CNS disease e.g. tumour 5. Altered GCS/cognition 6. Focal neurology 7. Hx of malignancy 8. Age >60

Answer 92

1. IV fluids aiming UO >0.5ml/kg/hr 2. Bisphosphonates to reduce bone resorption 3. Tx underlying illness e.g. UTI, tox ingestion

Answer 93

Deathcap (amanita phalloides) GI - N/V/craamps CNS - confusion, coma Renal failure liver failure

Answer 94

1. Early decontamination - induce emesis if within 4h of ingestion 2. Activated charcoal if <36h since ingestion 3. Supportive measures - IV fluids 4. Contact toxicologist 5. Specific antidotes - NAC - Atropine - Silibinin - Penicillin G

Answer 95

Lack of beat to beat variability/reduced variabillity Resting tachycardia >160 Late decelerations

Answer 96

1. Papilloedema - raised ICP 2. Meningism, neck stiffness (raised ICP) 3. CN III palsy - aneurysm 4. Cushing syndrome features - underlying possibel dx 5. Hypertensive retinopathy - end organ damage 6. Signs of CCF

Answer 97

1. Hydralazine 5-10mg IV Q10mins up to 80mg 2. Labetalol 10-20mg Q20 mins 3. GTN patch 50mcg 4. GTN sublingual 300-600mcg then infusion 5mcg/kg/hr titrated to response 5. Nifedipine 60mg QID PO

Answer 98

1. Gastroenteritis - diarrhoea, vomiting, contact hx 2. UTI 3. Sepsis - fever 4. Malrotation - distended abdo, distress 5. Pyloric stenosis - projectile vomiting, olive shaped mass, visible peristalsis 6. Intussuception - intermittent crying/pallor, well in between 7. NEC - premature baby 8. Reflux - small milk possets in otherwise well baby 9. Overfeeding - hx of overfeeding, absence of features of serious cause

Answer 99

1. Rigid cervical collar 2. Forehead/head taped to bed, taped thorax & abdo 3. Foam hard block & spinal board 4. Sandbags/pillows and tape 5. Vacuum mattress

Answer 100

Class Ia - procainimide, quinidine 1b: lignocaine, phenytoin 1c: flecainide Class II - beta blockers (block AVN, reduce sympathetic activation of heart) Class III - Sotalol, amiodarone (K channel blockers) - prolong repol & QTc Class IV - CCBs - reduce conduction via AVN & reduce contractility

Answer 101

1. Prolonged resuscitation, until temp 30-32 2. Warm to 32 degrees - prioritisation 3. Reduce adrenaline dose - single dose if temp <30 and 1mg Q8mins until temp 35 4. Early ECMO 5. Pulse check with Doppler/echo required as CPR should not be interrupted 6. Do not cease CPR until normal core temp even if dilated pupils (not considered dead in hypothermia)

Answer 102

Bradycardia Heart block Osborn J waves Slow AF VT/VF VE wide QRS Prolonged QT

Answer 103

4mL x BW (kgs) x TBSA of burns (%) replace half over first 8 hours 2nd half over next 16 hours

Answer 104

Age <3 Submersion >5 mins pH <7.1 Metabolic acidosis GCS <9 (Coma on arrival to ED) 10: No attempted resus in first 10 mins after rescue 90% recovery if <3 of above 5% if >3 Predictors of poor outcomes At scene: - immersion >10m - Delay to CPR e.g. no bystander CPR, unwitnessed arrest - Time to first breath - Water temp - Presence of cardiac arrest - Identifiable precipitants e.g. arrest secondary to AMI whilst swimming In ED: - asystole - CPR >25 mins - dilated, non reactive pupils and pH <7 - Dilated non reactive pupils and GCS M5 - High lactate ICU - Loss of GWMD on CTB within 36h - Absence of purposeful motor response GCS <% - Absence of brainstem reflexes, pupil response and spontaneous breathing at 24h

Answer 105

Applies to non traumatic headaches with max intensity within 1 hour in patients 15+ Needs CTB if: Age 40+ Neck pain/stiffness Limited neck flexion Witnessed LOC Onset during exertion Immediately peaking pain (ie thunderclap) Mnemonic: OTAWA Onset with exertion Thunderclap Age 40+ Witnessed LOC Abnormal neck - limited flexion/neck pain & stiffness

Answer 106

<2 days - ABO, Rh incompatibility, sepsis, haemolysis (G6PD def) 2-3 days - physiological 3-7 days - sepsis, CMV, toxoplasmosis >1 week - congenital hypothyroidism, sepsis, hepatitis, biliary atresia, drug induced haemolytic anaemia, breast milk jaundice What are some historical features that would suggest pathological jaundice? - Poor antenatal care - Instrumental delivery - Projectile vomiting - Infective symptoms - PROM - Pale stools, dark urine - Low birth weight - Known Rh - mother Rh + father - Jaundice within first 24h

Answer 107

Brief (<1 min) resolved unresponsive episode with cyanosis, apnoea and loss of tone. Low risk features (must have ALL of the following): - Born 32+ weeks - Age >60 days - Duration <1 min - No CPR by trained professional - First episode - No significant concerning features on hx and exam

Answer 108

MRI brain - Subcortical/periventricular plaques - Demyelinated areas - Enhancement during activity and resolves with remission - Hypoattenuation LP - Oligoclonal bands - Normal protein - IgG elevated - Mainly T lymphocytes

Answer 109

- Albuminocytologic dissociation - elevated CSF protein in absence of CSF cells - Protein >0.4g/L - CSF cell count normal

Answer 110

1. Malignancy e.g. primary adenocarcinoma 2. Severe pneumonia with infarction 3. PE 4. TB 5. Supratherapeutic anticoagulation 6. Inhaled FB 7. Pulmonary contusion in trauma

Answer 111

IV fluids - Saline 1L bolus then 250mL/hr for 4 hours - Aim UO >0.5mL/kg/hr - Aim MAP >65, CVP monitoring Insulin 0.1U/kg/hr (max 15U/hr) - Aim BSL <12 - Start dextrose at BSLs <12 to prevent hypoG K replacement 10mmol/hr - Aim K 3.5-4 - Drops as insulin starts Treat precipitant e.g. sepsis Airway protection if required ICU DVT prophylaxis

Answer 112

1. Plaster care - monitor for numbness, pain to fingers 2. Appropriate analgesia advice 3. Elevation in sling 4. Return advice - severe pain, swelling, numbness 5. Follow up advice - GP/ortho 6. Post sedation advice 7. POP check plan

Answer 113

1. N/V 2. Tremors 3. Agitation 4. Headaches 5. Visual disturbance 6. Auditory disturbance 7. Anxiety 8. Sweating 9. Tactile disturbance 10. Disorientation

Answer 114

Type 1 (undisplaced) - Above elbow backslab + sling 3/52 at 90 degrees flexion Type 2 (angulated fracture, but intact posterior cortex) - Reduction to anatomical - Backslab Type 3 (displaced distal fragment posteriorly, interruption of ant and post cortices i.e. no cortical contact) - Surgical mx – K wires, closed reduction internal fixation or ORIF

Answer 115

Cardiac tamponade - Beck's triad Acute limb ischaemia Stroke symptoms Pulse deficits BP diff >15mmHg between arms AR murmur ECG - STEMI pattern - most commonly inferior but can be any - Pericarditis changes - Electrical alternans

Answer 116

1. Ruptured aorta 2. end organ ischaemia 3. extension of dissection despite medical mx 4. Refractory pain 5. Severe uncontrolled HTN

Answer 117

ECG - bradycardia, prolonged QTc, AF . U waves, ST depression, atrial ectopics, VT BSL - hypoglycaemia UECs - hypokalaemia CMP - hypophosphataemia LFTs - hypoalbuminaemia, malnutrition hepatitis

Answer 118

Congestive heart falure peripheral oedema Seizures Hypophosphataemia Hypokalaemia Haemolysis Rhabdomyolysis

Answer 119

1. Malrotation with volvulus - bilious vomiting and acute abdomen 2. Incarcerated hernia - irrtability, vomiting, inguinal mass 3. Intussusception - usu older but can occur with neonates. periods of pallor and intermittent pain. haematochezia 4. Biliary atresia - bilious vomiting 5. Hirschsprung disease - abdo distension, failure to pass meconium in first 48h. may present with enterocolitis 6. FB ingestion - usu 6 months +, vomiting, signs of perforation

Answer 120

1. Understand and retain information regarding the nature of their condition 2. Understand consequences of treatment and of no treatment 3. able to retain and weigh information (rationalise) 4. Able to communicate their decision Understand Retain Consequences Rationalise Communicate

Answer 121

Hb >80 Fibrinogen >1g INR 50x10^9/L (>100 if ICH) iCa >1.1 Lactate <4 BE <0-6 pH>7.2

Answer 122

Primary - Optimal medical therapy & AMI >40 days, EF <30% - Severe cardiomyopathy EF <35% - HOCM - Brugada - Long QTc syndromes Secondary - Sustained VT not in setting of peri-MI - Sustained not in setting of peri-MI - Resustatated cardiac death due to VT/VF - Syncope with structural heart disease & inducible VT/VF

Answer 123

1. Absence of IUP on TVUS if BHCG >1500 2. Absence of IUP on TA U if BHCG >5000 3. Gestational sac seen extra-uterine e.g. fallopian tubes 4. free fluid in pouch of douglas 5. Free fluid surrounding fallopian tubes 6. Adnexal mass 7. Haemosalpinx

Answer 124

1. Congenital long QT syndrome 2. Electrolytes (hypoK, hypoCa, hypoMg) 3. Hypothermia 4. Extreme bradycardia of any cause e.g. CHB with slow escape 5. Stroke, ICH (esp SAH) due to bradycardia

Answer 125

Single tier - Full trauma team activation based on physiological parameters, anatomical abnormalities or mechanism of injury - Leads to inadequate utilisation of resources and inc workload Two tier - Graded response - full trauma team only if abnormal physiological signs or certain physical signs - Subset of trauma team activated as required e.g. gen surg and radiographer, no anaesthesia if no airway support needed - Reduces unnecessary use of resources - Downside - potentially could delay diagnosis or treatment

Answer 126

1. Morbiliform rash 2. Onset rash with fevers 3. URTI symptoms incl. conjunctivitis or Koplik spots Features - Confluent red maculopapular/morbiliform - Starts on face/behind ears and spreads distally to whole body - Fever at onset - Day 3-4 - May desquamate Non susceptible: - Children <6 months if mother immune - Children 1-4 with 1+ measles vaccine - All pts who have had 2+ vaccines - Pts born prior to 1966 (natural immunity) - Measles IgG present - Previous laboratory confirmed measles

Answer 127

Agitation Vomiting Tremors Tachycardia seizures arrhythmias e.g. SVT hypotension Severe hypoK Tx - PO charcoal 1g/kg (max 50g) - given even if delayed presentation - Early airway protection - Dialysis - definitive mx, highly effective if started early

Answer 128

1. Widened mediastinum 2. Obliteration of aortic knob 3. Cardiomegaly 4. Pleural effusions 5. Dilated aortic arch 6. Double knuckle sign of aortic knob 7. Tracheal deviation 8. Distorted left main bronchus From Dunn: - Widened mediastinum >7.5cm at level of aortic knob is 90% specific - Blurred aortic knob - Doubel density of aorta - Tracheal deviation to right and anteriorly - Depression of LMB - NGT deviation to right - Cardiomegaly - Left side pleural effusion – if dissection + extravascular leak - Apical capping

Answer 129

History - Sudden onset pain/symptoms - AF - Prosthetic heart valve, valvular disease - No hx of intermittent claudication - Hx of endocarditis - Hx of mural thrombus Exam - Loss of pulse only in affected area - Sharp demarcation of ischaemic area in embolic disease; usu. diffuse in thrombosis - AF - Heart murmurs suggesting valvular disease - Good contralateral pulses - No chronic ischaemic changes (e.g. hair loss, skin atropy, ulceration)

Answer 130

1. Radial-radial or radial-femoral delay 2. Diff in BP between arms of >20mmHg 3. Absent pulses 4. Altered GCS 5. Stroke, symptoms, syncope, focal neurology 6. Paraplegia if spinal ischaemia 7. Pericardial friction rub 8. Elevated JVP, muffled heart sounds, hypotension (Beck's triad) - if tamponade 9. Pt distress, diaphoresis, pallor, tachycardia

Answer 131

Analgesia HR control to prevent reflex tachycardia (target HR 60-80) - Labetalol 10-20mg IV Q10mins - Metoprolol 1-5mg IV Q5mins BP control - GTN infusion 5-20mcg/min titrated to SBP <140 - Hydralazine 5mg IV titrated - Vascular surgery for OT - definitive mx - Invasive BP monitoring

Answer 132

D-Dimer - Quick readily available, no radiation, good NPV in low pre-test prob; if neg can prevent invasive ix - Difficult to apply in pregnancy; normal range in preg not known (may be elevated); poor PPV LL Doppler US - P: no radiation, good PPV (if +, prevents further ix) - C: Poor NPV in preg; unavailable after hours, requires trained clinician/sonographer VQ - P: Good NPV and PPV to rule in/out, lower maternal breast radiation - C: higher radiation dose to foetus, poor accuracy if background lung disease; if indeterminate result will require further ix CTPA - High sen/spec, identifies alt dx, good accuracy if lung disease - Radiation to breast tissue, foetal thyroid tissue with iodine contrast, requires time out of ED TTE - No radiation; can be done at bedside if unstable; provides info on RV strain - Rarely identifies clot

Answer 133

False positive D-Dimer: Low clot burden e.g. below knee DVT Mature thrombus Elderly Malignancy Infection, sepsis Renal failure False negative D-Dimer: - Low clot burden - Matured thrombus - Defective fibrinolysis

Answer 134

SVC obstruction 1. Mediastinal mass e.g. lymphoma 2. Thyroid cancer 3. Goitre 4. Thymoma 5. Malignancy e.g. metastatic lymphadenopathy from testicular cancer 6. Post radiotherapy 7. TB 8. Localised abscess

Answer 135

Fe2+ part of Haem changed to Fe3+ = methhaemoglobin which has reduced O2 carrying capacity = hypoxia DDx - LA e.g. lignocaine, prilocaine - Nitrites e.g. amylnitrite - Nitratets - GTN - Acetone - Dapsone - Chloroquine Mx - O2 NRB - Methylene blule 1mg/kg over 5 mins, repeat dose 30-60 mins - Remove precipitating agent

Answer 136

1. Sepsis - meningitis/encephaliltis 2. Toxidrome - NMA, 5HT, MH, sympathomimetic, anticholilnergic 3. Endo - thyroid storm, phaeochromocytoma 4. Environmental - heat stroke 5. Neuro - hypothalamic strkoe 6. Severe ETOH withdrawal - delirium tremens

Answer 137

1. Rhabdomyolysis 2. AKI, liver failure 3. Dehydration 4. Seizures, coma 5. DIC

Answer 138

- 0-6 hours: vomiting, diarrhoea, abdo pain, haematemesis, melaena - 6-12 hours: some improvement - 12-48h: multi-organ failure: shock, AG metabolic acidosis, liver/renal failure - 2-5 days: fulminant liver failure - 2-6 weeks: delayed sequelae: cirrhosis, GIT strictures

Answer 139

Clinical - CNS: dec GCS, seizures, ataxia - CVS: hypoTN, tachy/brady, prolonged PR, QRS, QT, pulmonary oedema - Anti-cholin: retention, tachy, delirium Ix - Carba level - Paracetamol level - ECG - BHCG - BSL

Answer 140

CVS - bradycardia, heart block, slow AF, ectopics, bigeminy Hypotetnsion Hyperkalaemia CNS: lethargy, confusion, delirium GI - N/V/AP

Answer 141

CNS: tremors, hyperreflexia, agitation, muscle weakness, ataxia, stupor, hypertonia, rigidity Coma, seizures, myoclonus CNS: hypotension Mx - Manage coma/seizures - Supportive - correct fluid/Na deficits - May need dialysis

Answer 142

CO, cyanide Aspirin, Alcohols Toluene Methanol, metformin Uraemia DKA Paraldehyde, propylene glycol Isoniazide, Iron, ibuprofen Lactic acidosis Ethylene glycoll Salicylates

Answer 143

2xNa + glucose + urea Normal = 10 Elevated osmolar gap seen with toxic alcohols e.g. ethylene glycol + AKAI & hypoCa

Answer 144

Ethanol - slows EG metabolism Or Fomepizole (ETOH substitute) CRRT - removes toxic metabolites, tx of AKI/hyperK, acidosis Pyridoxine Thiamine

Answer 145

ECG - Broad QRS - Tachyarrhythmias - Terminal R wave in aVR - Prolonged QT Mx - Terminate seizures e.g. midazolam 2.5mg - Serum alkalinisation, aim pH 7.5 - ETT - IV NaHCO3 - Fluid resus

Answer 146

Source: Dunn *INR -> 3.5 at 48 hours -> 4.5 at any time *oliguria or creatinine > 200 µmol/L *encephalopathy *persistent metabolic acidosis (pH < 7.30) despite adequate resuscitation or lactate > 3.5 mmol/L *hypoglycaemia *sBP < 80mmHg despite resuscitation *< 10% survival rate without transplantation *Severe thrombocytopaenia

Answer 147

CNS - agitation, anxiety, delirium, hallucinations, seizures, coma Autonomic: tachycardia, hyperTN, hypoTN, flushing, mydriasis, sweating, tachypnoea, hyperthermia, diarrhoea NM: tremors, hyperreflexia, clonus, myoclonus, hypertonia, rigidity

Answer 148

Hyperventilation - initial resp alkalosis, before HAGMA N/V Tinnitus Confusion APO Dehydration

Answer 149

Indication : ingestion >150mg/kg within 6 hours AC 50g +/- repeat dose in large ingestions Urinary alkalinisation - 1-2mmol/kg bolus NaHCO3 then 25mmol/hr Aim urine pH >7.5 Dialysis for severe toxicity - if severe HAGMA, APO, AKI - salicylate level >700 mg/L

Answer 150

Headache, N, V, ataxia, seizures, coma Chest pain, SOB Confusion, visual disturbance, focal neurology Bullous skin lesions Retinal haemorrhages Resp/cardiac arrest Cherry red oral mucosa (rare) Fever, tachycardia, tachypnoea, hypotension or HTN

Answer 151

1. Effective cough - encourage coughing 2. Ineffective cough (conscious) - 5x back, 5x front, assess & repeat 3. Ineffective cough (unconscious) - open airway, 2x rescue breaths, CPR 15:2, check for FB, intubation

Answer 152

Adv - Frees up staff for other resus duties - Minimises interruptions to CPR once attached - Effective, consistent CPR - Portable during patient transfer - Useful when manual CPR difficult e.g. in AV, cathlab - Useful for prolonged CPR Disadv - Deskills providers, focuses on device attachment - Risk of device misplacement during compressions - Blunt chest/abdo trauma - Risk of device malfunction

