Emergency Department, Poisoning, Shock

Constrictive pericarditis suspect? Mx?

Present as right sided failure signs CT pericardial sac >5mm thickness Most course unknown but rule out tuberculosis. Diuresis ± pericardial snipping ± inotrope

Face trauma

Septal haematomas Complication: septal necrosis >6h P: refer ENT for drainage as soon as possible ie simple incision and expression of clot followed by anterior packing 2-3d. Nasal bone fracture Finding: tenderness or contusion over bridge of nose. Ix: Imaging often unnecessary if tenderness or swelling isolated to bony bridge, patient can breathe through each naris, no deviated septum, no septal haematoma. Otherwise: "Water/OM/37º view" and "Caldwell/occipitaofrontal/15º view" P: ice, head elevation, refer ENT. If displaced: reduce <6h (alt reduce after 3-7d after swelling resolve). If nasal fracture >10d: ENT outpatient. Midface fracture Finding: contusion over cheekbone, enopthalmos, malocclusion, upper lip oedema, epistaxis, subconjunctival haemorrhage, dish face, cheek paraesthesia, cracked pot sound on upper teeth percussion. Ix: CT face. Types: LeFort I (transverse maxilla fracture; motion in the maxilla when the upper teeth are grasped and rocked, while the forehead is held stationary with the other hand). LeFort II (fracture lines extend superiorly in midface, shaped like a pyramid; finding nasal complex moves as a unit with the maxilla when the teeth are grasped and rocked, while the forehead is held stationary). LeFort III (rare; craniofacial dissociation) Cribiform plate of ethmoid bone fracture (finding: CSF leak, anosmia)(P: elevated head of bed 40-60º to reduce ICP and allow leak to seal) P: intubate for airway protection. Avoid nasopharyngeal airway Oral laceration P: if through-and-through: close in layers beginning with mucosa Tooth fracture Ellis Class I (finding: enamel only, not painful)(P: dental outpatient), Class II (finding: expose yellow dentin, may be painful)(P: cover exposed area with Ca hydroxide, wrap with dental foil, liquid diet and dental outpatient), Class III (finding: exposed dental pulp, seen as a red line or dot, exquisitely painful)(P: dental <48h) Partially avulsed teeth P: if intoxicated, neurologically impaired or require cervical spine immobilisation: remove to prevent aspiration. Otherwise, reimplantation under LA with acrylic splint or wiring stabilisation. TMJ meniscal or collateral ligament injury Finding: clicking or popping or inability to open mouth fully P: if no fracture or dislocation but with pain and difficulty opening mouth: soft food diet, avoid yawning or straining to open mouth wide, refer dental <2w. TMJ anterior dislocation Finding: unable close mouth, garbled speech, drooling Risk: open mouth wide eg yawn, laugh, kiss or sing Ix: XRay before reduction Tongue lacerations If <1cm, non-gaping and assessed to be minor by examiner: no need repair. Otherwise: suturing needed Auricular haematomas Complication: necrosis, infection, cauliflower ear P: drain as soon as possible after injury. If <2cm and <48h: needle aspiration. Otherwise I&D or evaucation using intravascular catheter. After drainage, levofloxacin (to cover skin flora and Pseudomonas)(if children: augmentin) 7-10d, daily f/u 3-5d (to evaluate reaccumulation or infection), return to sports only after 7d after injury. If >7d old: refer ENT or plastic surgeon for debridement of new perichondrial growth and any remaining haematoma. Auricular laceration Complication: infection, erosive chondritis, necrosis with resulting cartilage loss or cauliflower ear P: primary closure at time of presentation (and STO at 7-10d) unless obvious signs of inflammation (redness, warmth, swelling or pus discharge). If auricular avulsions, through and through lacerations of the auricle, external ear lacerations that extend into the external auditory canal, chronically split earlobes or clefts, or have associated middle ear trauma or basilar skull fracture: refer ENT. Post repair: follow up in 24h to assess for infection or haematoma. IM ATT as needed. If bites, excessive wound containation, vascular insufficiency (eg PAD) or immunodeficiency: prophylactic abx.

Poisoning - plan?

Exposure to medications, farming chemicals, industrial chemicals, self-brewed beverages, cherry or apple seeds. Sx: seizures, arrhythmia, burns - Paraquat: abdominal pain, nausea, vomiting, renal failure and fatal lung blisters and pulmonary oedema. Majority deteriorate at 72h. O/E: DRSABC. Do not give mouth to mouth if taken cyanide(ie electroplating, cherry and apple seed), organophosphate (ie insecticide), azine or phosphine. Exam eyes for pupils size, nystagmus, reactivity, dysconjugate gaze, increased lacrimation anticholinergics (finding: abdo hypoactive) organophosphates (finding: abdo hyperactive, diaphoresis, diarrhoea, urination, muscle fasciculations, bradycardia, emesis, lacrimation, salivation) opioid (finding: coma, respiratory depression, miosis/mydriasis) isoniazid (finding: coma) snake bite (finding: paralysis) ethylene glycol (finding: anisocoria) methanol (finding: blindness) Ix: - If pesticide poisoning: TDM PCM, salicylate and cholinesterase (ED HKL) - FBC, RP, Ca, Mg, PO4, LFT, Coag, VBG (ED HKL) - ECG P: - IVD Specific Ix: - TCA, methanol or ethylene glycol, aspirin: ABG - Lithium, methanol or ethylene glycol: UEC - Ethylene glycol or hydrofluoric acid: Ca levels (as hypocalcaemia can happen) - Hydrofluoric acid, digoxin, beta blocker, CCB: ECG - Etyhlene glycol: urine MCS can show crystaluria - Alkali ingested: oesophagoscopy after 24h - Paraquat urine and blood level P: - Wipe obvious contamination from around mouth. Dry caustic material: brush away before irrigation. Chemically contaminated clothing: remove clothing, wash body with tepid water and soap. Chemical in eye: irrigate with water for a minimum of 15min. - High flow oxygen to prevent complications (except in paraquat poisoning ie herbicide). - Ingested warfarin, BZD, beta blocker, CCB, digoxin, carbamates, organophosphate, cyanide, paracetamol, salicylate, TCA, isoniazid or paraquat in the last 1h: activated Charcoal 1g/kg up to 50g po/ng (ineffective for acids, alkalis, liquid hydrocarbon and small ionised metals such as iron, lithium or potassium) - Acid or alkali ingested: water or milk 1 -2 cups - Contact national poisons centre - Methanol or ethylene glycol: NG aspiration - Aspirin or lithium: haemodialysis - Beta blocker: glucagon - CCB: calcium chloride or glucagon - Iron: desferrioxamine - Isoniazid: pyridoxine - TCA: sodium bicarbonate - Methanol: ethanol, folate or haemodialysis - Ethylene glycol (antifreeze): ethanol, pyridoxine, thiamine or haemodialysis - Paraquat (herbicide): N-acetylcesteine, desferrioxamine, nitric oxide or haemodialysis within 6h - Carbamate (pesticide): atropine - Organophosphate (insecticide): atropine, pralidoxime - Cyanide: oxygen, amyl nitrite, hydroxocobalamin, sodium thiosuphate, sodium nitrite or dicobalt edetate - Sustained release CCB, iron or lithium: whole bowel irrigation - Hydrofluoric acid: skin: wash area and apply calcium gluconate gel. Eyes: irrigate with calcium gluconate in NS. Ingested: Ca or Mg salts. - Beta blocker poisoning with cardiovascular collapse: Amrinone (ie pyridine phosphodiesterase 3 inhibitor, which improves prognosis in patients with congestive heart failure) or isoprenaline (ie non-selective β adrenoreceptor agonist that is structurally similar to epinephrine) - CCB poisoning with cardiovascular collapse: Amrinone (ie pyridine phosphodiesterase 3 inhibitor, which improves prognosis in patients with congestive heart failure)

Snake bite

FBC, RP, LFT, Coag, CK RPP (rapid proximal progression) chart If signs of systemic envonemation (eg collapse, convulsions, weakness, paralysis, respiratory failure, shock, or bleeding): antivenom (alt neostigmine) IM ATT 0.5ml stat

