ACRONYMS
Lactic acidosis LLTIPS
Inhibitors
Inducers
L eukaemia
L ymphoma
T hiamine def
I nfection
P ancreatitis
S mall bowel syndrome
S odium valproate
I soniazid
C holamphenicol
K etoconazole
F luconazole
A lcohol binge
C iprofloxacin
E rythromycin
S ulphonamides
C imetidine
O meprazole
M etronidazole
+ warfarin
C arbemazepine
R ifampicin
A lcoholism
P henytoin
G riseofluvin
P henobarb
S ulphonylureas
+ folic acid
Causes of DIC = VHOTMISS
V ascular
H epatic
O bstetric
T rauma
M alignancy
I mmune
S epsis
S hock / snakes
Vasculitis, large aneurysm
Failure
Amn fl emb, HELLP, abruption, septic abortion
Burns, rhabdo, thermia, fat emb, brain inj, decr O2
AdenoCa, lymphoma, promyelocytic
Transfusion, anaphylaxis
Gram –ive, viral haemorrhagic
ARDS, pancreatitis
Causes of ARDS = VHOTMAST
V ascular
H epatic
O bstetric
T rauma
M OF
A ltitude
S epsis
T ox
fat, clot, air embolism
Failure
Amniotic fluid embolism, eclampsia
Severe HI, multiple #, >8iu blood transfusion in a day
ARF, DIC
HAPE
Pneumonia, pancreatitis, G-ives
Smoke, metals, NO, NH3, chlorine, SO2, aspirin, HC,
paraquat, opioids, cocaine, nitrofurantoin
Causes of pancreatitis: GETSMASHED
G allstones (35-40%)
E TOH
T rauma
S corpian bite / toxin
M umps, EBV, HIV, coxsackie, parasitic
A utoimmune (SLE, Sjogrens, vasculitis)
S teroids
H yperCa / lipids
E RCP (5% risk)
D rugs (5%; sulphonamides, thiazides, valproate)
TTP = FARTN
F ever
A anemia (haemolytic)
R enal failure
T hrombocytopenia
N euro Sx
Enhanced elimination = PAM PACAAT PALAAT
Urinary alkalinisation
P henobarb
A spirin
M ethotrexate
MDAC
P henobarb
A spirin
C olchicine (DECONTAMINATION > RESUS)
A nticonvulsants (carbamazepine, phenytoin, Na valproate)
A mitrip
A manita mushroom
HaemoD
T heophylline
P henobarb
A spirin
L ithium
Anticonvulsants (Na valproate, carbamaz)
A lcohol
T heophylline
CI for thrombolysis = ABC CHAMP
Absolute CI
A ortic dissection / active bleeding
B errycarditis
C NS (ICH ever / ischaemic CVA in past 6m / OT in past 2m)
Relative CI
C oagulopathy / cavitatory lung disease / CPR
H TN (>180 / >110)
A llergy, age >80yrs
M ajor trauma in past 2m
P regnancy / PUD / procedures in past 3w
Simple febrile convulsion = FATGIDS
AGMA: CATMUDPILERS
F ever >38.5
A ge 6m – 5yrs
T ime <15mins
G eneralised 1Y
I ntracranial pathology absent
D eficit absent
S ingle seizure per episode of fever
C O, cyanide
A lcoholic ketoacidosis
T oulene
M etformin, methanol
U reaemia
D KA
P araldehyde, paracetamol OD
I soniazid, iron
L actic acidosis A
Tissue hypoxia
B1
Systemic disorders
B2
Drugs/toxins
C
Hereditary metabolic
E thylene glycol, ETOH XS
R habo
S alicylates, starvation
NAGMA: USEDCARP
U reterostomy
S mall bowel fistula
E xtra Cl
D iarrhoea
KA (resolving)
Iuretics
C arbonic anhydrase inhibitors
A ddisons
R TA
P ancreatic fistula
Metabolic alkalosis: GRORORE
Cl insensitive
Cl sensitive
Normal BP
High BP
Prolonged QRS and QTC: PAACCTT A ntihistamines
A ntimalarials
T ype Ia/c
T CA
C ocaine
C arbamazepine
P henothiazines
Prolonged QRS only: PLAT
P ropanolol
LA
A mantadine
T ype IV
Prolonged QTc only: LMAO AT SS L ithium
M ethadone
A ntipsychotics
O ‘s
A ntibiotics
T ype III / IV
S umatriptan
S SRI
And ethylene glycol!
Incr K
May incr K
Incr K
Incr K with type 4
G I losses
R enal losses
O ther
Post-diuretic
Contraction alkalosis
Post-hypercapnia
CF
R enal losses
Bartter, Gitelman, diuretic
efeeding alklosis
O verdose of base
Milk alkalki, NaHCO3
ther
Severe hypoK/Mg
R enal losses
Liddle, diuretic, RAS, CRF
E ndocrine
Conns, Cushings, steroids
Diphenhydramine
Quinine, chloroquine
Procainamide, quinidine
Chlorprom, stemetil
Diltiazem, verapamil
HaloP, risperidone, quetiapine, droperidol
OP’s, ondansetron, omeprazole
Erythromycin, clarithromycin, tetracycline
Amiodarone, sotalol, Ca ant
Amitriptyline
IMPORTANT TRIALS
CV
ISIS2:
1988; 17,000; aspirin vs SK vs aspirin + SK vs placebo in MI
Aspirin+SK > aspirin / SK
Aspirin = SK
Aspirin alone + SK alone > placebo
3% decr AR mortality, 25% decr RR mortality
ISIS1 + 3: beta-blockers in MI
50% decr infarct size, reinfarct, mortality
30% decr ICH
Decr short term mortality with TL; decr cardiac rupture
Worsens Sx with large infarct / LVF
CLARITY-TIMI / COMMIT: clopidogrel in MI
Improved hospital and 30/7 outcome
CURE: clopidogrel + aspirin vs aspirin in MI
20% decr death / MI / CVA in 3-12/12 in clopidogrel+aspirin
vs aspirin alone
1% incr bleeding rate
SYNERGY: heparin + aspirin vs aspirin in MI
Decr reinfarct / mortality by 33% in heparin+aspirin vs aspirin alone
GUSTO: thrombolysis in MI
5% decr AR mortality
PIOPED: investigation of PE diagnosis
Clinical assessment and VQ scan established diagnosis in only minority of patients
CTPA: 83% sens, 96% spec, 92-96% PPV, 10% inconclusive
VQ:
98% sens, 10% spec,
>50% inconclusive
+ive (13%)
88% likelihood of PE; 96% PPV if mod/high pre-test prob
Intermediate
15-30% likelihood
Low prob
4-12% likelihood
-ive (14%)
<5% likelihood; NPV 96%
NS
NINDS: tPA vs placebo for NIHSS scores / mortality / probability of favourable outcome in CVA
600 patients; multiple centre RCT; industry sponsored; poorly matched
50% treated <90mins; no control over post-TL trt
improved outcome at 3-12/12
13% absolute increase in minimal / no disability
3% decr mortality: 17% mortality tPA (21% placebo)
6% ICH tPA (0.6% placebo) – 50% were fatal
ECASS: tPA vs placebo for TL <6hrs
600 patients; multiple centre RCT; industry sponsored; post-hoc analysis; well matched
tPA no significant improvement in outcomes; increased mortality
27% ICH tPA (17% placebo)
ECASS II: tPA vs placebo for TL <6hrs
800 patients; multiple centre RCT; industry sponsored
No statistically significant change in outcome; increased ICH
ECASS III: tPA vs placebo for TL 3-4.5hrs
Multiple centre RCT; industry sponsored
Better NIHSS score at 90/7 tPA and decr mortality; but incr ICH
CAST + IST: aspirin in CVA prevention post-TIA
20-30% decr risk of CVA
TOX
Salt Lake Study: HBO in CO poisoning
Good study; high FU
Low no. suicides, high no. chronic exposure
Poorly matched groups, corrected for in analysis
20% decr cognitive sequelae at 6/52 and 6/12 (25 vs 45%, 20 vs 38%)
Alfred Study: HBO vs 48hrs 100% O2 in CO poisoning
50% lost to FU; only severely poisoned studied, poor methods
No benefit
ID
Early goal directed therapy (Rivers et al, NEJM, 2001): RCT; severe sepsis
Improved survival 16% compared to control
May not be applicable to Australasia as have lower mortality rates than USA
Endpoint:
CVP 8-12
CVO2 >70%
MAP 65-90
UO >0.5ml/kg/hr
If low MAP / CVP
500ml (10ml/kg) N saline Q5-10minly
+ watch for improved / worsened CV status
If MAP not achieved
Commence NAD + insert CVL/AL
Endpoint:
PWP 15-18
MAP 90-110
HR 80-120
If CO not achieved (ie. CVO2 <70%, UO low, incr lactate) - CONTROVERSIAL
Commence dobutamine (controversial; may decr BP and incr HR)
Aim HCt >30% (transfuse; controversial)
Aim Hb >7
APC in sepsis: 6% decr mortality (controversial)
Use if severe sepsis with dysfunction of >2 organ systems / APACHE >25
24mcg/kg/hr INF for 96hrs
CORTICUS (NEJM, 2008): hydrocortisone in septic shock
No improved survival or reversal of shock, but did speed up reversal of shock in those who did
survive
11% decr mortality if relative adrenal insufficiency
Controversial – recommended if septic shock requiring vasopressors
200-300mg hydrocortisone per day
SAFE study (NEJM 2004): saline vs albumin in ICU in critically ill patients
RCT, double blinded
No significant difference in mortality, survival time, organ dysfunction, duration of mechanical
ventilation / dialysis, hospital / ICU LOS
Decr mortality in albumin in severe sepsis (statistically insignificant)
Incr mortality in albumin in trauma
Dopamine vs NAD in shock (NEJM, 2010)
No significant difference in outcome
Dopamine: Incr adverse events, incr mortality in cardiogenic shock
Low dose dopamine for renal protection (Lancet, 2000)
Not recommended
NAD + dobutamine vs adrenaline in septic shock (Lancet, 2007):
No difference
RS
BiPAP in COPD (Bronchard et al):
Decr mortality; NNT 10
Decr ETT; NNT 5
Decr hospital and ICU LOS
(no effect on mortality when CPAP for CCF)
RESUS
CRASH-2 trial (
2010, The Lancet): tranexamic acid 1g
Large RCT trial of effects of tranexamic acid on death and transfusion requirement in trauma
patients with, or at risk of, significant haemorrhage
Decr death if given <3hrs of trauma (incr risk if given after >3hrs)
CONTROL trial: factor VIIa in blunt trauma
Incr mortality
No improvement of any clinically significant outcomes
5% incr VTE
Only as last resort after control of bleeding obtained
Permissive hypotension: if uncontrolled haem and early intervention can control bleeding
Aim:
SBP 60-80, MAP 40
CI:
Controlled haem, evidence of end organ failure (eg. MI), HI
Unclear effects on mortality and organ failure in long term
ARDS-net:
TV 6ml/kg (decr mortality rate 10%, from 40%  30%)
Permissive hypercapnia (aim pH >7.2 and adequate PaO2)
RR 18-22
PIP <30
Allow mod hypercapnia
Titrate PEEP to FiO2
Elevate head of bed 45deg
Prone ventilation improves oxygenation but no survival benefit
NEJM, 2002
HACA (Hypothermia after Cardiac Arrest,
)
Cooled for 24hrs
At 6/12 Favourable neuro
55% vs 40%
Ability to live independently and work parttime
Death
40% vs 55%
Trend to sepsis, bleeding and pneumonia in hypothermia group
NNT 6-7
Melbourne Study (Bernard et al, NEJM 2002)
Cooled for 12hrs
Good neuro outcome
50% vs 25%
Mortality
50% vs 70%
ILCOR Recommendations (2002)
Discharge to home or rehab
If unconscious (absent response to verbal commands; GCS <6; motor <4)
Initial rhythm VF
Out of hospital ROSC within
<60mins
TESTS AND SCORES
Trauma Score
<12 = serious
GCS
RR
SBP
Revised Trauma Score
GCS
RR
Low score = bad
Cons: poorly predictive of mortality
SBP
CRAMS Score
Circ
Resp
Abdo
<8 = bad
Pros: good for pre-hospital triage
Motor
CRT
Resp effort
Speech
Injury Severity Score
Head+neck
Abdo+pelvis
Chest Face
Extremities
<9 = minor
