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TC's emergency medicine wrap up 4

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TC's emergency medicine wrap up 4

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TC's emergency medicine wrap up 4

  1. 1. T C ’ S P O T P O U R R I T H E M E M E E D I T I O N
  2. 2. W H A T I S A M E M E ?
  3. 3. F E A S T S T U D Y • I’ve mentioned it before • Essentially found shocked septic kids in Africa did worse with fluid boluses over maintenance fluid • Comment from the floor was “yeah but they’ll all have malaria and the fluid will make their cerebral oedema worse” • Fair enough
  4. 4. S H U T U P F E R G I E • The non-anaemic and non-malaria patients were analysed • Found to have the same poor outcomes with fluid boluses over maintenance fluids as the anaemia and malaria kids • Regardless of whether albumin or crystalloids given
  5. 5. S G A R B O S S A C R I T E R I A • Smith modified Sgarbossa rule: • At least one lead with concordant STE (Sgarbossa criterion 1) or • At least one lead of V1-V3 with concordant ST depression (Sgarbossa criterion 2) or • Proportionally excessively discordant ST elevation in V1-V4, as defined by an ST/S ratio of equal to or more than 0.20 and at least 2 mm of STE. (this replaces Sgarbossa criterion 3 which uses an absolute of 5mm)
  6. 6. S E V E R E C U T A N E O U S A D V E R S E R E A C T I O N S • Drug hypersensitivity syndrome is the same as DRESS • SJS/TEN • Acute generalised exanthematous pustulosis (AGEP) • drug induced erythroderma • Severe, unexpected reaction to a medicine(s) • high fever, a morbilliform skin rash • inflammation of one or more internal organs including the liver, kidneys, lungs and/or heart • It generally starts two to eight weeks after taking the responsible medicine.
  7. 7. C U L P R I T S • Allopurinol • AEDs esp. carbamazepine, phenobarbitol, phenytoin • Sulfonamides • But really anything
  8. 8. M E A C U L P A
  9. 9. wire left in Individual Factors Patient Factors Task Factors Education and Training Team and Social Factors Working Conditions Equipment and resources Communi cation Organisati onal and strategic Factors
  10. 10. C H O I C E S R A N K R A T E 1 8 G I V C 8 . 5 F R R I C 0 0 : 4 6 6 F R S H E A T H 7 F R R I C 1 : 0 0 8 . 5 F R R I C 8 . 5 F R S H E A T H 1 : 0 5 1 4 G L U M E N C V C 1 4 G I V C 1 : 3 0 7 F R R I C 6 F R S H E A T H 2 : 1 0 1 6 G I V C 1 4 G 1 3 . 3 C M I V C 2 : 1 0 2 0 G I V C 1 6 G I V C 2 : 2 0 1 4 G I V C 1 8 G I V C 4 : 2 3 8 . 5 F R S H E A T H 1 4 G L U M E N C V C 5 : 2 0 1 4 G 1 3 . 3 C M I V C 2 0 G I V C 6 : 4 7
  11. 11. C O U N T R Y W E E K • 13yo playing football, someone stepped on his foot while trying to spin round • pain
  12. 12. T I L L A U X F R A C T U R E • Salter Harris III distal tibia epiphysis • Caused by an avulsion of the anterior inferior tibiofibular ligament • Mechanism of injury is thought to be due to an external rotation force • 12-14yo • A period of time exists when the lateral physis is the only portion not fused • An additional fracture in the posterior distal tibial metaphysis in the coronal plane would result in a…?
  13. 13. B A R B A R A • 70yo lady • sore right knee • normal XR with GP • moderate effusion, ROM ~70º • No PMHx
  14. 14. P L A N ?
  15. 15. W H A T A R E Y O U L O O K I N G F O R I N T H E S Y N O V I A L F L U I D ?
  16. 16. C O U R S E • D/C with NSAIDS and Dx with pseudogout • Recalled 2 days later after bacteria grown • Sent home by ED as patient feeling ok • No bloods done • Back 5 days after initial presentation with obvious septic joint
  17. 17. • Unwitnessed arrest • Initial non-VF Rhythm • Lack of bystander CPR • >30 min to ROSC • >30 min of CPR • Evidence of unresponsive hypoperfusion and microcirculatory failure: • pH <7.2 and Lactate >7 • Age >85 • End-Stage Renal Disease (ESRD • Non-Cardiac Causes: Cardiac arrest due to drugs, drowning, acute stroke, terminal cancer and trauma, just to name a few non-cardiac causes, are likely to result in poor outcomes post-resuscitation. Unfavourable for Cath
  18. 18. A V O I D • All STEMI criteria patients • excluded if sats <94% • There was an increase in the rate of recurrent myocardial infarction in the oxygen group compared with the no oxygen group (5.5% versus 0.9%; P=0.006) • An increase in frequency of cardiac arrhythmia (40.4% versus 31.4%; P=0.05). • At 6 months, the oxygen group had an increase in myocardial infarct size on cardiac magnetic resonance (n=139; 20.3 versus 13.1 g; P=0.04).
  19. 19. P L U G F O R A C H A R I T Y • I’ve belonged for ~5years • “Medics Beyond Medicine” • For doctors who want to connect with people with mental and physical disabilities rather than just see them in a clinical setting • Generally revolves around outings • Recently featured on channel 9 news
  20. 20. • Emma and Dave volunteered their time • “Daniel” here has myotonic dystrophy as seen by the tell tale baldness pattern • “Chris” has a rare chromosomal abnormality that means he has a compulsion to wear a cap in an inappropriate setting
  21. 21. A G E A D J U S T E D D - D I M E R • Wells score ≤4 • Age ✷ D-dimer (0.01mg/L) • ie a 70yo will have an acceptable D-dimer <0.7mg/L • Validated in multiple studies • I think we should use it
  22. 22. C E N T O R • History of fever • Tonsillar exudates • Tender anterior cervical adenopathy • Absence of cough • The Modified Centor Criteria add the patient's age to the criteria • Age <15 add 1 point • Age >44 subtract 1 point • -1, 0 or 1 points - No antibiotic or throat culture necessary (Risk of strep. infection <10%) • 2 or 3 points - Should receive a throat culture and treat with an antibiotic if culture is positive (Risk of strep. infection 32% if 3 criteria, 15% if 2) • 4 or 5 points - Treat empirically with an antibiotic (Risk of strep. infection 56%) • The presence of all four variables indicates a 40 - 60% positive predictive value for a culture of the throat to test positive for Group A Streptococcus bacteria. The absence of all four variables indicates a negative predictive value of greater than 80%
  23. 23. W H A T A N T I B I O T I C • Phenoxymethylpenicllin • Cheap, proven • Never been a resistant GABHS to penicillin • Good anaerobic cover just in case the patient has…
  24. 24. F U S O B A C T E R I U M N E C R O P H O N U M • lemierre’s syndrome • Thrombus of the internal jugular • Sepsis • Mortality of ~5% • Not sensitive to macrolides

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