Answer 153

Absent pulse/cardiac arrest HR <60 despite assisted ventilation for 30s

Answer 154

1. Clamp umbilicus 2. Move to resuscitaire/heat source, keep baby warm 3. Gentle stimulation - rub back 4. Assess APGAR (appearance/pulse/grimace/activity/respiration) 5. Ensure airway open If no adequate respiratory efforts, commence face mask rescue breathing @ 40-60 breaths/min If absent pulse or HR still <60 despite assisted ventilation for 30s, start CPR at 3:1 (90 compressions/30 breaths per min) Vascular access - UVC Newborn HR can be determined by auscultating heart or feeling for pulse at base of umbilicus Adrenaline dose 10mcg/kg Amiodarone dose 5mg/kg Defib 4J/kg IV fluids 10mL/kg IV/IO access

Answer 155

Adv 1. gives parents closure - see everything has been done 2. starts grieving process Disadv - May interfere with resus - May worsen staff grief to see parents distressed

Answer 156

1. Early commencement of CPR post arrest 2. CPR done by trained staff 3. Witnessed cardiac arrest 4. VT/VF on EMS arrival 5. ROSC in field 6. Mild therapeutic hypothermia

Answer 157

1. Pneumothorax secondary to intubation 2. RMB intubation 3. Aspiration 4. Airway rauma 5. Patient ventilator dysynchrony 6. Bronchospasm

Answer 158

- Spend up to 1 min checking for signs of life - Withhold adrenaline until temp >30-32 - Double duration between drugs if temp 30-35 (every 8 mins) - Early intubation - Mechanical CPR as chest more stiff - Prolonged CPR - Early ECMO CPR

Answer 159

1. Ice pack to face 2. Adenosine 100mcg/kg IV 3. Repeat dose 200mcg/kg then 300mcg/kg 4. IV verapamil - controversial 5. DC cardioversion 1J/kg then 2J/kg 6. Procainamide 10mg/kg IV over 30 mins then infusion 20mcg/kg/min 7. Amiodarone 8. Esmolol S&S - Shock - Poor feeding - Irritability - Heart failure/resp distress e.g. inc WOB, chest recessions, tracheal tug, crackles on auscultation - Cardiac murmurs - Hepatomegaly - Dec LOC - Sweating during feeding

Answer 160

RR lower e.g. 10 - allows time for expiration TV 5-7ml/kg - normal physiology and prevents barotrauma PIP 35-50cmH20 - to overcome high airway pressures PEEP 0-5cmH20 - pt will have high intrinsic PEEP, low extrinsic PEEP prevents gas trapping I:E ratio 1:4-8 - allows increased expiration time

Answer 161

1. Check ETT position and suction tube 2. Give bronchodilators 3. Check for and decompression pneumothorax 4. Change positioning - supine to more erect/lateral decubitus or prone 5. Adequate PEEP to maintain airway patency 6. Fluid resus +/- inotropes 7. Change ventilator mode, check connections 8. Anaesthetics/ENT assistance - bronchoscopy to identify level of obstruction - e.g. intubate both main stem bronchi

Answer 162

- Hx of depression - Other mental health history - Prev post partum depression - Pregnancy complications - Baby has health problems/special needs - Socioeconomic factors - Feeding difficulties - Lack of supports - Unwanted pregnancy

Answer 163

ITP - Recent viral illness, otherwise well - Isolated thrombocytopaenia - Normal vitals/perfusion - 60% have detectable anti-platelet abs HUS - Recent gastro (5-10d before rash) - Shigella, E Coli - Bloody diarrhoea (hallmark feature) - Oliguria/anuria/haematuria - Abdo pain - HTN - Ix - haemolysis - anaemia, inc LDH, dec haptoglobin, schistocytes - Elevated Cr DIC (e.g. meningococcaemia) - Rapid onset severe illness - Fever - Shock - Ecchymoses with poor perfusion/mottling - DIC - prolonged PT, dec fibrinogen, high D-Dimer

Answer 164

1. Fe deficiency anaemia - microcytic hypochromic; target cells 2. Leukaemia - blasts on blood film 3. Aplastic anaemia - low reticulocytes 4. GIT bleed e.g. Merckel's divertticulum - elevated reticulocytes 5. Haemogobinopathy i.e. thalassaemia - nucleated RBcs, microcytes 6. Congenital haemolysis i.e. sickle cell disease - sickle cells seen on film 7. Acquired haemolysis i.e. HUS - schistocyets, red cell fragmenst 8. Abnormal RBcs - spherocytosis - spherocytes

Answer 165

Exam - Signs of dehydration/shock - Sausage shaped a mass in RUQ - Bloody stools - Peritonitis - invol guarding, abdo distension, rigid abdo Xray - 2 large dilated loops of small bowel - Target sign - Crescent sign - Reduced/absent bowel gas pattern - Free air if perf - Bowel obstruction US - Target sign also - Absent blood flow in the intussusception area - Pseudo kidney sign - Mass seen in RUQ or RLQ Mx - Air enema/barium enema - higher success rate with air and intraluminal colonic pressure more accurately measured during procedure with lower radiation dose required. Lower risk of morbidity if perforation - Surgical if - perforated viscus - peritonitis, enema - enema unsuccessful - multiple recurrences - shock - ischaemic bowel, SBO Cx - Bowel ischaemia/necrosis - Bowel perforation --> peritonitis - Vomiting --> aspiration - Shock with cardiovascular collapse RFs - Male - HUS - HSP - Infectious ppt - adenovirus/rotavirus - Merckel diverticulum - Lymphoma/leukaemia of bowel wall - Foreign bodies - Recent bowel surgery - Prev intussusception - Age 2 months to 2 years - Family hx sibiling with intussusception

Answer 166

1. Intestinal malrotation/volvulus - Double bubble sign AXR 2. Merckel's diverticulum - Red current jelly stool/PR bleed - Obstruction, shock 3. Pyloric stenosis - RUQ mass - Non bilious projectile vomiting - Peristaltic waves - Abdo distension - VBG: hypochloraemic, hypoK metabolic alkalosis - Hypoglycaemia 4. Intussusception - RUQ mass - Abdo pain/pallor/lethargy - Well in betw episodes - PR bleeding 5. Duodenal/pyloric atresia - Double bubble sign (duodenal) 6. Gastro 7. UTI 8. NEC - Pneumotosis intestinalis - Prematurity

Answer 167

Obstructive - NEC - Pyloric stenosis - Biliary atresia - Midgut volvulus - Hernia - Intussusception Non-obstructive - Gastro - UTI - NAI e.g. ICH - SOL

Answer 168

1. Sepsis/infection e.g. meningitis/pneumonia 2. CHD - duct dependent lesions, hypoplastic left heart 3. Trauma/NAI - shaken baby, SAH, neglect with dehydration 4. Endo - CAH, Hypothyroid 5. Inborn Errors 6. Toxins - NAI related, incorrectly measured formula

Answer 169

No concerning features on hx & exam Age >60 dayas Born >32 weeks No CPR by trained HCP First event <1 min

Answer 170

ABCs Terminate - IV midazolam 0.1mg/kg Dextrose if hypoG 2mL/kg of 10% dextrose IV phenytoin 20mg/kg Seek and treat cause

Answer 171

Exam - Urinary retention; PVR >200mLs - Saddle anaesthesia - Arreflexia/hyporeflexia - Motor weakness - Loss of anal tone - Sensory changes in leg Causes - Disc prolapse, protrusion, ruptture - Trauma - lumbar spine # - Tumour pressing on cord - Epidural haemaotma - Spinal canal stenosis - Spinal infection Mx - Decompression surgery

Answer 172

Children <16 Pregnancy Non-trauma case GCS <15 Grossly abnormal vital signs Penetrating trauma Acute paralysis Known vertebral disease e.g. spinal stenosism, RA, prior c-spine injury Returned for reassessment of same injury

Answer 173

Short - Vascular - brachial a. - R/M/U n. - Compartment syndrome Long - Volkmann's ischaemic contracture - Myositis ossificans - Cubitus varus/valgus (malunion injury) - requires OT repair Surgical mx - Gartland type III - Neurovascular injury - Skin compromise - Open fracture - Backwards tilt of distal fragment >15degrees - Varus/valgus deformity - Displacement with >50% loss of bony contact - Rotational deformity

Answer 174

- Pneumothorax - Mediastinal compression - Subclavian vessel injury - Oesophageal injury - Brachial plexus injury - Tracheal injury - Thoracic outlet syndrome

Answer 175

Non union Malunion/deformity NV compromise - brachial plexus, subclavian art/vein Gleno-humeral joint stiffness Skin tenting/compromise

Answer 176

Absolute - Open # - Significant skin tenting/compromise - NV compromise - Floating shoulder Relative - Cosmesis - Shortening - Athletic patient - Polyttrauma

Answer 177

flucloxacillin 50mg/kg (max 2g) Q6H OR cefazolin 50mg/kg (max 2g) Q8H [children under 4 - higher risk of Kingella kingae]

Answer 178

1. Bony tenderness along distal 6cm of posterior edge of tibia or tip of medial malleolus 2. Bony tenderness along distal 6cm of posterior edge of fibula or lateral malleolus 3. Inability to weightbear immediately AND in ED for 4 steps

Answer 179

1. Bony tenderness at base of 5th metatarsal 2. Bony tenderness at navicular 3. Unable to WB immediately AND in ED for 4 steps

Answer 180

- Tibia/fibula # - Pilon # (distal tibia intra-articualr) - Calcaneal # - Vertical shear pelvic # - thoracolumbar spina # - Retroperitoneal injuries - Intracranial injuries

Answer 181

1. Consent 2. Preparation - cardiac monitoring, 2x IVCs each arm (below #) 3. Inflate BP cuff to 100mmHg above systolic 4. LA - prilocaine 2.5mg/kg 5. Fracture manipulation/reduction 6. Cuff to stay up for min 30 mins 7. Deflate and observe for LA toxicity

Answer 182

1. CRVO 2. CRAO 3. TIA/CVA 4. Optic neuritis 5. GCA 6. Vitreous haemorrhage 7. Retinal detachment

Answer 183

- CVA - CRAO - CRVO - Retinal detachment - Optic neuritis

Answer 184

Predisposing condititions - Crohn's, SLE, sarcoidosis, Ankylosing spondylitis, MS, Psoriasis - Malignancy - leukaemia/lymphoma - Infections - TB, CMV, herpes, adenovirus, syphilis - Trauma e.g. CFB, post traumatic injury/eye surgery Complications - Visual loss, glaucoma - Cataracts - Synechiae - Retinitis Meds - Topical steroids - dexamethasone, prednisolone - Tropicamide - for pupil dilation

Answer 185

- Microhyphaema - circulating RBCs - Grade I <1/3 AC - Grade II 1/3-50% - Grade III >50% - Grade IV - total anterior chamber volume (eight ball hyphaema) Complications - Rebleeding - Traumatic iritis (pt may represent with eye pain, photophobia, tearing) - Glaucoma (raised IOP) - Corneal staining - Senechiae - Vision loss - Optic atrophy Mx - Bedrest at 45 degrees - Eye shield - Limit activity - no electronic devices Reasons for inpatient mx - Other associated injuries - High grade injuries - Coagulopathy - Non compliant patients

Answer 186

Painful loss of vision Cloudy cornea, ciliary injection Severe eye pain, N/V Raised IOP 40-80mmHg Reduced VA Tx - Ophthal - IV/PO acetazolamide 500mg - Topical pilocarpine - constricts pupil - Topical beta blockers e.g. timolol - Topical apraclonidine - Analgesia and anti-emetics

Answer 187

TIA/Stroke CRVO - RAPD; Engorged retina 'blood & thunder' retina, retinal haemorrhage, tortuous engorged veins, abnormal red reflex CRAO - RAPD; Grey/pale retina, arterial supply compromise; cherry red spot Retinal detachment - retinal curtain on fundoscopy Optic neuritis - RAPD Vitreous haemorrhage - unable to see retina, blood in posterior chamber

Answer 188

Anterior uveitis/iris - cells/flare in AC, synechiae, peri-limbic inflammation Conjunctivitis - watery, inflamed, red conjunctiva, discharge Episcleritis/scleritis - diffuse inflammation Acute glaucoma - raised IOP Corneal abrasion - fluroscein uptake with corneal defect Dendritic ulcer - dendrite seen on slit lamp with fluorscein GCA - RAPD, temporal headache, jaw claudication, fever, night sweats, temporal artery tenderness/swelling with nodularity, loss of pulse

Answer 189

1. Pre-eclampsia/eclampsia/HELLP 2. Meningo-encephalitis e.g. post epidural 3. CVST 4. Hypoxic seizure secondary to PE 5. Hypoglycaemia 6. Epilepsy 7. ICH/SAH, trauma 8. toxic ingestion

Answer 190

1. Nulliparity 2. Extremes of age - geriatric preg, teen preg 3. FHx of pre-eclampsia 4. Prior hx of pre-eclampsia 5. Low socioeconomic status

Answer 191

1. Tocolytics (slows contractions) - salbutamol nebs 5mg/IV infusion - nifedipine 20mg PO Q30mins up to 3 doses 2. Oxytocin 10units IM 3. Betamethasone 11.4mg IM (foetal lung maturation) 4. Abx for PPROM (ampicillin 2g + gentamicin 5mg/kg IV) or benzylpenicillin 1.2g stat 5. MgSO4 4g over 30 mins then 1g/hr for neuroprotection 6. Disposition - O&G + paeds

Answer 192

1. Expectant 2. Medical - misoprostol 800mg PV 3. Surgical - suction D&C Surgical indications - Pt preference - Severe bleeding/shock - Septic miscarriage

Answer 193

1. Dysfunctional uterine bleeding e.g. peri-menopausal 2. Cervical cancer - may see lesion on spec 3. Trauma - hx, laceration seen 4. Endometrial cancer - USS shows mass, bulky uterus on bimanual 5. Fibroids - bulky uterus 6. PID - cervical motion tenderness, recent instrumentation, STI hx 7. Coagulopathy - hx, abnormal coagsDe

Answer 194

1. Has labour started? - pelvic pressure, contractions (strength, regular?), palpable uterine activity 2. PROM? - PV loss - Sterile speculum exam - assess cervix dilatation/thickening - Foetal fibronectin test (vaginal swab) - should be negative before 35 weeks, hence if +, suggests amniotic sac not sticking to uterus 3. Stage of labour? - Cervix length/effacement, dilatation 4. Foetal wellbeing - FHR, CTG 5. Mother's well being - vital signs ?pre-eclampsia 6. Risk factors for pre-term labour: prior pre-term labour hx, pregnancy hx so far ?polyhydramnios, oligohydramnios, short cervix; medical hx, infections

Answer 195

S&S - Prodrome symptoms/preceding illness - Arreflexia - Sensation usu. preserved - Ascending motor weakness & resp muscle involvement - Miller-Fischer variant (CN) - ataxia, ophthalmoplegia - Bowel and bladder function normal - Autonomic instability RARE Ix - MRI - no spinal cord pathology - LP: albumin-cytological dissociation - high protein, low WCC - EMG - peripheral demyelination - Anti-ganglioside abs raised Tx - Plasmaphoresis - IVIG

Answer 196

Causes - Malignancy (primary/secondary) - Infection e.g. epidural abscess, discitis - Vascular e.g. dissection causing ischaemic spinal artery - Demyelination - Trauma - Degenerative - Disc disease - Auto-immune e.g. MS S&S - Fixed level neurology of motor/sensory loss - Hyperreflexia (or hypo) - Sensation impaired at the level - No resp muscle involvement unless above C5 - Bowel/bladder dysfunction Ix - MRI - spinal cord lesion - LP - normal CSF Tx - Surgical decompression - abx, steroids

Answer 197

1. Small caliber needle 2. Atraumatic spinal needles e.g. Sprotte 3. Early mobilisation 4. Replacement of stylet before removal of needle Other cx - Spinal cord/nerve injury - use spinal needle, enter below spinal cord (i.e. L1 in adults) - Infection - sterile technique - Pain - LA to skin and subcutaneous space down to interspinous ligament - CSF leak - small needed i.e. 25G with introducer, gentle technique - Bleeding - address coagulopathy prior

Answer 198

1. Infection e.g. UTI 2. Drugs e.g. benzos 3. CNS e.g. stroke, tumour 4. Trauma e.g. ICH 5. Metabolic e.g. hyponatraemia, hypoglycaemia 6. GIT e.g. bowel obstruction, ischaemic gut 7. Withdrawal 8. Psychiatric

Answer 199

1. Midazolam 5mg IV aliquots 2. Phenytoin 15mg/kg IV over 30mins 3. Levetiracetam 1-2g IV 4. Sodium valproate 800-1200mg 5. Phenobarbitone 10mg/kg

Answer 200

1. Hypoxic brain injury 2. ICH 3. Non head trauma e.g. skeletal/spinal fracture 4. Rhabdomyolysis 5. Renal failure 6. Pulmonary oedema

Answer 201

512Hz tuning fork Rinne's - Positive = air conduction > bone conduction (i.e. normal or SNHL) (but in SNHL both AC and BC are both reduced overall) - Negative = air < bone (conductive HL) Weber's - If normal, heard in midline - Conductive HL (blockage) - localises to affected ear - SNHL - localises to non affected ear

Answer 202

binocular diplopia - horizontal, vertical or oblique paralysis of abduction, elevation & depression - eye is 'down and out' - ptosis - pupil dilation may or may not be present - Pupil constriction is mediated by parasympathetic fibers accompanying CN III, they travel peripherally and are susceptible to compression. Hence with compressive cause of CN III palsy (e.g. expanding aneurysm) the parasympethetic fibers are compressed leading to unopposed sympathetic tone causing pupil dilation

Answer 203

CN III palsy Physiological Trauma Structural defect e.g. congenital iritis, trauma, post surgery Acute angle closure glaucoma Horner's syndrome Drugs e.g. atropine, tropicamide Adie's pupil

Answer 204

1. Weakness of upper/lower facial muscles 2. Decreased ipsilateral taste to anterior 2/3 of tongue 3. Ipsilateral reduced tear production 4. Ipsilateral sensitivity to sound Causes - Bell's palsy - Ramsay hunt syndrome - Acoustic neuroma, facial neuroma, meningioma, metastatic disease - Trauma e.g. facial lac - Parotid neoplasm/mass - Malignant otitis externa - Suppurative otitis media - Botulism - Sarcoidosis Treatment - Eyecare to prevent corneal exposure - lubricating eye drops - Steroids - pred 60mg daily for 5 days then taper - Antivirals - controversial role

Answer 205

MG - Fatigability, ptosis - CT thymus, tensilon test, resp monitoring GBS - Hypo/arreflexia, asc weakness - LP - albumin-cytological dissociation, raised protein MS - Cerebellar signs, optic neuritis, hyperreflexia - MRI, LP Toxins - E.g. lead - Lead level, FBE, blood film (basophilic stippling) CVA Infection - Botulism - global weakness; blood cultures

Answer 206

Stroke - ischaemic/haemorrhagic Tumour Cerebral abscess Migraine Hypoglycaemia Todd's parasis (post seizure)