>25 = severe
>35 = very severe
Cons: doesn’t account for age / co-morbidities; retrospective; bad for penetrating
New Injury Severity Score
Pros: better mortality prediction
Just 3 worst injuries of above
External
CHADS2:
>75yrs
1 for CCF / HTN / Age
/ DM
2 for CVA / TIA / thromboembolism
0 = aspirin
= 2% risk/yr of CVA
1 = aspirin / warfarin
2 = warfarin
= 3% risk
= 4% risk
1.5%/yr ARR 1Y prevention; 2.5%/yr ARR 2Y
20% decr risk CVA
60% RRR
2.5%/yr ARR 1Y prevention, 8.5%/yr ARR 2Y
1%/yr =haemorrhage
3
4
5
6
= 6%
= 8%
= 12%
= 18%
ABCD2 score:
1 for
>60yrs
BP: >140/90
Clinical: speech disturbance
Duration: 10-60mins
Age:
2 for:
unilateral weakness
>60mins
DM
0-3 = 1% 2/7 risk = 15% 1/52 risk
4-5 = 4% 2/7 risk = 20-25% 1/52 risk
6-7 = 8% 2/7 risk = 25-30% 1/52 rsik
= do CT head and carotid USS within 48-72hrs; OP FU
= admit
Stroke screening tools: ROSIER scale, FAST, CPSS, LAPSS, MASS
Stroke assessment scale: NIH: correlates with infarct vol, weighted to ant circulation, allows comparison
over time, measures level of impairment
TIMI risk score
0-1
2
3
4
5
6-7
>0.5mm ST deviation
>2 angina in past day
>3 cardiac RF
>50% prev stenosis
>65yrs
Aspirin in past week
Incr cardiac markers
= 5% risk death / MI / urgent revasc at 2/52
= 8%
= 13%
Intermediate
Early invasive therapy good
= 20%
= 25%
High
= 40%
Pros: not dependent on physiology; validated; applicable to all
Cons: doesn’t weight RF’s; 0 score still has 2% risk
Grace Score
ST changes
Age
Biomarkers
HR
Estimate of in-hospital and 6/12 mortality
SBP
Cr
Killip class
Cardiac arrest
Pros: more precise
Cons: more difficult; RF’s not involved
Duke Criteria 2 major
2x +ive blood culture of typical MO >12hrs apart
Intracardiac mass
Periannular abscess
Partial dehiscence of prosthetic valve
New regurg on echo
Staph aureus, strep bovis
Strep viridians, enterococcus
HACEK
1major, 3 minor IVDU / congenital heart disease
5 minor
T >38
Vascular phenomena (organ emboli, mycotic aneurysm, splinter haem, Janeway)
Immunological phenomena (GN, Osler’s nodes, Roth spots)
+ive blood culture / echo not fitting major criteria
Modified Jones Criteria
2 major Carditis / new murmur
Chorea
Migratory polyarthritis
Erythema marginatum
Subcutaneous nodules
1 major, 2 minor PMH RF
T >38
Incr titre of antistrep ab
Incr ESR / CRP >30
Long PR
Arthralgia
66%
10-30%
60-70%
10%
Uncommon
SMART-COP
S BP <90
M ultilobar
A lb <35
RR
T achy >125
C onfusion
O2
P H <7.35
Predicts deterioration, need for ICU/vasopressors
0-2 = low risk
3-4 = mod risk
5-6 = high risk (33%)
>7 = high risk (50%)
92% sens, 62% spec
CORB
C onfusion
O 2 <90%
R R >30
B P <95
Predicts deterioration, need for ICU/vasopressors
>1 = severe
80% sens, 68% spec
CURB-65
C onfusion
U r >7
R R >30
B P <90
>65yrs
Predicts 30/7 mortality / ICU admission
0 = 0%
0 – 1: can send home
1 = 1%
2: borderline
2 = 7.5%
3 = 20%
4 = 40%
5 = 60%
Pneumonia Severity Index
History NH res, CCF/CVA/CRF, Ca, liver
OE
T, HR >125, RR >30, BP <90
Ix
BSL >14, Hct <30, PaO2 <60, Ur >11, Na <130, pH <7.35
Pleural effusion
Predicts mortality; class I – V; admit class III and over; 30% mortality class V
NYHA CCF:
I
II
III
IV
Sx on abnormal exertion
Sx on ordinary exertion
Sx on less than ordinary exertion
Sx at rest
10%/yr mortality
20%/yr mortality
40-50%/yr mortality
Killip Classification
I
II
III
IV
5% mortality
15-20% mortality
40% mortality
80% mortality
Brugada’s VT criteria
Absent RS in any precordial lead
RS >100 in any precordial lead
AV dissociation (<25% sens)
Wellen’s VT criteria
RBBB
LBBB
Other VT criteria
Well’s Criteria for DVT
No CCF
Bibasal rales + S3
Frank pul oedema
Cardiogenic shock
V1
V6
V1
V6
L sided incr rabbit ear in V1
RS ratio <1
QS wave
RS >60ms
R wave >30ms
RS ratio <1
Any Q wave
QRS >120-140
RBBB + QRS >140
LBBB + QRS >160
Concordance of QRS
LAD/RAD
1 for
-2 for
100% spec
>95% spec
Notched QRS (40% sens, >75% spec)
Fusion beats
Capture beats
Notched downslope of S
20% sens, 90% spec
RF’s
Ca <6/12
Recent POP
/
decr movement
Bedridden >3/7 /
major OT <4/52
Leg
Tender veins
Entire leg swollen
Calf swelling >3cm compared to opposite
Pitting oedema
Collateral superficial veins
alternative diagnosis more likely
0-2 = low risk
>2 = high risk
Well’s Criteria for PE
1 for
haemoptysis
Ca
1.5 for HR >100
Bedridden >3/7 /
PMH
PE
/
3 for
Sx of DVT
PE most likely diagnosis
RED = in PERC
OT <4/52
DVT
0-1 = 3-4% risk
2-6 = 20% risk
7+ = >60% risk
Subjective; extensively validated
Revised Geneva Score
1 for
2 for
>65yrs
haemoptysis; OT/leg # in 1/12; active Ca
3 for
4 for
5 for
HR 75-94; unilat leg pain; prev DVT/PE
Leg pain on palpation / unilat oedema
HR >95
0-2 = 8% risk
4-10 = 28% risk
11+ = 74% risk
More objective; less validated
PERC Criteria
EpiD
Age <50yrs
History No haemoptysis
No OT / trauma in 1/12
PMH
No PMH PE/DVT
DH
No OCP
OE
HR <100
SaO2 >95%
No unilateral leg swelling
Sens 97.5%
Spec 22%
SADPERSONS
PSYCH EXAM
ADDMIS
A ppearance
D isorders of thought
D isorders of perception
M ood and affect
I nsight
S Cognitision
ASA CLASS:
1 = healthy, no medical problems
2 = mild systemic disease
3 = severe systemic disease, but no incapacitating
4 = severe systemic disease that is constant threat to life
5 = moribund, expected to live <24hrs irrespective of operation
E = emergency
SAN FRAN SYNCOPE RULE
History
PMH
OE
Investigation
SOB
PMH CCF
SBP <90 at triage
Not in SR
New ECG changes
Hct <30
1 = 12% serious outcome <1/52; 95% sens, 60% spec; similar to physician judgement but 10% more sens
MMSE
10 points
9 points
5 points
3 points
3 points
Orientation
Language (objects, if and but, paper, close eyes, sentence, pentameter)
Attention + calculation (serial 7’s / world)
Recall (recall registration words)
Registration (3 words, rpt back)
>25 = normal
21-25 = mild
<20 = cognitive impairment
GCS
Eye
1
2
3
4
Verbal 1
None
To pain
To voice
Open spontaneously
None
<9 = severe
Motor
2
3
4
5
1
2
3
4
5
6
Sounds
Inappropriate words
Disorientated
Appropriate
None
Decerebrate (extension)
Decorticate (flexion)
Withdraws
Localises
Obeys commands
SGARBOSSA CRITERIA
Concordant STE >1mm
Discordant STE >5mm
Concordant STD >1mm
OTTAWA ANKLE RULES
Pain near malleoli
Pons
Midbrain
Forebrain
Up Up
Up Down
Down Down
+ inability to WB 4 steps immediately and in ED
Tender post / inf lat / medial malleolus
100% sens, 40% spec; decr XR by 30%
OTTAWA FOOT RULES
Pain in mid-foot
+ inability to WB 4 steps immediately and in ED
Tender base 5th MT and navicular
Pain in knee
+ inability to WB 4 steps immediately and in ED
>55yrs
Tender head of fibula / patella
Active knee flexion <90deg
100% sens, 80% spec
OTTAWA KNEE RULES
100% sens fo significant #, 50% spec; decr XR by 25%
NEXUS CRITERIA
Neuro deficit
ETOH
Xtra injuries
Unconsciouns / decr LOC
Sore on palpation
CANADIAN C SPINE
High risk:
Low risk:
CANADIAN CT HEAD
High risk:
Med risk:
Rule Of Nines
Leg
Sens 99.6%
OLD
>65yrs
NEURO SX
Paraesthesia
MECHANISM: fall >1m / >5 steps / axial load / >100kmph /
rollover / ejection / >55kmph / death at scene / bike
collision / motorized rec vehicle
INJURIES: sig closed HI, neuro Sx, pelvic #, multiple limb #
Rear ended
Sitting in ED
Ambulatory at any time
Delayed neck pain
No tenderness
OLD
NEURO SX
>65yrs
GCS <15 2hrs post
Vomiting >2x
INJURIES
Open / depressed skull #
BSF
MECHANISM: fall >1m / >5 steps / car v ped / ejection
Amnesia >30mins
Adult
18% each
Child 1yr old
13.5% (+0.5% per yr each)
Ranson’s Criteria
Arm
Torso
Head
Perineum
Neck
9% each
18% front, 18% back
9%
1%
1%
On arrival
A ge >55yrs
Same
Same
19% (- 1% per yr)
A ST >250
@ 48hrs
L DH >350-700
B SL >10
W BC >16
P aO2 <60
H ct drop >10%
<2
Ca
U r rise >5
B E >4
E stimated fluid sequestration >6L
0-2 = 1% mortality
3-4 = 15% mortality
Glasgow Scoring System
4-5 = 40% mortality
6-7 = 100% mortality
A ST >200
A lb <32
L DH >600
B SL >10
W BC >15
P aO2 <60
C a <2
U r >15
>3 = severe
Apache Score
Age
Physiology
T, MAP, HR, GCS
pH, Na, K, Cr, AA gradient, PaO2
WBC, Hct
Chronic Health
Chronic organ insufficiency
Immune compromise
ARF
Done at admission only >7 = severe = 11-18% mortality
65% sens, 76% spec
Light’s Criteria: 1+ of
Pleural chol
: serum chol
Pleural protein : serum protein
Pleural LDH
: serum LDH
Pleural chol
Serum alb
- pleural alb
Pleural LDH
Protein
WBC
Exudate
>30
High
>0.3
>0.5
99% sens for exudate
>0.6
65-85% spec
>1.1
>1.2
>2/3 upper limit of normal for serum LDH
Transudate
<30
Low
Complicated parapneumonic effusion/empyema:
pH <7.2 or 0.15-0.3 less than serum
Glu <2.5
LDH >1000
Loculated
Ongoing sepsis despite ABx
Empyema
Turbid with WCC >1000
MO on gram stain
Transudate
Increased hydrostatic pressure
CHF
Constrictive pericarditis
SVC obstruction
Decreased oncotic pressure
Cirrhosis
Nephrotic syndrome
Hypoalbuminemia
Iatrogenic / other
Peritoneal dialysis
Exudate
Malignancy – primary or metastatic; 38%
lung, 17% breast
Infection
Pneumonia
Viral, fungal, mycobacterial, parasitic
Contiguous infection
PE (80%)
Connective tissue diseases
SLE, RA
Inflammation
Uremia
Pancreatitis
Sarcoidosis
Hemothorax
Iatrogenic / other
Post-cardiac surgery
Post-radiotherapy
Drugs – amiodarone
“Classic” exudates that can be transudates
Malignancy
PE (20%)
Sarcoidosis
Hypothyroidism
Severity of Asthma
Severity of COPD
Mild
PEFR, FEV1 >75%
Mod
PEFR, FEV1 >50-75%
Severe PEFR, FEV1 <50%
Extremis Can’t do
SaO2 >95%
SaO2 90-95%
SaO2 <90%
SaO2 <90%
Mild
FEV1 <80%
Mod
FEV1 <60%
Severe FEV1 <40%
DRUG DOSES I FORGET
O+G
Tocolysis:
Salbutamol 100mcg/hr and increase until contractions stop
Nifedipine 20mg stat  rpt Q30min if ongoing  20mg TDS
MgSO4 20mmol over 30mins
GTN
CI: >34/40, fetal distress, placental abruption, infection, pre-eclampsia
Delay delivery by 24-48hrs in 80%
HR 100-120
HR >120
HR >140/low
Phrases
Words
Can’t do
Betamethasone 11.4mg IM Q24h x2; if <34/40; decr risk of ARDS by 50%
AntiD:
250iu if <13/40, 625iu IM if >13/40
Oxytoxcin 10iu IV stat  40iu over 4hrs or Ergometrine 250-500mcg IV/IM
Misoprostol 500-1000mcg PR or