Traumatic brain injury

Finding: - low GCS - sign of raised ICP ie headache, vomit, seizures, Cushing's reflex (ie HTN, bradycardia), pupil sluggish constriction to light, dilated pupils (d/t uncal herniation compressing oculomotor nerve) Complications: chronic traumatic encephalopathy (d/t recurrent mild TBI) Classification: 1) Severity. Mild is GCS 13-15. Moderate is GCS 9-12. Severe is GCS 3-8. 2) Mechanism. Blunt (low or high velocity). Penetrating (eg gunshot wound) 3) Morphology: skull fracture. Intracranial lesions Mild - Finding: transient LOC (internet: ≤30min), GCS 13-15, disorientation, amnesia (internet: ≤24h) - Prognosis: most fully recover (MTLS); 3% unexpected deterioration (MTLS); 30-53% may have persistent disabling symptoms (internet) - Ix: *If high risk (ie GCS<15 after 2h of injury, suspected depressed skull #, sign of basal skull #, vomit ≥2x, ≥65yo, anticoagulant use) or moderate risk (ie LOC>5min*, retrograde amnesia >30min, high impact mechanism), *unequal pupil* or focal neurological deficit: *CT* brain (MTLS) - P: head chart min 6h (ie vitals, pupils, GCS, power, clinical events eg vomit≥2x, seizure, diffuse headache, amnesia or abnormal behaviour). Half hourly x2h ➝ hourly x4h ➝ if extended: 2Hly x 6h. W/o antegrade amnesia, GCS, and sign of raised ICP. If after observation remain asymptomatic, alert, no neurological deficit: discharge with head advice and companion to monitor for 24h, w/o for "change in LOC, amnesia, worsening headache, vomiting, seizures, ENT fluid or neurological deficit". Rest a few days off from work. If headache: PCM KIV migraine drugs. If dizzy: bed rest. No "driving, aggressive sport, alcohol or sleeping pills". When feel better, mild exercise. Moderate - Finding: GCS 9-12 - Complication: impaired cerebral blood flow autoregulation; 10-20% deteriorate into severe TBI - Ix: CT brain - P: refer *neurosurgical ICU for frequent neurologic assessment*. Avoid opioid to prevent airway loss and hypercarbia. Early nutrition to prevent stress ulcer and improve immunity. At 48-72h after trauma: KIV thromboprophylaxis if benefit outweight risk. W/o SIADH, central DI or cerebral salt wasting. Severe - Finding: GCS 3-8 - Complication: 15% develop post traumatic epilepsy - P: intubation and ventilation. Refer neurosurgical. Limit secondary insult - intracranial insults: cerebral oedema. *Sedation*. IVI Fentanyl 0.5-2mcg/kg/h or IVI Morphine 0.05-0.1mg/kg/h for analgesia. IVI Midazolam 0.05-0.1mg/kg over 2-5min for sedation, then IVI Midazolam 0.01-0.2mg/kg/h. Early seizure prophylaxis with IV *Phenytoin* 1g (15-20mg/kg) in NS 100cc over 1h then 100mg TDS 7d (to decrease early traumatic seizure ie <7d of injury)(alt IV Levetiracetam 20mg/kg rounded to nearest 250mg over 60min, then 1000mg up to 1500mg over 15min BD). If raised ICP >20: IV Mannitol 20% solution 1g/kg over 5min or hypertonic saline to lower ICP (prerequisite: euvolaemic and normotensive). If raised ICP refractory to mannitol or hypertonic saline: barbiturates eg pentobarbital. - systemic insults: hypotension, hypoxia, hypercarbia, hypocarbia, hypovolaemia, anaemia, electrolyte imbalance. Aim MAP>90, SBP>110 (if 40-50yo: >100), PaCO2 35-40, PaO2 >75-100, tight sugar 6-8mmol/L, temp control, Hb>7 (restrictive transfusion)(MTLS) Add-on: - Recovery: Astrocytes in subventricular zone and dentate gyrus can go through division and differentiation into new neurons that are proposed to play a role in replacing neurons in the cortex and hippocampus after TBI. - Normal cerebral blood flow is 50ml/100g/min. If it <25ml/100g/min, will lead to reduced EEG activity. If ≤5ml/100g/min will lead to cell death)

Organophosphate poisoning

Finding: - onset min to hours - Muscarinic features: DUMBELS ie diarrhoea, urination, miosis, bronchorrhoea, bronchospasm, bradycardia, bradypnoea, emesis, lacrimation, salivation - Nicotinic features: fasciculations, muscle weakness, paralysis, diaphoresis, mydriasis, tachycardia, HTN - CVS: non-cardiogenic pulmonary oedema, hypotension (esp dimethoate), arrhythmia (prolonged QTc, PVC, VT and VF) - CNS: irritability, lethargy, seizure, coma Complications: - intermediate syndrome (finding: 24-96h after cholinergic crisis, respiratory paralysis, proximal truncal and neck flexor muscle weakness, decreased deep tendon reflexes, motor cranial nerve palsies)(occurs in 20-50% of cases; recovers over 1-3w)(P: supportive therapy) - OPIDN (organophosphate induced delayed peripheral neuropathies)(occurs days to weeks after cholinergic crisis)(d/t inhibition of neuropathy target esterase) - delayed neuropsychiatric sequelae (finding: memory, concentration, problem solving and dexterity defects) Start Rx with compatible clinical features without waiting for lab results. Ix: low serum plasma cholinesterase level (differential: hereditary deficiency, malnutrition, chronic debilitating illness)(high level: after cocaine, suxamethonium, morphine, codeine and nephritic syndrome) Wear gloves as absorbed through GI tract, respiratory tract, skin, mucous membrane and conjunctiva NG tube aspiration. If intubated, gastric lavage If muscarinic Sx: IV atropine 0.6-1.2mg (if paeds 0.01mg/kg, at least 0.1mg to avoid paradoxical bradycardia). After 5min, repeat PRN at double dose. IVI at 10-20% of initial total atropine bolus per hour. Aim: no rhonchi, HR>80, SBP>80, dry axilla and pupils no longer pinpoint. NB tachycardia is usu a result of hypoxia from pulmonary secretions and not a CI to atropine use. SE confusion, pyrexia, absent bowel sounds or urinary retention. If severe: pralidoxime 1-2g in NS 100ml over 30min, then IVI 8-10mg/kg/h, titrate up to 20mg/kg/h, max . SE headache, dizziness, diplopia, blurred visoin, HTN and T wave inversion. NB no definite evidence to prove or disprove use of oxime in organophosphate poisoning. If need intubation, use non depolarising agents as depolarising agents can have a prolonged action in the face of depleted AChE. Add-on: - inhibits AChE, resulting in excess ACh - insecticide may use hydrocarbon as a vehicle. Hydrocarbon aspiration causes pneumonitis - carbamates treat as per organophosphate. Less CNS abnormalities as lack CNS penetration. Not need pralidoxime.

Wounds

Finding: abrasion, laceration, scalded, jagged P: - analgesia - T&S. Use cyanoacrylate skin glue, steristrips or nylon/ethilon. LA lignocaine 1% 5mg/kg. Face 5-0, STO 3-5d. Torso 3-0, STO 10-14d. Elsewhere 4-0, STO 7-10d. WI D3. Keep dry until change of dressing. Seek review if dressing soaked with blood, pus or water. Gentle mobilisation only. - If needed: WD <4-8h and leave wound open - T. Cloxacillin 500mg 1w. Acriflavine lotion. CMC ointment. - In Msia, last tetanus vaccine is at 7yo and 15yo. Vaccine lasts 5y. If "wound clean but last vaccination >10y" or "wound dirty (eg soil, saliva, faeces or dirt) but last vaccination >5y: IM ATT 0.5ml. If wound dirty and never had tetanus vaccination: IM Tetanus Ig 250u. If wound near joints: refer ortho as may cause contractures Refer plastics if - facial or scalp lacerations with suspected cranio-facial bone fractures, including frontal bone/sinus which does not require acute neurosurgical intervention - linear laceration wounds >3cm involving the periorbital, nasal, perioral, cheek, preauricular/parotid regions - any lacerations involving the ear - any jagged facial wounds with missing tissues and/or exposing vital structures like bone or nerves - very contaminated facial/scalp wounds including animal bites or gunshot injuries - facial wounds with apparent nerve palsy or paraesthesia - huge and jagged scalp lacerations or avulsion injury with skin loss Add-on: - Age 10-64: Adacel tdap 0.5ml. tdap vaccine costs RM60 in private sector - Tetanus vaccines are age appropriate and need 10 yearly repeats Age ≥10 and had not received adacel tdap: boostrix tdap. Age 6 weeks to 7: dtap Age 7-9 or ≥65: Tetanus-diphtheria toxoid

Bleach poisoning

Finding: stridor, drooling, vomiting, inability to swallow, oropharyngeal, retrosternal or epigastric pain Acute complications: - upper airway obstruction from edema - aspiration - perforation of oesophagus or stomach: pneumothorax, pneumomediastinum, pleural effusion, or free intraperitoneal air on radiographs. - GI bleed - systemic acidosis from direct absorption during large acid ingestions - shock and hemolysis - tissue necrosis Delayed complications: oesophageal strictures, pyloric obstruction, squamous cell carcinoma of oesophagus. In patient with unintentional ingestions, the absence of ANY symptoms in addition to normal drinking and eating is sufficient to rule-out a significant visceral injury P: - supportive. If on skin and eyes: copious wash with water. Do not give charcoal as obscrue endoscopy and does not absorb caustics. Do not pass NG tube as high risk GI perforation. - if present <30min: drink small amount of water. Do not force if resistant. - if present <4-6h: secure airway early (oedema may progress over first 4-6h) - early endoscopy <24h (wound softening starts >24h and lasts 2w and endoscopy then risks perforation). If grade IIb and III injuries: oesophageal stent - All suicidal patients need hospitalisation for observation of developing signs and symptoms. - If evidence of perforation: prophylactic abx to cover anaerobes - Surgery. If perforated (ie endoscopy or radiographic findings, peritonitis, persistent hypotension), high risk of perforation (ie acidotic or hypotensive patients), complete endoscopy not possible due to significant oesophageal injuries: surgery.

Cerebral artery dissection

Finding: stroke Risk: severe neck hyperextension or direct blow to back of head Ix: early CT angiography P: heparin asap then antiplatelet or anticoagulate for 3m. If dissection with subarachnoid haemorrhage or refractory to medical therapy: neurosurgical or endovascular treatment

BZD overdose

Flumazenil (vial 0.5mg/5cc) BZD sedation: IV 0.2mg over 15s. After 1min, repeat PRN until 1mg. BZD overdose: IV 0.2mg over 30s (paed: 5mcg/kg max 40mcg/kg). After 1min, repeat PRN at 0.3mg, then 0.5mg, up to max 5mg.