Answer 207

Neurological dysfunction of 2x different anatomical parts of CNS on 2 separate occasions - lasts >24h or slow progression of sx over 6 months Types - Relapsing-remitting 80% - Primary progressive 20% S&S - Limb sensory sx, weakness - Optic neuritis, diplopia, central scotoma, visual field defects, pain with eye movements - Spinal cord disease - weakness, painful spasms, bladder dysfx - Lhermittes sign - painful electric shocks down legs with neck flexion - Uhthoff's phenomenon - reduced vision with exercise, hot meal/bath - Brainstem disease - Cerebellar signs - Bell's palsy - Cerebral disease - hemiparesis, dysphasia, stroke sx Ix - LP 90% have <10cells/mL in CSF. Mainly T lymphocytes, normal protein. IgG elevated, oligoclonal bands in 95% - MRI - demyelination, subcortical/peri-ventricular plaques Mx - High dose methylpred for 3-7 days 1g IV - ACTH 800U IV/IM over 3 weeks - Pred for mild attacks 75mg daily, reduce after 4 days - Plasma exchange - Prevention of relapses - AZA, cyclophosphamide etc

Answer 208

75% have thymic hyperplasia and 10% have thymoma Autoimmune attack of ACH receptors in skeletal muscle S&S - Gradual onset - Skeletal muscle weakness ONLY, inducible with exercise, reversed with ice - Proximal >distal - 20% have EOM initially (ptosis) before progressing to other areas - Facial muscles - difficulty chewing, loss of facial expression, bulbar weakness Ix - ACH-R antibodies - Muscle kinases - Edrophonium challenge - induces ptosis Mx - Avoid NMB (rocuronium ok, half normal dose 0.6mg/kg), avoid sux - Cholinesterase inhibitors - pyridostigmine 10-120mg daily/single dose - Neostigmine - Pred up to 100mg daily - Aza, mycophenolate - Thymectomy

Answer 209

Inflammation across width of spinal cord Causes - MS - Post infectious/vaccines - Idiopathic - ADEM - Viral e.g. CMV/HIV/HSV/enteroviruses - Parasites - Bacterial e.g. TB, cat scratch - Fungal - Autoimmune - SLE, sarcoid S&S - Isolated spinal cord dysfx w/o compressive lesion - Paraesthesias, weakness (mainly leg flexors, arm extensors) - Sphincter dysfunction - bowel/bladder dysfx - Temp dysregulation, labile BP - Can have total motor/sensory loss below level - Spinal shock Ix - MRI spine - galodinium enhancement of cord - CSF - Pleocytosis (inc WCC), inc IgG - Sepsis screen, autoimmune screen Mx - Intubation if high level - Neurosurg - IV methylpred - Plasmapharesis

Answer 210

Adhesive - Pro: Quick, good cosmetic results (similar to sutures), no difference in infection rate, less technical experience needed - Cons: risk of dehiscience, not appropriate for deep/irregular or high tension wounds, low tensile strength Suture - Pro: Good wound approximation, less dehiscience - Con: time consuming, req LA and suture removal Steri-strips Pro: - Easy, quick to apply - Appropriate for simple wounds needing approximation, allows drainage Con - Risk of dehiscience - Not appropriate for large, or wounds under tension/movement Staples - Pro: speed - Con: cosmetic

Answer 211

1. Disseminated shingles 2. Orbital cellulitis 3. Sepsis 4. Keratitis, uveitis, scleritis 5. Blindness 6. Optic neuritis/retinitis 7. Meningitis/encephalitis 8. Ramsay Hunt syndrome 9. Ocular ulceration Mx - Ocular protection - taping, avoid pads - Lubrication - Analgesia - Antivirals - if within 72h of onset aciclovir 800mg 5x/day for 7 days

Answer 212

Drugs - Sulfonamides, cephalosporins, NSAIDs, anticonvulsants e.g. carbamazapine Infections - EBV, HIV, HSV, Mycoplasma, fungal Malignancy

Answer 213

- SJS/TENs - Herpes zoster - Drug hypersensitivity - Bullous pemphigoid/pemphigous - Sunburn - Scalded staph syndrome - Toxic shock syndrome - Herpes simplex - Pepmhigus vulgaris

Answer 214

Drugs - Sulfonamides, beta lactams (cephalosporins/penicillins), allopurinol, carbamazapine, phenytoin, lamotrigine Malignancy - lymphoma, leukaemia Immunosuppression - HIV

Answer 215

Staph scalded skin syndrome Bullous pemphigoid Drug hypersensitivity Erythema multiforme Burns

Answer 216

<4 weeks - tract not fully matured, gastric/abdo wall may have separated. Risk of misplacement into peritoneal cavity. Do not resite! >4 weeks - resite ASAP in ED as tract may start closing in 24h If no PEG available, can use large gauge Foley catheter Then CT abdo with water soluble contrast to check position PEG Cx - Inadvertent removal - Wound infection, ulceration - Nec fasciitis - Bleeding - Leaking around stoma - Leakage of gastric contents into peritoneal cavity - Gastric outlet obstruction - Pneumoperitoneum - Ileus, gastroparesis - PEG blockage

Answer 217

Conservative - Small battery <12mm - Only 1 battery ingested - No prior oesophageal disease - Reliable parents, able to seek help urgently if symptomatic Endoscopy - Dislodged in oesophagus - Symptomatic e.g. pain - Coingestion with magnets Discharge advice - Seek help if severe pain, GI bleed - Avoid laxatives - Normal diet, encourage activity - Examine stools to confirm passage of battery - Repeat Xray in 10-14 days if not passed Xray findings - Step off sign - Double halo ring on AP

Answer 218

1. Sonographic Murphy's sign - probe tenderness 2. Thickened GB wall >3mm 3. Distended GB; diameter >4cm 4. Pericholecystitic fluid 5. Presence of gallstones Extra-hepatic biliary obstruction - Choledocholethiasis - Cholangiocarcinoma - Pancreatic mass Cx of extra- hepatic biliary obstruction - Cholangitis - Reduced absorption of fat soluble vitamins

Answer 219

Local - Pancreatic necrosis - Pseudocyst - Pancreatic rupture, haemorrhage - Abscess - Ileus - Splenic vein thrombosis - Duodenal obstruction - Chronic pancreatitis Systemic - Sepsis - SIRS/Shock - ARDS - Pleural effusions & resp failure - Dehydration - Renal failure - DIC - Multi-organ failure - hypoCa

Answer 220

Age >55 WCC >16 Glucose >200mg/dL LDH >350 IU/ AST >250 BISAP - BUN >25mg/dL - Impaired GCS - SIRS - Age >60 - Pleural effusion (0-2 = lower mortality; 3-5 = higher mortality)

Answer 221

1. Patient's wishes if competent 2. Advanced care directive 3. Family/NOK decision making if incompetent 4. QOL 5. Reversibility of condition 6. What intervention is required

Answer 222

Metabolic cx - metabolic alkalosis - vomiting causing loss of HCl - Hyponatraemia - 3rd space losses - Lactic acidosis - hypoperfusion - HypoK Others - Ischaemia, perforation - Hypovolaemia Causes - Adhesions - hx of prior surgery - Inguinal hernia - palpable mass, + cough reflex - Malignancy - hx, weight loss - Stricture - hx of Crohn's

Answer 223

1. Supportive - IV fluids, electrolyte losses, wound care, barrier nursing/dressings, analgesia, mucosal/ocular care 2. Manage superimposed infections 3. Transfer burns/ICU if extensive Cx - Massive fluid losses, hypovolaemia, AKI - Electrolyte imbalances - Shock - Secondary infection/sepsis - Multi-organ failure

Answer 224

1. Malignancy e.g. breast ca, lymphoma, leukaemia 2. Viral e.g. HIV, enteroviruses 3. Bacterial infection e.g. H. influenzae, strep pneumoniae 4. Autoimmune e.g. SLE, RA 5. Uraemia 6. Serum sickness 7. Post MI 8. Traumatic 9. Post radiotherapy

Answer 225

1. Inform and consent 2. Analgesia/sedation e.g. fentanyl 3. Attach pads AP, set rate to 60-80 4. Start pacing and slowly increase mA until pacing rate captured on monitoring (electrical capture) 5. Ensure mechanical capture (palpable pulse) 6. If no capture, increase current or re-site electrodes

Answer 226

- Early repol - Pericarditis - Brugada - Ventricular aneurysm - LVH - LBBB - Ventricular paced rhythm - Raised ICP

Answer 227

- AS - MR - MV prolapse - Pulmonary stenosis - TR - VSD - ASD - HOCM

Answer 228

1. Slow rising pulse 2. S4 3. Aortic thrill 4. Paradoxical splitting of 2nd heart sound 5. LVH - displaced apex beat

Answer 229

Brugada syndrome Atypical RBBB PE Myopericarditis BER Pectus excavatum AMI

Answer 230

1. Active haemorrhage e.g. GI bleed, ICH 2. Recent stroke within 3 months 3. Prior ICH 4. Severe coagulopathy 5. Known intra-cranial malignancy (primary/mets) 6. Structural cerebral vascular lesions e.g. AVM 7. Suspected dissection

Answer 231

No resolution of pain or ST segments Failure of STE to reduce by 50-75% by 90mins post lysis Persistent pain

Answer 232

1. CT - ICH/encephalopathy 2. UECs - AKI from HTN 3. ECG - signs of ischaemia 4. Troponins - ischaemia 5. Urinalysis - proteinuria 6. CXR - signs of APO, cardiomegaly, widened mediastinum 7. CT-A if suspecting dissection 8. TTE - LVH, APO, myocardial dysfunction

Answer 233

Dose - IM 4mg/kg, IV 1-2mg/kg - Onset: IM 2-4 mins, IV 60-90s - Duration: IM 15-30mins, IV 10-15 mins A/e - Laryngospasm - Emergence phenomenon - Vomiting - Resp depression - Hypersalivation

Answer 234

Hypotension - Fluid bolus, metaraminol/inotropes Hypoxia - Optimise pre-oxygenation - apnoeic oxygenation, BVM throughout apnoeic period, HFNC or NIV pre-oxygenation Anatomical difficulties - E.g. beard, obesity, facial anatomy - Positioning - ramp head up, pillows under, backup equipment - VL, LMA, bougie - Notify anaesthetics Ventilation difficulties - Ensure well sedated & paralysed, head up to unload diaphragm - Airway adjuncts Ensure peak pressure limits, backup equipment, prepare surgical airway if needed Difficult BVM - Airway adjuncts - OPA/NPA, positioning, 2 person technique Others to consider - Anaphylaxis - start adrenaline

Answer 235

DDx - Tension pneumothorax - Ventilator/circuit problems/malfunction - Intubation down RMB i.e. 1 lung ventilation - ETT obstruction e.g. mucous plugging/blood - Bronchospasm - give bronchodilators - Awake patient - ventilator asynchrony Mx - Disconnect from ventillator, BVM - determines if ventilator is problem - Seek ptx and decompress - CXR - check ETT position/ptx - Suction down ETT - Sedate and paralyse pt

Answer 236

1. Resolution of issue that required intubation e.g. intoxication 2. Spontaneous breathing 3. Resp: SaO2 >95% on FiO2 <0.40, PEEP <5, RR <30, TV >6mL/kg 4. Haemodynamic stability, no inotropic supportt 5. Sedation and paralysis worn off 6. Not a difficullt intubation 7. Obeying commands Non clinical - Staff able to manage extubation - Able to re-intubate if needed - Available equipment - No other suitable place for extubation e.g. ICU

Answer 237

RR lower than normal e.g. <10 to allow for expiration TV 5-7mL/kg - reduces barotrauma, normal physiology PIP 35-50cmH20 - to overcome high airway pressures PEEP 0-5cmH20 (as pt will have high intrinsic PEEP), lower PEEP prevents gas trapping I:E 1:4-8 allows increased expiration time

Answer 238

Airway - protection/patency Breathing - Respiratory failure (hypercapnoea/hypoxia), increased FRC, increased WOB, excess secretions, facilitate bronchoscopy Circulation - minimise O2 consumption, optimise O2 delivery e.g. sepsis D - terminate seizure, prevent secondary brain injury, obtunded and unable to support airway E - temp control e.g. serotonin syndrome F - facilitate procedures/transfer safety

Answer 239

1-2.5mg/kg IBW Onset 15-45s Duration 5-10m Use: stable pts, reactive airways, status epilepticus Disadv: hypotension, myocardial depression, reduced cerebral perfusion, pain on injection, variable response, very short acting

Answer 240

Dose 2-10mcg/kg Onset <60s Use - modified RSI in low doses; cardiogenic shock, haemodynamic instability Disadv: resp depression, apnoea, hypotension, slow onset, N/V, bradycardia

Answer 241

1.5mg/kg Onset 45-60s Duration 6-10mins Disadv: CI - hyperK, malignant hyperthermia Post burns, crush injuries, NM disorders Bradycardia post repeated doses HyperK Fasciculations

Answer 242

1.2mg/kg Onset 60s Reversed by sugammadex Disadv - allergy (rare)

Answer 243

0.15mg/kg Onset 2-3 mins Duration 45-60 mins Not for RSI (unless cannot use roc/sux) Reversed by sugammadex Disadv - slow onset, long duration

Answer 244

ECG - Epsilon wave, QRS widening, TWI V1-3 S&S - palpitations/syncope, cardiac arrest pp by exercise RV failure --> biventricular failure --> dilated cardiomyopathy Ix - TTE - dilated hypokinetic RV and dilated RVOT - Cardiac MRI - fibrofatty infiltration, thinning of RV - Histology - endomyocardial biopsy Tx - Anti-arrhythmics - BBs, amiod, sotalol - Warfarin to prevent thrombus - Radiofreq ablation - AICD - CCF tx - Cardiac transplant

Answer 245

Cardiac - Brady - short/long QT, Stokes Adams, sinus node disease, heart block, PPM malfuncion - Tachy - VT/Torsades, SVT, AF/flutter - ARVD, Brugada, HOCM - valvular disease e.g. AS - PE, AMI Neural/reflex - Vasovagal - Autonomic e.g. Parkinson's, DM - Situational e.g. cough, defacation ec - Orthostatic hypotension - Neuro - TIA, migraine - Breathholding in children - Meds - anithypertensives, diuretics, nitrates Ohers - Hypovolaemia - AAA - Ruptured ectopic - Addisonian crisis

Answer 246

- Onset without prodromal symptoms/warning - >55yo - Hx of CCF, CAD - Abnormal ECG - FHx sudden cardiac deah - Exertional symptoms - Elevated trop

Answer 247

Major criteria (JONES) - Joint pain - polyarthritis usu knees, ankles - Carditis - dx on TTE - subcutaneous Nodules - Erythema marginatum - Sydenham's chorea Minor (PROF) - PR prolongation - Raised ESR - Other joint pains - polyarthralgia in low risk or monoarthralgia in high risk - Fever >38 in high risk; 38.5 in low risk Ix - Throat culture - ASOT - Anti DNAse B titers - ESR & CRP >30 - ECG - prolonged PR - CXR - CCF - TTE - WCC >15, normochromic anaemia DDx - post strep reactive arthrittis - bacterial endocarditis in RHD - penicillin rash - Gonococcal arthritis Mx - IM benzathine penicillin 450000 unist if <10,kg, 600000 10-20kgs 1.2mill unist in >20kgs

Answer 248

o Anti-arrhythmics – sotalol, amiodarone, quinidine, procainamide, flecainide o Antibiotics: macrolides (erythromycin, clarithromycin) o Anti-psychotics – droperidol, haloperidol, quetiapine, olanzapine, chlorpromoazine o Antidepressants – TCAs (amitritptyline, nortriptyline), citalopram, venlafaxine, bupropion, escitalopram o. Anti-emetics - ondansetron o Antihistamines – diphenhydramine, loratadine

Answer 249

Major - BCs >2x 12 hours apart - Echo evidence of endoardial involvement Minor - Temp >38 - Immunological phenomena (Osler's, Roth spots) - Microbiological (+ve BC not meeting major criteria) - Embolic phenomena (arterial emboli, septic emboli, conjunc haemorrhage, painless skin lesions) - Risk factors - congenital heart disease, IVDU Need 2 MAJOR or 1 Major and 3 MINOR or 5 minor

Answer 250

Bacteria - neisseria meningitidis, strep pneumoniae, Haemohilus, group A strep Viral - enterovirus, adenovirus, CMV, EBV Mechanical e.g. NAI, coughing/vomiting Thrombocytopaenia - ITP, TTP, HUS, infection (e.g. HIV, EBV, malaria), pregnancy Leukaemia/lymphoma, aplastic anaemia Vasculitis - HSP (paeds) - GCA, SLE, Rheumatoid, sarcoid Sepsis - N. meningitidis - DIC

Answer 251

Paeds: - Kawasaki - Scarlet fever - Toxic shock syndrome (MSSA) - Scalded staph skin syndrome - Enterovirus - SJS/TENs - Sunburn Adult: - SJS/TEN - DRESS syndrome (anti-convulsants, allopurinol, abx) - Erythroderma - Viral - enterovirus

Answer 252

Eczema Psoriasis Keratoses - seborrheic keratosis

Answer 253

Disseminated HSV/VZV Bullous impetigo SJS/TEN Bullous pemphigous (root not intact) Bullous pemphigoid (roof intact) SLE

Answer 254

Children: - Measles - Kawasaki - Roseola - Parvovirus - Rh fever (erythema marginatum) - EBV - Rubella - Scarlet fever - Mycoplasma Adults - VIral e.g. HIV - SLE - Drugs - penicilllin/cefalosporins, NSAIDs, phenytotin, allopurino

Answer 255

Children - Chickenpox (VZV) - HSV - Hand/foot/mouth (coxsackie) - Enterovirus Adults - Shingles (VZV) - Gonococcaemia - Disseminated VZV/HSV

Answer 256

Erythema multiforme (drugs/viral/pregnancy) Urticaria Fixed drug eruption Cutaneous lupus

Answer 257

Children - Scarlet fever - Staph scalded skin syndrome - SJS/TEN Adult - Drug eruption - Staph toxic shock syndrome - SJS/TENs - DRESS - Urticaria - Acute GVHD Causes: Drugs - ACE I - captopril - Abx - vancomycin, doxycycline, penicillins - Anticonvulsants - carbamazepine - NSAIDs - TCAs e.g. amitriptyline Skin conditions - Atopic dermatitis - Psoriasis - Blilstering disease e.g. pemphigus/pemphigoid - SSSS - Seborrheic dermatitis Systemic - Lymphoma/leukaemia - GVHD - HIV

Answer 258

Hypertonic saline 3% 100mLs over 10 mins, repeat up to 3 infusions OR 1-2mL/kg over 1 hour End point: Aim Na 120-125 mmol/L Seizure endpoint Correct max 10mmol/L in first 24 hours

Answer 259

'Blood and thunder' retina ` 2 types: 1. Non-ischaemic - mild; venous stasis with continued retinal perfusion, can progress to ischaemic. No RAPD 2. Ischaemic - thrombosis of central retinal vein; increased vascular back pressure, causing decreased arterial flow to retina - VA loss - RAPD Sudden painless monocular visual loss