Intramyometrial 250-500mcg PGF2a
PPH
MgSO4 in eclampsia:
40mmol over 15mins
 20mmol rpt x2 Q15min if seizing
 10-30mmol/hr INF
Monitor Mg levels and for SE’s (lethargy, decr reflexes, flushing)
CaGlu is antidote
BP:
Hydralazine 5-10mg IV over 5-10mins  rpt Q20min
Nifedipine:
10mg PO
 rpt Q30min
Labetalol
20mg  40mg  80mg  to max 200mg
Methylodopa:
Nitroprusside:
PID:
Sexy:
Ceftriaxone 250mg IM stat
Azithromycin 1g PO single dose
Metronidazole 400mg BD 2/52
Severe: Ampicillin 2g IV Q6h IV
Gentamicin 5mg/kg OD IV
Metronidazole 500mg BD IV
OR
 5-60mg/hr INF
 10mg PO Q4hrly
 1-2mg/hr INF
 250mg PO Q6h
 0.1-5mcg/kg/min INF
(clinda if penicillin allergy)
Doxycycline 100mg BD 2/52
(roxy if BF)
TOX
Toxic doses
ACEi
Can have 2-3x dose and it’s fine
ETOH
2-5g/kg  coma
>4mmol/L  0 order kinetics
Withdrawal:
5-10mg PO
10-20mg PO
5mg IV
6-8hrly
1-2hrly
stat
Rpt up to 20mg in 30mins
Then Q30minly
Thiamine 500mg IV
Ethylene
Meths
Wernickes
1ml/kg lethal
ETOH if >3mmol/L
ETOH 1g/kg in 5% dex  150mg/kg/hr
Aim ETOH 20-30mmol/L / 100-150mg/dL
Haemodialysis if >4-8mmol/L (until <3mmol/L)
CNS  CV  renal
Pyridoxine 100mg IV
Thiamine 100mg IV
NaHCO3
0.5-1ml/kg lethal
Most potent cause of incr OG
ETOH as above until <6mmol/L
Haemodialysis if >15mmol/L
Pyridoxine and thiamine as above
Iso
+ folate 50mg IV
4ml/kg  coma
Incr OG as above, but minimal AGMA despite high ketosis
Haemodialysis if >65mmol/L
ETOH not used
Carbamazepine Delayed onset 2Y to anticholinergic
Na blockade SO TREAT AS TCA OD
Charcoal, MDAC, NaHCO3 (cardiotoxicity), haemodialysis
Na val
>200mg/kg  coma
Blood probs: decr plt/WBC (BM failure) decr BSL/Ca/phos
incr NH/LFT (liver failure) incr Na/MetHb, AGMA
Charcoal, MDAC, WBI if SR, haemodialysis (>1-1.5g/L)
Phenytoin
100mg/kg  risk of coma
Na blockade (IV)
Charcoal, MDAC
Type I antihis
Anticholinergic, anti adrenergic, anti serotonin, Na and K blockade
NaHCO3, MgSO4, inotropes, benzos for seizures
Olanzapine
>300mg  coma
Anticholinergic, anti adrenergic
Anticholinergic, seizures, agranulocytosis, myocarditis
>3g  severe
Na and K blockade, seizures
Anticholinergic, Na and K blockade, anti serotonin, EPSE
Clozapine
Quetiapine
Risperidone
Chlorprom
Haloperidol
Thioridazine
Na channel
>5g  severe
Anticholinergic, EPSE, seizures
Na and K blockade, EPSE, seizures
Anticholinergic, Na and K blockade (severe)
Citalopram, venlafaxine
Quetiapine, haloperidol
Propanolol
Risperidone, thioridazine
Aspirin
>300mg/kg  severe
>500mg/kg  fatal
Charcoal, MDAC, WBI if SR
NaHCO3 if symptomatic / level > 2.2 / pH <7.1
HaemoD if can’t UA / UA doesn’t work / level >4 despite trt / level >4 chronic / level > 6
acute / severe
Propanolol
As per TCA
Verapamil
Nifedipine
>15mg/kg toxic HyperG, hypoK, ketoacidosis, lactic acidosis, AGMA
>2mg/kg toxic
TCA
>10mg/kg
HypoG, hyperK
Olanzapine
40-100mg mod
Quetiapine
Chlorprom
Na valproate
Carbamazepine 20-50mg/kg mod
>300mg coma
>3g severe
>5g severe
400-1000mg/kg severe
>50mg/kg severe
Aspirin
150-300mg/kg mod
>300mg/kg severe
Colchicine
Paraquat
Isoniazid
>0.5mg/kg mod
>0.8mg/kg severe
20-40mg/kg death in 5/7-wks
>40mg/kg death in 1-5/7
>50mg/kg death in <3/7
>10g
Fe
Li
20-60mg/kg mod
>40mg/kg
Ethylene glycol
Meths
Isopropanol
2ml/kg
30ml of 40%
2.5ml/kg of 70%
Propanolol
Digoxin
Diltiazem
Verapamil
>1g
>10mg (>4mg in children)
5mg/kg (>10tabs in adults, >2 tabs in children)
16mg/kg (>10tabs in adults, >2tabs in children)
Theophylline
>110mmol/l
60-120mg/kg severe
>1g/kg MOF
>15g fatal
>120mg/kg lethal
Trt:
Syrup of ipecac 15-30ml
Gastric lavage: 200ml (10ml/kg) warm water
Charcoal: 25-50g (0.5-1g/kg)
WBI: 2L/hr (25ml/kg/hr)
Intralipid: 1ml/kg 20% over 1min  10ml/hr INF
MDAC: 50g (1g/kg) PO  25g (0.5g/kg) Q2h
Urinary alkalinisation: 1mmol/kg NaHCO3 IV bolus  2.5-25mmol/hr
OP
Pralidoxime 1-2g in 100ml N saline slow IV over 15mins  0.5-1g/hr
Endpoint: plasma cholinesterase >10%
Atropine 1-2mg  double dose Q2-3min  until dry secretions
Fe
Desferrioxamine 5-15mg/kg/hr (can cause hypotension)
Indication: >90mmol/L, 60mmol/L + Sx, severe toxicity
Endpoint: Sx gone, Fe normal, AGMA normal, urine normal
Cy
Hydroxycobalamin 5g in 100ml N saline over 15mins  rpt if no improvement
Endpoint: improved LOC, CV status, metabolic acidosis
Safe
Dicobalt EDTA 300mg in 20ml dex over 1-5mins  rpt if no improvement
Endpoint: as above
Bad SE’s esp if not poisoned
Amyl nitrite 300mg over 2-3mins INH
Na thiosulphate 12.5g IV over 10mins  rpt if needed
Endpoint: as above
Safe
Lead
Succimer 10mg/kg PO TDS
Dimercaprol 3-4mg/kg IM Q4h
Na Ca EDTA 25-75mg/kg
Isoniazid
Pyridoxime 5g IV over 3-5mins (or same dose as isoniazid)  rpt Q15min until seizures
Controlled
Morphine
Naloxone
MetHb
Methylene blue 1-2mg/kg IV over 5mins  rpt at 1hr if needed
Digibind:
Acute:
2/3 of wake up dose INF per hour
DOA 20-60mins
mg ingested x 0.8 x 2 = no ampoules
Chronic: (mmol/L level x kg) / 100 = no ampoules
CaGlu in HFl poisoning:
?NG????
60ml 10% IV if systemic
10ml 10% up to 40ml with KY TOP Q15min then 6x/day
0.5-1ml/cm 10% SC (not in hands / feet) – not diluted
N saline
10ml 10% with 40ml
+ heparin IV regional - large
10ml 10% with 40ml N saline IA regional over 4hrs (gold standard)
1.5ml 2.5% in N saline NEB
Ca antagonist poisoning: 60ml 10% CaGlu over 15mins  20ml/hr INF Endpoint: Ca >2
5mg glucagon stat
 1-5mg/hr
1iu/kg actrapid in 50ml 50% dex  0.5-1iu/kg/hr actrapid in 10% dex
1ml/kg 20% intralipid over 1min  0.5ml/kg/min INF
Dystonic reaction (EPSE) DB
Benztropine 1-2mg IV  rpt at 15mins if needed  1mg PO TDS
SS
SC
Cyproheptadine 8mg PO TDS
Chlorpromazine 50-100mg IV
NMS
NB
Bromocriptine 2.5mg PO TDS
Dantrolene
MH
MD
Dantrolene 1mg/kg IV  1mg/kg QID IV
Fe OD stages
0-3hrs  3-12hrs  12-48hrs  2-5/7  weeks
GI
Variceal haem:
Octreotide: 50mcg stat IV  50mcg/hr INF for 48hrs
Terlipressin: 2mg IV Q6h
Gastro:
Paedialyte 25ml/kg/hr for 4hrs
Liver failure:
Mannitol 0.3-0.4g/kg
Lactulose 20g PO / 300ml PR
Appendicitis
1g Ampicillin QID + 5mg/kg gentamicin OD + metronidazole
Cholecystitis
1g ampicillin QID + 5mg/kg gentamicin OD (+ metronidazole if gallstones)
Gastro
Norfloxacin 400mg (10mg/kg) PO BD 5/7 – E coli, Yersinia, salmonella, shigella
Doxycycline – cholera
Metronidazole 400mg (10mg/kg) PO TID 7-10/7 – C diff, giardia
Vancomycin 125-250mg PO QID 10/7 – severe C diff
Erythromycin 500mg (10mg/kg) PO QID 5/7 – campylobacter
H pylori
Pantoprazole 40mg BD + amoxicillin 1g BD for 5/7
 pantoprazole 40mg BD + amox + clarithromycin 500mg BD for 5/7
SBP
Ceftriaxone 2g IV OD / cefotaxime 2g IV TDS
Ceftazadime / cefazolin / vanc intraperitoneal
RS
Asthma
Salbutamol
MgSO4
AminoP
10mcg/kg (500mcg) over 2mins  rpt at 10mins  1-20mcg/kg/min
25-50mg/kg IV over 20mins
6-10mg/kg (500mg) over 1hr  0.5-1mg/kg/hr infusion
CV
Esmolol 500mcg/kg bolus  50-100mcg/kg/min infusion (thyroid storm)
HTN:
GTN 1-20mcg/min  titrated up 5mcg ever 5mins  max 200mcg/min
Labetalol 10-20mg  40mg  80mg  1-10mg/hr infusion
Esmolol 500mcg/kg bolus  50mcg/kg/min titrated to max 300mcg/kg/min
Na nitroprusside 0.1-10mcg/kg/min
Hydralazine 5-10mg IV over 5-10mins  5mg/hr INF
AF:
Amiodarone 2-5mg/kg over 10mins
Flecainide 2mg/kg over 30mins  200-300mg PO
Digoxin 500mcg IV  250mcg Q4-6h  up to 250mcg/day
Verapamil 1mg  rpt to 10mg IV
Metoprolol 5-10mg over 2mins
MI
Aspirin: 300mg
Clopidogrel: 300mg for TL, 600mg for PCI
UFH: 60Iiu/kg  12iu/kg/hr INF aiming APTT 1.5-4x normal
LMWH: 0.75-1mg/kg SC BD (give 30mg IV bolus if <75yrs)
Metoprolol: 50mg PO BD
Reteplase: 10iu IV over 2mins  2nd dose 30mins later
SK: 1.5million IU over 1hr
PE:
UFH: 80iu/kg IV  18iu/kg/hr INF
LMWH: 1mg/kg SC BD
r-tPA: 10mg IV bolus  90mg IV over 2hrs
SK: 250,000iu IV over 30mins  100,000iu/hr for 24hrs
IE:
ampicillin 2g IV Q4h
Fluclox 2g IV Q4h (not needed if subacute)
Gent 5mg/kg IV OD
METHB
CYANIDE
50% reversion in 24hrs, 90% in 48hrs
60% reversion in 3hrs, 80% in 8hrs
If prosthetic / IVDU:
ceftriaxone + vanc + gent
RF:
penicillin 10mg/kg BD for 10/7
SVT:
adenosine 6, 12, 18 (0.1mg/kg, 0.2mg/kg, 0.3mg/kg); reverts 90%; 15% recur
Verapamil 5mg IV slowly; 80% reversion, 95% with 10mg
Flecainide 2mg/kg IV over 30-45mins
TdP:
20mmol MgSO4 over 1-2mins  10-20mmol/hr
VT:
Amiodarone 150mg IV over 5-10mins  600mg/24hrs
Procainamide 100mg IV  50mg/min until reversion
Sotalol 1.5mg/kg over 3mins
Lignocaine 1.5mg/kg IV over 5mins
Product
Dose
Effect
Rbc
2u (15ml/kg)
Hb 20g/l, Hct 6%
Plt (single)
1u (5ml/kg)
Plt 50,000/mcl
FFP
4u (15ml/kg)
1 unit = 3-5%
Cryoppt
10u (1u/5kg)
Fibrinogen 75mg/dL
30% effective in 1hr
75% effective
65% effective
20-30% effective
NS
Seizure: midaz 0.15mg/kg IV/IN/IM
phenytoin 18mg/kg over 30mins
Phenobarb 18mg/kg over 30mins
Levetiracetam 20mg/kg
Na valproate 20mg/kg over 3-5mins
Thiopental 2-5mg/kg  2-5mg/kg/hr
Migraine:
paracetamol, nsaid, aspirin
Maxalon, chlorprom, stemetil
sumitrip
chlorprom
Stemetil
Maxalon 1
Droperidol
Sumitriptan
12.5-25mg IV
Effective in 85%
SE: decr BP, sedation
12.5mg IV
Effective in 80%
SE: phlebitis, akthesia
10mg IV
70-80% effective
2.5mg IV slow
80-100% effective
SE: QT prolongation
100mg PO / 6mg SC
60-75% effective; use in mod-severe
CI: vascular disease, preg, HTN, MAOI
SE: MI, HTN, arrhythmia, chest pressure, dizziness
Dihydroergotamine: 1mg IV over 3mins Q8h
85% effective
CI: preg, sepsis, vascular disease, HTN
SE: vasoC, ischaemia
Lignocaine:
Prilocaine:
Bupivacaine:
EMLA:
AnGEL cream:
TAC:
LAT/ALA:
DOA 40mins (2-5hrs with adrenaline)
5mg/kg plain, 7mg/kg with adrenaline
Use phentolamine to reverse adrenaline effect
Toxicity: dizziness, tinnitus, perioral tingling, decr LOC, agitation, nystagmus, muscle
twitches, seizures, decr BP, arrhythmia
6mg/kg plain, 8mg/kg with adrenaline; 3mg/kg for Bier’s block
DOA 6hrs
2mg/kg plain, 3mg/kg with adrenaline
SE: most cardiotoxic
prilocaine + lignocaine; onset 45mins; effective in 65% children
SE: local allergy 5%; vasoC; CI <6/12 as systemic absorption + risk of MetHb
amethocaine; onset 20mins