Dehydration

Grading - weight loss (<5%➝ 5-10%➝ >10%) - thirst (normal ➝ thirsty ➝ reduced) - behaviour (appropriate➝ irritable➝ lethargy) - peripheral temperature (warm➝ warm➝ cool) - pulse volume (good➝ reduced➝ thready) - HR (normal➝ tachycardia➝ tachycardia) - RR (normal➝ normal➝ tachypnoeic from acidosis) - BP [normal➝ narrowing pulse pressure➝ <5th centile i.e. SBP < (2xage) +65)] - fontanelle (normotensive➝ flat➝ sunken) - eyes (not sunken➝ sunken➝ sunken) - mucous membranes (moist➝ dry➝ dry) - skin appearance (normal➝ normal➝ pale or mottled) - CRT (<2➝ <2➝ >2) - skin turgor (<3➝ >3➝ >3) - oliguria (normal➝ <1cc/kg/h➝ <0.5cc/kg/h) Classification: - no clinically detectable dehydration (usu <5% loss of body weight) - clinical dehydration i.e. ≥2 moderate signs (usu 5-10% loss of body weight) - shock i.e. ≥2 severe signs (usu >10% dehydration) For fluid deficit calculations: use the lower end of the estimated percentages (i.e. moderate use 5%, shock use 10%) Complications: pre-renal AKI Rate of replacement - Paed protocol page 22: rapid in AGE, but should be slower in DKA and meningitis, and much slower in hypernatraemic states (aim to rehydrate over 48-72h, the serum Na should not fall by >0.5mmol/L/h) - Dr Marina: for AGE, if eunatraemic, replace fluid deficit with NS over 8-12h (Paed protocol p 232: over 4 hours if 5% dehydrated); if hyponatraemic over 24-48h; if hypernataemic over 72h. Hyponatraemic dehydration - o/e obvious BP drop per unit of water loss (as water does not stay in the extracellular compartment) - Complications: hyponatraemic encephalopathy (as a result of shift of water into neurons)(p/w convulsions) - due to Na loss>water loss - Risk: poorly nourished infants, drinking hypotonic solutions to replace fluid loss - P: --- IV 3% NaCl 4cc/kg over 30min (if hyponatraemic seizures)(raises Na by 3mmol/l). --- Replace fluid deficit based on level of dehydration over 48h (if dehydrated) --- Give half of Na deficit (if euvolaemia). Na deficit (mmol) = (135-Na) x0.6 x weight (kg). (NB NS contains 154mmol/l of Na; 3% NaCl contains 513mmol/l of Na) - Warning: limit Na ↑ ≤8mmol/L/d to avoid osmotic demyelination syndrome Hypernatraemic dehydration - p/w irritability, doughy skin, signs of extracellular fluid depletion are less per unit of fluid loss (because intravascular volume is relatively preserved) - Complications: cerebral shrinkage within a rigid skull (p/w jittery movements, hypertonia, hyperreflexia, ataxia, altered consciousness, seizures and multiple, small cerebral haemorrhages). Transient hyperglycaemia occurs in some (it is selfcorrecting and does not require insulin). - due to water loss>Na loss - Risk: high insensible water loss e.g. high fever, dry environment, profuse low sodium diarrhoea, diabetes insipidus, large amount of NaHCO3 infusion - P: --- Replace fluid deficit (estimated from examination) with NS over 48-72h (if dehydrated). Repeat Na 6 Hly until stable. Alternatively: calculate fluid deficit based on Na level. Current Na x 0.6 x Wt = Target Na x ["0.6 x Wt" + Fluid deficit in L] and replace the fluid deficit over 48H. Target Na is taken as 145 - Warning: limit Na ↓ <0.5mmol/L/h (i.e. <12mmol/L/d) to avoid cerebral oedema Add-on: - TBW (total body water) is 80% of total body weight in newborn, 60% of that in male, 50% of that in female

ED US ultrasound

Heart [for parasternal long axis, probe at left sternal edge 2-4th ICS marker R shoulder; for parasternal short axis, turn marker to L shoulder; for apical 4 chamber slide probe down until don't see heart then tilt probe anteriorly; subxiphoid view. - Normal heart [Finding: at subxiphoid view, RV basal diameter is 2/3rd of LV, LV wall is thicker than RV. Ventricular walls move ≥30% towards the centre is good contractility. Valves open and close normally. At parasternal long axis, there is septal movement and septum touches mitral valve. At parasternal short axis inferior, lateral, anterior and septal wall all come to the centre. At apical 5 chamber view with Doppler signal at the aortic valve, LVOT VTI 18-22cm indicate normal stroke volume) - Hypovolaemic shock [finding: hyperdynamic LV (ie ventricular walls touch or almost touch at the end of systole. LVOT VTI<18cm and fluid challenge increases it by ≥15% ie fluid responsiveness] - Distributive shock [finding: when early, hyperdynamic LV (ie ventricular walls touch or almost touch at the end of systole) and LVOT VTI>22cm. When late with myocardial depression, LVOT VTI<18cm. Fluid challenge increases LVOT VTI by ≥15% and inotrope increases LVOT VTI by ≥20%] - Obstructive shock [finding: LVOT VTI<18cm and fluid challenge increases it by ≥15%. If at subxiphoid view noted anehoic region at pericardial sac: indicates pericardial effusion (<1cm is small; 1-2cm is moderate; >2cm is large). If pericardial effusion and in clip mode, at diastole noted R ventricle is fully collapsed: tamponade. If in apical 4 chamber view, noted RV/LV ration > 0.9: suggests RV enlargement in PE. If in parasternal short view: noted LV D sign (ie bowing of the interventricular septum towards the LV): indicate increase pressure in the RV as in PE. If at apical view noted RV mid free wall akinesia and apical hyperkinesia ie McConell sign: indicate RV strain as in PE. If RV free wall hypokinesis or TAPSE<16mm: indicate RV systolic dysfunction as in PE] - Cardiogenic shock (finding: LV wall movement <30%. LVOT VTI <18cm, fluid challenge increases LVOT VTI by ≥15% and inotrope increases LVOT VTI by ≥20% ie contractile reserve present. In severe cases of cardiogenic shock, contractile reserve may be absent) IVC (measure IVC outer tablet to outer tablet 2cm from atriocaval junction; shake probe if obstructed by bowel gas as this moves gas away; if cannot see at midline, use rescue view ie transhepatic view at MAL with probe longitudinal and anterior tilt; posterior tilt gets aorta) - Undervolume (Finding: if not on mechanical ventilation: IVC<2cm, collapsibility index ie exp-insp/exp >50%. If mechanical ventilation: distensibility index ie insp-exp/exp >18%) - Haemorrhage (Finding: IVC <1cm in setting of trauma indicates high likelihood of haemorrhage requiring Tx) RUQ view (at MAL 8-11th rib) - Intraabdominal fluid (Finding: anechoic at Morrison pouch, caudal tip of liver (most Se), inferior pole of right kidney and subdiaphragmatic space - Pleural effusion/haemothorax (Finding: anechoic wedge superior to liver + absence of mirror sign + presence of spine sign ± absent curtain sign). LUQ view (at PAL 6-9th rib) - Intraabdominal fluid [Finding: anechoic at splenorenal recess, inferior pole of kidney, subdiaphragmatic space (most Se)] - Pleural effusion/haemothorax (Finding: anechoic wedge superior to spleen + absence of mirror sign + presence of spine sign ± absent curtain sign). Suprapubic view [2 views; transverse view scan until see prostate; Bladder volume (ml) is longitudinal view's craniocaudal dimension x horizontal view's transverse dimension x horizontal view's AP dimension x 0.52] - Intraabdominal fluid (Finding: anechoic at rectovesical, rectouterine/Pouch of Douglas, vesicouterine pouch)[causes: intraabdominal injury, ruptured AAA, ruptured ectopic pregnancy, ruptured hemorrhagic ovarian cyst, ascites, perforated gastric ulcer, dengue (in asymptomatic women, some intraabdominal free fluid may be normal)] Lung scan (set depth to 18; zone 1 at MCL rib 3-4, zone 2 MCL below nipple line, zone 3 and 4 MAL above and below nipple line) - Pulmonary oedema [Finding: B lines (ie hyperechoic-white vertical lines extending from the pleural line into the far field) in bilateral and all lung zones indicate fluid-filled alveoli] - Pneumothorax [Finding: absent sliding sign + barcode sign ± lung point] - Pneumonia (Finding: B lines, shred sign, air bronchogram that moves with respiration) - Normal [Finding: A lines (take 3 reverberations as adequate view; Dr Liana EP), Z lines (ie look like B lines but less echoic than pleural line, doesn't go all the way to the end of the screen ie short, does not erase the A-lines, and does not moving with lung sliding), and O-lines (ie absence of any horizontal or vertical artifact. A slight movement of the probe often brings out A-line)] - Atelectasis (finding: air bronchogram that does not move with respiration) Others: - AAA (Finding: aorta >3cm)(if aorta >5cm, assume any shock due to ruptured AAA). - DVT [Finding: non compressible vein or identification of echogenic material in vein "from common femoral vein at inguinal ligament to its division into femoral and deep femoral vein" or "from popliteal vein to its division into trifurcation"] Source: https://iem-student.org/rush/ https://onlinelibrary.wiley.com/doi/full/10.7863/ultra.15.14.08059 Dr Nadia

Paraquat poisoning

Herbicide. Forms PQ+ radical which causes lipid peroxidation. >10ml of 20% paraquat is potentially fatal. Finding: - corrosion of mouth, pharynx, oesophagus - cardiac effects with shock - renal and hepatic dysfunction Long term: pulmonary fibrosis P: - lowest FiO2 (as the redox cycling of PQ+ is sustained by O2). Aim adequate tissue oxygenation - Activated charcoal - Avoid gastric lavage due to corrosive risk - KIV lung transplant 6w post ingestion

Ingested battery (UpToDate)

If <12yo, battery ≥12mm or unknown size: XRay AP and lateral views from nasopharynx to anus If <2h of ingestion: honey 5-10ml (alt sucralfate 500mg) If >12yo and battery <12mm: no need radiography, observe at home. If battery passage not confirmed in 10-14d, abdo pain, haematochezia, or fever without confirmed battery passage: XRay If button battery lodged in oesophagus or "battery lodged in stomach and minor symptoms": endoscopic emergency removal If "<5yo and gastric button battery ≥20mm" or battery remains in stomach on follow up radiography after 48h: refer gastro If symptomatic intestinal button battery: refer surgical

Newborn (from birth to first spontaneous breath - AdvRes) resus?

