Need to know Flashcards
(71 cards)
1
Q
Risks associated with adverse transfusion reactions
A
TACO 1:100 Delayed haemolytic reaction 1:1,000 TRALI 1:5,000 Acute haemolytic reaction, 1:12,000 Anaphylaxis 1:20,000 Bacterial Sepsis 1:40,000 Blood born infection Hep B, 1:600,000 and Hep C / HIV < 1 in 10 million Transfusion associated GVHD - rare --> risk of any above causing mortality, > 1:million
2
Q
Lights criteria for pleural effusion
A
Transudate: - pleural:serum protein <= 0.5 - pleural:serum LDH <= 0.6 - pleural LDH <= 2/3 ULN serum LDH Causes: hypoalbuminaemia (cirrhosis, nephrotic), constrictive pericarditis, CCF
Exudate: - pleural: serum protein > 0.5 - pleural:serum LDH > 0.6 - Pleural LDH > 2/3 ULN serum LDH Causes: Autoimmune, oesophageal rupture, infection (TB, parapneumonic, fungal, empyema), malignancy, pancreatitis, post-CABG, PE.
3
Q
Causes of pleural transudate
A
hypoalbuminaemia (cirrhosis, nephrotic)
constrictive pericarditis
CCF
4
Q
Causes of pleural exudate
A
Autoimmune oesophageal rupture Infection (TB, parapneumonic, fungal, empyema) malignancy pancreatitis post-CABG PE
5
Q
canadian head CT rules
A
Applies to: trauma, GCS > 13, age >= 16, no anticoagulation/bleeding disorder
If high risk features
- GCS < 15 2 hrs after injury
- Suspected open or depressed skull fracture
- Signs of BOS fracture
- Vomiting >= 2 episodes
- age >= 65 yrs
Medium risk:
- amnesia prior to impact >= 30 min
- Dangerous mechanism (peds car, occupant ejected, fall > 3 ft/5 stairs).
6
Q
Signs of posterior MI on ECG
A
V1-V3 - horizontal ST depression - broad / tall R waves, > 30 msec - upright T waves - dominant R wave, R/S ratio > 1 in V2 ST elevation and q waves on V7-9, > 0.5 mm
7
Q
Signs of RV infarction on ECG
A
In inferior STEMI ST elevation in V1 ST elevation III > II ST elevation in V1 + depression V2 ST baseline in V1 and marked depression V2 ST elevation in V3-V6R (V4R)
8
Q
Reversal of anticoagulation with DOACs
A
Rivaroxaban and apixaban
- 3 or 4 factor PCC
- TXA
- Andexanet, 400-800 mg IV bolus then infusion
Dabigatran
- Idarucizumab , human fab fragment - SAS, 5g IV
9
Q
Warfarin reversal guidelines
A
Not bleeding
- INR 4.5-10, observe, or vit K 1-2 mg if high risk
- INR > 10, 3-5 mg vitamin K IV/PO and if high risk then add PCC 15-30 units/kg
Bleeding
Critical: Vit K 5-10 mg IV, PCC 50 units/kg and FFP 150-300 mls (for VII), or FFP 15 mls/kg if no PCC
Clinically significant: Vit K 5-10 mg IV, PCC 35-50 units/kg
Minor and INR > 4.5 or high risk: vit K 1-2 mg
10
Q
Massive transfusion definition
A
> 70 mls/kg (1 blood volume) in 24 hrs, or > 50% in 4 hrs.
Child: > 40mls/kg in 24 hrs (50% BV)
11
Q
Targets in massive transfusion
A
Temp > 35 PH > 7.2 iCa > 1.1 Platelets > 50 APTT < 1.5 INR <= 1.5 Fibrinogen > 1
12
Q
Australian snakes and envenoming syndromes
A
Black snakes - aches - myotoxic
Brown - ground (bleed onto) - coagulopathy
Death adder - breath (resp failure due to weakness) - neurotoxic
Taipan - lie (down) pan ( bleeding into) - neurotoxic and coagulopathy
Tiger - evil - all!