SE: local reaction 15%
tetracaine adrenaline cocaine
SE: less effective <4yrs; CI’ed in places where adrenaline CI’ed; toxicity if used on MM’s (so
use lower dose)
lignocaine + adrenaline + tetracaine; cheap; as effective as TAC; less toxic; onset 2030mins
Thrombolysis for CVA:
tPA 0.9mg/kg 10% as bolus, 90% over 60mins
GBS
IVIG 2g/kg for 5/7
MG
Crisis
Trt
Edrophonium 1  1  2mg IV slow push
Neostigmine 0.5-2mg IV
Pyridostigmine 60-90mg PO Q4h
Pred 100mg/day
ENVIRONMENTAL
AMS/HACE:
HAPE:
Acetazolamide 250mg PO BD
Dexamethasone 8mg stat  4mg Q6h PO/IM/IV
Nifedipine 10mg SL stat  20-30mg SR BD
ORTHO
Septic arthritis:
2g IV fluclox QID
1.2g IV penicillin QID
+ gent if <6yrs / IVDU
Bier’s block
3mg/kg 0.5% prilocaine
Inflate cuff 100mmHg over SBP
ID
Same dose prophylaxis
4mg PO BD for prophylaxis
Same dose prophylaxis
Ondansetron
0.15mg/kg IV/PO
Decr LOS, IV use, vomiting, hospitalization
No effect on readmission
Herpes simplex: Acyclovir 200mg 5x/day for 5/7 or 400mg TDS
Herpes zoster: Acyclovir 400mg 5x/day for 10/7
Neonatal / encephalitis: 10mg/kg IV TDS for 2/52
Kawasaki disease:
IVIG 2g/kg over 12hrs
Aspirin 30-50mg/kg/day until fever gone  3-5mg/kg OD for 6-8/52
OM
Amox /aug 15-25mg/kg TDS PO
Cefaclor 10mg/kg QID PO
Epiglottitis
Ceftriaxone 25mg/kg for 5/7 (+/- vanc)
Ludwig’s angina Benpen 1.2g IV Q6hr or Clinda 450mg IV Q8h
Metronidazole 500mg IV BD
Nec fasc
Meropenem 1g IV TDS + clindamycin
Fournier’s
Ceftriaxone 2g IV + metronidazole 500mg IV + gentamicin 5mg/kg IV
Meningitis
10mg (0.2mg/kg) dexamethasone IV Q6h for 4/7 within 1hr of ABx
 halves incidence of audio/neuro complications
 decr risk mortality in adults
Rifampicin 10mg/kg BD x4 for contact prophylaxis / ceftriaxone IM / cipro
Brain abscess
Fluclox 50mg/kg Q4h + cefotaxime 50mg/kg QID + metronidazole 7.5mg/kg TDS
<3/12
Unknown source
>3/12
Unknown source
<3/12
Meningitis
>3/12
Meningitis
Adult
Meningitis
<3/12
Pneumonia
>3/12
Amoxicillin 50mg/kg QID (covers listeria and Grp B strep in <3/12)
+ cefotaxime 100mg/kg stat  50mg/kg QID
or ceftriaxone 100mg/kg IM if no IV access
+/- 10-20mg/kg acyclovir TDS
Cefotaxime 100mg/kg stat  50mg/kg QID
Amoxicillin 50mg/kg QID
+ cefotaxime 100mg/kg stat  50mg/kg QID
or ceftriaxone 100mg/kg IM if no IV access
Cefotaxime 100mg/kg stat  50mg/kg QID
If suspect pneumococcus: vancomycin 12.5mg/kg QID
If suspect listeria: keep amoxicillin
Ceftriaxone 2g + benpen 1.8g
Amoxicillin 50mg/kg QID
+ cefotaxime 100mg/kg stat  50mg/kg QID
or ceftriaxone 100mg/kg IM if no IV access
Pneumonia
Amoxicillin 30-50mg/kg TDS
Well pneumoniae
Amoxicillin 30mg/kg TDS PO 5-7/7
Complicated pneumonia Augmentin 30mg/kg TDS (or cefuroxime 30mg/kg TDS)
Unwell pneumonia
Fluclox 50mg/kg QID
+ cefotaxime 50mg/kg QID or clindamycin
Atypical pneumonia
Roxithromycin 4mg/kg PO BD
<3/12
UTI
>3/12
UTI
Amoxicillin 50mg/kg QID
+ gentamicin 5-7.5mg/kg OD (if CNS not excluded, use cefotaxime)
Gentamicin 5-7.5mg/kg OD (or cefuroxime)
If well, ceftriaxone then discharge on augmentin
Gastro Na <120
Na 120-150
Na 150-160
Na >160
Per stool
Per vomit
NG rehydration
3% saline at 1ml/kg/hr
0.45% saline + 2.5% dex over 24hrs
0.45% saline + 2.5% dex over 48hrs
0.45% saline + 2.5% dex over 72hrs
10ml/kg
2ml/kg
25ml/kg/hr (or 100ml/kg over 4hrs)
or
5ml/min
ENDOCRINE
DKA
1L N saline  1L over 1hr  1L over 2hrs  1L over 4hrs  1L over 10hrs
Change to 0.45% saline + 5% dex once BSL <15
Aim decr glu by 5/hr, osm by 1-2/hr
Add KCl once K <5 and UO – 10mmol/hr if K 4-5, 30 if 3-4, 40 if <3
If BSL decreasing too fast, used 0.45% saline + 10% dex
Actrapid 0.1iu/kg/hr (max 6iu/hr)  0.05iu/kg/hr once BSL <12
NaHCO3 if pH <7, HCO3 <5, severe hyperK
0.5-1g/kg mannitol if cerebral oedema
5-10ml/kg 3% saline over 30mins if cerebral oedema
Thyroid storm
Esmolol 500mcg/kg  50mcg/kg/min infusion (if concern of COPD/CCF)
Propanolol 0.5-1mg/min to max 10mg
Propylthiouracil 900-1200mg PO loading  300mg/day
Hydrocortisone 100mg IV
GU
Priapism
Terbutaline
Pseudoephedrine
Adrenaline 1:100,000
5-10mg PO
60-120mg PO
2-3ml
500mcg SC
METABOLIC
HyperK
Salbutamol
5mg nebs rpt
Ca resonium
15-30g PO Q4-6h
10iu actrapid in 50mls 50% dex
NaHCO3
1mmol/kg over 15-3mins
Ca Glu
10-20ml of 10% over 5mins
Hypertonic (3%) saline
Indication:
Endpoint:
Onset 15-30mins
Onset 1-2hrs
Onset 15-30mins
Onset 5-30mins
Onset 1-3mins
DOA 2-4hrs
DOA 4-6hrs
DOA 2-4hr
DOA 1-2hrs
DOA 30-60mins
25-100ml/hr (1-2ml/kg/hr) via CVL
Coma, seizure, decr LOC
Na >125 / Sx resolved
RESUS
Cooling
32-34deg for 12-24hrs
 passively rewarm over 8hrs at 0.25-0.5deg/hr
30ml/kg 4deg N saline over 30mins
Paeds resus
Adrenaline
Amiodarone
MgSO4
NaHCO3
Atropine
Sux
Naloxone
10mcg/kg including in neonates
5mg/kg
0.1-0.2mmol/kg
1mmol/kg
20mcg/kg (min 100mcg, max 1mg)
Neonate: 3mg/kg; child: 2mg/kg
0.1mg/kg
NUMBERS I FORGET
RESUS
Cardiac arrest:
no CPR: no long term survival if time to shock >8mins
CPR: no long term survival if time to shock >12mins
Defib: 95% success if <30secs; 25% success if 2mins
Out of hospital: 35% survive to hospital, 5% survive to discharge
In ED: 70% survival
ETCO2 is 5 less than arterial; correlates well with coronary perfusion p and survival from cardiac arrest; if
<10mmHg, survival unlikely
Cardioversion: 0.8% risk of VF with sync cardioversion; 15% risk of asystole with VF
Propofol
Cons
Pros
Ketamine
Cons
CI
Pros
NO
Cons
CI
Pros
Sux
CI
Cons
Thio
Cons
resp depression in 50-60%
Apnoea in up to 20%
Ventilation needed in 1.5% (intubation in 0.02%)
SBP drop by >20 in 15%
Pain on injection
No analgesia
Myoclonic jerks + hypertonicity (rare)
Propofol-infusion syndrome (rare)
Onset 20secs; offset 9mins
Amnesia, bronchoD, anticonvulsant, antiemetic
HTN, incr HR
Salivation, bronchorrhoea, tearing
Laryngospasm 1-2.5%
Transient resp dep if rapid IV admin
Vomiting 8%
Incr ICP
Movement; ataxia during recovery
Dysphoric and emergence phenomena
URTI, LRTI, CF, <3/12, incr ICP, glaucoma, penetrating eye inj, HTN , CCF,
aneurysm, porphyria, thyrotoxicosis, IHD
Catatonia, amnesia, analgesia
Preserveation of resp and airway reflexes
BronchoD
Onset 40secs (8mins IM); offset 10mins (30mins IM)
Little sedation
Onset 5mins; rapid offset
Vomiting 5-10%
Dysphoria 1%
Apnoea 1-2% children <2yrs – resolves when stop gas
Dizziness
Mild CV depressant, pul vasoC
Pneumothorax, bowel obstruction, severe, HI, severe COPD, decompression
illness, recent drive, FiO2 >0.5 needed; intoxicated; decr LOC; prolonged use in
pregnancy
No resp depression
Anxiolysis; analgesia
Burns (9-66 days from inj, if >20% TBSA)
Neuro conditions (10/7 – 6/12 from SC inj, UMN lesion, peri nerve inj, peri
neuropathy, tetanus, muscular dystrophy, CVA)
Congenital neuropathy
Crush inj
Malignant hyperthermia
Incr IGp, IOp, ICP
Muscle fasciculations
HyperK (3-5mins after injection; lasts 10-15mins; by <1)
No analgesia
Pros
Etomidate
Cons
Pros
Fentanyl
Cons
Pros
Hypotension, arrhythmias
Apnoea, trismus
Phlebitis, emergence delirium
Amnesia, anticonvulsant
Onset 40secs; offset 10-30mins
No analgesia
Myoclonus in 20%
Vomiting
Pain on admin
Resp depression
Emergence phenomena
Adrenocortical suppression and seizures if infusion
No CV depression
Onset 15secs, offset 10mins
Chest wall rigidity if >5mcg/kg
Hypotension if BP maintained by sympathetic tone
Decr HR, resp depression
Onset <1min; offset 30-60mins
Less hypotensive as no histamine release
Analgesia
PAEDS
Paediatric Formulae
Weight (>1y)
(Age + 4) x2
Weight (<1y)
[Age (months) + 9] / 2
Age/4 + 4
Neonate 3mm
ETT
6/12 3.5mm
12/12 4mm
Age/2 + 12
to lips
Age/2 + 15
to nose
ETT length
Neonate
10cm
6-12/12 12cm
(Age x 2) + 85
BP
Neonate = 60mmHg
Infants 20/min
Ventilation rate
1-8y 15/min
>8y 12/min
Defib
4J/kg
Cardioversion
0.5J/kg, 1J/kg, 2J/kg
NG and IDC
2 x ETT
Chest tube
4 x ETT or 2 x NG
Bronchiolitis
RSV in 40-70%
Adenovirus rare but causes more severe disease
Rapid Ag test 85% sens, 99% spec
40% are admitted
Croup
Parainfluenza I 50%
CHANGES IN ELDERLY
15% decr TBW, 40% decr ECF, decr CI, incr SVR, decr ability to incr HR
Decr muscle, incr fat, decr plasma proteins, decr bone density
Decr pul compliance, incr diaphragmatic breathing
Decr GFR
Decr 1st pass, decr p450, decr GI motility and gastric acid secretion
Decr immunity
STATISTICS
Precision
False negative
False positive
Sens
Spec
Accuracy
PPV
NPV
Measure of accuracy of test
FN = 1 – sens
FP = 1 – spec
TP / (TP + FN)
TP rate = fraction of people known to have disease who test positive
TN / (TN + FP)
TN rate = fraction of people known to be disease free who test negative
(TP + TN) / N
Proportion of all test results that are correct (sens and spec)
TP / (TP + FP)
The probability a positive test actually signifies presence of disease
TN / (TN + FP)
The probability that a disease will not be present if the test is negative
NS
Reflexes:
CVA:
75%
C5-6
C7-8
C8
L3-4
L5-S1
S1
Biceps
Triceps
Finger
Knee
Ankle
Plantar
50% unknown
80% anterior
25% lacunar
20% posterior
20% embolic
80% MCA territory
5% atherosclerotic
2% dissection (10-25% if young/middle aged)
10% mortality
Thrombolysis <3hrs (<6-12hrs in MI)
NIHSS 4-25 for TL; <1/3 MCA involvement; plt <100; PT <15; <80yrs
2% decr mortality if <90mins; benefits at 3-12/12; NNT 8
3% risk of death from TL
BP >220/120
Trt
(BP >185/110 if for TL)
Aim 10-15% decr in 24hrs
ICH:
25%
50% ICH, 50% SAH
80-90% 1Y: putamen > thalamus > pons > cerebellum, brainstem, BG; central on CT
10-20% 2Y: peripheral on CT
40% mortality
OT if
<1cm from surface + <60yrs
Cerebellar haem >3cm
Hydrocephalus / marked mass effect
Endarterectomy if:
>80% stenosis (50% decr RR disabling CVA / death)
70-80% stensosis (25% decr RR)
BP >190/120
Trt
Aim
SAH:
160/90
/
MAP 110
70% ruptured Berry aneurysm: <50% aneurysms rupture; <50% AVMs have symptoms
15% perimesencephalic
50% mortality from initial bleed; 33% good recovery; 33% severe neuro deficit
Warning bleed in 50%
LOC in 66%
CT head 97.5% sens at 12hrs; 95% 12-24hrs; 85% 1-2/7; 75% 2-3/7; 50% >1/52
>100,000 RBC
LP
