High yield RV Flashcards
(113 cards)
1
Q
Management acute glaucoma
A
Pilocarpine 2% Q5min for 1 hr. Increase outflow.
Timolol 0.5% 1 drop ever 30-60 min. Redcues production and increases outflow.
Latanoprost 0.05% daily. Increases outflow.
Acetazolamide 500 mg. Decreased production
2
Q
Causes of painless red eye
A
Diffuse
- Lids: blepharitis, ecrtropion, eyelid lesion
- Conjuctivitis
Localised Pterygium Corneal Foreign body Ocular trauma Subconjunctival haemorrhage
3
Q
Causes of painful red eye
A
Corneal: HSV, bacterial/acantomoebal ulcer, keratitis, foreign body
Lid: chalazion, blepharitis, herpes zoster
Conjunctival: viral/allergic/bacterial conjunctivits
Acute angle closure glaucoma
Scleritis - vascular / connective tissue
Anterior uveitis / iritis, hypoyon, hyphaema
4
Q
Causes of sudden loss of vision
A
Transient - amaurosis fugax
Vaso-occlusive: CRVO, CRAO
Optic nerve - optic neuritics, GCA
Retinal detachment
5
Q
Dental block for lower mandible
A
Inferior alveolar nerve block - approach over contralteral canine, insert in pterygotemporal depression, advance 20-25 mm - contact with ramus of mandible, withdraw 2 mm, aspirate, inject 2 mls lignocaine
6
Q
Antibiotic therapy in retropharyngeal abscess
A
Amoxycillin & clavulanate 1g/200 mg IV Q6 H OR cephazolin 50mg/kg and metronidazole 12.5mg/kg IV BD
7
Q
Hard signs of penetrating neck trauma and implication
A
Require immediate surgical or endovascular intervention
rapidly expanding/pulsatile haematoma
Massive haemoptysis Air bubbling Vascular bruit or thrill Stridor/hoarseness or airway compromise Cerebral ischaemia Severe haemorrhage, Shock not responding to fluids, Decreased or absent radial pulse \+/- massive subcutaneous emphysema
8
Q
Zones of the neck and investigation of penetrating trauma
A
1 - clavicles/sternal notch to cricoid cartilage
2 - cricoid cartilage to angle of mandible
3 - angle of mandible to base of skull
Zone 1 - CTA, bronchoscopy, oesophagoscopy
Zone 2 - OT if stable and vascular injury, consider imaging prior
Zone 3 - CTA +/- others
9
Q
Grading of liver injury and implication
A
Grade III - subcapsular haematoma > 50%, rupture of haematoma, intraparenchymal haematoma > 10 cm or laceration > 3 cm deep
Grade V - venous injury
Grade VI - avulsion
OT if grade III +
10
Q
Grade of splenic injury and implication
A
Grade III - subcapsular haematoma > 50%, rupture of haematoma, intraparenchymal haematoma >5 cm or laceration > 3 cm deep
IV - segmental / hilar vessels
V - shattered, devascularised
OT if grade III/IV+
11
Q
General approach to psychatric patients
A
General Approach - SACCIT Safety Assessment Confirm provision diagnosis Consultation Immediate treatment Transfer of care
12
Q
Suicide risk assessment
A
SADPERSONS Sex - male Age - > 45 or < 19 Depression Previous attempt Ethanol / drug abuse Rationality (loss of) - schizophrenia, psychosis Spouse (absence of) Organised plan No support Sickness (illness)
0-2 discharge & FU
3-4 +/- admission
5-6 admission
>= 7 involuntary if needed
13
Q
Indications for hospitalisation in eating disorder
A
HR < 50, postural HR increase > 30 bpm BP < 90/60, systolic postural drop >= 20 mmHg K < 3 T < 36 / 35.5 Dehydration Na < 130 PO4 < 0.5 Long QTc > 450 msec Failure of outpatient treatment
14
Q
HIV PEP
A
unknown source: recommended if MSM or high prevalence country with anal or vaginal intercourse, 2 drug regimen
HIV positive source and detectable or unknown viral load: vaginal or anal intercourse give PEP, 3 drug regimen
Regimen
Lamivudine 300 mg PO daily for 4 weeks
Tenofovir 300 mg PO daily for 4 weeks
+/- Dolutegravir 50 mg PO daily for 4 weeks
15
Q
Diagnosis of thyroid storm
A
Clinical
- Temperature > 37.5
- Tachycardia out of proportion to fever
- Altered mental status
16
Q
Treatment of thyrotoxicosis
A
Propylthiouracil 1200 mg PO/NG
4mg IV dexamethasone TDS
6mg PO lugols iodine (after 1 hr)
80 mg Propranolol, IV esmolol 500mcg/kg/min then 50-100 mcg/kg/min
Supportive care
- hyperthermia –> external cooling
- electrolyte disturbance
- DC cardioversion for arrhythmias
- plasmapheresis / dialysis / haemoperfusion
17
Q
Pathophysiology, causes and electrolyte disturbance in addison’s disease
A
Adrenal failure
Causes:
1- autoimmune, infection, haemorrhage, infarction, congenital, malignancy.