Answer 260

Gas bubbles in arterial system - Pulmonary barotrauma - E.g. diving while breathing compressed gas (scuba). Failure to exhale; gas trapping during ascent causing alveolar rupture and gas entry into pulm capillaries from overpressurisation - Short shallow dives usu. - Risk factors - rapid ascension, not exhaling whilst ascending - Iatrogenic medical procedures - trauma - or a venous gas embolism entering via shunt (e.g. PFO, ASD Hx & Exam - Presents soon after ascent - Neuro sx - sensory/motor, headaches, confusion, seizures, visual disturbance, stroke - Haemopytsis - CVS - may be shocked, AMI - Vasogenic oedema - Hemiplegia, altered GCCS, blindness - Focal/sensory S&S - Arrhythmias/AMI Mx - ABCs, keep supine - resuscitate supine to prevent further migration of bubbles to brain - 100% O2 regardless of SaO2 to provide max gradient for diffusion of N2 bubbles out of bubbles - HBO reduces bubble vol, promotes Nitrogen resorption - IVT - Lignocaine at anti-arrhythmic doses - some studies show reduced incidence of neuropsych abnormalities - Use saline in ETT cuff in preparation for recompression; to prevent cuff leak in chamber

Answer 261

RFs - Long or multiple dives - Flying soon after dives - Exercise within 4h of dive - Obesity - Smoking - ETOH - Dehydration Clinical: - Onset within 6h Type 1 - No neuro sx - MSK (the bends): joint pain, rash, itching - Rash (cutis marmorata) Type 2 (the bends) - CNS: numbness, dizziness, weakness, ataxia - Motor/sensory changes - Spinall cord - bladder distension, sphincter dysfunction - Inner ear (the staggers) - vertigo, nystagmus, tinnitus, ataxia - CV/Resp (the chokes) - chest pain, cough, SOB, haemoptysis, CVS collapse, resembles ARDS

Answer 262

Reduces bubble volume and promotes N2 resorption and excretion Improves oxygenation to ischaemic tissue Inhibits secondary inflammation and reperfusion injury Reduces ICP Improves brain metabolism Reduces tissue oedema Stimulates body's anti-oxidant mechanisms Complications - Barotrauma - middle ear, pneumothorax - Claustrophobia - Cerebral O2 toxicity- ataxia, dizziness/vertigo, confusion

Answer 263

Symptomatic tx; O2, observation, monitor for APO, NBM Manage arrest as per ALS Spinal immobilisation if trauma e.g. diving High risk of ARDS up to 72h Intubate if no response to O2 and CPAP Abx - aspiration of pneumococcus in paeds broad spec if contaminated water ECMO

Answer 264

S&S - Tentacle linear marks, wheals, painful - Cardiotoxicity - HTN then hypoTN, impaired cardiac contraction - HyperK Mx - Antivenom neutralises cardiotoxicity - Vinegar helps inactivate undischarged nematocyst - Pressure immobilisation not recommended - Magnesium - Analgesia

Answer 265

Massive catecholamine release - Tachycardia, HTN, APO - Pain, erythema, NO WHEAL - Delayed onset of sx (up to 2h) - Muscle spasms, sweating, restlessness, agitation - Headache/N/V Mx - Phentolamine - alpha blocker - Mg - Vinegar (first aid)

Answer 266

Vascular spasm and thrombosis CV - direct myocardial necrosis esp. AC Arrhythmias VF more likely with AC Asystole with DC or high voltage AC Others: sinus tahy, AF, VEs, blocks, ST changes, prolonged QT Compartment syndrome Rhabdomyolysis, AKI (myoglobin release) Thermal burns Neuro - Tetanic contractions preventing release from source Resp arrest Management - Assume spinal cord injury - Aggressive, prolonged CPR as arrhythmias and prolonged resp arrest may be the only problem and victims usu. young - Early intubation as extensive burns and oedema may develop - IVT to ensure good UO 3-4ml/kg/hr

Answer 267

S&S - Headache, N/V/abdo pain - Tender regional lymphadenopathy - Severe coagulopathy (pro-coagulant and anticoagulation) Pro-coagulant (brown/tiger/taipan) - venom contains prothrombin activators --> complete defibrination and non-coagulable blood. consumes fibrinogen (low) Anticoagulant (red belly black snake) - No defibrinogen (fibrinogen normal) Other effects - Thrombocytopaenia - Neurotoxins - paralysis of msk and resp muscles --> limb paralysis, resp failure, bulbar palsy, ophthalmoplegia, ptosis Myotoxins - Muscle pain/weakness - Inc CK & myoglobinuria - Rhabdo and AKI Nephrotoxicity from myolysis, hypotension or coagulopahty Cardiac toxicity - myocardial dysfx, hypoTN Ix - Whole blood clotting time - Coags - INR >1.4, inc APTT, D-Dimer >2.5, fibrinogen low - FBE - anaemia, haemolysis, thrombocytopaenia - G+H - UEC - hyperK, AKI - Urine - haematuria - CK - VBG - ECG Management - PIB immediately - Anti-venom within 2h ideally - for confirmed snakebite or suspected but has clinical/lab evidence of envenomation i.e. coagulopathy OR regional lymphadenopathy from highly venous snake Cx of antivenom - type I hypersensitivity (bronchospasm, N/V/collapse), serum sickness, 5% severe anaphylaxis

Answer 268

1. Fever - consider veno-occlusive disease, acute chest syndrome, OM, local or systemic infection - Infectious crises common cause of death in children - Treat as though immunocompromised (functional asplenic) 2. Vaso-occlusive crisis - pain presentations 3. Acute chest syndrome - life threatening lung infarction, hypoxia and chest pain 4. Acute splenic sequestrations - usu infants; splenomegaly & haemorrhagic shock - Drop of Hb >20, thrombocytopaenia but normal or increased reticulocytes - ppt by infection 5. Aplastic crisis - severe anaemia - Drop in Hb and reticulocytes <1% - Triggered by viral infections (e.g. parvovirus) - Transfuse if Hb <25% from baseline - Usu. self limiting in 5-10d 6. Stroke 7. Priapism Specific treatments - Fever: empiric fluclox + gentamicin - Vaso-occlusive crisis - aggressive analgesia, PO/IV fluids - Acute chest syndrome - O2 and pain mx to prevent hypoventilation; empirical abx in case of pneumonia Investigations - FBE - sickle cells & Howell-Jolly bodies on smear - WCC 12-18 - Plts elevated - ESR >50 if infection - CXR Management - Hydration - O2 - Analgesia - treat underlying cause - Sequestration crisis - transfuse to prior Hb level - Abx

Answer 269

Abnormal platelet clumping due to high vWF levels Causes - clopidogrel, pregnancy, OCP, familial Ix - Coombs neg haemolytic anaemia - Hb <90 with reticulocytosis - Low plt, often <20 - Normal coagulation - Haematuria, renal failure Mx - Plasma exchange, FFP replacement - Steroids - Splenectomy - Ritixumab - Plt transfusion

Answer 270

Haemolytic Uraemic syndrome - Fibrin deposition in arteriole wall in systemic circulation, systemic circulation of toxins and complement activation. Common cause of AKI in <5yo Causes - 90% post diarrhoeal illness - usu. Shiga toxin producing E Coli (STEC), shigella, campylobacter, viruses - Malignancy - SLE - HELLP - Post partum - Malignancy - OCP, chemo, clopidogrel Hx & Ex - Fever, bloody diarrhoea, abdo pain - Haematuria, oliguria - APO - Hepatosplenomegaly Ix - Mod-severe anaemia, RBC fragmentation - Schistocytes, riticulocytosis - - Thrombocytospaenia <100 - Inc LDH - Dec haptoglobin - Bili normal/elevated - Coombs neg - AKI - may require dialysis - Stool MCS, shigella toxin E Coli PCR Mx - IVT/electrolytes in children - Eculizumab - Plasma exchange/haemodialysis

Answer 271

S&S - Bite site: itchiness, neuropathic pain, paraesthesia, myoedema (sustained contraction when muscle percussed or hit with tendon hammer) Late - agitation, muscle spasms of larynx/pharyngeal muscles - myoclonus - tremors - salivation - spinal paralysis - encephalopathy - Viral prodrome - headaches/fevers/rhinorrhoea/pharyngitis - Hydrophobia and unable to drink water - Coma/death Ix - Clinical diagnosis - Skin biopsy confirms - viral Ags/RNA Mx - Supportive - Prevention is key - immunisation and immunoglobulin if exposed to bites; almost 100% effective at preventing due to its long incubation period (30-60days or longer) - Woudn washout with soap and water Rabies vaccine - for minor scratches/wounds that bleed - IM 0.1mL inactive virus - Post exposure immunisation or pre-exposure for those at risk Rabies immunoglobulin - When wound is bleeding - 25 units/kg 2-3mL subcut around bite site, remainder IM thigh

Answer 272

Test source - HBsAg - Hep C - HIV Test exposed - Anti-HBsAg (prev. exp or vax) - HBsAg - Hep C (any prev. infection) - HIV (0, 4 weeks and 3 months post exp.) Others - US site for retained FB

Answer 273

1. Reassurance of low risk of transmission in 0.3% with HIV 2. Confidential f/up offered with ID clinic 3. Practise safe sex until known HIV neg 4. Avoid sharing any injecting equipment, donating blood/tissues 5. Offer support services 6. Repeat testing at 4 weeks and 3 months 7. Counsel on use of PEP - strict compliance, side effects

Answer 274

lethargy, seizures, poor feeding fever, hypothermia paradoxical crying (when comforted) hypotonicity bulging fontanelle (late) vomiting, irritability drowsiness, lethargy >2 years - can c/ o neck pain/photophobia/headache

Answer 275

Rubella Parvovirus Enterovirus Adenovirus Kawasaki

Answer 276

<3 months - Amoxicillin 50mg/kg Q6H + cefotaxime 50mg/kg Q6H - Add vancomycin 15mg/kg Q6H if pneumococcus likely >3 months - Cefotaxime 50mg/kg or ceftriaxone 50mg/kg - Add amoxicillin 50mg/kg if Listeria or immunosuppressed - Add vancomycin if G+ diplococci or Pneumococcal Ag+ Meningococcal disease (neisseria meningitidis) - Benpen 45mg/kg up to 1.8g Q4H for 3-5d - Ceftriaxone if allergy Adults - ceftriaxone 2g/cefotaxime 2g IV (treat pneumococcus, meningococcus, haemophilus) - add vanc if S. aureus/strep pneumonia - Add ampicillin for listeria (or benpen 2.4g) Steroids - reduces hearing loss and mortality in strep pneumoniae - given before 1st dose abx

Answer 277

Measles IgM (peaks day 7-10) IgG - prior infection/immunisation PCR - throat swab/NPA

Answer 278

1. Contacts - identify staff in contact, all pts in same waiting area 2. Health body notifications 3. Treatment of contacts - MMR vaccine if 1st contact with patient <72h - Immunoglobulin if contact b/w 3-7d - Pregnant - offer immunoglobulin 4. Treat patient - supportive, most healthy pts can be managed at home

Answer 279

Dengue Typhoid Malaria Japanese encephalitis Pneumonia Viral encephalitis Enteric fever Meningitis

Answer 280

FBE - normochromic normocytic anaemia Thrombocytopaenia May have haemolysis - elevated LDH, unconj. bili Raised ESR VBG: lactic acidosis Blood film - Thick - presence of intra-erythrocyte parasites Thin films - to ID plasmodium and determines % of affected RBCs PCR - confirms species of malaria on positive blood smears

Answer 281

Hyperparasitaemia Cerebral malaria - coma, seizures, encephalopathy, movement disorders AKI & ATN Black water fever - massive haemolysis + haemoglobinuria and severe AKI APO Severe anaemia Spontaneous bleeding and DIC Sepsis, pneumonia Chronic malaria Treatment - Supportive, ABCs, IVT, cooling - Treat AKI, anaemia, APO, seizures etc Artesunate - 2.4mg/kg at 0, 12 and 24 hrs Quinine if artesunate not available

Answer 282

Incubation 5-10d S&S - High fevers - Fronto/retro-orbital headache - Conjunctival erythema - Profuse sweating when fever settles - 2 rashes - First rash 1-2d of fever; diffuse skin flushing initially face/neck then whole body on days 3-4 - Second rash - within 1-2d of fever settling; starts on dorsum of hands/feet --> trunk, usu. facial sparing - Morbiliform rash and lasts 1-5 days - Bone/muscle pain - URTI sx ABSENT Dengue haemorrhagic fever - Small proportion of cases; bleeding and DIC, hepatomegaly, pharyngitis, bronchopneumonia Dengue shock syndrome - 20-30%; days 2-6 - Rapid deterioration and shock

Answer 283

Clinical diagnosis Viral serology for IgG and IgM Viral culture FBE - thrombocytopaenia, leukopaenia, elevated WCC CXR - pneumonia, pleural effusions CTB - cerebral oedema, may have ICH Mx - supportive

Answer 284

Anterior - Contralateral LL paralysis - Behavioural disturbance, confusion - Incontinence Middle - Contralateral hemiplegia & sensory loss UL/face > LL - Homonymous hemianopia - Eyes deviate to side of lesion - Dyphasia or neglect Posteiror - Hemianopia or quadrantopia - Memory loss - Hemisensory loss Lacunar (lenticular nucleus, thalamus, internal capsule, deep cerebral WM, caudate nucleus, pons & cerebellum) - Usu. isolated motor or sensory loss (face/arm/leg) - Vision and speech intact - A/w poorly controlled HTN/DM Vertebrobasilar - Cerebellar/brainstem - Ataxia, dizziness, N/V/nystagmus - CN palsies Lateral medullary infarction (Wallenberg syndrome) - PICA stroke - Ipsilateral LMN V, XI, X paralysis - Horner's syndrome - Ataxia, vertigo - Contralateral spinothalamic (pain/temp) loss Lateral pontine syndrome - LMN ipsilateral paralysis of upper and lower face - Ipsilateral loss of lacrimation/salivation/loss of taste to ant. 2/3 of tongue Inferior medial pontine syndrome - Ipsilateral CN VII palsy - Lateral gaze palsy - Contralateral weakness of ULs and LLs

Answer 285

Age >60 BP >140/90 Clinical features - unilateral weakness 2+ - Speech disturbance w/o weakness +1 - Other sx 0 Duration - <10mins 0 - 10-59 mins +1 - 60+ mins +2 Diabetes +1 Low risk: <4 start aspirin only High risk 4+ start dual antiplatelets

Answer 286

Inclusion - Clinical dx of stroke causing measurable neuro deficit - onset of symptoms <4.5h before starting treatment (or taken from time last seen well if unknown) - age >18 Exclusion - Ischaemic stroke/severe head trauma past 3 months - ICH or prev ICH - Intracranial neoplasm - GI haemorrhage in prev 21 days - intracranial/intraspinal surgery in prior 3 months - GI malignancy - Active internal bleeding - Persistent BP >185/110 - Suspected aortic dissection - Bleeding diasthesis - Plts <100 000 - Anticoagulation with INR >1.5 Therapeutic heparin within past 24h e.g. for VTE/ACS

Answer 287

Neurosurg Head up 30 degrees Intubation if needed Reverse coagulopathy BP control aim SBP 150-180 Invasive BP monitoring Glycaemic control Maintain normotemp Seizure control/prophylaxis Pressure care IDC Anti-emetics

Answer 288

Labetalol 10-20mg IV every 10 mins up to max 300mg in 6 hours or infusion 2-8mg/min Hydralazine 5mg IV - Repeat every 20 mins up to 25mg in 6 hours GTN 30mg in 100mL IV, start at 3mL/hr, increase by 1mL/hr every 5-10mins to desired BP Nitroprusside 0.5mcg/kg/min infusion

Answer 289

Grades I-V I – asymptomatic or mild headache II – moderate-severe headache, meningism and no weakness III – mild alteration in mental status IV – depressed LOC and/or hemiparesis V – posturing or comatose Asymptomatic Moderate headache Drowsiness Stupor Coma

Answer 290

Prev SAH FHx of SAH Female Smoking HTN CTD - PCKD, Marfan's, EDS, Kleinfelter's Ethanol binge Coarctation of aorta

Answer 291

Reversible cerebral vasoconstriction syndrome Idiopathic thunderclap headache Carotid/vertebral artery dissection Other ICH CVST Benign post coital/exertional sudden onset headache

Answer 292

Rebleeding Ischaemic neurological deficit, stroke Immediate: - Myocardial dysfunction - Neurogenic APO Delayed - Rebleeding usu. 3-5 days, 50% within 6 weeks - Vasopasm, delayed neuro deficits (usu. 7 days), due to breakdown of products in subarachnoid space - Hydrocephalus - days to weeks, may require ventricular drainage - Hyponatraemia - Seizures - Neuropsych - anxiety, depression, cognitive disability

Answer 293

CTB LP blood >100 000 RBCs in last tube = SAH - Xanthochromia does not occur in bloody tap CT angio - identifies aneurysm, AVM, carotid/vertebral artery dissection. Useful if LP contraindicated MRI/MRA Cerebral angiography ECG - ST T waves may mimic ischaemia, peaked/inverted Ts Bloods - Coags UECs -hyponatraemia ABG - monitor oxygenation

Answer 294

ABCs, O2, supportive care Head up 30 degrees Mannitol if mass effect Quiet dark room, anticonvulsants Nimodipine PO 60mg Q4H reduces vasopasm, prevents secondary ischaemia - or IV 1mg/hr over 2 hrs, inc up to 20mg/hr Neurosurg

Answer 295

Adults - Strep pneumoniae - Neisseria meningitidis Neonates, <3 months - E Coli - Group B strep Newborns - LIsteria also Non vaxxed children - H. influenza B CNS shunts/open wounds - Staph Viral - HIV, EBV, CMV, enteroviruses, herpes, mumps, cocksackie Fungi - Cryptococcus, toxoplasma

Answer 296

Haloperidol, chlorperazine, maxolon, prochloperazine S&S - Fever, muscle rigidity, stupor, coma, tremors - Reflexes - reduced/absent - Autonomic instability - tachycardia, sweating, hypersalivation, labile BP - Altered GCS/coma DDx - Heat stroke - MH - Sepsis - 5HT toxicity Ix - FBE - elevated WCC - CK >1000 - Raised LFTs - Myoglobinuria - AKI - Metabolic acidosis - Hypoxia Mx - Supportive, withdraw agent - Cooling - CV/resp support, IVT - Dantrolene 3mg/kg per day up to 10mg/kg - Bromocriptine 2.5mg PO

Answer 297

External compression - Disc disease, extra-spinal tumours, epidural abscess Intraspinal - Syryngomyelia, intra-spinal tumours Vascular - Dissection, SLE Infective - myelitis, polio Autoimmune - MS Idiopathic - MND (isolated motor disease)