Rebleed 20% (50% mortality); vasospasm 30% (30% mortality)
Trt
Aim
SBP >180/120
pre-haem BP /
SBP 120 – 180 / MAP 110
CV
Norms: CO 5.5L/min; SV 70ml; EF 65%; EDV 130ml
Infective endo:
AF:
native:
mortality 25%; worse acute; better subacute
Staph aureus in normal (30% in normal, 66% in IVDU)
Prosthetic:
mortality 50%
Strep viridans in abnormal (50-60%)
Mitral in normal; triscuspid in IVDU
2/3 cardiovert within 24hrs
40% due to IHD
0.1% risk if lone AF <60yrs
1.5% if low risk and anticoagulated
4.5% if low risk and uncoagulated
Post-cardioversion:
55% in SR @ 1yr
90% success <48hrs, 50% success >48hrs
1-5% risk of embolism
2.5%/yr ARR 1Y, 8.5%/yr ARR 2Y
60% RRR CVA
1%/yr haemorrhage
1.5%/yr ARR 1Y, 2.5%/yr ARR 2Y
20% decr risk CVA
Warfarin:
Aspirin:
Syncope:
MI:
1% ED visits; 5% hospital admissions; 2% incidence >80yrs
40% unknown
20% vasovagal
10% cardiac (exertional = HOCM, AS)
10% postural (abnormal = decr SBP >20mmHg, or SBP <90)
situational
carotid sinus sens (abnormal = decr SBP >50mmHg, or ventricular pause >3secs)
pacemaker failure
ECG finds cause in 5%; blood tests in 2.5%
Prox LAD
Ant-septal
Lateral
Inferior
RV
Mortality 70%
Mortality 10%
Mortality 5%
Mortality 25-30%
aVR
V1
CHB, RBBB, Mobitz II
Ventricular rupture
RV in 1/3; CHB; papillary muscle rupture
CHB
Circulation balanced 60-65%; R dominant 20-25%; L dominant 10-15%
15-30% silent
15% with initial normal ECG’s develop criteria on serials
10% incr sens if RV and post leads
12% in hospital mortality
Irreversible damage in 20-40mins
1/3 have no RF’s
Risk stratification:
40%
V low <2% chance of MI / death in 6/12
55%
Low
2-10% chance
30% reclassified as high risk
5%
High
>10% chance
Normal ECG + trop: 1% risk MI
Normal ECG + trop + <40yrs, no PMH, no RF  0.1-0.2% risk MI
Trop T
Trop I
Tot CK
CKMB
CKMB mass
Reperfusion in general:
PCI:
99% sens
95% sens
90% sens
Higher
95% sens
75-90% spec
82-95% spec
90% spec
Higher
99% spec
Detectable 2-12hrs
Detectable 2-12hrs
Detectable 4-8hrs
Detectable 4-8hrs
Duration 14/7
Duration 7/7
Duration 4/7
Duration 2/7
2.5% decr AR mortality
47% decr RR mortality
5-10% incr improvement of LVEF
6-7% dec AR mortality, 90% reperfusion rate
<1hr since Sx
Available <60mins
1-2hr since Sx
Available <90mins
3-12hr since Sx and offsite
Available <120mins
>12hrs
If unstable
Large infarct: anterior / RV / inferior plus significant ST depression / LBBB
Cardiogenic shock / severe CCF (Killip >3) and <75yrs
CI to thrombolysis
As rescue therapy if TL fails
Best if: >70yrs, late, large, anterior / RV, CCF, prev CABG
TL:
5% decr AR mortality, 60-80% reperfusion rate
Too late for PTCA / PTCA not available
>30mins pre-hospital transfer time
<6-12hrs since Sx (<3hrs in CVA)
tPA best if: <75yrs;
decr BP; indigenous; >4hrs delay; ant MI; CI to SK
2% decr AR mortality compared to SK
Aspirin: 1Y prevention for AMI:
2Y prevention for AMI:
In unstable angina:
In MI (ISIS2):
not recommended
decr ARR serious vascular events 8%  6.7%
decr ARR CVA 2.5%  2%
decr ARR coronary evetns 5%  4%
50-70% decr MI / death
3% decr AR mortality
same as reperfusion therapy
25% decr RR mortality
Clopidogrel:
In MI (CURE):
20% decr mortality (with aspirin)
1% incr bleeding rate
Heparin:
In MI:
33% decr mortality (with aspirin)
GTN:
In MI:
35% decr mortality
BB:
In MI:
50% decr mortality, infarct size, reinfarct rate
30% decr ICH
Statins: 30% decr coronary events over 5yrs
15% decr CVA
PE:
10% mortality rate
5x incr risk during pregnancy
DVT in 30-50% patients
50% no RF’s, 15-30% trauma, 10-25% Ca, 5-15% immobilization
SOB most common Sx
D dimer ELISA
95% sens
Qualitative
80-85% sens
USS leg
60% sens, 93% spec
TTE
60-70% sens, 90% spec
TOE
80-97% sens, 88-100% spec
Thoracic USS
75% snes, 95% spec
CXR
Abnormal in 70-85%
ECG
Abnormal in 70-90%
Risk stratification
High = massive 40-50% PA occluded
Mod = submassive
RV dysfx
Low = non-massive No RV dysfx
TL indications in PE:
CV compromise / cardiac arrest likely 2Y to PE
PE <5/7
>40% pul vascular occlusion
RV dilation / hypokinesis / RVSP >40mmHg
Significant co-morbidities: COPD, CCF, prev PE
Floating thrombus
HR:SBP >1
Incr trop
ECG showing RV strain
>15% short term mortality
3-15% short term mortality
3% short term mortality
Severe hypoxia
Pericardial tamponade:
Pericarditis:
15-60ml normal
200ml  tamponade
200-250ml must be present to be seen on CXR
2L can be tolerated if slow accumulation
Pulsus paradoxicus = decr SBP >10-20mmHg on inspiration
Cancer most common cause of chronic; SOB most common Sx
Echo: >2cm effusion depth
RA / RV / LA collapse
Dilated IVC with lack of collapse
25% Idiopathic
25% Ca
ECG abnormal in 90%
Pericardial effusion in 40%
Incr trop in 50%
CCF:
If Sx  2yr mortality 35%, 6yr mortality 65-80%
ACEi:
40% decr mortality; decr re-hospitalisation
BB:
decr disease progression / hospitalization; incr survival / cardiac performance
Morphine:
10% incr mortality, hospital LOS, need for ventilation
CPAP:
decr need for intubation / ICU
No change in hospital mortality / LOS
Diuretics:
No study has ever shown benefit
HTN:
Mild
Mod
Severe
Malignant
Aim
WPW:
95% orthodromic, 5% antidromic
ECG changes
140-159
160-179
>180
>180
90-99
100-109
>110
>120
+ evidence of end organ damage
<110
or 25% reduction in 12-24hrs
K
>10
9
7-8
VF, asystole, sinus arrest, brady, CHB
Sine wave
Loss of P waves Wide QRS, S+T waves merge
Idioventricular rhythm, BBB
6.5-7
Small P waves, ST depression
Blocks
6-6.5
Long PR, long QT
5.5-6
Peaked T waves
3.5 – 5 Normal
Decr
Long PR, T wave flat/inverted, ST depression
U waves (mimic long QTc)
VF, VT, atrial arrhythmia
Ca
Incr
Decr
Short QT; peaked wide T waves; J waves
Long QTc
Mg
Incr
Long PR, wide QRS
CHB
Long QTc
TdP, AF, SVT
Decr
dsd
RS
NIV:
Decr need for intubation by 25% overall
CPAP decr need for intubation by 90% in APO
Incr survival to discharge
Decr ICU LOS, intubation
Less evidence in pneumonia, ARDS, asthma, children
25% don’t tolerate
Indication:
type II resp failure
pH 7.25-7.35
paO2 <60 on FiO2 50%
paCO2 >50
RR >24
Incr WOB
Type I resp failure
RR >30
CPAP
Improved compliance, FRC, VQ
Decr preload + afterload  incr CO
Decr intrapul shunting
BiPAP
Decr WOB, afterload
Pneumothorax: 1Y:
50-85% re-expansion rate without intervention
0.1% risk non-smoker, 12% smoker
2Y:
30-65% re-expansion rate without intervention
>70% smokers
30-50% recurrence rate; 20% recurrence within 1yr
CXR 90-95% sens; sliding lung 95% sens, comet tail >95% sens
O2 4x incr reabsorption
Asthma
CXR
USS
PaCO2 >40 = bad = likely if
PEFR <200 / <30% predicted
FEV1 <1L / <25% predicted
Will detect 100-300ml fluid on PA/AP
75-100ml on lateral decubitus
800-1000ml on supine
100% sens for >100ml; can detect 5-50ml
Decr pneumothorax from 15% to 5% when used to guide drainage
Pleural effusion Removing >500ml/hr will cause re-expansion pul oedema if >1.5L removed
Drain if deeper than 1cm on USS
O+G
Pre-eclampsia:
>160/>110 x1
or
>140/>90 x2
+ >300g/24hrs
+ generalized oedema
or
other end organ damage
In 5-7% pregnancies
30% recurrence in next pregnancy
Fetal and maternal mortality 2%
Trt >170/110
Aim <160/110
Eclampsia
Fetal mortality up to 30%
Beta-hCG:
Urine:
Blood:
+ >50%
+ <50%
- <35%
- >35%
>20iu/L 95-100% sens; <1% false negatives
>5iu/L Sens 100%
in 2/7 suggests viable pregnancy (decr from 12/40 onwards)
in 2/7 suggests ectopic
in 2/7 suggests ectopic
in 2/7 suggests miscarriage
Fundus height:
12/40
16/40
20/40
Symphysis pubis
Half way
Umbilicus
TVUS:
4.5-5/40
5.5-6/40
6/40
Bad
Empty gestational sac with diameter >18-20mm
Gestational sac >16mm / CRL >6mm without cardiac activity
TVUS zone
TAUS zone
1500-2400
3000-6000
Ectopic
In 2% pregnancies
25-30% ectopic pregnancy rate in subsequent pregnancies
80% ampullary
PID:
Works from 5/40
If >6/40 and nothing seen  TVUS
10% infertility after 1st episode, 20% after 2nd, >50% after 3rd
Changes in preg CV
Haem
RS
GI
GU
APH
Gestational sac
Yolk sac
Fetal pole and cardiac activity
Can lose 30% blood vol before decr BP
Uterus decr CO 10-30% when compresses
40% incr CO; 15-20 incr HR by term; 10-15 decr BP and MAP in 2nd trimester but
normalizes by 20/40; decr DBP>SBP; 20% decr SVR; 50% incr plasma vol; 100x
incr uterine blood flow; split S1; loud S3; SM; LAD
20-30% incr RBC vol; 30% incr RBC mass; decr Hct; incr WBC
20-30% incr O2 consumption; 40% incr TV; 25% incr MV; 20% decr FRC; 25% decr
RV; no change in VC / RR
2-3x incr ALP; decr alb 5
50% incr GFR and CrCl; glycosuria in >50%
In 2-5% pregnancies
30% placenta preaevia
Painless profuse PV bleeding
Bright red
Non-tender soft uterus
Maternal shock (mortality 0.03%)
Fetus OK
USS 95% sens
20% placental abruption Painful PV bleeding or may be concealed (1-2L)
Dark red blood
Tender tense large uterus
Maternal shock (<1% mortality) Fetal shock (15-35% mortality)
USS 25% sens
Uterine rupture
PV bleeding
Palpable fetal parts; small uterus
High maternal morbidity
High fetal morbidity
Vasa praevia
PPH
1Y
2Y
Perimorbid CS
Painless small amounts PV bleeding
Mother OK
75% fetal mortality
>500ml in 1st 24hrs / >1L after CS
Massive = >50% circulating blood vol in <3hrs / >150ml/min
2-5% of SVD
Tone, trauma, tissue, thrombin
From 24hrs – 6/52
Immediate
10mins
20mins
70% survival
15% survival
2% survival with poor outcome
RENAL / URO
Renal stone:
90% opaque
70% CaPhos (O), 15% struvite; 10% urate (L); 1% cysteine (partially O)
CTKUB: 97% sens and spec
IVP: 80-85% sens, 95% spec
USS: 65-93% sens, 90-95% spec
AXR: 50% sens
Renal failure
Mild
Mod
Severe
Failure
CAPD
>100 WBC
>50% neutrophils
Usually staph
Na deficit
H20 deficit
(135 – Na)
x 0.6 x kg
((Na – 140) / 140) x 0.6 x kg
GFR 60-90ml/min
GFR 30-60
GFR <30
GFR <15
GI
Upper GI bleeding:
PUD:
60% PUD (25% duodenal ulcer, 20% gastric ulcer, 25% gastritis)
20% Mallory Weiss tear
7-10% Variceal: most common cause of rebleed
30% duodenal, 15% gastric
H pylori most common cause; ELISA IgG 85% sens, 80% spec; Urease 90-95% sens; Faecal Ag >90%
sens and spec; trt success 85%