2ndry - pituitary failure, exogenous steroid supression
Hypoglycaemia, hyponatraemia, hyperkalaemia.
18
Q
Dose of dextrose in hypoglycaemia
A
2-5 mls/kg IV 10% dextrose (adult 125-250 ml)
19
Q
Diagnosis of DIC
A
Raised D-dimer
Raised PT
Low platelets
Low fibrinogen
20
Q
Causes of DIC
A
HOTMISS Hepatic failure Obstetric: amniotic fluid embolism, eclampsia, FDIU Trauma Malignancy: prostate, leukaemia Immune: transfusion, anaphylaxis Sepsis: gram neg, viral haemorrhagic Shock, snake bite
21
Q
Low risk chest pain
A
Age < 40 Symptom free Normal ECG and biomarkers No high / intermediate features Aytpical nature of symptoms
22
Q
High risk chest pain & management
A
> 10% risk MI / death
ECG persisttent or dynamic ST depression or new TWI, or transient ST elevation in 2 leads, or Wellens syndrome
Elevated troponin
Cardiac failure, MR or haemodynamic instability
Repetitive or prolonged ongoing chest pain / discomfort
Sustained VT
Syncope
Diaphoresis
LVEF < 40%
Prior MI, PCI or CABGS
admit to monitored bed, consider perfusion imaging, PCI within 2 / 24 hr 72 hrs depending on specific symptoms.
23
Q
STEMI mimics
A
Pericarditis Benign early repolarisation LVH (MI if ST/R ratio > 0.25) LV aneurysm LBBB +/- AMI
24
Q
Indications for reperfusion therapy in ACS
A
STEMI
ST elevation in 2 contiguous leads or new LBBB, >1mm in limb leads >2 mm in precordial leads
Other
High risk ACS without STEMI (wellen’s T waves with STE aVR)
Cardiogenic shock of ischaemic origin
Cardiac arrest with ROSC
Haemodynamically significant ventricular arrhythmias resistant to treatment
Failure of ST elevation to improve by 50% within 90 min of thrombolysis
Ongoing pain uncontrolled by standard therapies without STEMI criteria
25
Indications for PCI rather than thrombolysis
< 1 hr & <60 min to PCI
1-3 hrs sx & <90 min to PCI
3-12 hrs sx & < 2 hrs to PCI
>12 hrs and haemodynamically unstable
26
Contraindications to thrombolysis
```
Aortic dissection
New neurological signs
Significant head / facial trauma 3 months
Previous ICH
Previous Ischaemic stroke < 3 months
Known intracranial AVM
Malignant intracranial neoplasm
Acute pericarditis
Active bleeding
```
```
Relative
Anticoagulation
Non-compressible vascular puncture
HTN, DBP > 110
Surgery < 3 weeks, CNS surgery < 2 months
GIT / urinary bleeding in prev 4 weeks
Malignancy
Pregnancy
```
27
Criteria for diagnosis of VT
```
Absence of RBBB / LBBB morphology
Extreme axis
Very broad (>160 msec)
AV dissociation
Capture beats
Fusion beats
Positive or negative concordance in chest leads
```
Brugada criteria - if yes to any = VT
absence of RS complex in all precordial leads
R to S interval > 100 msec in 1 precordial lead
AV dissociation
Morphology criteria for VT present in V1/2 and V6
Dominant R wave in V1 - RBBB like: smooth R, RSr', qR
Dominant S wave in V1 - LBBB like: josephsons sign in S wave