If laboured breathing or persistent cyanosis, monitor SpO2 P: 1. If HR <100, perform positive pressure ventilation. At 1 min of life, target SpO2 60% (2min, 65%) (3min, 70%) (4min, 75%), (5min, 80%), and (10min, 85%) 2. If HR <60, start 1:3 breath:compressions, adrenaline iv 10-30mcg/kg, and NS IV. Intubation using an uncuffed ET tube size 3-3.5

Methadone

Indication: - Excitation or exacerbation of pain with morphine - Neuropathic pain (methadone is the only opioid good for neuropathic pain as also acts on the NMDA receptor) Caution: not recommended for initial management of acute pain due to its relatively slow onset of action. Very good oral absorption (in contrast to morphine and pethidine) and does not undergo extensive first pass metabolism. Must not be given IV due to a greater risk of respiratory depression. Start with 5-10mg po q6-8h For prolonged use, bd to avoid accumulation as half life 72h Methadone 20mg po = Morphine 30mg po

Carbon monoxide poisoning

Ix: COHb (>2% in non smokers or >10% in smokers) P: - 100% non rebreather mask for 4-6 hours (removes 90% of CO; reduces half life of CO from 320min to 74min) - Hyperbaric oxygen. (If If LOC, ischaemic cardiac changes, neurological deficit, significant metabolic acidosis, COHb >25%) hyperbaric oxygen at H Tengku Mizan or KK (reduces half life of CO from 320min to 20min)

Ottawa rules

Knee injury: - If ≥55yo, unable to flex to 90º, unable to take 2 steps on each leg after injury and in ED, or patellar or fibular head tenderness, arrange for knee XRay Ankle injury: - If unable to bear weight after injury and in ED or malleoli posterior edge or tip tenderness, request ankle Xray series Foot injury: - If unable to bear weight after injury and in ED or 5th metatarsal base or navicular tenderness, request foot Xray series

Traumatic primary survey conditions

Life threatening conditions: ATOMFC airway obstruction, tension pneumothorax, open pneumothorax Massive haemothorax ie blood ≥1500ml or "≥200ml/h for ≥3h". P: safe O 1 pint then massive Tx protocol. Urgent thoracotomy. Flail chest Flail chest is ≥2 consecutive ribs fractured on ≥2sites Complication: pulmonary contusion (finding: delayed XRay changes)(P: oxygen and ventilation. Selective intubation. Judicious fluids) Cardiac tamponade - Finding: Beck's triad (ie BP↓, muffled heart sounds, distended neck veins/JVP↑) - Others: dependent oedema, pulse pressure↓, pulsus paradoxus (BP drops >10mmHg with inspiration from loss of the higher left ventricular pressure), displaced apex, JVP Kussmaul sign (ie JVP rises on inspiration instead of drops); ECG shows pulseless electrical activity, small ECG voltages, electrical alternans; CXR shows enlarged cardiac shadow; FAST scan shows pericardial fluid - Risk: trauma - P: IVD to increase venous return. Needle pericardiocentesis under cardiac monitoring [angiocath 18G (Green) attached to syringe; insert between subxiphoid directed towards L MCL/tip of scapula at 40º angle to skin, continual approach as needle approaches right ventricle, once pericardial fluid aspirated, insert cannula into pericardial space, attach 3 way tap and remove 20cc fluid, recheck BP, repeat removal of 20cc PRN). Thoracotomy for direct operative repair

Declare death

Listen to the heart for 1min, breathing for another 1min, pulse for 1min, pupilary reactions and sternal rub. Exclude pacemaker and any tissue with radiation [brachytherapy or radioactive iodine (half life 8 days)] Death: delivered to mortuary 1h after announced time of death. Last office (e.g. removal of medical equipments and tie to reduce rigorous mortis) is done by nurse (NB try CPR for 30min if applicable. Death-in-line patients i.e. not for active resus are usually palliative in intent instead of curative). Borang daftar kematian signed by MO.

Pusat Racun Negara

Mon-Fri 8.10am-5.10pm +604 657 0099 Mon-Fri 5.10pm-10.10pm +6012 430 9499 Weekend and public holiday 8.10am-5.10pm +6012 430 9499

Medications that can be administered via ETT

NAVELO Naloxone Atropine Vasopressin Epinephrine Lignocaine O2

Opiod overdose

Naloxone (vial: 0.4mg/1cc) Partial reversal: IV 0.4mg/h (dilute 2mg/5cc into 500cc NS; ie 4mcg/1cc; give 100cc); then increase 0.1-0.2mg every 2-3min, up to 10mg given. Overdose: IV 0.4-2mg stat (paed: 0.1mg/kg). After q2-3min, repeat PRN up to 10mg.

Non depolarising NM blockage poisoning

Neostigmine (2.5mg/cc; undiluted) Non-depolarising neuromuscular blocking agent: 2-3mg over 60s (up to 5mg)

Neurogenic shock

Neurogenic shock: - Findings: variable features of spinal shock + low BP - Others; reduced JVP, bradycardia - d/t spinal cord sympathetic tone↓, causing venous return↓, causing pooling of blood in extremities - Risk: spinal shock, Parkinson's disease, multiple system atrophy, postural orthostatic tachycardia syndrome (POTS), and autonomic neuropathy from GBS - P: noradrenaline or metaraminol (α1 agonist with β effect)

NAR

No CPR No intubation No inotrope No haemodialysis

Needle stick injury (NSI)

Office hour: - Inform sister medical ward. Fill in forms in NSI kit. Bring to PC clinic. PC clinic nurse will take the bloods. After office hour: - Inform sister medical ward on call. Fill in forms in NSI kit. MO 3rd call to take the bloods (using lab form chopped with NSI) and send directly to virology lab and fill in the continuation sheet in the NSI kit, which is to be send to PC clinic the next working day. Do not squeeze the pricked finger Run it under running water Bloods: - HIV, HepB surface Ag and anti-HCV - For healthcare worker, add HepB surface antibody Risks of transmission by NSI if patient positive: - HBV 33% - HCV 3.3% - HIV 0.3% HepB: - If your HepB surface antibody is >10miu/mL (adequate) no treatment needed - If your HepB surface antibody is below that, HBIG in one arm, and Hep B vaccine 0, 1 and 6 at the other arm HepC: - no post exposure prophylaxis - if source positive, healthcare worker to add HCV RNA test at 6/52 post exposure HIV: - if patient is positive, start ART (tenofovir-emtricitabine + raltegravir) BD within 24h for 28/7 (not effective if started after 72h). Avoid unprotected sex for 6/12 - if patient not known (pricked by needle in bin), whether to start ART depends on the particulars of the needle stick injury e.g. shallow or deep prick, how much blood on the needle etc

Adrenal insufficiency

P/w - persistent hypotension despite fluid challenge - (congenital) mimics pyloric stenosis but with acidosis instead of alkalosis. females have ambiguous genitalia Ix: - 8am cortisol <550 nmol/L - iv/im synacthen 250mcg. At 0, 30 and 60min, cortisol levels all <550 nmol/L - hyponatraemia, hyperkalaemic acidosis P: - t prednisone Add-on: - normal 8am cortisol is >500 nmol/L - adrenal insufficiency can also be shown by a random cortisol <100 nmol/L, low serum aldosterone - taking traditional medicine causing adrenal suppression - congenital cause is most commonly secondary to CAH 21-hydroxylase deficiency - synacthen test: insert branula. Take serum cortisol (in plain tube) and ACTH (in EDTA tube with ice) for 0min. Give IV Tetracosactide 1 amp. Take serum cortisol at 30min and 60min. Use 1 set blood form for 3 sample serum cortisol and 1 form for ACTH.