Answer 298

- Asynchronous start/stop activity - Paradoxically worse with pharmacotherapy - No increase in lactate - Lack of physiological change e.g. hypoxia, tachycardia - generalised seizure activity with normal awareness - Episode >5 mins Exam findings - Atypical movements e.g. side to side head movements, arching of back, thrashing - Yelling - Pelvic thrusting - Eye closure - Lack of post ictal deep breathing Risk factors - Female - Hx of abuse - PTSD - Personality traits

Answer 299

Transverse hemisection of spinal cord from penetrating injury Ipsilateral loss of motor function, proprioception and vibration contralateral loss of pain and temperature sensation (spinothalamic)

Answer 300

Cerebellar stroke Cerebellar/posterior fossa tumour ICH - cerebellar vestibular migraine MS Infection - encephalitis/meningitis, cerebral abscess Seizures - atypical Subclavian Steal syndrome Head trauma, concussion Medication toxicity e.g. carbamazepine, phenytoin, lithium

Answer 301

1. Resuscitate flat to prevent migration of further bubbles to brain 2. Give 100% O2 regardless of SaO2 to provide maximum gradient for diffusion of nitrogen out of bubbles - or use PEEP/CPAP/BIPAP 3. Lignocaine at anti-arrhythmic doses - some studies show reduced incidence of neuropsychiatric abnormalities

Answer 302

1. Reduces bubble volume, promotes nitrogen resorption and excretion 2. Inhibits secondary inflammation and ischaemic tissue 3. Reduced ICP 4. Improves brain metabolism 5. Reduces tissue oedema 6. Stimulates body's antioxidant mechanisms Complications of HBO - Middle ear barotrauma - Cerebral O2 toxicity e.g. vertigo, confusion, dizziness, seizures - Pulmonary barotrauma - pneumothorax (rare) - Ocular toxicity, myopia, cataracts with prolonged therapy - Claustrophobia

Answer 303

Previous PROM Genital infections e.g. BV Antepartum bleeding Smoking Polyhydramnios Trauma

Answer 304

Placenta praevia - Painfree - Non tender uterus - No signs of foetal distress - PV loss bright red Placenta abruption - Maternal distress from pelvic pain - Tense tender uterus - Maternal shock out of proportion to PV loss - PV loss dark red with clots - Foetal distress - bradycardia, decreased movements Premature labour - Cervix dilated - Contractions/uterine activity (4+ contractions over 20 mins) - May have sudden gush or continuous leaking of fluid if PROM, foetal parts or cord on view

Answer 305

Trauma Heart Endocrine - CAH Metabolic - hypoglycaemia - hypothyroid Inborn errors of metabolism - urea cycle defects, profound HAGMA Sepsis Formula overdilution/underdilution - hypo/hyperNa Intestinal - malrotation, midgut volvulus, NEC, Hirschprung's, intussusception Toxins - 1 pill killers (CCB/TCA/opioids, sulfunylureas, anti-arrhythmics class I) Seizures

Answer 306

Small vessel vasculitis of skin, GIT, joints, kidneys Normal platelets Triad: palpable purpuric rash + abdo pain + arthritis Clinical features - Boys>girls - Palpable purpura of lower legs - Arthritis - wrists/elbows/knees - Abdo pain - colicky - Bloody stools - Gross haematuria (rare) - HTN secondary to kidney involvement Ix - Urinalysis - proteinuria, haematuria - UECs - AKI - Abdo US - may have intussusception - ESR/CRP - FBE - anaemia. thrombocytopaenia would point towards ITP Mx - Supportive - NSAIDs for pain - Steroids if AKI Indications for admission - Severe arthritis - Intussusception - Kidney involvement - HTN, AKI, proteinuria

Answer 307

Emergencies - NEC - Malrotation with midgut volvulus - Incarcerated hernia - NAI - Testicular torsion - Hirschprung's enterocolitis - constipated, not passing meconium in first 48h - Pyloric stenosis Non emergencies - Constipation - Colic - Gastroenteritis 3 months to 3 years: Emerg: - Intussusception - Testicular torsion - Appendicitis - Vaso-occlusive crisis - NAI - Volvulus (less common) Non-emerg - UTI - Constipation - HSP - Gastro 3 years to 15 years - Appendicitis most common - DKA - Vaso-occlusive crisis - Ectopic preg - Ovarian torsion/testicular torsion - Tumours - UTIs - Pancreatitis

Answer 308

Clinical features - bacterial overgrowth in bowel --> translocation into bowel wall --> products endotoxin and gas - Neonates - usu 2 days to 9 days (but can be up to 3 weeks) - Usu. premature - Poor feeding, lethargy, abdo distension - Bilious vomiting - Temp instability - Apnoea - Abdo tenderness - Bloody stools! Ix - AXR - ileus/obstruction, pneumatosis intestinalis, portal venous gas Tx - Treat cause esp. sepsis - NBM - NGT decompression - Aggressive IVT - Broad spec abx: Ampicillin for G+, gent/cefotaxime for G-, metro for anaerobes - Surgical consult - may require resection of necrotic bowel

Answer 309

1. Significant imminent harm to self 2. Significant imminent harm to others 3. Failed verbal or less restrictive de-escalation measures 4. Patient requires ongoing assessment and treatment 5. Patient lacks insight/capacity to make informed decisions about their health

Answer 310

- Usu. within 1st month, but can be any age Clinical features - Well until gut twists (volvulus) causing bowel obstruction and ischaemic gut - Abrupt abdo pain, bilious vomiting, abdo distension, irritability - Shocked - Abdo distended, rigid, tender+++ Ix - Upper GI series with contrast - high SEN for malrot. Bird's beak appearance in duodenum as contrast is cut off abruptly. or corkscrew appearance of bowel - Abdo US - CT abdo - Contrast enema - AXR - may show obstruction, but low SEN/SPEC Tx- - Resuscitate - Surg

Answer 311

Most common cause of obstruction under 2y - 2months to 2 years - Telescoping causing ischaemia S&S - Intermittent pain & lethargy (well in between) - Sausage shaped mass in RUQ - Occult blood in stools, currant jelly Ix - US - target sign - AXR - crescent sign Tx - Air contrast enema - diagnostic and therapeutic - IV fluid resus - Surgical reduction if free gas on xray

Answer 312

Congenital aganglionic mega-colon - causes inc muscle tone and contractility of aganglionic segment of bowel Males, Down syndrome more common S&S - Failure to pass meconium in 1st 48h - Bilious vomiting - Reduced stool frequency - abdo distension Ix - Barium enema - cone shaped transition zone - Rectal manometry - lack of anal sphincter relaxation - Rectal biopsy (definitive) Mx - Gastric decompression - Rectal tube - IVT - Surgical resection of aganglionic segment Cx - toxic megacolon - massive dilation of colon proximal to aganglionic segment

Answer 313

Transient synovitis - 3-8yo, recent URTI - Can walk but with pain - Mild/mod reduction in hip movement esp. int rotation - Otherwise well Septic arthritis - Severe limitation of ROM Perthes (2-12) - Avascular necrosis of femoral head - Intermittent limp; hip groin or knee pain SUFE (11-15) - Referred pain to thigh/knee - Externally rotated foot - Xray - Kleins lines are abnormal - line along superior aspect of femoral neck to superior aspect of acetabulum normally passes through femoral eiphysis. Here is passes above - Mx - traction and internal fixation Others - Malignancy - bone tumours - OM - Trauma

Answer 314

Features - Cortisol deficiency - Aldosterone deficiency - Androgen excess Clinical features - Ambiguous genitalia at birth in females due to high conc. of androgens in utero - Boys usu. minimal features - Present usu. 7-14days of life - vomiting, weight loss, lethargy, dehydration - HypoNa, hyperK - Shocked Mx - Glucocorticoids - Mineralocorticoids -

Answer 315

<1500g - use 3.5Fr >1500g - use 5Fr 1. skin prep, flush line 2. Trim umbilical stump to 1.5cm from abdomen 3. Measure length - abdo to xiphersternum + stump length 4. Place suture at base of stump for haemostasis 5. Immobilise umbilical cord by grasping edges at 3 and 9o'clock with artery forceps 6. Identify the Umb vein (larger caliber, thin walled, single vessel) 7. Insert tip of catheter in cephalad direction and advance to desired length 8. Suture catheter in place 9. Xray to confirm position Complications - Sepsis, bleeding, clot formation, embolism - Catheter malposition - arrhythmias, hepatic necrosis, portal HTN

Answer 316

1. LA infiltration to lateral canthus 2. Incise skin over lateral canthus towards bony orbit 3. Retract lower lid 4. Divide inferior lateral canthal ligament 5. Divide superior lateral canthal ligament also, if pressure does not drop sufficiently Indications - raised IOP compromising retinal blood supply

Answer 317

Consent patient, explain procedure and risks Cardiac monitoring 1. IVCs into both hands 2. Inflate Bier machine cuff to 100mmHg above patient's systolic BP 3. Inject prilocaine 2.5mg/kg 4. Manipulate and reduce the fracture 5. Leave BP cuff on for minimum 30 mins, max 90mins before inflating 6. monitor for LA toxicity Contraindications to Bier block 1. Proximal upper limb fractures 2. Soft tissue injuries/open injuries at torniquet site 3. PVD, compromised circulation injury in affected limb 4. Uncooperate pt, refusal 5. Severe uncontrolled HTN 6. Unable to obtain IV access at site of bier block

Answer 318

Consent, explain risks Patient seated 45 degrees Sterile field, aseptic technique Use 16G pericardiocentesis needle, insert under US guidancebetween xiphoid and left costal margin, angle 15 degrees, aiming to left shoulder Aspirate blood until haemodynamics improve usu. up to 50mLs

Answer 319

Consent, include alternatives, risks of block failure, LA toxicity etc Sterile technique, US probe, chlorhex prep to skin Prepare LA 3mg/kg ropivacaine 0.75% and dilute to saline for volume Inject small amount of lignocaine to skin (skin wheal) Identify anatomy on US Use in plane technique to insert needle, ensuring needle tip visualised at all times. If lost, rock US probe to find tip and re-orientate Fascia iliaca - visualise needle passing under the fascia. Aspirate and inject, visualise the fascia layer separating as LA enters Femoral block - when needle visualised near nerve, aspirate and inject slowly, aspirating every 3-5mL to ensure no vessel entry and aim to inject around the nerve Review for signs of LA toxicity and make nursing staff aware of these, monitor block effectiveness closely for next 15 mins Document procedure Advantages of fascia iliaca block - Better analgesia - femoral, obturator, lateral cutaneous nerves - Lower risk of nerve injury - Longer DOA - Easier anatomy - Lower chance of LA toxicity b/c lower risk of intravascular injection Advantages of femoral nerve block - Denser block for femoral nerve - Quicker onset - Better distal coverage incl. shaft of femur to knee - Overall lower dose of LA

Answer 320

String yank - tie string to curve of hook, downwards pressure on eye of hook and yank string Adv- less invasive, leaves small wound, no additional trauma, can be done without LA, more likely to be successful Disadv - potential injury to pt/or staff as hook flies out. Pain/trauma if not done correctly Advance and cut technique - advance hook through surface and cut barb off Adv - easy, quick if barb close to skin surface Disadv - traumatises and contaminates tissue, requires LA, requires metal cutting equipment

Answer 321

Consent, sterile techinique etc Have patient lying at 45 degrees Anatomical landmarks - 2cm below umbilicus in midline OR - 5cm cephalad to ASIS and 5cm medial to ASIS US guided LA to skin Infiltrate LA with 21G needle beneath skin, towards peritoneum, and aspirate syringe until peritoneal fluid aspirated Attach 20mL syringe and withdraw 20mLs - send for biochem (protein, glucose, LDH), MCS & G stain & cytology. Place occlusive dressing For therapeutic tap: insert 16G cannula along anaesthetised track at 90degrees to skin, when flashback seen, advance plastic sheath and remove stylet Complications - Shock - Hypovolaemia - Renal failure - Perforation of bowel/bladder - Peritonitis - Haemorrhage

Answer 322

Check for pneumothorax Increase FiO2 to 100% - requires maximall oxygen Increase PEEP - Increases surface area for gas exchange - Decreases atelectasis Prone positioning (e.g. in COVID/ARDS) - Reduces VQ mismatch - Less lung compression from abdo Ensure adequate sedation and paralysis - Reduces O2 consumption and CO2 production Suction airway Treat sepsis – reduces metabolic demand Optimal fluid balance – maximise O2 delivery Optimise Hb – improve oxygen carriage Recruitment manoeuvres – opens collapsed alveoli Increase I:E ratio towards 1:1 – increases FRC, recruitment Others if fails: - ECMO Ventilator settings TV 5-7mL/kg PEEP 5-24cmH20 Plateau pressures <30 cmH20 Endpoints post intubation - Aim SaO2 88-95% (PaO2 55-80) - pH 7.3-7.45

Answer 323

1. Pt sitting upright head central 2. Rapid head down 30 degrees below flat facing affected side 3. Hold for 1 min until sx resolve 4. Turn head to other side same position 30 degrees head down, 1 min 5. Then continue to rotate unil head facing floor 6. Hold for 1 min 7. Then sit back upright, head central for 20mins

Answer 324

Ix - Total/differential cell count - Smear & culture - Cytology for malignancy e.g. lung/breast - Biochem - protein, albumin, LDH - Glucose - TB markers - if pleural fluid lymphocytosis - Amylase - if pancreatic disease/oesophageal rupture Bilateral - more likely cardiac/renal/hepatic Rapidly developing - haemothorax/parapneumonic/empyema Moderate-large unilateral without infection = malignancy

Answer 325

Protein >30g/L Causes - Pneumonia - Malignancy - PE (but transudate in 20%) - TB - RA - RA, SLE - Dressler's - Pancreatitis - Oesophageal perf - Intra-abdo abscess

Answer 326

Protein <30g/L Due to imbalance of hydrostatic/oncotic pressures Causes - Heart failure - Cirrhosis - PE - Ascites - Nephrotic syndrome - Iatrogenic e.g. CVC inserted intra-thoracic - Dialysis

Answer 327

Purulent pleural fluid Positive gram stain/culture WCC >50000 Pleural glucose <3 Pleural fluid pH <7.2 Pleural fluid LDH >1000

Answer 328

Supportive - O2, analgesia, fluids, consider SIADH Medical - IV abx (piptaz or cefotaxime + vanc if suspecting MRSA) - Large bore chest drain 20Fr Surgical - Fibrinolytics via chest drain - VATS - Open thoracotomy

Answer 329

Resuscitation Risk Assessment Supportive Care Investigations Decontamination Enhanced elimination Antidotes Disposition

Answer 330

1. Induced emesis 2. Gastric lavage 3. AC 4. Whole bowel irrigation

Answer 331

Adult 50g Children 1g/kg Agents that bind poorly - Hydrocarbons - Alcohols incl. toxic alcohols - Metals (Fe, Li, lead, mercury, Arsenic) - Corrosives - acids/alkalis Cx of AC - Aspiration - Direct administration into lung can be fatal - Impaired absorption of other antidotes/drugs - Corneal abrasions CIs - Non toxic/subtoxic ingestion - Incomplete resus - Agent not bound to AC - Corrosive agents - Risk assessment - good outcome with antidote/supportive care - Uncooperative pt - Decreased GCS/delirium

Answer 332

S&S - Tongue/peri-oral numbness - Lightheadedness - Twitching - Seizures/coma - Resp/cardiac arrest Mx - Stop offending agent - Prolonged normal resus - Lipid emulsion - 20% 1mL/kg bolus then infusion 0.25mL/kg/min - Hyperventilate to avoid acidosis - Give NaHCO3 1mmol/kg - Midaz/propofol sedation - Normal ALS, consider small doses of adrenaline instead of 1mg (give 100mcg)

Answer 333

>10g or >200mg/kg (whichever is less) Massive ingestion = >500mg/kg or 30g Repeated supra-therapeutic ingestions >150mg/kg/24 hours for preceding 48h >100mg/kg/24 hours for preceding 72h Timing of paracetamol levels - 4 hours post standard - 2 hours post liquid ingestion - 4 & hours post SR - 2 hours post first paracetamol level if staggered

Answer 334

Valid for only single ingestion of IR where time of ingestion is known Pts may ingest over 1-2 hours period making timing inaccurate Not valid for SR preparations If time of ingestion unknown, treat with NAC if level could be in toxic range Not valid before 4 hours or after 16 hours (but extrapolated to 24h)

Answer 335

AC 50g within 2 hours (up to 4 hours if >30g) If MR tablets, give 50g within 4 hours Children - give 1g/kg max 50g

Answer 336

Respiratory alkalosis followed by HAGMA Clinical featuers - GIT - N/V - CNS - tinnitus, vertigo, hearing loss, seizures, cerebral oedema - Hyperthermia - Hyper/hypoglycaemia - Hypokalaemia Doses <150mg/kg - minimal sx 150-300mg/kg = mild/mod tox >300mg/kg = severe; HAGMA, coma, seizures >500mg/kg = potentially lethal Decontamination - AC 50g up to 8h post ingestion if >150mg/kg - If >300mg/kg secure airway first, and give via NGT Enhanced elimination - Urinary alkalinisation - Sodium bicarb 1-2mmol/kg IV bolus - IDC to monitor urinary pH, aim for >7.5 - Give KCl to correct hypoK Mx - Seizures - benzos - Declining GCS/coma - intubation - Sodium bicarb 8.4% aliquots until pH >7.45 - IV crystalloids for hypotension - Haemodialysis

Answer 337

Dihydropyridines - cause vasodilation, less myocardial depression/conduction delays Non-dihydropyridines - Negative inotropy/chronotropy - Vasodilation - Doses 2-3x usual = serious toxicity - >10 tablets = life threatening S&S - Hypotension, HB - Refractory shock, death, pulmonary oedema - HyperG - Lactic acidosis - N/V/ileus - CNS - agitation, confusion (poor perfusion), seizures/coma Ix - ECG - bradycardia, HB, sinus arrest, asystole - BSL - VBG - hyperlactataemia, metabolic acidosis - UECs - AKI secondary to shock - CXR - APO - TTE - impaired contracility Mx - Early I&V if life threatening toxicity - invasive BP monitoring - AC 50g within 2h of IR and 12h of MR - WBI in some cases - Atropine - Cardiac pacing to >60 - Hypotension - fluid resus Give 30mL calcium gluconate (6.6mmol, 3g) bolus over 5 mins - repeat x3 in 1st 60 mins - infusion to maintain iCa 1.5-2mmol/L - Monitor Ca Q2H Adrenaline/adrenaline/vasopressin High dose insulin euglycaemic therapy (HIET) Early VA ECMO Others - sodium bicarb if severe metabolic acidosis - methylene blue/lipid emulsion

Answer 338

For CV toxicity in non dihydro CCB OD and some BB toxicities resistant to fluids/adrenaline A/e - Hyperglycaemia - HypoK - Vasodilation Dose 1unit/kg short acting insulin then 1unit/kg/hr infusion 50% dextrose 50mLs also given and 100mL 10% glucose/hr Maintain BSL 5.5-11, K2.8-3.3 Endpoint - cease when CV toxicity resolved