28
Causes of long QTc
Drugs: amiodarone, sotalol, azithromycin, antipsychotics, phenothiazines (haloperidol)
Electrolytes - hypokalaemia, hypoMg, hypocalcaemia
Hypothermia
Ischaemia - AMI
Raised ICP
Congenital long QT
29
Diagnosis / management of hypertensive emergency
BP > 180/120 with end organ dysfunction
Brain - enecphalopathy, CVA
CVS - APO, ACS, aortic dissection
Targets
- ICH: SBP < 180 (possibly 140 if anticoagulated)
- CVA 10-15% reduction if > 180 / 105
- Aortic dissection: HR 60-80, SBP 100-120
- Encephalopathy 10-15% reduction, or DBP 100
30
DDx hyperthermia and mental status changes
```
Heat stroke - environmental exposure
NMS - muscle rigidity
Serotonin toxicity - clonus
Malignant hyperthermia - drug exposure, masseter spasm
Sepsis
Thyroid storm
Stimulant toxicity
```
31
Radiation syndrome
>2 gy: Haematopoietic syndrome - pancytopaenia
10-15 gy: GIT syndrome
15-30 gy: vascular syndrome
> 30 gy: cerebral syndrome
32
Toxidrome and management of chironex fleckeri poisoning
Severe pain, immediate, whip like. Cardiac toxicity - hyper/hypotension, arrhythmias, VT.
```
Vinegar / sea water.
Antivenom
Indications: unconsious, hypotension/arrhythmia, hypoventilation, neurological symptoms or severe pain.
3 vials if life threatening.
Adjunct magnesium sulfate.
```
33
Toxidrome and management or irukandji syndrome
Sodium channel effects and catecholamine release
Impending doom, severe pain, agitation.
Vingear / sea water
High dose IV analgesia
magnesium
Antihypertensive - GTN
34
Travel related non-specific illness
```
Malaria, dengue
Enteric fever - salmonella typhi
Hepatitis
Viral haemorrhagic fevers
TB
```
```
Influenza, pneumonia
Sepsis
HIV
Meningococcal
Measles
```
35
Causes of long QT
Antiarrhythmics - sotalol
Antipsychotics - amisulpride, ziprazidone
Methadone
Citalopram/escitalopram
Antibiotics - fluroquinolones, macrolides
Ondansetron
antifungal - fluconazole
Other causes
electrolyte - hypomagnesaemia, hypocalcaemia, hypokalaemia (pseudo-long)
Heart disease - cardiomyopathy, heart failure, MI, CHB
Congenital
Hypothyroidism
SAH
36
Indications for multi-dose charcoal
```
Carbamazepine
Dapsone
Phenobarbitone
Quinine
Theophylline
```
37
Indications for whole bowel irrigation
```
Iron > 60 mg/kg
SR potassium > 2.5 mmol/kg
Arsenic / lead & symptoatmic
SR verapamil / diltiazem
Body packer
```
38
Toxicological Indications for haemodialysis
```
Carbamazepine
Sodium valproate
Phenobarbitone
Toxic alcohols
Metformin
Lithium
Potassium
Salicylate
Theophylline
```
39
Management of calcium channel blocker overdose
```
R: > 10 tablets
R: IVT, Atropine for bradycardia then adrenaline, Calcium gluconate 10% 30 mls, infusion of adrenaline for hypotension. intubation for shock. HIET.
echo - cardiogenic vs vasoplegic
D: Charcoal, whole bowel irrigation.