NSAID’s 2nd (20% have Sx)
Duodenal = 90-95% have H pylori
Gastric = NSAID (70% have H pylori)
H pylori: 10-20% get PUD
bleeding stops spontenously in 80%
5-6% mortality
20% haemorrhage, 20% penetration, 5% perf, 2% GOO
GORD: omeprazole help Sx in 80%; H2 better at helping Sx than omeprazole
20-50% have H pylori
Varices: bleeding stops spontaneously in 20-30%
10-15% haemorrhage/yr
25-40% mortality (15-20% 6/52 mortailty)
20-30% recurrence (most common cause of rebleed in upper GI bleeding)
SB tube: 50% recurrence; controls bleed in 80%; 30% complication rate
Sclerotherapy: 40% complication rate
Ligation / sclero: stops bleeding in 80%
Octreotide: stops bleeding in 80%
TIPS: controls bleeding in 90%
Lower GI bleed
20% bleeds; 5-10% mortality
80% stop spontaneously
60% due to diverticular disease; 10-20% no cause; 12% angiodysplasia; 2% Ca
90% GI FB’s pass sponteanously; 80% are paeds; cricopharyngeal narrowing at C6 most common site of
obstruction in paeds, distal oesophagus most common in adult
SBP:
WCC >500-1000; neut >250; low glu; high protein; G stain and culture 70% sens
Enterobacter (63%; eg. E coli (30%), klebsiella (10%)) > strep pneumonia, enterococci, anaerobes
(5%), staph aureus (10%), pseudomonas (5%)
10% >1 MO
30% ascitic patients develop SBP in 1yr
Ages for diseases:
<1/12
<3/12
2-6/12
6-18/12
18-24/12
1-3yrs
1-7yrs
4-6yrs
5-8yrs
Abdo USS:
90% sens for 250ml
96% sens for 500ml
95% spec
Ascites: Transudate
Exudate
<30g/L protein
>30g/L protein
Blood
>300 WBC
Lactate
Amylase
Liver failure:
Nec enterocolitis
Volvulus / malrotation, feeding intolerance, incarcerated hernia,
testicular torsion
Pyloric stenosis
Intussusception
Kawasaki disease
Croup (most 18m)
Epiglottitis (most <2yrs)
HSP
Bacterial tracheitis
CCF, cirrhosis, constrictive pericarditis
Ca, infection, venous obstruction, pancreatitis, lymphatic
Obstruction
Ca
?infection
SBP
Pancreatitis
Jaundice seen when bil >40
70% unconjugated = 2, 30% conjugated = direct
Fulminant
>75% mortality
Onset of encephalopathy within 2/52
Acute
Onset of encephalopathy within 8/52
Bad prognosis: Hep C/D/E, idiosyncratic drug reaction
Good prognosis: Hep A, paracetamol
Adults
50-70% paracetamol
20% no cause
Paeds <1yrs
Paeds >1yr
13% idiosyncratic drug reaction
8% Hep B (more in developing world)
<5% Hep A
4% Hep C
40% metabolic
25% other
15% neonatal haemochromatosis
15% viral hepatitis
45% unknown
25% Hep C/D/E
10% Hep A
10% drug related
5% Hep B
Appendicitis
20% fetal loss in preg
30% retrocaecal, 30% pelvic
Anorexia most common Sx; pain migrates to RIF in 50%
50-75% have classical Sx
McBurney’s point = 1/3 way from ASIS/umbilicus; appendix is medial and inf to point
USS 80-90% sens, 90-100% spec – diameter >6cm, target sign, wall thickness >2mm
CT + MRI 90-95% sens, 95% spec
Acceptable negative laparotomy rate 10-20%
Biliary
Gallstones present in 10-20%; symptomatic in 20%
Ca is most common cause of CBD obstruction
Cholecystitis >90% gallstones, 10% acalculus (anaerobes and coliforms)
Bacteria present in 50% cholecystitis (75% G-ive, 15% G+ive, anaerobes rare)
Acalculus cholecystitis >50% mortality
70% cholesterol stones (radiolucent); 30% pigment stones (radio-opaque)
Murphy’s sign 85-95% sens, 85% spec
USS
90-95% sens, 95% spec for gallstones
90% sens, 80% spec for cholecystitis – GB >4x8cm, wall >4mm, CBD >10mm
CT
Lower sens
Diverticulitis
Occurs in 10-25% people with diverticular disease
Usually anaerobes and G-ive rods
Significant bleeding usually R sided; 5-15% bleed
CT
97% sens, 100% spec
Volvulis
Sigmoid 2/3, elderly; sigmoidoscopy 90% success rate, but 90% recurrence
Caecal 1/3, young; mortality 10-40%
Obstruction
SBO >2.5cm
LBO >5cm
>5 AF levels abnormal
AXR
75-80% sens, 50% spec
USS
95% sens and spec
CT
90% sens, 95% spec
Elderly AP
10% mortality; 40% initially misdiagnosed
Cholecystitis most common cause
Hernias
Inguinal:
Femoral:
75%; 2/3 indirect, 1/3 direct; 3%/mth strangulation; cough impulse
above and medial to symphysis pubis; most common inc in women
Indirect: lat to inf epiG art; frequent strangulation
Direct: med to inf epiG art
20%/mth strangulation
Med to inf epiG art; below and lat to pubic tubercle
Ischaemic colitis >50% mortality
Pancreatitis
Mortality 2-10%
ETOH most common cause; gallstones most common cause in women
Bacteria present in 20% (50% in cholecystitis)
CRP >150 at 48hrs is predictor of severity
Lipase
Incr earlier (in 4-8hrs), for longer (1-2/52)
95% sens and spec
Does not correlate with severity
Amylase
Incr later (2-12hrs), for shorter (1/52)
80-90% sens (less sens with ETOH), 75% spec
Does not correlate with severity
CT
80-95% sens
GU
Renal colic
90% stones radio-opaque (25% gallstones)
90% pass spontaneously
70% Ca phos / oxalate (radio-opaque)
10-15% struvite – infective  staghorn
10% urate (radiolucent)
1% cysteine (partially radio-opaque)
Narrowest part is VUJ : 1-5mm
4mm = 90% pass
5mm = 80% pass
5-8mm = 15% pass
>8mm = 5% pass
Haematuria absent in 5-10%; gross haematuria in 30%
CT KUB 97% sens and spec
AXR 50% sens
USS may miss if <5mm / mid-ureter
ENT
OM
Incr cure rate by 10%, decr duration fever by 1/7
No effect on rate of complications
Pharyngitis
Decr duration Sx by 0.5 days, decr severity Sx, decr infectious period from 2/52 to 1/7
Decr risk RF by 70%
Decr risk OM by 70%
Decr risk quinsy by 85%
Decr risk sinusitis by 50%
No effect on risk of post-strep GN
Ludwig’s angina 50% failure rate for RSI
TOX
Concerning doses
Metformin
>10g
Digoxin
>10mg (>4mg in children)
Fe
>60mg/kg
Lithium
Paracetamol
>200mg/kg
Aspirin
>300mg/kg
>60mmol/L (>90mmol/L is high risk)
>2.2mmol/L for alkalinisation
Decontamination
Charcoal: 45% decr absorption at 30mins, 40% at 1hr, 15% at 2hrs
Syrup of ipecac: decr absorption 30% if in 1st hr
Gastric lavage: 25% decr absorption if at 30mins, 10% if at 1hr
Fe OD
Markers of toxicity: WCC >15, BSL >8, AGMA
METABOLIC
Na deficit (mmol/L) = (0.6 x kg) x (desired Na – actual Na)
90% DM is type II
HONK: pH >7.3, HCO3 >15, AG normal, BSL >600, ketones +, osm >320
DKA: pH <7.3, HCO3 <15, AG high, BSL >250, ketones +++, variable osm
HONK: N saline resus  replace with 0.45% saline over 48-72hrs  add 5% dex when BSL <15
DKA: N saline resus  replace with N saline over 24hrs
 0.45% saline + 5% dex when BSL <15
HONK: 0.05iu/kg/hr
DKA: 0.1iu/kg/hr
HONK mortality: 15-45%
DKA mortality: 5-15%
TRAUMA
Hyphema: rebleeding in 3-5/7 in 30%
FAST: 96% sens for >800ml FF
90% sens for >250ml FF
95% spec
100% sens, 96% spec for need for laparotomy in hypotensive patient
insufficient sens to rule out significant inj in stable patient
USS chest:
90% sens, 95% spec for haemothorax
Sliding lung sign 95% sens, 90% spec
Absent comet tails >95% sens, 60% spec
USS AAA:
ED doc 90-100% sens, >95% spec for >3cm
USS IVC:
normal 15-20mm with 5mm decr during insp
Hypovolaemia: <14mm, with >40% collapse on inspiration
Hypervolaemia: >20mm, without any insp collapse
Burns:
Minor
Full
<2%
Partial <15%
Burns unit
>10% TBSA adult
>5% TBSA child
Mod
2-10%
15-25%
Major
>10%
>25% (-5 if <10 / >50yrs)
>5% full thickness
Special areas
Brooke-Parkland: 2-4ml/kg/% burn (+maintenance if child)
1st half in 8hrs, 2nd half in 16hrs
Aim UO 0.5-1ml/kg/hr
Penning’s criteria:
Haemothorax
Thoractomoty
C1
C2
C3-4
C5+
10mm
5mm
7mm
20mm
Small
Mod
Large
Massive
<50% width C4 in children
<350ml
350-1500ml
>1500ml (>15ml/lg)
>300ml/hr for 2hrs
>600ml/6hrs
>4ml/kg/hr
Stable
>200ml/hr for >2hrs
>1500ml overall
Unstable
>100ml/hr for >2hrs
>1000ml overall
Compartment syndrome: 1-10mmHg
<15mmHg
20-30mmHg
>30mmHg
Normal
Safe
Cause damage
Emergency fasciotomy
Boehler’s angle: <20deg = fracture
DPL:
1L (10ml/kg) saline; 98% sens; 1% complication rate; 15% false +ive
>20ml frank blood
>100,000 RBC/ml
if blunt
>5000 RBC/ml
if penetrating
>500 WBC/ml
if <3hrs since inj
bile / food
ORTHO
Jt aspirate:
Normal
Inflamm
Septic
WCC <200, <25% PMN
WCC 2000-50,000; >50% PMN
WCC >25,000; >85% PMN
Septic arthritis:
15% mortality
50% staph, 40% grp A strep in adults
ENVIRONMENTAL
Heat stroke
T >40, altered LOC, anhydrosis, MOF
Mortality 10-50%
Decr T by…
Incr T by…
Blanket
Ice packs
Ice/warm water immersion
Evaporative
Humidified O2
Gastric lavage
Peritoneal lavage
Thoracic lavage
Haemodialysis
CPB
0.5-2deg / hr
0.04-0.08deg / min
0.15-0.25deg / min
0.3deg /min
4-10deg / hr
1-1.5deg / hr
0.5deg / min
2-4deg / hr
3-6deg / hr
2-3deg / hr
7-10deg / hr
Hypothermia:
Severe <28; mod 28-32; mild 32-35
check pulse for 60secs (instead of 10)
1x shock + drugs  withhold until >30deg  then 2x interval between drugs until
35 deg
Heat IVF to 42 deg
Use 5% dex as energy substrate
Rapid rewarm to 30deg then slower
45% survive with normal function, 15% with severe brain inj
100% good outcome if GCS >8 at 2hrs
>90% if GCS >3 at 2hrs
Good prognosis: witnessed
<5mins to retrieval
<5mins submersion
GCS >5 on scene
<10mins to CPR
<10mins to first resp effort = <10% significant neuro deficit
<30mins to spontaneous breathing
SaO2 >94%
ROSC pre-hospital / no resp arrest
Pupillary response / motor response to pain on arrival
Cold water
Bad prognosis: above + male
<3yrs
>10-25mins submersion
>25mins resus
Fixed dilated pupils at 6hrs
GCS 5 on arrival = 80% risk death / severe deficit
VT/VF on initial ECG / asystole
Metabolic acidosis pH <7.1 on arrival
Altitude
High >1500m (4900ft)
AMS begins >2500m
HAPE begins >3500m
Most can acclimitise up to 5500m
Changes
Incr RR, HCO3 diuresis, pul HTN, incr lung vol
Incr SV, incr BP, incr CO, peri vasoC
Incr RBC (days-wks), incr EPO (hrs), incr 23DPG
Burns
>20%  fluid shifts, recommend IVF + IDC + NGT
>40%  recommend stress ulcer prophylaxis
>50%  potentially fatal
>60%  decr CO
>80% full thickness  unsurvivable
50deg  5mins
55deg  30secs
60deg  5secs
70deg  1sec
Admit burns unit:
AGE
DCS
Partial thickness >20%
Partial thickness >15% if chemical
Partial thickness >10% if <10yrs / >50yrs
Full thickness >5%
Other major burn criteria