Answer 339

Propranolol - also causes Na channel blockade - QRS widening, ventricular arrhythmias and direct CNS toxicity (very lipophilic) Sotalol - K efflux blockade - QT prolongation & Torsades Effects - hypotension, bradycardia, heart failure [APO] , cardiogenic shock - Resp - bronchospasm esp asthmatic - Metabolic - hypoG, hyperK - Neuro - altered GCS, coma usu. secondary to hypotension Mx - Reus - atropine/adrenaline/isoprenaline - Pacing often ineffective - ECMO if refractory For Torsades (sotalol) - MgSO4 10mmol IV over 15 mins - Correct hypoxia/hypoK, hypoCa - Isoprenaline infusion if HR <100, or overdrive pacing to HR 100-120 Propranolol - QRS widening - Sodium bicarb 2mmol/kg IV every 1-2 mins until QRS narrows - Defib - attempt but may not be effective - Hyperventilate to pH 7.5-7.55 to decrease sodium channel blockade

Answer 340

Effects - Increased inotropy (mild) - Increased automaticity - Negative dromotropy (slows AVN conduction) - increased vagal tone Clinical features - GI - A/N/V/D - HyperK - Increased automaticity - atrial tachycardia (flutter/AF) with AV block - VF/VT, VEs - Bradyarrhythmias e.g. slow AF - Hypotension/shock CNS - letharyg/confusion Mx - Treat hyperK - Treat arrhythmias - Digibind

Answer 341

TCAs Anti-arrhythmics: 1A - quinidine, procainamide 1c - flecainide LAs - bupivacaine, ropivacaine Anti-malarials Propranolol Carbamazepine Quinine ECG findings - QRS widening - QTc prolongation - Terminal R >3mm in aVR or R/S ratio >0.7 - sinus tachy/VT/VF Mx - AC 50g via NGT once intubated - Hyperventilate to pH 7.5-7.55 - IV sodium bicarb - Midazolam for seizures - IVT for hypotension - vasopressors - Lignocaine 1.5mg/kg IV (after bicarb and hyperventilation) once pH >7.5 - competitive inhibition of Na channels TCAs - Don't forget anticholinergic sx

Answer 342

Sources - petrol additive, industrial solvents, windscreen washing S&S - Ataxia, N/V - CNS depression/confusion/seizures/coma - Ocular - blindness, decreased VA, photophobia, pupils may be fixed dilated, retinal oedema, hyperaemia of optic disc - Oliguric renal failure - APO - HAGMA Ix - Osmolar gap (methanol is the most potent alcohol in increasing osmolar gap) - HAGMA - Methanol level - CTB - bilat putaminal hypodensity/haemorrhage Mx - Skin decontamination; charcoal resistant - Ethanol infusion (same as for EG tox) until serum methanol <6 mmol/L - IV 8mL/kg loading of 10% ethanol then 1-2mL/kg/hr - Dialysis (indications - ocular manifestations, AKI, pH <7.2) - HCO3 if pH <7.3 - Folate - Thiamine - Pyridoxine - Mg supp

Answer 343

Antifreeze, radiator additives, brake fluid Features - HAGMA, osmolar gap - Calcium oxalate crystals in urine (oxaluria) - HYPOCALCAEMIA - AKI - Hepatotoxicity - rare Tx - IV 8mL/kg loading of 10% ethanol then 1-2mL/kg/hr - Haemodialysis if pH <7.15, AG > 25, AKI or EG >4-6mmol?L Others - pyridoxine, thiamine, HCO3, calcium, Mg, 4MP

Answer 344

Fires involving woo, plastics, synthetics S&S - Confusion, tachypnoea, hypotension, bradycardia - Altered GCS, coma Ix - Profound metabolic acidosis - Lactic acidosis Tx - Hydroxycobalamine IV - Antidotes (sodium nitrite, amyl nitrite, sodium thiosulfate) - This induced methaemoglobinaemia which removes cyanide and increases its metabolism to less toxic metabolite Hydroxycobalamin (Vit B12) - MOA: induces methaemoglobinaemia which removes cyanide from cytochrome and increases its metabolism to a less toxic metabolite - Disadv – can cause arrhythmias, not readily available Sodium nitrite - MOA – forms cyano-hb , binds free cyanide - Disadv: can cause methhaemoglobinamia in burns. Also causes vasodilation Sodium thiosulfate - MOA: enhances elimination; detoxifies cyanide - Disadv – causes N/V

Answer 345

Haem portion of Hb is oxidised from ferrous to ferric state causing reduced O2 carrying capacity Causes cyanosis that does not improve with O2, and leftward shift of O2Hb dissociation curve = impaired O2 delivery to tissues Sources - nitrites, phenols, chlorates (matches) - Sulfurs, LAs ('caines') - Chloroquine - Anti-anginals high doses of nitrites - Vit K - Dapsone Ix - ABG - hypoxia - Methaemoglobin levels - Chocolate coloured blood - ECG may show signs of ischaemia - Supplemental O2 doesn't improve cyanosis S&S - Dark chocolate lips/tongue (cyanosis), chocolate brown blood - SOB, fatigue, headache, dizziness, tachycardia - Hypoxia, seizures, coma, arrhythmias, AMI, metabolic acidosis - Hypoxic injury & death Mx - Methylene blue 1mg/kg over 5 minutes

Answer 346

Deathcap (amanita phalloides) - 95% of fatal ingestions Time of ingestion most important, S&S - GIT upset, watery diarrhoea - Then latent phase where pt seems well before --> severe liver & kidney failure at 3-4 days Tx - early and aggressive gastric decontamination with ipecac if <2h, charcoal if >3h - Supportive - NAC, penicillamine (not proven) - Determine if other people have ingested - Education on not eating field mushrooms Disposition

Answer 347

Focal neurological deficit Midline spinal tenderness present Intoxication present Distracting injury Altered level of consciousness

Answer 348

Age 65+ Paraesthesia to extremity Dangerous mechanism (fall from 3ft, high speed MVA/ejection/rollover, bicycle collision, motorbike) Low risk factors present - sitting in ED - Ambulatory at any time - Delayed (not immediate) onset neck pain - No midline tenderness - Simple rear end Able to actively rotate neck 45dg left and right

Answer 349

bilateral C2 pedicle # from severe flexion injury usu. no spinal cord injury as spinal canal is wide here

Answer 350

Usu. C2 #, unstable (but not as bad as flexion teardrop) A/w central cord syndrome

Answer 351

compression C1 # Diving injury Unstable

Answer 352

Spinal shock - Usu. symptoms below the level of injury. temporary symptoms - Transient spinal cord injury lasting days to weeks - Good prognosis - recovery in days to weeks - Areflexia, flaccid paralysis - MRI - no demonstrable findings Neurogenic shock - A/w bradycardia, hypotension - Labile temp, usu hypothermia - Usu. T6 or above - A/w flaccid muscle paralysis, paralytic ileus, paralysis of bladder - high aspiration risk (sphincter relaxation)\ - MRI - cord oedema, haemorrhage, contusion injuries that cause the symptoms - Poorer prognosis due to haemodynamic instability

Answer 353

EFAST Adv - Bedside, suitable in unstable patients - Immediate results - Repeatable - Good quantification of blood loss to determine need for laparotomy Disadv - Difficult in obese patients, not fasted - Bowel gas may obscure - Fluid not always blood e.g. ascites - no info on organ injuries - Operator dependent, needs experience - Less sensitive for less severe/small haemoperitoneum than CT CT with contrast Adv - Reliably excludes intra-abdo haemorrhage that requires surgery - Provides anatomical info to grade injuries to determine OT mx - Determines if fluid is blood (active blush post contrast) - Visualises retroperitoneal structures and bony structures (not seen on US) - Low false neg rate for significant injury Disadv - False negs for bowel injury - Not suitable for unstable pts - requires time out of ED - Less suitable in women/children - Contrast risks - allergy - Radiation - Lower sensitivity for pancreatic injury or diaphragmatic injuries

Answer 354

>1 normal or calcified <0.9 ischaemic <0.8 claudication with exercise <0.6 severe ischaemia <0.3 rest pain <0.2 gangrene

Answer 355

Arterial occlusion - absent/reduced pulses - Embolic - AF, mural thrombus, prosthetic heart valves or - Thrombotic - atherosclerosis, hypovolaemia, thrombophilia, hypotension, malignnacy Small vessel disease -diabetes Venous obstruction, often a/w - disseminated adenocarcinoma - Heparin induced thrombocytopaenia - Warfarin - Antiphospholipid syndrome Microvascular thrombosis - DIC - Purpura fulminans e.g. meningococcal septicaemia Trauma e.g. iatrogenic S&S - Intermittent claudication with exercise, relieved iwth rest - Rest pain - Leg ulcers - Reduced/absent pulses - Leg ulcers - distal - Cool skin - Femoral bruit - Muscular/skin atrophy - Loss of hair, thickening of toe nails Ix - Doppler US - Ankle BPI - Angiography - CT angio - ECG for AF - Echo - if suspect cardiac embolus - Lactate - ischaemia - CK - UEC - renal function - Limb xray if suspect OM Mx - Analgesia - If functional ischaemia - outpatient review, aspirin, smoking cessaiton, exercise increases time to claudication, lipid control - Limb threatening - vascular surgery e.g. bypass graft, angioplasty, stenting - Abx if infection - Heparin infusion - Embolectomy for acute embolus - Angiography +/- bypass for thrombosis - Catheter directed thrombolysis if thrombotic occlusion <2 weeks - Surgical revascularlisation if immediately threatened limb, symptoms >2 weeks

Answer 356

Embolic - Sudden onset - Usu hx of AF - Claudication - rare - Examination does not show chronic PVD changes - Pulse deficits only to affected area - Sharp demarcation of ischaemia Thrombosis - Gradual onset - AF usu. absent or coincidental - Hx of claudication - Chronic PVD changes are common - Widespread pulse deficits - usu. bilateral - Diffuse ischaemia

Answer 357

1. Rupture 2. Aorto-enteric fistula - massive UGIB 3. Aorto-venous fistula (into IVC) - rare, produces heart failure

Answer 358

S&S - Temporal/occipital headache - Visual - blindness (Retinal iscahaemia) - Limb claudication - Jaw claudication - Diplopia - May have cough, sore throat, hoarse voice - Arm claudication - Thoracic aortic aneurysm Exam - Fever in 15% - Swelling with nodularity over temporal arteries - Loss of temporal artery pulse - Tenderness over temporal arteries - Bruit over large vessels - Neuropathy in 15% Ix - CRP, ESR >20 in M, >30 in F - FBE - normocytic normochromic anaemia, leukocytosis - LFTs -ALP may be elevated - Temporal artery biopsy Diagnostic criteria: any 3 of - Age >50 - New onset localised headache - Tenderness or decreased pulse of temporal artery - ESR >50 - Temporal artery biopsy consistent with arteritis Mx - Methylpred 1g daily for 3 days - PO pred 40-60mg for up to 4 weeks then taper - Low dose aspirin prevents thrombotic complications - Tocilizumab - MTX

Answer 359

MgSO4 0.2mmol/kg over 20 mins IM adrenaline 10mcg/kg (max 500mcg) IV adrenaline 0.5-1mcg/kg Aminophylline 10mg/kg (max 500mg) IV over 60 mins IV salbutamol 5-15mcg/kg over 10 mins Ketamine 0.25-0.5mg/kg for tolerance of bipap and bronchodilation

Answer 360

<0.4 = pure NAGMA 0.4-0.8 = NAGMA + HAGMA 0.8-2 = pure HAGMA >2 = HAGMA + metabolic alkalosis or chronic respiratory acidosis

Answer 361

1. Trismus 2. Kissing tonsils causing drooling 3. Uvula deviation away from affected side 4. Tonsil displaced inferomedially CI to draining in ED 1. Severe trismus, poor visibility 2. Non compliant/uncooperative pt 3. Coagulopathy Cx from drainage - Haemorrhage - ICA injury - Airway obstruction - Extension of infection - deep neck space infection - Inadequate drainage

Answer 362

1. Infection/sepsis 2. Non compliance with meds 3. Trauma 4. Surgery 5. DKA 6. Exogenous iodine (e.g. radioiodine) 7. Thyroid hormone ingestion 8. AMI/PE Clinical features - Fever - Tachycardia - Arrhythmias e.g. AF - Heart failure - CNS: agitation/delirium/psychosis/seizures/coma - GI: diarrhoea/N/V/abdo pain

Answer 363

1. Spinal cord compression e.g. tumour, epidural abscess, epidural haematoma if anticoagulated 2. Cauda equina e.g. from disc disease 3. GBS 4. Disc herniation/protrusion/prolapse causing cauda equina 5. Pathological fracture causing cord compression 6. Spinal mets 7. Epidural abscess/discitis 8. Transverse myelitis 9. Vascular occlusion/dissection to spine

Answer 364

Gastric outlet obstruction Small bowel obstruction, perforation Peritonitis Electrolytes - hypokalaemia, dehydration Fat soluble vit malabsorption Dumping syndrome Diarrhoea Internal hernias Strictures UGI ulcers Pancreatitis

Answer 365

Bundle branch pattern e.g. rsR' (taller R rabbit ear) QRS complexes not as broad usually Lack of concordance Often absent p waves or small p waves after QRS HR usu >220 absence of respiratory variability - no variation in RR interval

Answer 366

- Sufficient blood products to be taken during transfer - Vascular access/infusions carefully secured as difficult to resite enroute - Patient weight/girth limits - Noisy environment - difficult to communicate e.g. with patient/other staff - Patient temperature management - temp lower at altitude - risk of hypothermia, can exacerbate coagulopathy - Communication with patient/NOK - high risk of deterioration with little that can be done enroute

Answer 367

Demand pacing - as required, if system senses ventricular activity it will not deliver pacing spike. Risk of oversensing and failure to deliver pacing spike when required Non-demand pacing - fixed ventricular rate regardless of intrinsic activity Risk of R on T phenomenon and Torsades Optimal site of transvenous pacing wire tip is at the apex on RV Confirming position: 1. ECG - shows complete mechanical capture with LBBB pattern and LA deviation if in RV ECG guidance - monitor for P wave and QRS morphology to determine location of tip of pacing wire as it passes through atria, tricuspid valve and RV then ST segment elevation as it comes in contact with endocardium in RV US guidance - visualise tip of wire in apex of RV CXR/fluoroscopy - visualise wire location at apex of RV on background of cardiac silhouette

Answer 368

1. Refractory hyperK >6.5mmol/L 2. Refractory metabolic acidosis pH <7.1 3. Severe hypo <100/hyper >160 natraemia 4. Serum Urea >35mmol/L 5.Serum creatinine >400micromol/L

Answer 369

Pericarditis Asterixis, myoclonus Psychosis/ALOC/confusion/drowsiness/seizure Uraemic frost/scratch marks

Answer 370

Foetal fibronectin acts as 'glue' between amniotic sac and uterine wall. Used to test in women 22-35 weeks experiencing symptoms of pre-term labour. Negative result suggests highly unlikely for delivery in next 7-14 days elevated levels >50ng/mL is a/w increased risk of spontaneous preterm labour It has high negative predictive value (NPV) i.e. negative is highly accurate Low positive predictive value (PPV) i.e. positive not necessarily accurate

Answer 371

1. Shortened open cervix, fully dilated 2. Soft cervix 3. Bloody show 4. Contractions <5 mins apart 5. Head on view/bulging perineum, crowning 6. Broken waters 7. sensation of urge to push/defecate

Answer 372

1. Pre-eclampsia/eclampsia/HELLP 2. Vaginal bleeding/suspected abruption 3. Intra-uterine abruption 4. Intra-uterine infection 5. Pathological foetal heart rate/non reassuring CTG/foetal distress 6. DIC 7. Foetal demise 8. maternal instability/shock

Answer 373

Anticholinergics (incl. TCAs, antipsychotics, anithistamines, antiparkinsonians) - impair thermoregulation and ability to sweat Diuretics - volume depletion Laxatives - volume depletion Sedatives (incl. alcohol) - behavioural change, not able to rehydrate Beta blockers - inhibit CO to skin, reduced peripheral vasodilation, reduced sweating Thyroid replacement - increases metabolic and heat production

Answer 374

- Core temp >41 - AKI/hyperK - Prolonged coma - Cerebral oedema, seizures/focal signs - Hypotension not responding to cooling/fluids - Need for intubation - Altered coagulation - AST >1000

Answer 375

1. GBS 2. Transverse myelitis 3. MS/demyelation 4. Metabolic myopathy e.g. from alcohol 5. Tox - tick paralysis, snake bites, botulinum 6. Viral myositis 7. Poliomyelitis 8. Endocrine e.g. hypothyroidism

Answer 376

1. Dehydration e.g. vomiting/diarrhoea 2. Meds e.g. diuretics, insulin, steroids, beta agonists 3. Strenuous exercise followed by rest 4. Alcohol 5. Emotional stress 6. Carb rich meals

Answer 377

Prolonged PR interval Prolonged QT - 'pseudo long QT' due to merged U wave but actual Q not long T wave flattening/TWI ST depression in precordial leads Ectopics Peaked p waves

Answer 378

1. Medications may affect vital signs/examination/impacts of injury e.g. beta blocked 2. Altered baseline neuro state/cognition e.g. dementia 3. Assumptions that altered LOC is normal baseline for patient 4. Mechanism based trauma call criteria are bsed on injuries sustained in younger patients and in geriatrics minor trauma e.g. fall from standing height can result in significant trauma 5. Low impact injuries can cause significant injuries 6. Often unwitnessed falls, poor collateral history 7. Multiple co-morbidities/concurrent illnesses/frailty

Answer 379

1. Reduces respiratory reserve due to reduced vital capacity, reduced resp muscle strength 2. Reduced bone mineral density/osteoporosis 3. reduced immune function 4. Impaired/delayed wound healing 5. Chest wall rigidity 6. Reduced muscle mass, muscle weakness 7. Increased adverse effects to drugs e.g. opiates

Answer 380

Signs - Injuries at various stages of healing e.g. new/old bruises - Pattern injuries e.g. neck strangulation, throat, breasts - Sexual assault injuries e.g .peri-anal/oral - Injuries hidden by clothing/heavy makeup - Bilateral extremity injuries - Burns e.g .cigarette, hair pulled out - Evidence of strangulation e.g. hoarse voice, subconjuctival haemorrhage - Stated mechanism not consistent with observed injuries

Answer 381

- Decreased vol of blood products used i.e. reduced cost/wastage/complications from blood products - Improved patient outcomes incl. bleeding rate, length of stay and mortality

Answer 382

- Rib fractures - spiral humeral - Skull fractures - depressed, multiple - Spinal fractures - Bucket handle/metaphyseal corner long bone fracture - Multiple fractures of differing ages - Scapula - Sternum

Answer 383

1. Vertical incisions bilateral anterior axillary lines 2. Horizontal bilat peri-clavicular 3. Subcostal chevron Cx of UL escharotomy 1. Ulnar nerve at medial epicondyle 2. Radial nerve at elbow (laterally) 3. Radial nerve nere sensory branch at wrist 4. Ulnar nerve at wrist 5. Cephalic vein at wrist