ECMO
```
40
Management of B-blocker overdose
bradycardia - atropine, adrenaline, pacing
| hypotension - IV fluid, adrenaline, HIET, IAPB/ECMO
41
Management of sodium channel blocker poisoning
soidum bicarbonate 1-2 mEq/kg , Q2-5 min to improve BP and narrow QRS. Slow IV push (2-5 min). End point is pH 7.5-7.55
Intubation, hyperventilation. Target pH 7.5
NGT for charcoal 50g
Seizures - benzodiazepines 5-10mg IV
Hypotension: fluid, noradrenaline
Arrhythmia - soidum bicarbonate, lignocaine if pH > 7.5
Hypertonic saline 3% 3 mls/kg IV
42
Acute and chronic lithium poisoning clinical features
Acute - GIT; N/V/D, abdo pain.
- supportive, avoid dehydration / hyponatraemia
Chronic - CNS: hyperreflexia, agitation, weakness, ataxia. hypertonia, coma, seizures.
- cease lithium, replace volume, airway protection, haemodialysis (serum li > 2.5)
43
Risk assessment and treatment in iron overdose
> 60 mg/kg systemic toxicity
> 120 mg/kg potentially lethal
Fluid replacement.
Decontamination: endoscopy, Whole bowel irrigation
Desferroxamine: increases excretion. 15 mg/kg for 4 hrs.
44
Management of toxic alcohol poisoning
Intubation, with Na bicarb prior
Hyperventilate due to acidosis
IV benzodiazepines for seizures.
Mx hypoglycaemia, hyperklaemia, hypomag.
Reduce metabolism: ethanol 8 mls/kg 10% ethanol IV and then 1-2 mls/kg/hr.
Haemodialysis
45
Management of eclampsia
Airway support, oxygen. Left lateral position.
Stop seizure: benzodiazepine, midazloam (0.15mg/kg IM or IV up to 10mg)
Prevent further seizure: Magnesium sulfate
4g in 100 mls over 15 min and Infusion 2g/hr, target 2-3.5 mmol/L
Treat hypertension: labetolol and hydralazine, target SBP reduction 20-30 mmHg and disastolic by 10-15, to BP < 160/90 where possible.
- Labetolol 20mg IV Q10 min, infusion 20-60 mg/hr
- Hydralazine 5mg-10mg IV and infusion 5mg/hr
Urgent Delivery
46
Management of haematemesis, including specifics for variceal bleeding
Supportive - O2, airway
Circulation - volume, transfuse Hb < 70 or haemodynamically unstable. inotropes if needed.
Reverse anticoagulation - give Vit K / Platelets / FFP.
TXA
Treatment of underlying cause: endoscopy, surgical
IV PPI
IV ceftriaxone if liver disease
Varices:
IV octreotide 50 mcg bolus of 2mg terlipressin.
Baloon tamponade.
TIPS
47
General acute and chronic fracture complications
Acute complications
soft tissue injury - compartment sydnrome, skin necrosis, rhabdo
nerve: neuropraxia, trasection
vascular: contusion, distal ischaemia, haemorrhage
Infection
Visceral complications
Fat embolism
Iatrogenic - anaesthesia, manipulation, hospitalisation
```
Delayed complications
Union - non, slow, delayed, mal
Traumatic epiphyseal arrest
Joint stiffness, early OA
AVN
Contracture
Chronic regional pain sydnrome
Osteomyelitis
Social - loss of function, mobility, work
```
48
Management of amputated part
Tetanus prophylaxis
IV antibiotics
Care of amputated part
- Wrapped in saline soaked gauze
- Put in a jar
- Put the jar in very cold water, ~ 4 deg
Aim reimplantation < 6 hrs, muscle necrosis at 6 hrs warm ischaemia
49
Back pain red flags
signs/symptoms or definite risk factors for spinal infection
signs/symptoms of spondyloarthritis (night pain, improves with movement)
New or progressive neurological deficit
History of malignancy
Significant trauma
Unexplained weight loss
Elderly, corticosteroid or osteoporosis RFs
50
Indications for angiography in pelvic fractures
Haemodynamically stable, 1-2 units/hr
Positive blush on CT > 1.5 cm
Ongoing pelvic blood loss with other source excluded. Venous bleeding more difficulty.