Major trauma assessment

Polytrauma is a clinical syndrome in a patient who sustained serious injurie affecting ≥2 major organs or physiological systems Full PPE (mask, gown, gloves) Response AVPU Airway (see SOB) and cervical immobilisation - If failure of ETT insertion d/t laryngeal oedema, severe maxillofacial injury that distorts anatomy or severe oropharyngeal haemorrhage that prevents vocal cord visualisation: surgical airway eg cricothyroidotomy (eg percutaneous needle cricothyroidotomy or surgical cricothyroidotomy) or tracheostomy (by ENT) - If not Alert, Intoxicated or Distracted by other pain: cervical collar (length as measured by horizontal line between chin and shoulder) Breathing (see SOB) - If impending respiratory failure (eg restless or obtunded), apnoea, severe head injury (risk of functional airway occlusion), cardiopulmonary arrest: ventilate - If open wound: 3-sided occlusive dressing Circulation - Finding: pallor, CRT, coolish peripheries, temp, pulse volume, HR, BP, abdo bruise/seatbelt sign, tenderness or distension, peritonitis (percussion tenderness, involuntary muscle guarding, rebound tenderness), gentle pelvic palpating, urethral/vaginal bleed or scrotal haematoma, long bones ie humerus and femur, FAST intraabdominal free fluid - Causes of haemorrhagic shock in trauma: thoracic injury, great vessels injury, intraabdominal injury, retroperitoneal injury, pelvic injury or multiple long bones fracture If bleeding: bandage and elevation, direct 1 point compression, haemostatic suture, haemostatic agents eg tranexamic acid, tourniquet 2-3cm above for 20-30min, angioembolisation. If fracture: splint. If femur fracture: hare traction splint. Disability - Finding: unequal pupils (↑ICP ➝ uncal herniation ➝ compress oculomotor nerve ➝ sluggish pupillary constriction to light ➝ pupil dilation)(Ix: CT brain) and GCS (actual GCS is that without hypotension)(P: if GCS≤8 intubate for airway protection) Exposure - Finding: limb fractures, l/w, abrasions, hypothermia (T<34), logroll for spinal bruise, wound, bleeding, tenderness, step deformity, PR laxed anal tone, PR bleed, pelvic fracture, high riding or mobile prostate, rectal wall integrity - P: if limb fracture: upper or lower limb splint. Spinal board is for transfer only, remove as soon as possible <90min when on flat surface Primary survey adjuncts: - Traumatic XRay series [chest and pelvic XRay. If Nexus NSAID (ie neurological deficit, spinal tenderness, not Alert, Intoxicated or Distracted by other pain): cervical XRay. If penetrating trauma to abdo: AXR with markers. - GXM and VBG. If suspect abdo injury and haemodynamically abnormal: coag. - CBD (if no urethral blood)(take UPT and urine dipstick TRO microscopic haematuria) and RT (if no facial trauma or basal skull #)(presence of blood in the gastric contents suggests an injury to the esophagus or upper GI tract) - ECG and FAST If FAST +ve and pt stable: CT If FAST +ve and pt unstable: op If FAST -ve and pt stable: serial FAST x3 every half hourly, observe or CT If FAST -ve and pt unstable: seek extraabdominal source eg hollow viscous injury (uncommon in blunt abdo trauma)(eg mesenteric injury, duodenal hematoma, and perforation of the stomach, small intestine, and colon), retroperitoneal injury KIV DPL, op Penetrating abdominal trauma (MTLS): If haemodynamically normal - if lower chest wound: serial FAST, CT, thoracoscopy or laparoscopy - If anterior abdo: DPL, serial FAST and wound exploration. - If back and flank: DPL, serial fast, double or triple contrast CT If haemodynamically abnormal, free air, peritonitis, positive DPL, FAST or CT, evisceration or gunshot wound: laparotomy Blunt abdominal trauma (MTLS): Finding: abdo bruise, distension, tenderness, doughy consistency If haemodynamically stable: CT (may have occult intraabdominal or retroperitoneal injuries) and IV Cefobid, Flagyl and Pantoprazole If haemodynamically abnormal with suspected abdo injury, free air, diaphragmatic rupture, peritonitis, positive FAST, DPL or CT: laparotomy Secondary survey: head to toe exam, AMPLE and DXT Finding: scalp bogginess, scalp bleeding, eye, nose, mouth, facial bony prominence crepitus, deformity, malocclusion, ENT bleed, CSF leak, septal haematoma, periorbital swelling, face trauma, opthalmological problems, focal neurological exam, peripheral neurovascular status HEATS: high impact trauma include falls >6m (one storey is equal to 3 meters), high risk auto crash [ie intrusion: >30cm occupant site or >46cm any site, ejection (partial or complete) from automobile, or death in same passenger compartment], Automobile vs pedestrian/bicyclist, "Thrown, run over, or with significant (>30km/h) impact", Motorcycle crash >30km/h Add-on: Estimated blood loss in closed # (if open: loss is 2-3x greater): - Pelvis #40-80% TBW or 2-4L - Femur # 20-50% TBW or 1-2.5L - Tibia # 10-30% TBW or 0.5-1.5L - Humerus # 10-30% TBW or 0.5-1.5L DPL: misses diaphragm and retroperitoneum injury. Positive if free aspiration of blood, GI contents, vegetable fibers, or bile through the lavage catheter FAST operator dependent, misses diaphragm, bowel and pancreatic injuries. CT: transport required, missess diaphragm, bowel and some pancreatic injuries. If need transfer to another hospital, can transfer after primary survey of ABC done

Traumatic secondary survey conditions

Potentially life threatening conditions: Simple pneumothorax (P: if large air leak with inadequate ventilation or persistent lung collapse: thoracotomy) Haemothorax (P: if clotted: thoracotomy) Pulmonary contusion Tracheobronchial injury Finding: persistent pneumothorax, subcutaneous emphysema, haemoptysis P: KIV intubation. Bronchoscopy. Tube thoracostomy. If rupture of mainstem bronchus: thoracotomy Blunt cardiac injury (finding: abnormal ECG usu sinus tachycardia)(Ix: if haemodynamic consequence: echo. CK elevated sometimes only)(P: treat dysrrhythmias, perfusion) Traumatic aortic injury Finding: abdominal bruit. CXR shows widened mediastinum (>8cm supine, or >6cm upright), indistinct or abnormal aortic contour, deviation of trachea or NGT to the right, depression of left main bronchus, elevation of right mainstem bronchus, loss of the aortopulmonary window, widened paraspinal stripe, widened paratracheal stripe, left apical pleural cap, large left hemothorax, fracture of 1st or 2nd rib or scapula Ix: helical CT or aortography risk: rapid acceleration/deceleration P: thoracotomy Diaphragmatic injury Finding: most often left side. Bowel sound in thorax. CXR inability to trace the normal hemidiaphragm contour, intrathoracic herniation of a hollow viscus (stomach, colon, small bowel) with or without focal constriction of the viscus at the site of the tear (collar sign). If large, the positive mass effect may cause a contralateral mediastinal shift visualisation of a nasogastric tube above the hemidiaphragm on the left side. Left hemidiaphragm much higher than the right Rib fracture Complications: Rib 1-3: high impact injury. Rib 4-9: pulmonary contusion and pneumothorax. Rib 10-12: suspect intraabdominal injury. Ix: request left oblique XRay if suspect left rib fracture. If ≥3 ribs fractured: ABG P: analgesia. KIV intercostal block. if 1 rib fractured: surgical outpatient. If ≥3 ribs fractured: surgical urgent Traumatic asphyxia Finding: petechiae, swelling, plethora, cerebral oedema P: airway control, oxygen Esophageal injury Finding: unexplained pain, unexplained shock, CXR mediastinal air, unexplained left haemothorax or effusion Ix: endoscopy, contrast radiography Cause: severe epigastric blow P: thoracotomy Subcutaneous emphysema Cause: airway injury, pneumothorax, blast injury Liver (finding: AST or ALT >130U), spleen and kidney injuries - P: if haemodynamically stable: nonoperative observation. If bleeding: angiography eg splenic artery embolotherapy Small bowel injury Others: head injuries, spinal cord injuries, pulmonary oedema or aspiration Fractures (P: neurovascular exam. Circulation chart. Backslab, splint. W/o compartment syndrome)

Anaphylaxis

"Urticaria, generalised itching or flushing, oedema of lips, tongue, uvula or skin over min to hours" + "resp distress, hypoxia, hypotension, cardiovascular collapse, or sx of organ dysfunction eg hypotonia, syncope or incontinence" (Tintinalli) 2 or more of "skin or mucosal involvement", respiratory compromise, hypotension, or "persistent GI cramps or vomiting" min to hours after allergen exposure (Tintinalli) Complication: - biphasic phase of mediator release (cysteinyl leukotrienes), peaking 8-11h after inital exposure, manifesting SSx 3-4h after inital clinical manifestations cleared. Occurs in 4-5% of cases - mortality (risk: faster onset of Sx)(50% of fatalities occur within 1st hour) Cause: 30% unknown - Oxygen - Keep normotensive. Lie supine (if SOB: sit up). IVD NS 1-2L bolus (paeds: 10-20cc/kg bolus) P: - Gastric lavage & activated charcoal if drug was ingested - IM Adrenaline 0.5mg ie 1:1000 solution 0.5ml to anterolateral thigh (better absorption)(paeds: 0.01mg/kg ie 1:1000 solution 0.01ml/kg) stat. After 5-10min, repeat PRN x3. Then, if still need adrenaline, is called refractory anaphylaxis. IV Adrenaline 0.1mg (take 1:1000 1ml/1mg dilute into 10cc, give 1cc). Then, IVI Adrenaline 0.1mcg/kg/min [dilute single strength as adrenaline 2mg into 50cc (ie 40mcg/cc) and give 0.15cc/kg/h (alt in district dilute 1:1000 solution 0.5ml into 500cc NS, giving 1mcg/1ml solution, eg if 60kg, to give 360mcg/1h, ie 120dpm)]. Adrenaline is CI in IHD, severe HTN, pregnancy or b-blocker use. In those cases, consider IV/IM glucagon 0.5-1mg. - IM/IV Piriton 10mg TDS [alt Benadryl (diphenhydramine) 10mg or Phenergan (promethazine) 25mg] - IV Ranitidine 50mg TDS (if CrCL<50: BD) - IV/IM/PO Hydrocortisone 200mg stat and 100mg QID x2-3d (onset of action 4-6h)(cf prior to blood transfusion, sometimes give hydrocortisone iv 100mg od for 2 days) - If persistent angioedema (finding: hoarseness of voice, throat discomfort, stridor): Neb adrenaline 1:1000 4mg/4ml. Prepare for intubation or cricothyroidotomy. Refer ENT TRO laryngeal oedema - If persistent bronchospasm: neb salbutamol 5mg in NS 3ml q20min - Stop beta blockers - Refer medical - Observe in ED for 6-12h for tachycardia, widened pulse pressure (DBP drop). Before discharge, warn that rebound anaphylaxis can occur <48h. Later - allergic under anaesth clinic eg skin prick testing or challenge testing - training for injectable adrenaline - Medic alert bracelet 0123411137 www.medicalart.com.my RM100 for 5 years; RM500 for life-memnership; and RM50 basic emblem cost Prevention for contrast in allergic people: - T. Prednisolone 40mg 12h and 40mg 2h before procedure (alt IV Hydrocortisone 200mg stat 30min before procedure) - Green branula (set a day prior to exam)

Geriatric trauma ie >65yo

- Fall risk. Risk: older, female, previous fall, lower extremity weakness, balance difficulties, psychotropic drug use, arthritis (MTLS). - Osteoporotic bone risk fracture and higher incidence of occult fracture. P: if persistent hip pain despite negative radiographys, pay attention to acetabulum fracture which is easily missed - Diminished functional reserve (eg lower cardiac output or inadequate response to injury causing acidosis). P: careful fluid resus <1-2L (as may not tolerate large volumes and cause APO) - Ageing of electrical conducting system causing lower maximum tachycardic response (max HR=220-age). - Rigid chest wall and lungs, smaller lung volumes, less cilia, and more mucous producing cells risk pneumonia. - Cerebral atrophy and loss of water and proteins affect shape of ventricles. - Ageing skin delays wound healing. P: dressing - Ageing skin reduces defences against microorganisms. P: tetanus immunisation - Ageing skin lose temperature autoregulation and risk hypothermia. P: warm fluids, warm blankets, monitor temp regularly. - Comorbidities and preexisting medications. Hypotension should never be attribued to antihypertensive until haemorrhage and ischaemia is ruled out - Higher incidence of ICB even with minor head trauma. P: liberal use of CT - Difficult airway due to dentition, nasopharygneal fragility, macroglossia, microstomia, cervical arthritis. - Normal BP may be HTN. BP of 110 may be low for patient. - Osteoporotic and osteoarthritic cervical spine and canal stenosis make cervical fractures hard to diagnose. P: consider early MRI - Elderly abuse. Finding: injury, unreasonable confinement, intimidation, cruel punishment

Consent for the underaged <18yo

- Legal guardians - JKM. (If not life-threatening and police unable to get legal guardians) JKM can represent legal guardian to sign consent - Consultant. (If life threatening and police unable to get legal guardians) consultant can sign consent. If emergency surgery needed, 2 specialist needed to give consent usu anaesth specialist and surgeon.