13
Q
DDx LAD
A
LVH LBBB LAFB Pacing Old inferior MI WPW
14
Q
DDx RAD
A
LPFB RVH Lateral MI Lung disease - pulmonary HTN, acute PE VT Hyperkalaemia Sodium channel blockade
15
Q
Parkland formular for fluid replacement in burns
A
4 mls x weight (kg) x % TBSA burnt
1/2 in first 8 hrs
remainder in next 16 hrs
16
Q
PPM problems
A
Failure to pace - lead displacement, insulation break or lead fracture
Failure to capture - electrolytes, drugs, ischaemia, scar tissue, new BBB
Failure to sense - regular pacing despite native rhythm, lead displacement/fracture/insulation break, not sensitie enough
17
Q
Commencement settings for temporary pacing wire
A
Rate 60-80
Output at 2, decrease until loss of capture, then increase to lowest capture x2 + 1
Sensitivity of 1-2 mV, can test
Asynchronous
18
Q
Dialysable toxins
A
Carbamazepine Lithium Metformin Theophylline Toxic alcohols Sodium valproate Salicylate
19
Q
Indications for multi-dose activated charcoal
A
Carbamazepine Colchicine Dapsone Phenobarbitone Quinine Theophylline
20
Q
Indications for whole bowel irrigation
A
Iron overdose > 60 mg/kg SR KCl ingestion > 2.5 mmol/kg SR verapamil / diltiazem ingestion Symptomatic arsenic ingestion, lead Body packer
21
Q
Calculation of osmolar gap and causes
A
Measured osmolality (normal 270-290) - calculated osmolarity
normal -4 to + 10
= 1.86xNa + urea + glucose in mmol/L
causes: lithium, calcium, alcohols, proteins (AAs)
22
Q
Indications for prolonged resuscitation
A
Young person with persistent VF (electrical storm)
Hypothermia
Asthma
Toxicological
Thrombolytic for suspected PE
Pregnancy prior to resuscitative hysterotomy
23
Q
Indications for cessation of CPR
A
ROSC
Pre-existing chronic illness preventing meaningful recovery
Acute illness incompatible with life
No response at 20 min of effective resus - no ROSC, shockable rhythm or reversible causes
24
Q
Predictors of difficult intubation
A
Look externally Evaluate 3/3/2 mouth opening, thyromental, thyrohyoid Mallampati Obstruction / obesity Neck mobility
25
Predictors of difficult BVM
```
Mask seal compromise
Obstruction / obesity
Aged
No teeth
Stiffness - asthma / COPD / pulmonary oedema / pregnancy
```
26
Expected rate of cooling with various techniques in hyperthermia
Ice packs 0.05 deg / min
Immersion in ice bath 0.2 deg / min
Evaporative spraying 0. 3 deg / min
Peritoneal lavage 0.5 deg / min
27
Expected rate of warming with various techniques in hypothermia
Forced air warmer 1.5-2 deg / hr
Warmed IV fluids (40 deg) ant humidified O2 1-2 deg/hr
Pleural lavage (40 deg) ?5 deg/hr
Cardiac bypass 7.5 deg/hr
28
Indicators of unsalvagable patient with hypothermia
```
K >10
Core temp < 6-7 deg
Core temp < 15 with no circulation for 2 hrs
PH < 6.5
Intracardiac thrombus on echo
Severe coagulopathy
```
29
Prognostic factors in drowning
Patient factors: age < 3, elderly, trauma, comorbidities (epilepsy)
Submersion factors: unwitnessed, > 10 min, cold/fresh water
Rescue factors: No resus in 10 min, early EMS
Resus response: resp effort < 15-30 min, no response to 30 min resus, ROSC prior to ED arrival
Arrival to ED: pH < 7.1, fixed dilated pupils, coma on arrival (<20% good outcome), no signs of life on arrival
30
Glaucoma manaement
Acetazolamide 500mg IV
Pilocarpine 2%, 1 drop Q5 min for 15 min then 30 min (pupil constriction)
Timoptol 0.5%, 1 drop Q30-60 min (decreased production aqueous)
Latanoprost 0.005% 1 drop (increaes outflow and decreases IOP)
Laser iridotomy . iridoplasty.
31
Pregnancy failure
Mean sac diameter > 25 mm with no foetal pole
| Visible foetal pole, CRL > 7mm with no FHR
32
BHCG at which gestational sac should be visible
1500 units/L
33
Hard signs of penetrating neck trauma
```
Bubbling from wound
stridor / hoarse voice
Massive haemoptysis
Rapidly expanding / pulsatile haematoma
vascular bruit / thrill
Cerebral ischaemia
Severe haemorrhage / unresponsive shock
```
34
Pleural fluid findings, to determine exudate
Pleural fluid protein: serum > 0.5
Pleural fluid LDH: serum > 0.6
Pleural fluid LDH > 2/3 ULN of serum LDH
35
Management of HR / BP in aortic dissection
IV esmolol 500 mcg/kg over 1 min, then 50 mcg/kg over 4 min, then infusion of 50-200 mcg/kg/min, aim HR 60-80
IV GTN 10 mcg/min increase every 3-5 min, 5-50 mcg/min to SBP 100-120
36
Differentiating causes of hypovolaemic hyponatraemia
Urinary sodium
- low < 20 mmol/L. pre-renal - sweating, vomiting, SBO, third space, burns
- high > 20 mmol/L. renal - RTA, renal failure, addisons, thiazide diuretic, osmotic diuresis
37
Differentiating causes of euvolaemic hyponatraemia
Urinary vs serum osmolarity
Low urine osmolarity. water overload, psychogenic polydipsia, potomania.