Contraindications: Require laparotomy
51
Ottawa knee rules
```
age > 55 yrs
Tender head of fibula
Tender patella
Unable to flex to 90 deg
Unable to take 4 steps - immediately and in ED
```
52
Classification of tibial plateau fractures
```
Classification: Schatzker
1-3: lateral tibial plateau with increasing articular depression
1 - fracture with < 4 mm depression
2 - fracture > 4 mm depression
3 - depression only : 3a laterally, 3b medially
4 - medial plateau wedge / compression
5-6: both tibial plateaus
5 wedge
6 tibial metadiaphyseal
```
53
DDx of child with a limp
Foot
Toddlers #
Hip
- transient synovitis (kinder / primary school), good ROM
- Septic arthritis - fever, reduced ROM
- perthes (pre/primary school), moderate ROM ongoing sx at 2-3 weeks.
- SUFE (pre/adolescent), x-ray, limited IR, trethowan's sign (kleins line)
54
Types of blast injury
Primary - direct effect / endothelial dysfunction
Secondary - projectiles
Tertiary - blast wind
Quaternery - burns, asphyxia, toxic inhalation
55
Causes of syncope
Simple: postural / situational (cough, straining)
Carotid sinus sensitivity
Cardiac - tachy/brady, valve, PPM, HCM
Vascular - dissection, subclav steel
Resp - PE
Hypovolaemia - GIT bleed, ectopic, addisonian
Neurological - seizure, SAH, TIA
Psychiatric
Haematological - anaemia
Drugs - angina, diuretic, antihypertensive
56
Organisms causing infective endocarditis
Staph aureus
Strep viridans, strep bovis/mutans
Enterococci
HACEK: haemophilus, aggregatibacter, cardiobacterium, eikenella, kingella
57
Diagnosis of endocarditis
Modified duke criteria. 2 major, 1 major 3 minor, 5 minor
Major
- 2 positive cultures with typical organisms
- endocardial involvement
- echo with IE evidence - intracardiac pass, perivalve abscess
- new valvular regurg
Minor
- Predisposing factor, IVDU or congenital heart disease
- fever > 38
- vascular phenomenon (emboli, infarcts)
- immunological phenomenon (GN, oslers nodes)
- positive cultures
58
Causes and management of antepartum bleeding
Causes
- placental abruption
- placental praevia
- vasa praevia
Placenta > 2 cm from os on US, Sterile Spec exam
CTG
Bloods
Steroids if 23-34 weeks, IM betamethasone 11.4mg
625 units anti-D
Mag sulfate for neuroprotection if < 30 weeks
59
FiO2 provided via various O2 delivery devices
```
2L NP 0.28
4L NP 0.36
6L HM 0.45
10L HM 0.65
15L NRBM 0.6-0.8
ETT and reservoir self inflating BVM 0.98
```
60
Unconscious victim from house fire
Carbon monoxide - COHb, O2 therapy
Cyanide - lactate and AV o2 gap. hydroxyocobalmin
Trauma
Burns
61
Diagnosis of peritonitis in peritoneal dialysis patient
Anorexia, nausea
Fever
Abdominal pain
Cloudy effluent - WCC > 100 cm3 > 50% polymorphs
62
Wells score for DVT and interpretation
1 point
- active cancer
- paralysis / immobilisation
- bedridden for > 3 days c/o surg
- localised deep venous tenderness
- swelling whole leg
- unilateral calf swelling > 3 cm
- Unilateral pillitng oedema
- Collateral superficial veins
- alt diagnosis more likely (-2)
D dimer if <=1, if greater than US
Score 1-2 = mod risk, 17%
63
Signs of limb threatening ishcaemia
```
Reduced sensation