Children trauma

- Weight based drugs. P: Broselow tape to estimate weight - Floppy epiglottis. P: Use straight blade laryngoscope. - Large occiput cause passive flexion of cervical spine. P: Padding underneath torso. - Cephalad and anterior larynx. P: When trying to intubate, get lower than the patient and look up 45º - Narrow cricoid ring. P: Use uncuffed ETT for <8yo. - Oropharyngeal airway insert directly, no 180º rotation - Nasotracheal intubation not for <9yo d/t acute angle in nasopharynx area towards to anterior-superior located glottis - Surgical cricothyroidotomy only for >12yo. If <12yo: needle cricothyroidotomy. - Slightly higher blood volume 80mlkg. If hypovolaemic shock: 20-60ml/kg bolus of isotonic crystalloid, 10ml/kg of O-ve packed cell (MTLS) - Different disability assessment. AVPU. Rule out hypoglycaemia as glycogen stores easily depleted. If ≤2yo: pGCS (internet). If <4yo: modified verbal score (MTLS). - Large surface area to volume ratio risk hypothermia. Complication: coagulopathy. P: overhead heat lamp, thermal blanket, warm fluid - Head injury findings. Infants: full fontanelle, split sutures, altered consciousness, paradoxical irritability, persistent emesis, sun setting eyes. In children: headache, neck stiffness, photophobia, altered consciousness, persistent emesis, cranial nerve involvement, papilloedema, decorticate/decerebrate posturing. If <2yo without Sx of intracranial injury but with risk of skull fracture eg skull haematoma: skull XRay. If SSx of intracranial injury: CT brain. - Higher risk of SCIWORA. 30-40% of spinal cord injuries are SCIWORA. Most common spinal injury is cervical spine C1-2. - Cervical XRay preodontoid space normally ≤5mm (if adult ≤3mm) and normal anterior pseudosubluxation of C2 on C3. - Shallow pelvis higher risk of bladder rupture. P: prolonged observation with v/s monitoring and serial exam - Handle-bar injury have delayed Sx after 24h. P: prolonged observation with v/s monitoring and serial exam - Non accidental injury. Finding: discrepancy between history and physical injury (eg bites, cigarette burns, rope marks, sharply demarcated 2nd/3rd degree burn, multiple SDH, "perioral, genital or perianal injury", "long bone fracture in <3yo"), delayed presentation, repeated trauma (eg multicoloured bruise, frequent previous injuries), different history between guardians, hospital shopping, inappropriate response - Different normal values. MTLS: - 0-12mo: 0-10kg, HR<160, BP>60, RR<60, UO 2ml/kg/h. - 1-2yo 10-14kg, HR<150, BP>70, RR<40, UO 1.5ml/kg/h. - 3-5yo: 14-18kg HR<140, BP>75, RR<35, UO 1ml/kg/h. - 6-12yo: 18-36kg HR<120, BP>80, RR<30, UO 1ml/lkg/h. - >12yo: 36-70kg, HR<100, BP>90, RR<30, UO 0.5ml/kg/h.

Cardiac arrest

1) One person for compressor (alt with AED) - Straighten bed. CPR ie 2min cycles of 30 midsternal compressions followed by 2 ventilations (ie rate of 100 compressions/min; depth of 1/3 of chest/2in/5cm; push fast push hard, minimal interruptions, rotate compressor every 2min; manual bagging at rate of 6-8ml/kg LBW over 6-8sec with O2 15L/min). Inform MO. [If newborn to 8yo: start with 5 rescue breaths then cycles of 15 midsternal compressions followed by 2 ventilations] 2) One person for AED (alt with compressor) - Vital signs, DXT and cardiac monitoring - Charge up defibrillator prior to the assessment. - In between 2 min cycles, reassess ECG ≤3sec and check for pulse ≤10sec. (a) if pVT or VF: synchronous DC shock 200J (children: 4J/kg)(if monophasic: 360J)(if have pacemaker: defibrillate at 8cm away)(alt midsternal precordial thump), repeat PRN 360J. (b) if ECG shows a rhythm that can theoretically generate a cardiac output + pulse present: stop CPR (c) if asystole: KIV 1x precordial thump. If cardiac contraction generated, repeat at 60-80bpm. If no response after 30sec: revert to perform standard cpr (d) if asystole with P waves present (ie ventricular standstill) or occasional electrical activity: transcutaneous pacing 3) One person for airway - Insert ET tube size 7 (8 if big) to 22cm or between two black lines. LMA instead if ETT insertion >20sec. If on LMA or ETT: perform continuous compressions, ventilate after q15 compressions 4) One person for medications - Insert 2 large bore branula at fem/neck/cub fossa (at least pink) (if failed twice, gain IO access, which needs a drill if >7yo) (if gaining IO access ≥90sec, give medications via ET at 3-10x IV dose). Run 1 pint NS fast if no CI. - IV Adrenaline 1mg stat (if child: 0.01mg/kg ie take 1:10,000 0.1ml/kg) q3-5min ie repeat after every 2nd CPR cycle (take 1 vial of 1:1000/1mg/1cc dilute into NS 10cc, give 10cc)(alt take undiluted 1:10,000/0.1mg/1cc give 10cc. Saline flush afterwards) - If cardioversion given, after 2nd shock: IV Amiodarone 300mg (if child: 5mg/kg 3min)(take 2 vials of 150mg/3cc diluted into D5 20cc) slowly to avoid heart block, followed by saline flush. After 4th defibrillation: IV Amiodarone 150mg and saline flush. After 5th shock: IV Lignocaine 1-1.5mg/kg. - If asystole: KIVIV Aminophylline 250-500mg. If arrest was due to vagal overactivity eg tracheal suctioning: atropine. - If acidosis KIV NaHCO3 undiluted 50-100ml. I've seen pH7.1 given 100ml 5) One person for time keeper. Aim spontaneously breathing, coughing, moving, or capnography >30mmHg If patient survive: Keep MAP>60. Strict I/O. CBD. Keep DXT ≥4. Ix: ABG, FBC, RP, LFT, Ca, Mg PO4, ESR. If suspected infection: blood C&S. If suspected PE: D-dimer P: - IV ranitidine 50mg tds (if CrCL<50: BD) - Refer dietitian. RT feeding 50cc. If tolerate x3, ↑to max 300cc. Causes: 5H5T - Hypoxia, hypovolaemia, hyperhypokalaemia, H+ acidosis, hypothermia - Tension pneumothorax, tamponade, toxin, thrombin MI, thrombin PE Add-on: CPR provides 20-30% of cardiac output only cf pre-arrest value. Expired air provides FiO2 of 15 - 18%.

Advanced life resus

1. Airway - cricothyroidotomy (if facial trauma or laryngeal obstruction) (alt tracheostomy, transtracheal catheter ventilation) - finger sweep (if foreign body airway obstruction)(alt removal with direct laryngoscopy with Magill forcep or rigid bronchoscopy) 2. Circulation - IVD NS (if haemorrhage or impaired ventricular filling e.g. tamponade, pneumothorax or PE)(NB avoid IV dextrose as after brain is hypoperfused, hyperlgycaemia worsens neurological outcome) - IVD NS 30cc/kg (hypotensive)(which is equal to replacing 25% of a child's blood volume). If DKA or congenital heart disease, halve this - Blood products (if haemorrhagic shock and not responding to 40-60cc/kg of crystalloid) - needle pericardiocentesis (cardiac tamponade)(1cm left of xiphisternum aiming left scapula) and direct operative repair - nitric oxide gas (if pulmonary embolism)(pulmonary vasodilation) 3. Other circumstances - "if severe metabolic acidosis pH<7.2, persisting severe respiratory acidosis 10min after CPR or TCA or aspirin overdose": IV NaHCO3 1mmol/kg/dose (vial: 10mmol/10ml. Use undiluted), repeat q10min PRN at 0.5mmol/kg/dose with ABG guidance - raise leg, give IVD and perform CPR in left lateral tilt position of 15º (if pregnant)(to reduce caval compression). If unsuccessful after 4-5min, perform immediate Caesarean (to save baby's life)

AOR and abscond

AOR - Underage patients are not allowed to AOR Abscond - if left without a documented competency assessment, duty of care to call and make sure patient understood the specific risk related to their health condition - If cannot get hold of patient, inform nearby KK to follow up and document or police know to go and find them at their home.