Answer 384

RFs - Prematurity - Trisomy 21 - Tracheomalacia/structural airway abnormalities - Age <6 months - Previous severe croup - Neuromuscular disorders e.g. CP Signs - Barking cough - Hypoxia/cyanosis - Increased WOB/chest wall retractions etc - Altered LOC - Persistent stridor at rest Tx - Dexamethasone 0.6mg/kg - Neb adrenaline 5 mL of 1:1000 Modifications to intubation - Contact anaesthetics - gaseous induction ideal - DSI - Apnoeic oxygenation - Continuous adrenaline nebs - Ensure position of comfort e.g. sitting up with parent during pre-oxygenation - Use VL - Use smaller ETT - Most experienced operator - Set up for surgical airway

Answer 385

Delirium - Acute onset - Fluctuating course - Secondary cause e.g. sepsis, AMI, pain etc - Inattention - Altered GCS - Disorganised thinking

Answer 386

- Furniture - low height bed, side rails - Nursing supervision for high risk patients - Monitoring - bed monitors/alarms - Building features - non slip flooring, adequate lighting - Access to usual walking aids, visual aids - Orientating patient - clear signage - Screening- falls risk assessment tools - Polices/procedures - for falls safety - Providing non slip socks

Answer 387

- Hx of spinal anatomical abnormality predisposing e.g. disc disease, trauma - Pain worse with back extension - Worse with walking downhill - Present on standing/lying - Pain better in foetal position lying - Pain better climbing stairs - Better leaning forwards on walker - No colour changes to lower limbs - Paraesthesias - Bilateral/symmetrical limb weakness Features that differentiate it from vascular claudication - Normal pulses - No stigmata of PVD e.g. hairr loss, arterial ulcers, dependent colour changes - Normal ABI - Back/leg pain exacerbated by back extension if neurogenic

Answer 388

Mild toxicity if >200mg/kg Severe toxicity with >400mg/kg S&S - Lethargy - Tachycardia - Coma - Thrombocytopaenia - Metabolic acidosis - Hyperammonaemia - Hypotension - Seizures - Resp depression - HyperNa - HypoG Severe toxicity - Hypernatraemia - Metabolic acidosis HAGMA - Hyperlactaemia - HypoG - HypoCa - HypoPO4 Mx - AC 50g for large ingestions o MDAC – binds drug in small intestine, prevents re-absorption - WBI - Airway management - Symptomatic, supportive tx - Carnitine – benefit uncertain. Reduces absorption of valproate - Meropenem may increase clearance - Dialysis Indications for dialysis - Large ingestions >1g/kg - Lactic acidosis - CNS – seizures, coma - Serum level >1000mg/L - Shock, hypotension

Answer 389

Placenta praevia - Placenta overlies the os - Painless bright red PV bleeding - PV exam C.I. - risk of haemorrhage - soft tender uterus - no foetal distress Causes - Prior praevia - Previous LUSCS - Multiparity - Increased maternal age - Multiple gestations - Prior TOP - Smoking Placental abruption - placenta detaches from uterus - Painful heavy PV bleeding - Shocked mother and foetus - Tender contracted uterus Causes of abruption - HTN (most common) - Trauma – MVA, assault - Smoking - Alcohol - Obstetric factors o Short umbilical cord o Sudden uterine decompression – PROM, delivery of first twin o Retroplacental fibroid o Retroplacental bleeding from needle puncture i.e. post amniocentesis o Idiopathic -

Answer 390

Pleural effusions Ascites Oligouric renal failure Ovarian torsion DVT/PE

Answer 391

HARD - Haematoma - large and expanding, pulsatile - Absent distal pulse - Audible Bruit/palpable thrill - Rapidly expanding haematoma - Distal ischaemia - pallor, pain, paraesthesia, pallor Soft signs - Small, non expanding haematoma - Palpable but diminished pulse - Isolated peripheral nerve injury - Hx of severe haemorrhage in the field - Unexplained hypotension - Large, non pulsatile haematoma - Delayed cap refill

Answer 392

Age 2 weeks to 2 months Male predominance Assessment - Projectile non bilious vomiting (feeds) - Feeding after vomits (hungry) - Stomach dilated - Olive shaped mass Ix - US - Thickened pylorus - Thickened duodenal wall >4mm - Canal length >14mm - Barium meal shows elongated pyloric canal and string sign Tx - IVT - saline + K replacement - Surgical correction after alkalosis corrected

Answer 393

Overstimulation of autonomic nervous system (symp and parasymp) from certain stimulus. Occurs in injuries above T6 spinal cord level Triggers - stimulation below T6 - Bladder incontinence/distension - Faecal impaction/constipation - Fractures - Skin breakdown e.g. cellulitis - Epididymo-orchitis S&S - Above lesion: sweating, pallor - Severe HTN - Bradycardia - headache, blurry vision, nasal congestion Cx - stroke, death, seizures, renal failure, ICH, APO Mx - Remove stimulus - BP control - Positioning - sit patient up

Answer 394

Type I - small <1cm and minimal tissue damage Type II - >1cm with moderate soft tissue damage; moderate energy injury Type III - high energy, extensive soft tissue damage and potentially vascular injury 3A - adequate soft tissue coverate despite extensive soft tissue laceration/flaps 3B - inadequate tissue coverage with bone exposure/periosteal stripping 3C - any open fracture with arterial injury requiring repair

Answer 395

Risk - increased creatinine x 1.5 or UO <0.5mL/kg/h for 6 hours Injury - increased creatinine x2 or UO <0.5mL/kg/hr for 12 hours Failure - inc Cr x3 or Cr >4mg/dL or UO <0.3mL/kg/hr for 24 hours or anuria for 12 hours Loss - persistent ARF = complete loss of renal function for >4 weeks ESRD Implications - Progression down the RIFLE criteria is a/w increased LOS in ICU, hospital and higher mortality + lower renal recovery

Answer 396

Exposure to serotonergic agent plus - Spontaneous clonus - Inducible/ocular clonus with agitation or diaphoresis - Inducible/ocular clonus with agitation or diaphoresis - Inducible/ocular clonus and hypertonia, temp >38 - No clonus but has tremor & hyperreflexia

Answer 397

Mix of excitatory and inhibitory actions hence cycling between alertness and sedation Rapidly absorbed post oral administration, peaks 30 minutes post ingestion Features of toxicity - Vomiting - Profound coma and respiratory depression - Agitation - Cycling between coma and agitation common - Seizures in 5% - Generalised hypotonia and minimal to no reflexes - Non-reactive pupils of variable size - Myoclonic movements (Face, upper limbs) - Bradycardia - ECG – u waves - Mild hypothermia Withdrawal - Similar to ethanol withdrawal - Requires large amounts of benzos Mx - Ventilation if profound bradypnoea, otherwise conservative 3 predictors of severe GHB withdrawal - Short time intervals between dosing <2-4 hours - Waking up during the night to dose - Higher daily doses >30g or 15mLs Signs of severe GHB withdrawal - Disorientation - Hallucinations/delirium - Hyperthermia - Hypertonia - Seizures Pharmacological tx for GHB withdrawal - Diazepam 20mg loading then every 1-2h until 60mg or light sedation - Baclofen 25mg tds - Antipsychotics – olanzapine 2.5-5mg (max 20mg daily) or quetiapine 25-50mg (max 200mg daily) - Clonidine 75mcg to manage tachycardia, HTN, tremor, restlessness - Phenobarbitone 30mg increments hourly up to 120mg if benzo resistant

Answer 398

Type A - due to tissue hypoperfusion and hypoxia e.g. sepsis, ischaemia, seizures Type B - metabolic. normal oxygenation and perfusion e.g. medications (metformin), malignancy, toxic alcohols, liver disease

Answer 399

increased p wave amplitude prolonged PR Widespread ST depression and TW flattening/TWI Prominent U waves (usu. V2-3) Apparent long QT due to fusion of T and U

Answer 400

RCH discharge when: - Some children can be discharged at 1 hour if o Resolution of all signs of severity o Normal activity o Adequate parent skill and familiarity with asthma o Proximity to ED - All other children can be discharged if able to tolerate 3 hours without requiring salbutamol MDI - Adequate oxygenation (mild hypoxia 90-94%) still ok for discharge if clinically well and responded to treatment - Adequate PO intake Discharge instructions - Education on symptom recognition and mx - When to return to ED - Emergency management - Role of reliever and preventer therapy - Inhaler technique - Follow up with GP - Updated asthma action plan

Answer 401

Organisms - S. aureus - Strep pyogenes - Candida albicans Risk factors Oversupply milk Missed feeding/poor feeding with introduction of solids High stress Cracked damaged nipples Incomplete breast feeding Inexperience Previous treated mastitis Maternal fatigue Tongue tie Facial abnormalities of baby Inpatient mx if - Sepsis - Abscess requiring drainage - - Severe pain - Compliance issues e.g. intellectual disability, poor health education Mx - Flucloxacillin - Regular massage, expressing, hot packs

Answer 402

Wedge compression fracture - Ant column compression - Common; majority of spinal # - Due to loss of BMD in OP - T12/L1/L2 common - Usu. stable - Mech: trauma, OP, steroids. Axial loading & flexion causing anterior column # Burst fracture - Vertical compression - Comminuted # of ant/post vertebral body; stable but fragments can protrude and cause spinal injury - Mech: MVA, fall from height, axial loading with compression - Potentially unstable Chance - Horizontal through vertebral body separating into upper/lower parts - Usu. seatbelt injury in MVA - Usu upper lumbar spine - Usu. with intra-abdo injuries (pancreas, duodenum, aorta) - High mortality - Unstable, requires surgical fixation Thoracic #/dislocation - Very unstable, severe neuro deficit due to failure of all 3 spinal columns from multiple forces (compression, flexion, rotation, shear force) e.g. seatbelt injury or direct trauma e.g. falling on object or object onto back - T11-L2

Answer 403

Does not test brainstem function Does not assess higher cognitive function May be difficult to interpret if language barriers or communication problems Cannot be used in intubated patients Difficult to assess in intoxicated patients, often used in intoxicated where not validated Subjective assessor Does not detect subtle changes in conscious state

Answer 404

Le Forte fractures esp 2 and 3 Basal skull fractures Fracture through transverse foramen of cervical spine Hangman's fracture Jefferson fracture Petrous temporal bone fractures Occipital condyle fractures

Answer 405

1. Apnoeic oxygenation, Pre-oxygenation to prevent desaturation - incl. NIV, NP 2. DSI 3. Keep upright improves ventilation 4. BVM with PEEP 5. Inotropic support/fluids prior to intubation 6. Cardiac stable induction drugs, or lower doses 7. Invasive monitoring IAL 8. Rescue meds e.g. adrenaline metaraminol 9. Bolus steroids if normally on steroids 10. Prevent acidosis - HOC3 if severe acidosis 11. PEEP for APO

Answer 406

Threatened miscarriage - Hx - unknown LMP, planned pregnancy - Ex - passing products, open os, blood/membranes Ectopic pregnancy - Hx of pregnancy, unconfirmed IUP, unilateral pain, hx of PID - Ex - adnexal tenderness, closed cervix Fibroids - Prior hx, prev US - Ex - enlarged bulky uterus Endometriosis - Hx - bleeding outside periods, heavy painful periods, prev laparoscopies Cervical cancers Late pregnancy cx - placental abruption, praevia PID

Answer 407

- Previous violence towards client - Relationship between client and partner e.g. previous stalking, controlling, recent separation - Background of partner e.g. unemployed, health/drug & alcohol problems - Children involved? harm to children - Sexual assault? Measures to consider - Mandatory reporting if child at risk - Police reporting with patient's consent, or if direct threat of death e.g. guns - Intervention must have patient consent - Provide appropriate medical assessment and therapy - Tx with compassion, respect and tolerance

Answer 408

RF - Constipation - Low fiber diet - Pregnancy - Dehydration - Meds e.g. opioids DDx - Anal fissure - Genital herpes - Proctitis - Rectal prolapse - Trauma CI to ED I&D - Coagulopathy - Uncooperative pt - Portal HTN - Pregnancy - Concern for abscess - If small - If >72h Procedure - Patient lying in lithotomy position ideal - LA gel and 1% lignocaine into haemorrhoid - Elliptical incision to overlying skin to expose haemorrhoid and drain the clot - Control bleeding with pressure, insert gauze into wound for pressure and leave in place for several hours

Answer 409

- Pre-existing perceptions/mistrust of hospitals due to previous experiences - Location - often in remote areas - Language barriers - Fear of discrimination - Lack of cultural safety and awareness in healthcare - Lack of appropriate health education provided to ATSI communities Ways to improve communication - Engage ATSI liaison officers - Cultural safety awareness training - Involve community members and family - Communication - provide written and spoken, clear simple language, slow speech - Visual cues - Avoid eye contact, sit beside not in front

Answer 410

Transient synovitis Acute myositis Septic arthritis/OM Perthes Developmental dysplasia of the hip Trauma e.g. stress fracture NAI Malignancy Rheumatological e.g. juvenile arthritis, reactive arthritis, HSP, vasculitis - Surgical e.g. testicular torsion/appendicitis

Answer 411

In a child with hip pain, presence of the following 4 increases likelihood of septic arthritis 1. Temp >38.5 2. NWB 3. Leucocytosis >12 4. ESR >40, CRP >20

Answer 412

RV free wall akinesis with sparing of the apex highly suggestive of acute PE

Answer 413

Type A aortic dissection Post cardiac surgery esp. valvular Cardiac rupture

Answer 414

- Aspiration risk - dec lower oesophageal sphincter tone, inc abdo pressure, dec gastric emptying - Oedematous airways - tongue/supraglottic airways oedematous and more friable prone to bleed - Decreased FRC and increased O2 consumption - hypoxic more quickly, less tolerant of apnoeic periods - BVM more difficult - due to low FRC, elevated diaphragm, raised intra-abdo pressure - Obesity more common - causes neck extension when supine (more anterior larynx) and shorter neck in obese gravid woman - Larger breasts - causing difficult laryngoscopy

Answer 415

Adv - Fastest - Allows point to point transfer if both hospitals have helipad, avoids double handling of patietn - Response not traffic dependent Disadv - Medical interventions difficult in flight - Noise, vibration, G forces may exacerbate pain/alter haemodynamics - Motion sickness - Unstable temp - Not pressurised - low paO2 at altitude - Restricted by weather/landing sites - Expensive

Answer 416

critical aortic stenosis coarctation of aorta large VSD AVSD Truncus arteriosus Others - TGA - Hypoplastic left heart syndrome - TOF - TAPVC - Tricuspid atresia - Pulmonary atresia

Answer 417

EFAST showing free fluid Peritonism Pneumoperitoneum, free air under diaphragm Significant GI haemorrhage High grade solid organ injuries if embolisation not available or not appropriate Penetrating abdo trauma/hypotension Evisceration injury GSW traversing peritoneum

Answer 418

monitored and witnessed arrest and PEA AND defibrillator not immediately available

Answer 419

Monitored and witnessed VF/VT arrest Connected to defibrillator and shock can be administered within 20s

Answer 420

Raised Intrathoracic pressure impedes venous return Impedes coronary blood flow risk of barotrauma increases impedence to defib

Answer 421

Diagnostic criteria - Drinking more or for longer than intended - Thought about cutting down but couldn’t - Drinking/recovering from drinking interferes with family, work, education - Continuing to drink despite problems with friends/family - Finding yourself involved in dangerous situations as a direct result of drinking - Continuing to drink despite adding to another health problem, feeling depressed/anxious/blacking out - Drinking more as a result of tolerance - Experiencing withdrawal symptoms Medications - Benzos - Thiamine - Naltrexone - Acamprosate - Disulfiram

Answer 422

Advanced age social isolation low SES Disability, physical impairment dementia, cognitive impairment depression, psych problelms caretaker - mental illness, substance abuse

Answer 423

Lack of endogenous insulin i.e. first presentation T1DM Lack of exogenous insulin (missed dosing, insulin pump failure) Pregnancy Excess carb load Sepsis Pregnancy Drugs e.g. cocaine Meds - antipsychotics

Answer 424

1. Patient’s mouth and nose covered by O2 mask with low flow up to 10L/min 2. Additional droplet protection by covering O2 mask with facemask 3. Avoid auscultation, avoid listening/feeling for breathing 4. Do not clear airway with any methods other than head tilt, chin lift 5. No open source suction (Yankeur) until appropriate room with PPE staff 6. Provide passive O2 at 10L/min, avoid PPV until pt in appropriate location with staff in airborne PPE 7. Minimise BVM and if requires BVM then use 2 hands 8. Well fitted supraglottic airway device is preferred to face mask if ventilation required 9. Suctioning through ETT should cocur through a closed inline system in isolation area 10. Mapleson circuit (anaesthetic bag) preferred as it provides passive O2 flow without needing to delivery PPV 11. VL Aerosol generating resus maneuvres - PPV – yes - ICC – yes - Mechanical CPR – Yes - CPR – no

Answer 425

Ix - Glucose - Urine Na - Urine osmolality - Serum Na - Serum osmolality - Most recent serum Na (for chronicity) - TFTs - Cortisol levels Hypovolaemic hyponatraemia High urinary sodium - Diuretics - Mineralocorticoid deficiency - Na losing nephropathy Low urinary sodium - GIT losses - Skin losses - 3rd spacing e.g. pancreatitis, peritonitis Euvolaemia hyponatraemia Normal/high serum osmolality - Hyperlipidaemia - Hyperproteinaemia - Hyperglycaemia Low serum osmolality - SIADH - Psychogenic polydipsia - Severe hypothyroidism - Drugs - GC deficiency Hypervolaemic hyponatraemia High urinary Na - Acute oliguric AKI - CRF Low urinary Na - Nephrotic syndrome - CCF - Liver failure

Answer 426

1. C-spine immobilisation - trauma intubation 2. Small doses of IV ketamine - sedate to take control, optimise pre-oxygenation 3. Continue active warming if hypothermic 4. Potential chest trauma - exclude ptx before PPV

Answer 427

Xray - if known radiolucent stone, can be tracked with plain XR in outpatients - or if other imaging modalities unavaialble US - Young pts - Multiple presenters, recurrent renal colic - Pregnancy CT - Pts over 50 with 1st presentation renal colic or where other comorbidities suspected - Pt not settling as expected with analgeisa - Haemodynamic instability

Answer 428

Settings - Use predicted body weight - TV 4-8mL/kg - Increase PEEP 5-24cmH20 - Plateau pressures <30cmH20 Endpoints - Permissive hypercapnoea - Aim SaO2 88-95% (PaO2 55-80) - pH 7.3-7.45 If persistently hypoxic - Increase FiO2 to 100% to max O2 required OR - increase PEEP to increase SA for gas exchange and decrease atelectasis - Prone position - allows better VQ mismatch, less lung compression from abdo - Ensure optimal sedation/paralysis - decrease O2 consumption/CO2 production - Physio/suction - improves gas exchange - Treat sepsis - reduces metabolic demand - Optimise fluid balance - maximise CO/O2 delivery Optimise Hb - improve O2 carriage - Recruitment maneuvres - opens collapsed allevoli - Increase I:E ratio towards 1:1 - increases FRC, recruitment - Others - inhaled NO, ECMO

Answer 429

Major incident declared Exact location Type of incident Hazards present Access route to incident Number and type of casualties Emergency services present and required

Answer 430

Sieve type prioritises urgency of patient treatment Sort time prioritises urgency of patient transport Triage sieve Performed by first senior AV officer at incident site to determine who is taken to each patient treatment zone and in what order. Classification - Red (Priority 1) – prioritise for transport to casualty clearing station o RR <10 or >29 o Unable to protect airway o CRT >2s o Pulse >120 - Yellow o No red criteria o CRT <2s or pulse <120 - Green o Walking patients o Potential discharge at scene or move to low acuity area for mass transfer - Black o Dead o No respiration despite airway patent o Not moved from scene Triage sort Occurs at the on-site clearing station, determines order of transport to hospital Similar parameters

Answer 431

Red/pink = immediate care needed, critical injury but good chance of survival if simple life saving measures provided - E.g. may only need relief of airway obstruction or tptx, >40% TBSA burns Orange/yellow - Significant injury, not immediately life threatening - Likely to survive if simple care within hours - Requires definitive care Green - Walking wounded - Minor injuries requiring care - Can be delayed whilst others receive tx Blue - Expectant management and analgesia only - E.g. GCS 3 - CPR required - Age >60, >50% burns - Elderly shocked pts or with multiple severe injuries (SNT/thoracic) Black - Dead

Answer 432

Tasks - Communication – to all staff, patients, departments etc - Create capacity o Clear resus of stable patients e.g. to ICU, non resus beds o Transfer stable admitted pts ot ward o Move pts who are not suitable for discharge/admission to SSU/decanting area o Discharge stable patients if possible - Prepare ED o Disaster triage packs/patient documentation o Allocate senior medical/nursing staff to triage team o Decide area for triage o Prepare equipment for expected injuries o Prepare supplies/fluids/dressings o Obtain suitable blood products e.g. MTP Form resus teams/allocate roles Staff – notify staff, assign roles, call in extra staff Areas – establish triage area, decontamination area, make space etc Equipment – additional monitors, ventilators, US, MTP, lines etc

Answer 433

Efficient and fair system to treat those in greatest need ahead of those who arrived before them. TRIAGE Time critical assessment Resource allocations appropriately Immediate prioritisation Adaptability Greatest good Ethical decision making - has to be fair

Answer 434

Close entry and exit points. Fire Warden takes charge. Check the local area for signs of fire/smoke and move away from immediate danger. Establish communication with the hospital Incident Commander. Record everyone present in the department. Prepare for possible evacuation.