High urine osmolarity. SIADH. lung mass, CNS infection/mass, medications.
38
Differentiating causes of hypervolaemic hypernatraemia
Urine sodium
- Low < 20 mmol: CCF, Liver failure, hepatorenal syndrome
- High > 20 mmol: diuretic, renal failure, steroids
39
4 elements of competence
- understand information
- remember information
- utilise information (weigh up)
- communicate a choice
40
Serotonin syndrome
- Spontaneous clonus
- Inducible / occular clonus AND temp > 38 AND agitation/diaphresosi/hypertonia
- Tremor AND hyperreflexia
41
indications for RRT
Oliguria (< 200 mls/12 hrs) or Anuria
Serum urea > 35 mmol/L
Serum Cr > 400 mmol/L
Serum K+ > 6.5 or rapidly rising
Serum sodium < 100 mmol/L or > 160 mmol/L
Pulmonary oedema not responding to diuretics
Severe metabolic acidosis, pH < 7.1
Uraemic syndrome (asterisks, psychosis, myoclonus, seizures, pericarditis)
Overdose with dialysable toxin
42
Dialysable toxins
```
Phenobarbitol
Lithium
Acidosis
Salicylates
Metformin
Alcohols
Theophylline
Valproic Acid
```
43
Multi dose activated charcoal
```
Aminophylline / theophylline
Barbiturates
Carbamazepine / concretion forming drugs (salicylates)
Dapsone
Quinine
```
44
Risk assessment in TCA poisoning
< 5mg/kg minimal symptoms
5-10 mg drowsiness, mild anticholinergic effects
> 10 mg/kg potenital for major toxicity
> 30 mg/kg severe toxicity, pH dependent cardiotoxicity and coma > 24 hrs
QRS > 100 msec predicts seizures
QRS > 160 msec predicts VT
45
Features of Haemolytic Uraemic Syndrome & management
Preceeding Diarrhoea or respiratory infection.
Microangiopathic haemolytic anaemia, thrombocytopaenia and acute kidney injury.
Dialysis for AKI.
Antihypertensives.
Transfuse for anaemia. No platelet transfusion.
Avoid antibiotics (increases toxin release)
46
Thrombotic Thrombocytopaenic Purpura - features & treatment
```
Microangiopathic haemolytic anaemia
THrombocytopaenia
Neurological abnormality
Fever
Renal abnormality
```
Treatment with steroid, anti-platelet, immunosuppression & plasma exchange
47
Treatment of severe / critical asthma (paediatric)
Continuous nebulised salbutamol
Nebulised iptratropium Q20 min 3 doses
Methyprednisolone 1mg/kg
Magnesium sulfate 0.2 mmol/kg over 20 min (to 8mmol)
Aminophylline 10mg/kg IV to 500 mg over 60 min
Adrenaline 10 mg/kg IM
Invasive respiratory support
48
Brugada algorithm
Presence of any = VT
Absence of RS complex in all precordial leads?
RS interval > 100 msec in 1 precordial lead?
AV dissociation?
Morphology criteria for VT present in precordial leads V1/2 and V6?
- RBBB: V1/2 tall L rabbit ear in V1/2, smooth R, or qR
- LBBB: V1/2 - dominant S wave, josephsons sign (notching of S),
49
Athrocentesis findings in Infective, inflammatory and on-inflammatory causes of arthritis
Infective: WCC >50,000 / microL, >85% polymophs, turbid, positive gram stain. Bacterial arthritis.
Inflammatory: WCC 2,000-50,000 / microL, >50% polymorphs, crystals (urate, calcium pyrophosphate). Gout, pseudogout, reactive arthritis
Non-inflammatory: WCC 200-2,000. Variable polymorphs. Microscopy unremarkable.
50
Indications for digoxin immune fab fragment
Acute
- arrest
- arrhythmia
- > 10 mg adult / > 4 mg child
- serum level > 15 nmol / L
- K+ > 5.5
Chronic - clinical features (CNS, CVS, GIT) and elevated level
51
Describe the clinical findings in central cord syndrome, and usual mechanism
Hyperextension injury
Motor: UL > LL, Distal > proximal
Sensory: variable, but usually loss of pain/temp in UL
Sphincters: variable, urinary retention common
52
Describe the mechanism and clinical findings in anterior cord syndrome
Vascular insufficiency or anterior compression (hyperflexion, bony fragments) of anterior spinal artery.