Decreased power
Absent CRT
Cold limb
Severe pain
```
64
Causes of neonatal jaundice
```
Unconjugated
- haemolysis: ABO, rhesus, spherocytosis, G6PD
- sepsis
- RBC breakdown: cepahlhaematoma
- GIT obstruction/ileus: pyloric stenosis
- hypothyroidism
- physiological / breast milk
Conjugated
- biliary atresia
- choledocal cyst
- Metabolic: galactosaemia
```
65
Imaging in appendicitis - sensitivity / specificity
Ultrasound: sensitivity 80-90%, specificity 90-100%
- low sensitivity if perforated
CT: sensitivity 90-95%, specificity 95%
- alternative diagnosis, perforation
MRI: 95% sensitivity, 99% specificity
- consider in pregnancy
66
Possible button battery ingestion <= 12 yrs
Immediate XR
Remove if: oesophageal, magnet coingestion or symptomatic
> 15 mm, age < 6 - X-ray in 4 days and remove
< 15 mm OR > 6 yrs, x-ray in 10-14 days if not passed
67
Possible button battery ingestion > 12 yrs and > 12 mm
Immediate XR
Remove if: oesophageal, magnet coingestion or symptomatic
Observe at home and confirm at 10-14 days if not passed
68
Possible button battery ingestion > 12 yrs and < 12 mm
```
Asymptomatic
Only 1 battery
no magnet ingested
< 12 mm certain
No pre-exisiting oesophageal disease
Patient/caregiver reliable
```
--> DC and confirm at 10-14 days
If not x-ray
69
Management of TENS / SJS
```
Stop offending agent
IV immunoglobulin
Consider immune suppression / plasmapheresis
Skin care
Admission - derm/plastis
analgesia
Antibiotics if infection
```
70
DDx of blistering skin rashes
```
Necrotising fascitis
Disseminated gonococcus
Sunburn
Kawasaki
TSS
Staph scalded skin
Erythema multiforme - SJS - TENS
Pemphygoid, pemphigus
Insect bites
Mustard gas
```
71
DDx of purpura
Palpable
- Polyarteritis nodosa
- HSP
- Infective: Menigococcal, Neisseria gonorrhoea, Staph, enteroviruses, haemorrhagic fevers
- Emboli
Non-palpable
- normal platelets
- - cutaneous: truama, steroids, elderly
- -systemic: uraemia, vWF deficiency, scurvey
- thrombocytopaenia
- - liver disease w/ portal hypertension
- - leukaemia / lymphoma
- Immune: ITP, drugs, infection (HIV)
- Cytotoxic medication, alcohol
72
Management of Gout
NSAID - indomethacin 50 mg TDS
Prednisolone 15-30 mg PO daily until symptoms abate ~ 3-5 days, tapered over 2 weeks
Colchicine 500 mcg stat, and 500 mcg in 1 hr. Max 6mg/4 days. (500 mcg TDS)
73
Arthrocentesis of the knee
medial approach, 1cm inferior to femoral condyle, inferior to patella, anterior to tibial plateau
74
Complaint response
```
Support
Acknowledge
Investigation
Notify / report / document
Respond
Implement
Communicate / educate
Evaluate
```
75
Elements of open disclosure
```
Acknowledgement of adverse event
Expression of regret
Factual explanation
Information about further treatment
Potential consequence
Steps being taken to manage / prevent recurrence
```
76
Differentiate between moderate, severe and critical asthma
moderate - limitation of talking, increased WOB
Severe - mod-marked WOB, accessory muscle and recession, single words. agitated/distressed.
Critical - maximal WOB, recession, exhaustion, silent chest, not talking. confused/drowsy. marked tachycardia.