Withdrawals (Dr Ng)

All substances last in our body for 1/52 and at most 2/52 Withdrawal for amphetamine, alcohol, smoking or coffee can be treated with t. diazepam 5mg tds x3/7, then bd 3/7, then od 7/7

Haemorrhagic shock (MTLS)

Assume adults blood 70cc/kg. Paeds 80ml/kg. Pregnancy at term/postpartum 100cc/kg (signs of hypovolaemia become apparent later) Class I: blood loss 0-15% (ie assume 0-750cc) - Finding: asymptomatic [ie normal BP, slight tachycardia but HR <100 (shock index ie HR/SBP>0.7), normal pulse, CRT<2, RR<20, UO >30cc/h, normal mental state] - P: replace with 1-2L crystalloid Class II: blood loss 16-30% (ie assume 800-1500cc) - Finding: ↑DBP (d/t peripheral vasoconstriction), HR>100, CRT>2sec, RR <20, urine 20-30ml/h, pale, anxious or aggressive - P: replace with 1-2L crystalloid Class III: blood loss 31-40% (ie 1550-2000cc) - Finding: low BP, HR 120-140 (thready pulse), CRT>2, anxious, confused, RR>20, urine 10-20ml/h, pale, anxious, aggressive or drowsy - P: replace with 1-2L warm crystalloid. Aim SBP 90-100mmHg (permissive hypotension). If still hypotensive, safe O (MTLS). IV Tranexamic acid 1g stat and IVI 1g in 1pint NS over 8h. Definitive intervention. Class IV: blood loss >40% (ie >2000cc) - Finding: BP unrecordable or very low, HR>140 (very thready), CRT undetectable, RR>20, UO 0-10ml/h, pale and cold and ashened, drowsy, confused or unconscious - P: replace with safe O straight (to resume O2 carrying capacity of blood). Definitive intervention

Orthostatic hypotension

BP lying to standing drop by SBP 20 or DBP 10 at 1min Plan: - Encourage oral fluids - Prop up bed (to train baroreceptors) - Calf exercises before standing - TED stocking - Tilt-table training. At 3 min: if HR high but BP still low: indicate peripheral resistance problem -> off any CCB, change to β-blocker, TED stocking. If still cannot, off anti-HTN, accept high BP i/v/o quality of life - KIV Fludrocortisone

IVD Maintenance

Based on age: - D1OL: D10 60cc/kg/d - D2OL: 1/5NSD10 90cc/kg/d - D3OL: 1/5NSD10 120cc/kg/d - D4-30OL: 1/5NSD10 150cc/kg/d - 1mo-6mo: 1/5NSD5 150cc/kg/d - 6mo-1yo: 1/2NSD5 120cc/kg/d - >1yo: 1/2NSD5 volume by Holiday-Segar 100/50/20 (consider adding 0.5-1.5g KCl in each pint)(new guidelines suggest using NSD5 as isotonic and kidneys will eliminate extra Na and not cause Na overload) - When child's weight >50kg: replace HSD5 with NS (as daily Na requirement is >150mmol/d). - Adult: around 35cc/kg/d If fever, ↑10% for each ºC If worried about SIADH esp severe pneumonia in children: limit to 2/3 maintenance Indications for NS : - Shock - Replacing fluid deficit. Paed protocol page 22: use an isotonic solution for replacement of the deficit. If ongoing losses >0.5cc/kg/h e.g. from drains, ileostomy, profuse diarrhoea: replace 4 hourly losses over next 4h with NS or Hartmann. - Risk of hyponatraemia. Paed protocol page 20: children at risk of hyponatraemia (e.g. Na<135, intravascular volume depletion, hypotension, excessive gastric or diarrhoeal losses, require replacement of ongoing losses, CNS infection, head injury, bronchiolitis, sepsis, salt-wasting syndromes, diabetes, cystic fibrosis, pituitary deficits, peri- or post-op) should be given isotonic solutions NS ± glucose with careful monitoring to avoid iatrogenic hyponatraemia in hospital - AGE >2yo. Dr Marini: fluid maintenance in AGE use HSD5 for <2y whereas NS for >2y. Add-on: - In district: Adult drip set is 20 drops = 1ml. Therefore, 60ml/h=20drop/min ie divide by 3. Paed drip set is 60 drops = 1ml. Therefore, 60ml/h=60drop/min. - Infants need more water because they have immature tubular reabsorption and larger body surface area per weight (insensible losses 300ml/m2 ≈ 15-17ml/kg/d) - Indication for 1/5 Saline D5: to replace ongoing hypotonic fluid losses eg in high dependency, renal, liver and intensive care - Indication for human albumin. Paed protocol page 22: if fluid loss with high protein content leading to low serum albumin eg burns - replace with 5% Human albumin - Paed daily requirement Na 2-3mmol/kg/d and K 1-2mmol/kg/d - Adult daily requirement Na 1-2mmol/kg/d and K 0.5-1mmol/kg/d - Adult daily input: 2.2L from food and drinks, 0.3L from metabolism; output: 0.9L insensible loss from skin and lungs, 0.1L from faeces, and 1.5L from urine

Alcohol

Binge drinking is 5 standard drinks in 2 hours (female: 4) Acute ethanol intoxication finding: Altered judgement, decreased inhibition, euphoria, decreased coordination ➝ Slurring of speech, ataxia, poor balance, agitation ➝ Decreased alertness to lethargy ➝ Coma, respiratory depression, loss of protective airway reflexes ➝ Deep coma Ix: - If altered mental status and h/o trauma or with focal neurologic deficit: CT brain P: - If intoxicated: IVD NS 10-20cc/kg to flush out the alcohol. CBD. - IV Thiamine 200mg BD 3d (alt T. or IM 100mg OD x3d)[alt IV Pabrinex 10 mins (ie. thiamine, riboflavin, nicotinamide, pyridoxine, ascorbic acid)] - If life threatening intoxication or BAC>500 mg/gL(108.6 mmol/L): HD Withdrawal can start few hours after last drink, but delirium tremens usu not until 48h after last drink Withdrawal Sx: headache, N&V, fever, tremor, dilated pupils CIWA (i.e. clinical institute withdrawal assessment) for alcohol. If ≤8: mild. If 9-15: moderate. If >15: severe and increased risk of delirium tremens and seizures Complications: - delirium tremens (p/w hallucinations, disorientation. Usu between 48-96h after last drink. Lasts 1-5d)(finding: tachycardia, HTN, hyperthermia, agitation, and diaphoresis) - Wernicke (p/w gradual onset opthalmoplegia eg "restricted bilateral convergence or lateral rectus palsy", nystagmus, ataxia, confusional state, hypothermia, coma) - Korsakoff (p/w retrograde and anterograde amnesia, confabulation) - alcoholic hallucinosis (p/w occurs 24h after the last drink and continues for about 24h. Persecutory, auditory, or visual and tactile hallucinations) Risk factor: addiction. CAGE≥2 Se for for addiction (i.e. Concerned about own drinking/think should cut down, Apparent problem to others/annoyed by critcisms, Grave consequences with drinking/guilty, Evidence of dependence/eye opener) P: - If delirium tremens: IV Diazepam 5-10mg. After q5-15min, repeat PRN up to 20mg/15min. Aim sedation (i.e. drowsy but rouses when stimulated). Then T. 10-20mg QID - If CIWA≥16: T. Diazepam 20mg 2Hly up to 80mg/24h [alt IV Diazepam 10mg (at 5mg/min) 4Hly] - If CIWA 10-15: T. Diazepam 10-20mg QID - If CIWA<10 for 24h: stop diazepam - If agitated: add T. Haloperidol 2.5-5mg BD - If Wernicke-Korsakoff syndrome: IV Thiamine 500mg TDS x2/7. Then IV 100mg BD until can take oral dose Diazepam CI RR<10 or SBP<100 Use Lorazepam instead of diazepam if severe liver disease i.e. AST/ALT >4000, severe respiratory disease or pregnancy

Cardiogenic shock

Cardiogenic shock: - IV Dopamine 5-20mcg/kg/min (start 2-5mcg/kg/min, max 50mcg/kg/min)(CCU preparation: count dopamine needed = 6mg x body weight in kg. Take dopamine needed from vial of 200mg/5cc, diluted into NS 50cc, which results in dopamine 6mg/kg/50cc, ie 120mcg/kg/1cc, give 2.5cc/h=0.042cc/min=5mcg/kg/min)(ED preparation: take 2 vials of 200mg/5cc, dilute into NS 50cc, which results in 400mg/50cc, ie 8mg/cc). KIV add IVI Adrenaline for post resus stabilisation. When SBP↑ to 100 after dopamine ± adrenaline: change dopamine to ivi Dobutamine 2.5-10mcg/kg/min (start 0.5-1mcg/kg/min, max 40mcg/kg/min)(CCU preparation same as dopamine. Take dobutamine needed from vial of 250mg/20cc)(ED preparation: take 2 vials of 250mg/20cc, diluted into 50cc with NS, which results in 500mg/50cc ie 10mg/cc) - Dopamine is a precursor of adrenaline and will act on both dopamine and adrenergic receptors - Dobutamine is a better inotrope than dopamine, but dobutamine is no immediately good for hypotension as it vasodilates. This reduction in afterload however, after the initial shock, is good to rest the heart Dopamine - Indication: second line drug for symptomatic bradycardia (after atropine). Use for hypotension as a inotrope agent. - Dose: IVI 2-20mcg/kg/min - Caution: Prior to initiating, correct any hypovolemia with adequate fluid replacements. Cautionary use in cardiogenic shock with CHF. May cause tachyarrhythmias and excessive vasoconstriction - Interaction: do not mix with NaHCO3. Adrenaline - Indication: cardiac arrest, symptomatic bradycardia (alt to dopamine after atropine), severe hypotension (can be considered when pacing and atropine fails, when hypotension accompanies bradycardia, or with phosphodiesterase enzyme inhibitor), anaphylaxis, severe allergic reactions (combine with large volumes of fluids, corticosteroids, antihistamines) - Dose: --- cardiac arrest: IV/IO 1mg (10ml of 1:10000 solution) every 3-5min, followed by 20cc NS flush and elevation of extremity 10-20sec --- CCB or BB overdose: higher doses IVI 0.1-0.5mcg/kg/min --- ETT 2-2.5mg diluted in NS 10cc --- Profound bradycardia or hypotension: 2-10mcg/min - Caution: raised BP and HR may increase myocardial oxygen demand and induce MI. Higher doses maybe required to treat poison, drug induced shock but practice caution as it can contribute to post resuscitative myocardial dysfunction