Motor: Loss / weakness below affected level
Sensory: loss pain/temperature (preserved prop/vib)
Sphincters: variable
53
Outline approach to patient complaint
SAIN RICE
Support
Acknowledge complaint, apologise for experience
Investigation of what occured - staff, records
Notify / report / document - units, legal, executive, MDO
Respond - in writing, meet with complainant
Implement - systems to prevent recurrence
Communicate / educate - events via network
Evaluate - response
54
Elements of open disclosure
```
Acknowledgement of adverse event
Expression of regret, sincere
Factual explanation of what happened
Information about further treatment
Potential consequences for patient
Steps taken to manage / prevent recurrence
```
55
Indications for charcoal administration in paracetamol overdose
1. < 2 hrs in cooperative adult
2. < 4 hrs if IR and > 30 g
3. < 4 hrs with SR ingestion
56
Outline approach to staggered ingestion of paracetamol
Assume at earliest time
Commence NAC < 8 hrs if APAP available, otherwise commence empirically
If < 2 hrs from the last ingestion, repeat APAP at 2 hrs
57
Thresholds for supratherapeutic paracetamol ingestions
> 200 mg/kg or 10 g in 24 hrs,
> 500 mg/kg or 30 g massive ingestion
> 300 mg/kg or 12 g in 48 hrs
> theapeutic dose / day for > 48 hrs and symptoms
58
Indications for NAC in SR paracetamol overdose
> 200 mg/kg or 10 g or clinical suspicion
- start NAC. 2 levels 4 hrs apart.
- if > 30 g, double second bag
- if double nomogram, double second bag
< 200mg/kg or 10g.
- 2 concentrations 4 hrs apart, and start NAC if either over nomogram line.
- if intentional, just start, and stop if 2 below threshold
59
Standard NAC infusion for paracetamol overdose
NAC 200 mg/kg oer 4 hrs
| NAC 100 mg/kg over 16 hrs
60
Digoxin toxicity clinical features (Hx/Ex/Ix)
Cardiac
- Atrial tachycardia
- High grade AVB
- Automaticity (VEB)
* regularised AF, bidirectional VT
Neurological
- yellow vision, haloes
- confusion, delirium
GIT
- N&V
- diarrhoea
61
Causes of complete heart block
```
AV node blocking drugs
Hyperkalaemia
Inferior MI
Infiltrative (Sarcoid, amyloid)
Inflammatory (Rheumatic fever, myocarditis)
Autoimmune (SLE)
Cardiac surgery (MVR)
```
62
Scarbosa criteria (modified)
Concordant ST depression > 1 mm in V1-3
Concordant ST elevation > 1 mm in any lead
Excessively discordant STE in any lead (>25% of s wave)
63
Criteria for low risk BRUE
```
No concerning features on history / exam
AND
- > 60 days old
- born > 32 weeks and CGA > 45 weeks
- no CPR by HCP
- first event
- < 1 min
```
64
Radiation exposure and syndrome
> 2 gy: haemotoietic syndrome. pancytopaenia by 3 weeks.
10-15: GIT syndrome. D&V, bloody diarrhoea. associated with radiation pneumonitis, renal failure, liver injury.
15-30: Vascular syndrome. cerebral oedema and vascular collapse.
> 30 Gy: Cerebral syndrome, N&V&D. CVS collapse. death within 48 hrs.
65
Calculation of digoxin fab dose
serum digoxin (ng/ml) x weight (kg) / 100 = number of ampoules
66
Information to recieve when notified of major incident
```
Major incident declared?
Exact location
Type of incident
Hazards
Access
Number of casualties
Emergency services present / needed?
```
67
Preparation for major disaster
```
Space
People
Equipment
Drugs
Other notifications - director / CEO / media / Secuirty
Post-disaster care
```
68
Outline disaster triage
```
SIEVE - on site, to treatment post
Black - not breathing with open airway
Red - high/low RR or CRT > 2 sec
Yellow - normal RR and CRT, not ambulant
Green - ambulant
```
SORT - on site, treatment to hospital
1-4 points per observation HR, RR and GCS
Red / Yellow / Green / Black
In ED: ATS
1: Airway / breathing intervention (OT, ICU)
2: shock (OT, angio, ICU)
3: non-ambulant not shocked. Ward +/- delayed OT.
4: treatment required, non-spinal.
5: observation only, ambulant.
69
Indications for resuscitative thoracostomy
Stab wound to heart with pericardial tamponade
Penetrating chest trauma with signs of life < 10 min
Possibly blunt trauma with evidence of pericardial tamponade
In ED if no perfusion on arrival, or unresponsive due to shock.
70
Causes of priapism
```
Medications
- impotence treatment, intracavernosal PGE
- silendafil
- Antipsychotic, stimulants, lithium, heparin/warfarin, prazocin
Idiopathic
Sickle cell disease
Haematological malignancy
Spinal cord disease
Vasculidities
```
71
Diagnostic criteria for Rheumatic Fever
2 major or 1 major and 2 minor
Major: carditis, chorea, erythema marginatum, subcutaneous nodules or polyarthritis
Minor: Temp > 38, ESR > 30 / CRP > 3, Arthralgia, history of rheumatic fever, long PR