77
Indications for BiPap in COPD
Moderate to severe dyspnoea with use of accessory muscles
Moderate to severe acidosis and/or hypercapnoea (CO2 > 45)
RR > 25 / min, pH < 7.35, PCO2 > 45
78
Scoring and implication in pneumonia
```
SMART COP
SBP < 90 (2)
Multilobar
Albumin < 3.5 g/L
RR > 25 (<50) or > 30 (> 50)
Tachycardia > 125
Confusion
Oxygen < 95% (<50) or < 90 (>50)
pH < 7.35 (2)
```
5-6 high risk (1:3 risk IVRS) or vasopressor
79
Antibiotic treatment of pneumonia
Mild: amoxycillin or doxycycline
Moderate: benzylpenicillin and doxy
High: ceftriaxone and azithromycin
80
Causes of cavitating lung lesion
```
TB
Malignancy (SCC)
Pneumonia - staph aureus, TB, gram negative, anaerobes, strep (oral)
Hodgkin’s disease (Advanced)
Progressive massive fibrosis
Granulomatosis with polyangiitis
Infected bullae / cysts
Pulmonary infarction
Consolidation surrounding bullae
```
81
Outline set-up for intubation
Patient
Equipment: SOAPME
Team
Plan
82
Post intubation hypoxia
```
Dislodged/disconnected ETT
Obstruction / kinking
Pneumothorax
Equipment
Stacking breaths
```
83
Signs of local anaesthetic toxicity
tinnitus, visual changes, anxiety/agitation
perioral numbness
CNS excitation: agitation, twitch, seizure
Depression: drowsy, coma, apnoea
Diplopia
CVS: HTN, tachy, ventricular arrhythmias
84
Management of local anaesthetic toxicity
```
O2
Benzodiazepines
ACLS
Lipid emulsion (Cardiotoxicity) 20%. 1.5 mls/kg IV, Q5 min x2, then infusion 15 mls/kg/hr for 30-60 min.
- max 12 mls/kg
```
85
Ulnar nerve block
Under FCU at proximal palmar crease 4 mls of 1% (ulnar nerve), then 5 mls of 1% subcutaneously fanwise to dorsal midline (superficial cutaneous branches)
86
Median nerve block
0.5 to 1 cm lateral to palmaris longus, or 0.5 cm medial in FCR. 5 mls of 1% under flexor retinaculum (or paraesthesia (<1cm)
87
Radial nerve block
Extensor carbi radialis, 5-10 mls lignocaine subcutaneous in a ring around radial border to area overlying radial pulse, at the level of proximal palmar crease.
88
Dose of bupivicaine, onset and length of action
2 mg/kg, onset 15-30 min and lasts 7-14 hrs
89
Dose of ropivicaine, onset and length of action
3mg/kg, onset 15-30 min, lasts 7-14 hrs. less cardiotoxic.
90
Dose of prilocaine 0.5%
3 mg/kg
91
How to do ear block
2-3 mls of LA in diamond shape around ear. Inferior to lobule, direct needle medially infiltrating with 2-3 mls, then remove and direct posteriorly. Then superior to pina, direct medially, infiltrate, remove. Direct posteriorly, infiltrate, remove.
92
Escalating management of seizures
midazolam 0.15mg/kg to 10mg x2
Levetiracetam 40 mg/kg IV 15 min
Phenytoin 15-20 mg/kg, < 50 mg/min
30 min - intubation, phenobarb 15-20 mg/kg
PLUS specific treatment depending on cause
93
CSF findings in bacterial, viral and TB meningitis
Bacterial - > 500 polymorphs, low glucose, high protein
Viral - lymphocytes, normal protein, normal glucose
TB - lymphocytes, low glucose, high protein
94
Causes of encephalitis
```
HSV
Mycoplasma pneumonia
EBV, CMV, aborovirus
Immune mediated / post infectious (ADEM)
Anti-NMDA receptor
Limbic encephalitis (paraneoplastic)
```
95
Indications for clot retrieval in ischaemic stroke
Potentially disability stroke (NIHSS >=6)
Pre-stroke mRS <= 1
Occlusion of: ICA, M1, Dominant vertebral vessel, basilar artery or M2 if high NIHSS >10 and ineligible for Thrombolysis with ischaemic penumbra
96
Indications for TPA in ischaemic stroke
Ischaemic stroke in preceeding 4.5 hrs
Clinically significant deficit (NIHSS > 4) suggesting CVA (speech disturbance / neglect / hemiparesis)
CT demonstrating no haemorrhage / non-vascular cause of stroke
Age > 18 yrs
Hospital factors: access to imaging and staff trained to interpret, access to stroke management team with expertise in thrombolysis, pathways / protocols available
And no contraindications
97
Contraindications specific to thrombolysis in stroke
Coma / obtunded with fixed eye deviation and complete hemiplegia
BP > 185/110
Severe neurological impairment, NIHSS > 22
Age > 80
Rapidly improving
Extensive MCA stroke > 1/3 MCA distribution or multilobar
98
LP findings in SAH
70% drop in RBCs - probably traumatic tap
> 10,000 RBC - SAH
> 500 RBC - probably SAH
99
Key Features in guillian barre syndrome & treatment
```
Preceeding infection.