Answer 435

RV Dilatation (RV/LV ratio >1) * Ventricular bowing/D-shaped septum * Presence of “clot-in-transit” visualised in the right ventricle8 * McConnell’s sign (RV hypokinesis with apical sparing) * TAPSE Reduction (TAPSE <18mm or <16mm

Answer 436

* Multiple magnets or magnet plus metallic object * Sharp or pointed objects (e.g. fish bone, pins or needles) * Lead-containing objects (e.g. fishing sinker, curtain weight or air rifle pellet) * Organic toxic material, plants, medication patches * Large objects (>6 cm long and/or >2.5 cm wide) * Superabsorbent polymers * Multicomponent objects may break apart and progress separately in the gastrointestinal tract (e.g. Toys with lights, motors and batteries) and may require removal * Failure to pass into the stomach for >24 hours * Coin at the level of cricopharyngeus muscle

Answer 437

(Age + 4) x2

Answer 438

- Refractory hyperK - Oliguria <5mL/kg/day - APO with hypoxia non responsive to other measures - Uraemic encephalopathy - Metabolic acidosis pH <7.2 - Dialysable toxic ingestion - Temp control - Severe hypo/hyperNa - Cr >1000 - Urea >30

Answer 439

Lung consolidation - hepatisation Air bronchograms - may be dynamic or static Small volume complex effusion - heterogenous, hyperechoic floating structures/particles (plankton sign)

Answer 440

Compressed lung, jelly fish sign (atelectasis) Absence of air bronchograms Large volume pleural effusion (anechoic) Measurement of pleural effusion size = distance from diaphragm (cm) to lung x 200mL

Answer 441

- PE - Phlegmasia cerulea dolens - Chronic venous insufficiency - Post-thrombotic syndrome -Recurrent DVT - Venous ulcers - Pulmonary HTN if recurrent PE

Answer 442

HTN >160 Abnormal renal/liver function >2x normal limit Stroke history Bleeding disorders/events previously Labile INR Elderly >65 Drugs/alcohol e.g. antiplatelets/NSAIDs

Answer 443

- Previous severe withdrawal - Psychotropic medication use - Intercurrent illness - Increased duration of chronic alcohol consumption

Answer 444

- Inter-observer variability in subjective scores e.g. history, exam, ECG interpretation - designed to stratify undifferentiated pain, not those already diagnosed with ACS - No comparison of scoring systems to clinical gestalt - No consideration of shared decision making - May still misdiagnose atypical presentations - Difficult to use if communication problems

Answer 445

Applicability - needs to be developed using data from setting where it will be subsequently used Calibration - must accurately quantify level of risk Distinguishes between pts who do and do not experience event of interest Outcome oriented - must predict outcome of interest e.g. death for the population Feasibility - must be suitable for implementation in clincial practice Incorporate socioeonomic factors Must have potential to be updated

Answer 446

Ventricular septal rupture Free wall rupture/perforation Papillary muscle rupture MR Infarct extension Cardiogenic shock LV aneurysm Arrhythmias Heart block Pericarditis Dressler's syndrome

Answer 447

Tilt bed to left, wedge under right hip Manual displacement of uterus to relieve aortocaval compression Inc rate of compressions to 120/min Chest compressions higher up in sternum Resuscitative hysterotomy within 4 mins/after 4 mins if detectable FHR ECMO CPR Large bore access in ULs, avoid femoral lins due to compression from gravid uterus Aggressive detection/management of bleeding and DIC MTP early Avoid vasopressors until after delivery of foetus due to significant reduction in placental blood flow

Answer 448

Volume overload Dilutional coagulopathy TRALI Hyperkalaemia Hypocalcaemia ABO incomptability Blood borne infections Hypothermia Metabolic acidosis

Answer 449

1.5% absolute reduction in all cause mortality in hospital within 28 days of TXA use Reduction in mortality due to bleeding within 28 days No diff in number of pts requiring blood transfusion No diff in mean total cells transfused No diff in need for surgical intervention No diff in vascular occlusive events/thromboembolic cx No diff in dependence at hospital discharge or at day 28 if still in hospital

Answer 450

- IV MgSO4 2g bolus repeat if required - DC cardioversion – unsynchronised as may not synchronise - Overdrive pacing – to increase the HR and shorten the QR interval - Can also do chemical overdrive pacing e.g. with isoprenaline - Alkalinisation if due to Na channel blocker toxicity - Correct electrolytes e.g. hypoK, hypoMg - Cease QT prolonging drugs

Answer 451

Higher specificity resulting in less imaging when applied Imaging reduced by over 40% with CCR compared with 13% with NEXUS Midline tenderness does not mandage imaging if other low risk criteria are met Can clear c-spine in presence of distracting injury if other low risk criteria met Criteria are more objective compared to subjective criteria of nexus. E.g. active rotation of neck 45 degrees L/R and low risk criteria of being ambulant or sitting or delayed neck pain Adv of NEXUS: - Does not require interpretation of mechanism of injury and allows clinical clearance even with severe mechanisms of trauma - Can be applied to children <16 - Simpler criteria than CCR and easier to remember - Included >65yo population in the study; CCR excluded this group

Answer 452

VA ECMO - Complete or partial cardiac support and gas exchange, oxygenation via external device; reduces myocardial burden - Cx - bleeding diasthesis, thrombus formation, infection, distal limb ischaemia, embolisation of thrombus IABP - Increases coronary artery perfusion during diastole as balloon inflates to occlude aorta - Cx: traumatic rupture of aorta, reduced perfusion to distal limb, viscera, spine (ischaemia) - Haemorrhage on insertion - AV fistulae - Arterial thrombus formation - Infection LVAD - Assists LV contraction via mechanical device; reduces O2 demand - Dx - device failure, RH failure, VT, thrombus/embolism, bleeding (pericardial effusion), infection

Answer 453

haemorrhage causing airway obstruction puncture of posterior tracheal wall Pneumothorax pneumomediastinum Failure, dislodged ETT Damage to structures e.g. thyroid Subcut emphysema Damage to recurrent laryngeal nerve

Answer 454

OA - <2000 Haemathrosis <200 Crystal arthropathy 2000-50000 Septic arthritis >50000 with high polymorphs

Answer 455

FLACC (face/legs/activity/cry/consolability) Wong-Baker faces scale Disadvantages of pain scales - Assumes level of comprehension - May be difficult to use if language/communication barriers - Variable interpretation by clinicians Pharmacological - PO paracetamol/ibuprofne - PO oxycodone 0.1mg/kg - IN fentanyl 1.5mcg/kg - IV morphine 0.1mg/kg - Inhaled nitrous - IM/IV ketamine Non-pharmacological - Play therapy - Distraction therapy - Splinting/immobilisation - Ice packs

Answer 456

VT/VF Cardiac stunning causing hypoperfusion Seizure Hypoxia - electrical injury to lungs/diaphragm TBI

Answer 457

- CVST - Post partum pre-eclampsia, eclampsia, HELLP - Post epidural headache - ICH - Dehydration - Stroke - Migraine

Answer 458

Multiple puncture attempts Larger gauge needle used Not replacing stylet before removing needle Patient sitting up instead of lying on lateral position

Answer 459

1. Simple analgesia – paracetamol 1g QID, ibuprofen 400mg TDS and anti-emetics 2. Opioid analgesia e.g. tramadol 50-100mg QID 3. IV fluids 4. Caffeine 500mg IV 5. Epidural blood patch – 20mLs of patient’s blood from vein and injected into epidural space

Answer 460

FiO2 >60% with refractory hypoxia Requiring PEEP >10cmH20 TV <4-5mL/kg (hypoventilation) Low minute ventilation 5L/min FVC <15mL/kg Unable to trigger breaths

Answer 461

Differential cyanosis - ie worse in lower limbs Systolic BP arms > legs Hypotension Radiofemoral delay Weak/absent femoral pulses ESM or systolic murmur over precordium a/w bicuspid aortic valve Heart failure symptoms - tachypnoea, hepatomegaly Mx - Prostaglandins E1 - IV fluids 10mL/kg - O2 - Transfer paediatric cardiothoracic surgery

Answer 462

MS Post viral e.g. herpes zoster, HIV, measles, mumps Bacterial e.g. syphilis, TB Autoimmune e.g. sarcoidosis, SLE Drugs e.g. methanol poisoning, chemotherapy agents

Answer 463

Loss of lung sliding Lung point Barcode sign on M-Mode Loss of lung pulse Loss of B lines under pneumothorax Increased clarity of A lines

Answer 464

GBS + status Maternal infection e.g. UTI/gastro PROM Instrumental delivery Hx of PID Maternal fever Maternal substance abuse Low SES

Answer 465

Age > 40 years Presence of Malignancy (cancer) Heart Rate > 120 beats per minute Initial Percentage of Epidermal Detachment > 10% Serum Urea Level > 10 mmol/L Serum Glucose Level > 14 mmol/L Serum Bicarbonate Level < 20 mmol/L

Answer 466

1. Blood at meatus 2. Pelvic fracture 3. Significant pelvic injury, perineal bruising, straddle injury 4. Penetrating injury near urethra 5. Inability to void 6. Gross haematuria 7. Pelvic trauma prior to insertion of IDC

Answer 467

I - contusion, blood at urethral meatus, normal urethrogram II - stretch injury, elongation of urethra without contrast extravasation III - partial disruption; extravasation of contrast at injured site, but contrast still seen in bladder IV - Complete disruption; extravasation of contrast without contrast going into bladder. <2cm urethral seaparation V - complete disruption, transection of bladder >2cm separation; extension of lac into vagina or prostate

Answer 468

1. Coagulopathy e.g. INR >2 2. Overlying infection/cellulitis 3. Non-distended bladder <250mLs 4. Overlying trauma/haematoma 5. Bladder cancer 6. Pregnancy 7. Lower abdo hernia mesh/repairs

Answer 469

1. Pseudomonas aeruginosa - Ciprofloxacin 2. Vibrio species - doxycycline 3. Aeromonas species - ciprofloxacin

Answer 470

Drugs - All anti-psychotics e.g. esp droperidol, haloperidol, chlorpromazine (Largactil) - Anti-emetics – maxolon, prochloperazine - SSRIs - Buspirone (anti-depressant) - Sumatriptan - Abx – erythromycin - Anti-malarials e.g. chloroquine - Anti-convulsants e.g. carbamazepine - H2 antagonist e.g. ranitidine - Recreational drugs e.g. cocaine S&S - Laryngeal dystonia – throat pain, dyspnoea, stridor, dysphonia - Oculogyric crisis – rotatory eye movements, deviagetd gaze - Facial spasms e.g. eyelids, facial muscles - Buccolingual crisis – tongue protrusion - Torticollis, antecollis/retrocollis – twisting of neck, head forwards or backwards - Torticoplevic crisis – abdo rigidity and pain - Scoliosis/lordosis - Opisthotonic crisis – spasms of entire body – back arching, UL flexion, LL extension Tx - Benztropin 1.2mg - Benzodiazepines

Answer 471

- high variability and non-standardised - inter-observer variability between triaging clinicians. Smaller hospitals allocate higher triage categories for same acuity Often have minimal information at time of triage, may need re-triaging leading to delays in assessment/treatment Differences in perception of urgency between patients and staff can cause poor outcomes May overcategorise e.g. chest pain cat 2

Answer 472

Drugs - e.g. AZA, NSAIDs, chemo drugs, piptaz Infection - EBV, CMV, HIV Autoimmune - SLE Radiation exposure Aplastic anaemia Toxins - hydrocarbons, mustard gas

Answer 473

Massive overdose >30g Evidence of acute liver failure Unknown time of ingestion but deranged LFts Staggered overdose >200mg/kg or unknown dose but >8 hours post ingestion

Answer 474

MOA - inhibits intestinal ammonia production - enhances transfer of ammonia from blood into GIT Cx - Diarrhoea - Dehydration - Hypovolaemia - Hypokalaemia - Ileus - Metabolic alkalosis - Aspiration

Answer 475

Older age Known IHD/structural heart disease e.g. cardiomyopathy, prev AMI FHx sudden cardiac death

Answer 476

Mental health patients Drug/alcohol use Prior bad experience in hospital Low health literacy Indigenous patients Perceived long waits Language barriers Homelessness Younger age and males Previous DAMA Dependent partner/children at home Strategies: - Separate paeds area with separate staff assessing patients - Early senior review of drug affected pts - Regular nursing review for vital signs, pain relief, food etc - Provide meds for anxiety/mental health - Use interpreters - Bilingual signage - Alcohol withdrawal pathways and early treatment - Dedicated mental health space

Answer 477

Systolic murmur Slow rising pulse paradoxical splitting of 2nd heart sound S4 Aortic thrill LVH - displaced apex

Answer 478

TTP HUS HELLP DIC Malignancy Malignant HTN - shear stress from high BP Mechanical heart valves SLE Antiphospholipid

Answer 479

- Rate >200 - Irregular, extremely high up to 300bpm - Wide QRS - Beat to beat variation in QRS morphology Management - Unstable  DC cardioversion - Stable o Avoid AVN blocking drugs (adenosine, CCB/BB) because most accessory pathways have a shorter refractory period hence blocking AVN may cause ventricular rate to be more rapid if it conducts via the accessory pathway = can cause VT/VF o Procainamide (class I antiarrhythmic that targets the accessory pathway, prolongs action potential duration in atrial and ventricular myocardium)  NO AV node blocking effect  Effective with reverting and slowing the rate  Safe in children  Bolus + infusion

Answer 480

Volvulus (midgut) malrotation Obstruction - intestinal/duodenal atresia Meconium ileus Imperforate anus Tracheo-oesophageal fistula/oesophageal atreasia Stenosis - pyloric stenosis (older) Aganglionosis (Hirschsprung's) NEC Diverticulum (Merckel's) - older infants

Answer 481

Resuscitation Adult 50mL bolus 50% dextrose IV, repeat PRN Children 2mL/kg of 10% dextrose IV, repeat PRN Aim BSL >4 Repeated hypoglycaemia – 10% glucose infusion start at 100mL/hr and monitor BSL Children – use maintenance fluids with saline + 5% dextrose +/- potassium Dextrose is a temporising measure until octreotide Risk assessment - 1 tablet for a non-diabetic can cause profound hypoglycaemia - Within 8 hours or longer with XR and can last up to several days - Hepatic/renal impairment will predispose to hypoglycaemia - Children – 1 tablet can be fatal Ix - BSL - ECG - Paracetamol level - Hourly BSL until pt is stable on octreotide - UEC – monitor K and renal function Decontamination - AC50g in cooperative patient if presents within 1 hour of standard preparation of <4 hours in MR - Paediatric 1g/kg Antidote - Octreotide

Answer 482

Normal CSF ranges Typical CSF findings in a normal adult include: Appearance: clear and colourless White blood cells (WBC): 0 – 5 cells/µL, only lymphocytes Red blood cells (RBC): 0 – 5 cells/µL Protein: 0.15 – 0.45 g/L Glucose: 2.8 – 4.2 mmol/L (or >60% serum glucose concentration) Opening pressure: 10 – 20 cmH2O

Answer 483

Hb Hepatic disease Heart disease HR >100 Hypotension Haemorrhage (malaena) Urea low Male/Malaena Syncope * Patients with no risk factors (score 0) are low risk and can be managed as outpatients * Patients with any risk factors (score 1) are high risk. * Determine which patients with upper gastrointestinal bleeding are at high risk of needing intervention (transfusion, endoscopy, ICU).

Answer 484

Benign: - Hydrocele - transillumination, fluctuant, fluid filled - Epididymitis - tender, swollen, red scrotum, relieved with elevation of scrotum (Prehn's sign), + cremesteric reflex - Varicocele - bag of worms consistency on palpation - Uncomplicated inguinal hernia - reducible mass, non tender Non-benign - Torsion - high riding, horizontal, absent cremesteric reflex - Incarcerated inguinal hernia - irreducible tender mass - testicular neoplasm - hard non-tender mass - Traumatic scrotal haematoma - bruising, swelling - Scrotal abscess - Scrotal cellulitis

Answer 485

Iritis Myocarditis and meningitis Pericarditis Arthritis Colitis Thyroiditis Dermatitis The first presentation of these checkpoint inhibitor related inflammatory conditions are often dermatologic (eg. eczema, DRESS syndrome, Stephens-Johnsons) usually 2-4 weeks after starting the checkpoint inhibitor or gastroenterologic (e.g. colitis); other “mab”-related disease may present months after starting the medication

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