Occurs within 5-20mins of ascent, or in water
50% within 1hr, 90% within 6hrs
Electrical
>1000V = threshold for severe inj
Vertical = 20% mortality Horizontal = 60% mortality
Lightning = 10-30% mortality
1mAmp  tingling
2-10mAmp  pain
10mAmp  paralysis / tetany
100mAmp – 1Amp  VF, rest arrest, burns
>10Amp  asystole
Low volt AC  VF, rhabdo, ARF, deep tissue burns
High volt AC / DC / lightning  asystole, superficial burns
ID
Needlestick inj:
Transmission:
Hep B: E+ive, 40%; E-ive 5% (2-30% risk)
Hep C: 2-10% (<2% risk)
HIV:
0.3%
Gloves decr by 50%
Prophylaxis decr seroconversion by 80%
Full 4/52 course tolerated by 35%
HIV transmission:
0.8% anal receptive
3-15% prev in homos
0.6% shared IVDU
1% prev in IVDU
0.3% needlestick
0.1% vag / insertive anal <0.1% prev in heteros
<0.1% MM exposure
Hep B transmission
15% sex
Hep C transmission
15% sex
HIV:
PCP occurs in 60%
Malaria
Falciparum
>90% within 2/12; more resistance
Vivax
50% within 2/12; most common; can be delayed months
Most common cause of fever in traveller
Dengue
4-10/7 incubation
Risk of SBI:
<4w and well
<5%
<4w + ill
13-21%
<4w + bronchiolitis: 3-10% so do septic screen
<6w
15% overall
Height of fever irrelevant this young
6w – 3m well
<5%
6w – 3m ill 13-21%
4w – 2m + bronchiolitis: 3-5% so do urine
6w – 3m 6-10% overall if any fever
UTI (paeds)
3m – 6m
6m – 2yrs
Overall <2yrs
<1%
<1% (incr if higher fever)
3%
Seizure + well
Seizure + ill
0.3% SBI
15-18% SBI
3-8% with no source have UTI
<3/12
30% systemic sepsis
>3/12
5% systemic sepsis
85% E coli, 6% proteus
Nitrites
40% sens, 99% spec
WBC
50-90% sens and spec (dipstick 75% sens)
Bacteria
50-90% sens, 10-90% spec
MSSU
>5-10 WCC
Catheter
>1-5 WCC
SPA
>0 WCC
Meningitis (paeds)
Meningitis
CSF
Bacterial
Viral
Partial Trt
TB
5% mortality
FND in 15% (30% pneumococcus)
Decr LOC 15% (more pneumococcus)
Seizures 30%
60% strep pneumonia
16% N meningitides
14% grp B strep
WCC 200-10,000
WCC 100-700
WCC 200-5000
WCC 100-500
FND prominent
PMN 100-10,000
PMN <100
PMN 10-100
PMN high early
MMN <100
MMN >100
MMN >100
MMN high late
Pro >1
N
Either
Pro >1
Glu low
N
Either
Glu low late
Protein incr 0.01 per 1000 RBC
Opening p
Adult 7-18cm 22-25G, 12cm
8-18yrs 7-20cm 22-25G, 6cm
1-8yrs 1-10cm
2cm
SIRS = >2 of
T <36 or >38
HR >90
RR > 20 or PaCO2 <32
WCC <4 or >12 or >10% bands
Organ dysfx
SBP <90 / 40 below normal / MAP <60
BE < -5
Lactate >2
UO <30ml/hr
FiO2 >0.4 or PEEP >5
Cr >160
Decr LOC
Severe sepsis
= SIRS + organ dysfx
HR >160 infants, HR 150 children
RR >60 infants, RR >50 children
Lactate good for risk stratification: >2 = 4% mortality, >4 = 28% mortality
Incr mortality by 8%/hr for delay in ABx
Septic shock
= severe sepsis + uncorrectable hypotension
Unknown source
RS
GI
UTI
Skin
Fluclox + gent
Ceftriaxone + azithromycin
Ampicillin + gent + metronidazole
Ampicillin + gent
Fluclox
Febrile convulsion
4% incidence; 35% recurrence
3% go on to epilepsy (same as general population)
Nec fasc
Mortality 25-35%
Clostridium perfringens most common cause
B fragilis and E coli in Fournier’s
Kawasaki
IVIG 2g/kg IV over 12hrs
Aspirin 30-50mg/kg/day until fever gone  3-5mg/kg OD for 6-8/52
ENDOCRINE
DM:
Type I
10% DM
90% immune mediated; 10% unknown
50% concordance in twins
>80% loss islet cells for features of DM
Type II 80% DM
100% concordance in twins
MODY 2-5% DM
DKA
Fetal mortality 30-50%; mortality 5-15% (1% in children); 70% mortality if cerebral oedema
Acetoacetate on ketostix urine test
B-HB on blood; more in alcoholic ketoacidosis
B-HB converted to acetoacetate
Acetone on breath test
5-10L fluid deficit; 5-10mmol/kg Na deficit; 3-5mmol/kg K deficit
DERMATOLOGY
EM minor
EM major
No MM involved
1MM involved
SJS
Epidermal detachment <10% BSA
>1MM involved
Mortality 10-15%
TEN
Epidermal detachment >30% BSA
MM often involved
Mortality 25-35%
TSS
Toxic
Shock
T >38.9
SBP <90
S
SSSS
Rash  desquamation; involvement 3+ systems
No MM involvement
FACTS I FORGET
DISCHARGE PLANNING
Diagnostic certainty
SH
Predictors of early readmission – reliance on others, assistance needed
Symptom control
PO intake
Mental state
Test mobility
Time of discharge
Communication
Check contact details
Organise OP FU
Discharge medication
Statutory requirements (eg. Work certificate)
Discharge info and letter
Transportation
DERMATOLOGY
Kawasaki disease
Fever >5/7 + 4/5 of
MM involvement: cracked lips, strawberry tongue
Bilat conjunctivitis with perilimbic sparing
Polymorphous generalized rash
Peripheral redness and oedema
Cervical lymphadenopathy
Do echo at 2/52  6/52  1yr
MI is leading cause of death; mortality <1%
Measles
Fever >38
Rash – erythematous maculopapular
1 of: cough / coryza / conjunctivitis / Koplick spots
Mortality 10-15%; 50% due to pneumonia
ENVIRONMENTAL
PIB
Funnel web, mouse spider
All snakes inc sea
Cone shell
Blue ringed octopus
Redback
20% envenomation rate
Female bite  Severe pain (in mins/delayed), erythema, sweating, piloerection
 lactrodectism (severe pain, sweating, piloerection)
maybe weakness, N+V+AP
 2 vial AV IM (serum sickness 10-15% for all AV)
10-25% envenomation rate
Male bite  pain + fang marks
 within 30mins, autonomic storm  NCPO, spasms, paralysis, coma
 PIB, 1 vial AV  rpt
<5% envenomation rate
Mod local
Non-specific general
 PIB, funnel web AV
Local pain
Blue ulcer  necrotizing arachnidism, metHb
Necrotising arachnidism
Funnel web
Mouse spider
White tail
Recluse spider
Black house
100%
90%
80%
99%
85-95%
60-98%
Box Jelly
Carybdeid
Blue bottle
Blue ringed
Stone fish
Sea snake
Brown snake
Tiger snake
Black snake
Taipan
Death adder
Immediate severe pain
Cardiotoxicity  collapse in water  cardiac arrest, arrhythmia, HTN /decr BP
Muscle spasms + paralysis
 vinegar, 1-6 vials AV, MgSO4
Mild local
Irukandji Syndrome on beach  sympathetic storm  HTN, CCF, NCPO, collapse
Severe generalized pain
 vinegar, MgSO4, anti-HTN
Severe local in water
 hot water
Paralysis  collapse on beach
 PIB
Severe pain
 hot water, 1-3 vials AV, ABx, ADT
Paralysis in 2-6hrs
Myolysis + ARF
 PIB, 1-3 vials AV
60% snake deaths, 70% snake bites
Cardiotoxicitiy  early collapse
Early severe coagulopathy
Thrombotic microangiopathy  ARF
 PIB, 2 vials AV
25% snake deaths
Cardiotoxicity  early collapse
Early coagulopathy
Late neurotoxicity, severe myolysis, ARF
 PIB, 2 vials AV
Marked local
Coagulopathy, neurotoxicity, myolysis, ARF
 PIB, 1 vial AV
10% snake deaths
Early collapse, coagulopathy, neurotoxicity, myolysis
 PIB, 1-3 vials AV
5% snake deaths
Early neurotoxicity
 PIB, 1 vial AV
ID
Live attenuated BCG
MMR
VZV
Polio
Notifiable disease
Avoif if immunosuppressed
Campylobacter, chlamydia, gonorrhea, hep A+E, flu, legionella, listeria, MMR,
syphilis, salmonella, VZV
TRAUMA
Brown Sequard Ipsilateral motor, position, vibratory
Contralateral pain, T
Central
Anterior
Human bites:
Staph aureus
Upper > lower bilaterally
Bilat motor weakness
Eikenella
Dog bites
• Staphylococcus
Streptococcus
Haemophilus species
• Eikenella
Pasteurella
Proteus
Klebsiella species
• Enterobacter species
• Capnocytophaga canimorsus – overwhelming sepsis in immunocomp
• Bacteroides Moraxella Corynebacterium Neisseria Fusobacterium
•
•
•
•
•
Prevotela Porphyromonas
Cat bites – 60-80% get infected
Staphylococcus Streptococcus
Pasteurella Actinomyces Propionibacterium
Bacteroides
Fusobacterium
Clostridium
Wolinella Peptostreptococcus species
Bartonella  cat scratch disease  regional lymphadenopathy after 7-12/7
Marine assoc
Staph, strep
G-ive rods esp Vibrio
Tetanus Prophylaxis
Hx
Clean
Dirty
Td
TIG
Td
TIG
✓
No
✓
✓
≤ 5y
No
No
No
No
5-10 y
No
No
✓
No
>10 y
✓
No
✓
No
<3 or unknown
Immunised
HBsAg+
HBsAg-
Unknown
Unvaccinated
HBIg (400iu IM) + vacc
Vacc
Vacc
Vacc + responder (anti-HBs >10)
No Rx
No Rx
No Rx
Vacc + non- responder (anti-HBs
<10)
HBIg (400iu IM) + vacc
Booster
If hi-risk,
Rx as H
Source
Mx
HIV -
Nil else
Likely/confirmed +
PEP 4/52 (ideally <24-36h) 2 drugs standard
3 drugs if hi-risk
Unknown
O+G
Safe in preg:
Usually no PEP 2 drugs if hi-risk
cephalosporins, azithromycin, nitrofurantoin, penicillins
Maxalon, ondansetron, stemetil, promethazine
Heparin
Not safe in preg: fluroquinolones (ie. Ciprofloxacin), sulphonamides (eg. Cotrim), tetracyclines (eg. Doxy),
gent, metronidazole
Oral hypoglycaemics
Warfarin, thrombolysis
NSAIDs, aspirin
Stemetil
Phenytoin
Amiodarone, ACEi, AII receptor antagonists
Lithium
Most common cause of vulvovaginitis: bacterial vaginosis
GI
H pylori:
NSAIDS:
PUD:
PUD:
Omeprazole:
GI bleed:
PUD:
H2 antagonists: GORD:
PUD:
Misoprostol
Sucralfate
Bismuth cmpds
Octreotide:
Varices:
Gastroscopy:
SB tube:
GI bleed:
Varices:
Banding/sclera: Varices:
TIPS:
Varices:
Angio+embo:
Complications:
Varices:
PUD:
Hepatitis
Acute
IgM anti HAV
HAV RNA
IgM anti HBcAg
HBsAg
HBeAg
HBV DNA
A
B
C
HCV RNA
D
HDV RNA
PUD in 20%; most common cause; duodenal > gastric
Symptoms in 20%; endoscopic evidence in 50%; 2 nd most common
cause; gastric > duodenal
Decr LOS, active bleeding at endoscopy, need for OT
No effect on transfusion, recurrence, mortality
Heal earlier
Better at treating Sx than omeprazole
Heals 85% duodenal in 4-8/52, 70% gastric in 8/52
80% relapse at 1yr if no maintenance
For NSAID related disease
Better in smokers
For H pylori related disease
Decr active bleeding; transfusion need by 33%; as effective as
sclerotherapy
Decr rebleeding by 60%, mortality by 45%, emergent OT by 65%
Controls bleeding in 70-90%
50% recurrence; 25-30% complication rate
stops bleeding in 80-90%
40% complication rate for sclerotherapy
Stops bleeding in 90%; 25% decr 1yr mortality, 50% decr
rebleeding
Stops bleeding in 80%
Haem 20% (most common), penetration 20%, perf 5%, GOO 2%
Previous
Chronic
No
Carrier
No
Immune
IgG anti HAV
.
Anti HBsAg
Anti HBeAg
IgG anti HBcAg
5-10%
HBsAg >6/12
HBeAg (phase 2)
IgG anti HBcAg
Anti HBeAg (phase 3)
Hep B DNA
75-85% (less in kids)
IgG anti HCV
5-10% co, 80% super
1-10%
HBsAg
IgG anti HBsAg
.
0.2-1%
-
Low
-
.
IgM anti HDV
HEV Ag
IgM anti HEV
E
IgG anti HDV
.