ascending weakness.
LMN lesion (areflexia and weakness)
Autonomic dysfunction
CSF - high protein, low WCC
Normal MRI
Rx - IVIG, respiratory support and plasmaparesis
```
100
Key features and treatment MS
Discrete episodes of neurological symptoms
Cranial - optic neuritis
Peripheral - UMN lesions, bilateral and asymmetrical
paraesthesia
Cerebellar dysfunction
CSF - t lymphocytes and IgG oligoclonal bands
MRI - demyelination, plaques (subcortical and perivenctricular)
Pulse 250-500 mg IV BD methylprednisolone
101
Key features and treatment myaesthenia gravis
```
Ptosis/diplopia, opthalmoplegia.
Bulbar - dysarthria, dysphasgia
worsens through day.
Improves with cold. Antibody test - ACh receptor
Rx - IVIG and plasmapheresis
```
102
Causes of paediatric ataxia
Post-viral acute cerebellar ataxia
Poisoning - anticonvulsant, oils, alcohols
Tumours - posterior fossa
Trauma - NAI, concussion
Metabolic - hypoglycaemia, hyponatraemia, liver failure
Infection - meningitis, labrynthitis/neuronitis
Vascular - CVA, vasculitis
Immune - ADEM
103
Causes of peripheral vertigo
```
BPPV
Vestibular neuronitis
Acute labyrinthitis
Meunière disease
Ototoxicity
VIII nerve lesion - acoustic neuroma
Cerebellopontine angle tumour
Post-traumatic
```
104
Features of peripheral vertigo
```
Acute onset, moderate to severe
Paroxysmal symptoms, positional
Nauseated
Unidirectional, horizontal or rotatory nystagmus which is suppressible and fatigues
No CNS signs or symptoms
```
105
Causes of central vertigo
```
Cerebellar haemorrhage and infarction
Vertebrobasilar insufficiency
Neoplasms
MS
Lateral medullary syndrome
Migranous vertigo
```
106
Features of central vertigo
```
Sudden or gradual onset
Persistent symptoms
Not positional
Vertical or bidirectional nystagmus, which doesn't fatigue
Usually other CNS signs or symptoms
Normal hearing
```
107
In massive transfusion, treatment for platelets < 50
1 adult dose platelets
108
In massive transfusion, treatment for INR > 1.5
FFP 15 mls/kg
109
In massive transfusion, treatment for fibrinogen < 1
Cryoprecipitate 3-4 g
110
Alteration to MTP in setting of severe head injury
Aim SBP 100 (no permissive hypotension)
| Aim Platelets 100
111
Contents of FFP
Clotting factors
Fibrinogen
Factors VIII and IX
112
Contents of Prothrombin Complex Concentrate
Factors II, IX, X
Small amount of VII and V
Heparin (prevents thrombus at injection site)
113
Contents of Cryoprecipitate and dose
Factor VIII
Fibrinogen
Factor XIII
vWF
Dose 1 unit / 10 kg