No
IgG anti HEV
IgG anti HEV
HAEMATOLOGY
Clotting probs  retroperitoneal bleeding, intra-articular bleeding, delayed bleeding
Plt probs  mucocutaneous bleeding = gum, petechiae, purpura, epistaxis, GI/GU bleed, menorrhagia,
bruising
DIC  incr DD, decr plt (most common lab finding), incr INR, decr fib
Absolute
Relative
Recent bleed <4/52
Surgery <3/52
Active bleeding or diathesis
Active PUD
Bleed
Sig closed HI <3/12
Anticoagulant use
Face trauma <3/12
Non-comp vasc punc site
CPR >10min
Prior ICH
Severe/poorly controlled HT
Ischemic CVA <3/12
HT >180/110 on presentation
Cerebral vasc lesion
Ischemic CVA >3/12
Malig lesion 1° or 2°
Dementia
ICH
Aortic dissection
Other
Pregnancy
Pericarditis
TOXICOLOGY
WBI:
Intralipid:
MDAC:
SR preps
Agents that don’t bind charcoal
Fe (>60mg/kg)
Li (>40mg/kg)
Lead, arsenic, SR verapamil/diltiazem, SR KCl (>2.5mmol/kg), body
packers, pharmacobezoars
LA
Propanolol, verapamil
TCA
Carbamazepine / phenobarb coma, phenytoin, valproate
Aspirin
Theophylline
Quinine
NaHCO3:
Phenobarb coma
Aspirin
Methotrexate
Haemodialysis: Carbamazepine / phenobarb, valproic acid
Aspirin
Theophylline
Metformin, alcohols
Lithium (>6mmol/L acute OD, >2.5mmol/L chronic)
Charcoal haemP: Carbamazepine / phenobarb, phenytoin
Aspirin, paracetamol
Theophylline
Amanita
DRUGS
NO
BLOODS
Ur
Incr
Decr
Cr
Incr
Decr
Ur:Cr Incr
50-100
Decr
max 70:30; onset 4-5mins; MAC 1.02 (weak)
Pros: analgesia, amnesia, no decr RR or airway reflexes
Cons: diffusion hypoxia at high doses; mask intolerance; vomiting 5-10%; dysphoria
1%; apnoea 1-2% <2yrs, 1:300 otherwise
CI: pneumothorax, bowel obstruction, gastric distension, severe HI; severe COPD,
decompression illness, >50% O2 needed, decr LOC, pregnancy
Renal failure, CCF, dehydration, catabolism, sepsis, OT, steroids, starvation, GI bleed
Preg, severe liver disease, low protein diet, anabolism, Ur cycle defects
Decr GFR, incr muscle mass, catabolism, muscle disease
Elderly, decr muscle mass
Prerenal, sepsis, GI bood, dehydration, CCF, RAS, steroids, tetracyclines
Renal, acute
Renal, chronic; hepatic failure, muscle trauma, preg, trimethoprim
CV
JVP
Apex
Heave
Thrill
S1
S2
Split S1
Split S2
S3
S4
Ejection click
Raised
Paradoxical
Large a
Absent a
Systolic wave
Tapping
Prolonged
Triple
Large RV / LA
Loud
Soft
Loud
Soft
Increased
Fixed
Reversed
R heart failure, fluid overload, decr HR, SVC obstruction
Cardiac tamponade, constrictive pericarditis
Tricuspid stenosis, pul HTN, pul stenosis, CHB, flutter, HOCM, AS
AF
TR
MS
AS
HOCM
Severe AS
MS, TS
MR
AS
AR
Tachy
LBBB, 1st deg HB, MI
HTN
MI
RBBB
RBBB
PS, MR, VSD
ASD
AS, coarctation LBBB
Rapid diastolic filling; CCF, AR, MR, VSD, PDA, MI, maybe physiological
Poorly compliant V; AS, PS, MR, pul HTN, HTN, MI
AS
Mid-systolic click
Opening snap
PSM
ESM
Late systolic
Early diastolic
Mid diastolic
Continuous
Inspiration
Expiration
HOCM
AS
AR
MS
MR
MV prolapse
MV prolapse
MS
MR, TR
AS, PS
MV prolapse
AR, PR
MS, TS
VSD
ASD
PDA, coarctation, venous hum
Incr R murmurs
Incr L murmurs
Incr by Valsalva and standing; decr by squatting, hand grip, leg elevation; SM
Loud reverse split S2, S4, ejection click, ESM, large a wave, narrow pulse p, slow rising
pulse, sustained displaced apex beat, thrill if severe, LVH on ECG
Soft S2, S3, early diastolic murmur (+/- SM), Corrigan’s sign, Quinke’s sign, Traube’s sign,
Duroziez’s sign, water hammer pulse, wide pulse p, Austin Flint murmur, displaced apex
beat, LVH
Loud S1, opening snap, mid diastolic murmur, tapping apex beat, small pulse p, thrill; RAD;
RV strain; P mitrale, AF
Soft S1, incr splitting S2, S3, S4, PSM, small vol pulse, RAD, LV strain, P mitrale, AF
Mid-systolic click, late systolic murmur
Anti-arrhythmics:
IA
IB
IC
II
III
IV
Procainamide, quinidine, disopyramide
Lignocaine, phenytoin
Flecainide
Beta-blockers
Ca antagonists
Wide QRS, QT
Wide QRS, PR
Long PR; HB
Wide PR, QRS, QT
Long PR
OK in WPW:
Flecainide, procainamide, verapamil (if narrow complex)
Not OK in WPW: Adenosine, BB, Ca antagonists, dig
Cyanotic heart disease
TOF
Total anomalous venous drainage
TGA
Truncus arteriosus
Tricuspid atresia
ECG
Decr complex size; Osborn wave (esp II, III, aVF, precordial); HB’s; AF, VF, asystole,
prolonged PR, long QRS and QT, STE
Long QTc; AF, SVT, RBBB
Hypothermia
Hyperthermia
RESPIRATORY
Cavitating lung lesions:
Cancer:
SCC; Hodgkins
Autoimmune: granulomatosis, sarcoidosis, Wegener’s, RA, progressive massive fibrosis
Vascular:
septic emboli, pul infarct
Infectious:
Staph aureus
Klebsiella
G-ives, anaerobes
Fungi, aspiration, 2Y TB
Infected bullae / cysts
Trauma:
traumatic cyst
Young:
bronchogenic cyst, laryngotracheal papillomatosis
Abscess
Staph aureus (esp if immunocompromised)
Klebseilla
G-ive, anaerobes (esp if immunocompetent)
Fungi (aspergillus, cryptococcal), aspiration, 2Y TB
Aspiration
Staph aureus, strep pneumonia
Klebsiella
G-ives, anaerobes
E coli, enterobacter, H influenza, pseudomonas
CXR initially normal in 25%; 40% who aspirate get pneumonia
Empyema/effusion
Staph aureus, strep pneumonaie (esp effusion)
Empyema
Klebsiella
Pseudomonas, nocardia, TB
Effusion
G-ives, anaerobes
Mycoplasma, Hib
CCF, trauma, PE, Ca (more likely if large), autoimmune, renal failure
R = ovarian Ca
L = pancreatitis, chylothorax, CCF
Round pneumonia
Strep pneumonia, staph
Legionella
Coxiella
Interstitial lung disease: A-SHITFACED
Diffuse, tiny, haze
A typicals
S arcoidosis
H istiocytosis
I diopathic
Viral, atypicals, radiation
T umour
F ailure
A utoimmune
Mets, lymphangitis
SLE, RA, scleroderma, granulomatosis
C ollagen vascular disease
E nvironmental
D rugs
Pul fibrosis
Ground glass, reticular
Linear and nodules
Upper zone SETCARP
Asbestosis, silicosis, coal, farmer
Methotrexate, amiodarone
S ilicosis, sarcoidosis
E osinophilic pneumonia
TB
C oal, CF
Dirty looking
A spergillosis, ank
R adiation
spond
P CP, pneumoconiosis
Lower zone BADRASH
B ronchiectasis
A spiration
D rugs
RA
Methotrexate, nitrofurantoin,
hydralazine, amiodarone, paraquat,
smoke inhalation
A stebestos
S cleroderma
H amman Rich, histiocytosis
Honeycomb BIGHIPS
Pul nodules: CAVIE
C ancer
A utoimmune
V ascular
I nfection
E nviro
B leomycin
I diopathic
G ranulomas
H istiocytosis
I nterstitial pneumonia
P neumoconiosis
S arcoidosis
Adenoma
Neoplasia
Mets
Colon, breast, renal, testicular,
melanoma, TCC
AdenoCa
Central SCC, small cell
Peri
Large cell, bronchoalveolar
Granulomatosis, RA, Wegener’s, silicosis
AVM, haemartoma, PE, infarct
Round pneumonia
Miliary TB
Varicella pneumonia
Fungal
Histoplasmosis, aspergilloma
Pleural plaques
Pleural masses MALLETS M esothelioma
A denoCa, asbestosis
L ymphoma, leukaemia
E mpysema
T hymoma
S plenosis
NEUROLOGY
MCA
Contralat face+arm >leg hemiplegia + sensory loss
Honomynous hemianopia
Dom: aphasia, agnosia (Broca’s and Wernicke’s)
Non-dom: spatial neglect, dressing apraxia
ACA
Contralat leg > arm hemiplegia + sensory loss
Disorder of conjugate gaze
Confusion, personality change
Dom: aphasia
Non-dom: neglect, confusion
Opthalmic
Amaurosis fugax
PCA
Ipsilat cranial nerve III deficit
Contralat sensory loss
Honomynous hemianopia, quadrantanopia
VertebroB
Ipsilat cranial nerve deficit
Contralat body signs
Cerebellar signs
NO MOTOR LOSS
Lat med S
Ipsilat VII, IX, X  Horner’s syndrome, ipsilat facial numbness, dysphagia, dysarthria
Contralat loss pain and T in body
NO MOTOR LOSS
Disorder of conjugate gaze
Cerebellar signs
Wallenberg
Ipsilat facial loss of pain and T, weakness
Contralat loss pain and T in body, weakness
Cerebellar signs
Int capsule
Contralat motor loss
NO SENSORY LOSS
Thalamus
Contralat sensory loss
NO MOTOR LOSS
Wasting
Tone
Fasciculations
Reflexes
UMN acute
None
Decr
No
Incr
UMN chronic
Mild
Incr
No
Incr
LMN
Severe
Decr
Yes
Decr
Plantar
Up
Up
None
Spinal cord
NMJ
Loss at level
Incr below level
Normal
Fatiguable
ILCOR changes
Major
30 chest immediately
Minor
AED ASAP – now BLS skill
Change op Q2min
Annual BLS training
Emphasis on signs of life rather than vital
No finger sweep
Chest compressions only OK
Place hand over centre of chest
Precordial thump de-emphasised
Major
No interruptions – push hard, push fast
Compress charging
Change Q2min
No atropine
ETCO2
Minor
100/min
Drug IV/IO not ETT
Single shocks
200J
USS for checking heart activity
Avoid hyperoxia
Hypothermia for surivivors
Precordial thump for witnessed collapse
Angioplasty post ROSC
CT head:
Lat ventricle  3rd ventricle  quadrigeminal cistern, suprasellar cistern  4th ventricle
Ring enhancing lesions:
Mets
Radiation necrosis
Tuberculoma
Haematoma (resolving)
Aneurysm
Multiple sclerosis
Primary brain tumour (glioblastoma, CNS lymphoma, cystic astrocytoma)
Abscess toxoplasma, TB
cryptococcus, candida
Staph aureus, strep
prevotella, pseudomonas
anaerobes, bacteroides
neurosyphilis
A. Synovial Fluid
Class 2
Class 3
Class 4
Inflammatory*
Purulent
Hemorrhagic
Cloudy-opaque
Cloudy-opaque
Cloudy
Dark yellow
Dark yellow-green Pink-red
Volume (ml)
>3.5
>3.5
>3.5
Viscosity
Low
Low
Variable
3000-100,000
>40,000
>2000
Wbc/L
PMNs
30%
50%
75%
Gram + culture
Neg
Usually positive
Neg
Glc:serum
<
<<
=
Differentials
Rheumatoid
Pyogenic
Trauma
Gout
S. aureus
Fracture
Pseudogout
Gonococcus
Bleeding
Reiter’s
(25% G+C only)
diathesis
Ank spond
Hemophilia
Psoriatic
Neuropathic
Sarcoid
Hemangioma
IBD
Bleeding
Scleroderma
neoplasm
Rh fever
TB, viral
*pseudogout = pos birefringence; gout = neg birefringence; RA = phagocytic PMN inclusions;
Reiters = phagocytosis of leucs by macrophages
Type of fluid
Appearance
Normal
Normal
Clear
Light yellow
<3.5
High
<200
<25%
Neg
=
N/A
Class I
Non-inflamm
Clear
Light yellow
>3.5
High
200-2000
<25%
Neg
=
Degenerative
Trauma
AVN
Neuropathic
HPOA
Early inflamm
B. CSF
Parameter
Pressure cmH2O
Wcc/mm3
Predominant
cell type
Glucose
Protein
Normal
7-20
<5
neonates <30
Lymphocytes
0 PMNs
0.6 x serum
0.8 in neonates
15-45 mg/dl
Bacterial
Very high
>200
up to 20,000
PMN
(10% lymphocytes)
Low
0.3 x serum
High > 50
Viral
N / slightly high
<1000
TB / Fungal
Very high in TB
<1000
Lymphocytes
(50% PMN initially)
Normal or high
Lymphocytes
Normal or high
High
Low / N
Organisms
90 in infants
0
80% +ve
60% if pretreated
0
80% +ve ZN
90% crypto Ag
C. Abdominal Paracentesis
Traditionally classified as transudate vs exudate
More useful is serum-ascites albumin gradient (SAAG)
SAAG
Protein
pH
LDH
Glucose
WCC
Causes
Transudate
High (>11g/l)
< 30g/l
> 7.3
Low
Normal
<1000 /l
Portal HT present:
Cirrhosis
Heart failure
Constrictive pericarditis
Budd-Chiari or veno-occlusive disease
Exudate
Low (<11g/l)
> 30g/l
< 7.3
High
Low
> 1000 /l
Non-portal HT etiology:
Malignancy
Inflammatory / Infection
Pancreatitis
Lymphatic obstruction
Bacterial peritonitis likely if: (ADHB RMO Handbook 2005)
 Wcc > 500 x 106 / L
 Predominantly neutrophils