Skull fracture

Classification - Vault (linear vs stellate; depressed vs nondepressed; open vc closed) - Basilar (with or without CSF leak or cranial palsy usu CN VII and VIII) Depressed skull fracture - Finding: usu temporal as skull thinnest at temporal bone - Complication: post traumatic epilepsy - Ix: if overlies dural sinus: CT venography - P: early seizure prophylaxis. If "depression >1cm, grossly contaminated wound, infected wound, mass effect, intracranial haematoma or large contusion requiring surgery, focal neurology, frontal sinus involvement or evidence of dural penetration eg intracranial air, CSF or brain visible": for "debridement, removal of free bone fragments, dural inspection and repair and skull reconstruction" Basal skull fractures - Finding: racoon eyes, battle sign, ENT bleed, CSF rhinorrhoea, CSF otorrhoea, haemotympanum - Complications: cranial nerve injury usu CN VII and VIII, arterial injury, CSF leak - Ix: CT brain and CT face. CECT temporal bone by ENT. If suspect vascular injury from basal skull fracture: CT angiography - P: if ENT bleed, refer TRO ENT external ear canal lacerations or basilar skull # . ENT may give appointment to detect delayed onset facial nerve palsy, which is treated with prednisolone 1mg/kg 1w. If CSF leak: refer neurosurgical, bed rest, head elevation and avoid high blood pressures, nose blowing, valsalva maneuvers or use of straw. If persists, CSF diversion using lumbar or ventricular drain or repeated LP for not more than 14d after initial head injury. Surgery if CSF leak still persists, concomitant intracranial pathology requiring surgery, delayed post traumatic CSF rhinorrhoea, fracture involves sinuses, >1cm, comminuted, depressed skull base fracture, fracture with cranial nerve deficits or tension pneumocephalus. If "<2yo, h/o LOC or post traumatic amnesia, scalp laceration or haematoma, suspected penetrating injury by metal or glass or presence of foreign body": skull XRay (internet)

Traumatic Intracranial lesions

Classification: - Focal (epidural, subdural or intracerebral) - Diffuse (concussion, hypoxic ischaemic encephalopathy or diffuse axonal injury) Extradural haemaorrhage - Finding: brief LOC ➝ lucid interval for few hours ➝ rapid neurological deterioration. CT biconvex shaped haematoma between dura and inner table of skull - Risk: temporoparietal fractures cutting middle meningeal artery, skull # or injury to dural sinus - P: if >30cm3: frontotemporal craniotomy. May consider op too if clot >15mm, midline shift >5mm, focal neurology or GCS<9. If no op, repeat scan after 6-8h Subdural haematoma - Finding: LOC, focal neurology. CT crescent shaped haematoma between dura and arachnoid - Complication: mortality 60% - d/t disruption of bridging vessels - P: if SDH>1cm, midline shift >5mm, GCS<8 with rapid decline, pupillary dilation or ICP>20mmHg: frontotemporal craniectomy with wide dural incision Intracerebral haemorrhage - Term: if <1cm called contusion. If >1cm called haematoma - Complication: post traumatic epilepsy - P: early seizure prophylaxis. If progressive neurological decline, lesion volume >50cm3, mass effect, midline shift ≥5mm, compression of cisterns, refractory ICH, or "GCS 6-8 with frontal or temporal contusions >20cm3": surgical decompression. Keep Plt>100, bring INR<1.6 ≤2h with FFP 4u or IV Vitamin K 10mg. Expert suggest suspended anticoagulation for 7-10d but no guidelines. Diffuse axonal injury - Finding: unconscious and persistent vegetative state; CT brain shows punctate haemorrhages at grey-white border or at corpus callosum - Ix: MRI diffuser tensor imaging - P: if diffuse lesions: frontotemporoparietal or bifrontal decompressive craniectomy. Concussion - Finding: confusion or LOC within min; GCS15; no imaging evidence of brain injury - Complication: post concussive syndrome - Post concussive syndrome (c/o physical, cognitive, mood or sleep disturbances)(prognosis: most recover within several weeks)(Ix: if persistent or disabling: MRI)(risk: women and elderly. Not severity of brain injury)

On Shock

Clinical syndrome which occurs when there is an abnormality of the circulatory system [usu take as SBP <90. In children, SBP <(2xage) + 65. Pulse tachycardic or thready] that results in inadequate organ perfusion and tissue oxygenation: - altered mental state eg anxious, aggressive, drowsy, confused - skin CRT slow, pale, cold, diaphoretic, ashened - lactic acidosis (lactate >2), tachypnoeic - urine output <20ml/h Complication: AKI, myocardial failure (d/t increased myocardial oxygen demand 2º catecholamine release), MI, stroke, centrilobular hepatic necrosis or intestinal ischaemia, MODS ie multiple organ dysfunction syndrome (≥2 of SBP<90, acute mental status change, PaO2<60 on RA, PaO2/FiO2<250, increased lactic acid, oliguira, Plt<80, liver enzymes x2 ULN) Causes: 1) Hypovolaemic (findings: cool peripheries, dry mucous membranes, CRT>3sec, raised DBP d/t peripheral vasoconstriction): haemorrhage, dehydration, DKA, diabetes insipidus or diuretics 2) Distributive (findings: warm peripheries, lowered DBP d/t peripheral vasodilation): septic (lactate >10 in shock likely sepsis), anaphylactic, hypoxic, drugs (eg CCB), or neurogenic 3) Cardiogenic (findings: weak pulse, cardiomegaly): arrhythmia or structural disease (eg valvular disease, IHD, pericardial disease, congenital heart disease, obstructive cardiomyopathy, dilated cardiomyopathy, primary pulmonary HTN) 4) Obstructive (ie venous return↓, raised DBP): SVC obstruction (o/e facial plethora, neck vein dilation, conjunctival injection), Pulmonary embolism, Cardiac tamponade, Tension pneumothorax Maintain MAP>65. Reverse trendelenburg. - Decompensated: IVD crystalloid 20cc/kg 15-30min (if on ROF, give 200-300cc and reassess) (if have HF and lungs A profile: can give 200ml stat, reassess, if still A profile, repeat 200ml). - Compensated: IVD crystalloid 10cc/kg 1H. Then inotropes. Ix: - FBC (Hb, WCC), RP, Ca, Mg, PO4, VBG with lactate, DXT - ECG, CXR, USS P: - CBD. strict I/O, , insert 2 large bore branula (green 18G 96ml/min; grey 16G 196ml/min; orange 14G 343ml/min)(not pink 20G 65ml/min; blue 22G 36ml/min; yellow 24G 22ml/min)[if femoral: angiocath orange 14G 83mm 249ml/min, 133mm 219ml/min (for obese patients)] - FM O2 4-10L/min - Post resus stabilisation: IVI Adrenaline 0.1-0.5mcg/kg/min up to 50mcg/min (I've seen ED HKL double strength: take 6 vials of 1:1000/1mg/1cc, diluted into NS 50cc, which results in 6mg/50cc, ie 120mcg/1cc, give 0.2cc/kg/h =24mcg/kg/h =0.4mcg/kg/min)(alt single strength: take 3 vials but give 0.4cc/kg/h) Add-on: - Dr Ng KS: 30cc/kg max 3 cycles, then start inotropes (ie 90cc/kg corresponds to 10% dehydration i.e. 0.1L/kg = 100cc/kg) - Phenylephrine selectively binds to α1 receptors which cause blood vessels to constrict - Fick's formula (needs Hb and ABG) for cardiac output and cardiac index ie CI. Aim CI>2.5 and MAP>60 (normal cardiac output is 4-8L/min and cardiac index is 2.5-4.0L/min). If CO or CI low or decreasing, consider increasing fluids. If not fluid responsive, consider norepinephrine or dopamine.

Amphetamine and cocaine

Common finding for amphetamine and cocaine: - tachycardia, arrhythmias, vasospasm and its complications eg "ACS, HTN emergencies, acute aortic syndrome, TIA, acute cerebral infarct, intracranial bleed", increased alertness, psychomotor agitation, mydriasis, seizure, hyperthermia, diaphoresis, rhabdomyolysis and its complication eg hyperkalemia, jaw clenching, tooth grinding (bruxism) - For amphetamine, urine toxicology positive results are generally expected up to several days. For cocaine, even though half life 45-75min, urine toxicology may be positive for 3d after use, interpret with caution. Other findings specific for amphetamine: - Tweaking esp metamphetamine ie psychiatric Íx similar to schizophrenia (paranoid, hallucinations, agitation, delusions) - Met-bug ie visual or tactile hallucinations of "bugs" esp methamphetamine - Hyponatraemia in MDMA pneumothorax and pneumomediastinum Findings specific for cocaine: - arrhythmia - ACS (MI risk increased 24x in 60min after use)(Ix: ECG is not Se nor Sp. Recommend troponin) - intracranial bleed - Pneumothorax, pneumomediastinum, pneumopericardium, noncardiogenic pulmonary oedema, AEBA - Ischaemic bowel and infarction, bowel perforation, rhabdomyolysis, renal failure, hyperthermia Ix: - as clinically indicated: CT brain, ECG, CXR, FBC, RP, LFT, CK(CE) P: - IV Diazepam 5-10mg. After 15-10min, repeat PRN until patient calms down. If agitated, may require up to 80mg. - IVD - If seizure: BZD. Rule out hyponatraemia and intracranial pathology. Phenytoin not recommended. - If HTN emergency: GTN, nitroprusside. If inadequate response, KIV phentolamine (alpha antagonist; avoid beta blocker d/t unopposed alpha effect), CCB - if cocaine body packer: KIV GI decontamination by whole bowel irrigation - if cocaine chest pain: morphine, oxygen, aspirin, nitroglycerin - if cocaine fast AF or narrow complex tachyarrhythmia: NaHCO3. 2nd line: lignocaine. Add-on: Amphetamine - Two examples are 3,4-methylenedioxymethamphetamine (MDMA, Ecstasy) and methamphetamine. Methamphetamine is usually in a form of crystal (aka ice drug) and can be rapidly absorbed by inhalation, ingestion and injection; it has a much greater CNS potency than other amphetamines and a long half life of 19-34 hours. The duration of effect may last more than 24 hours. - Causes release of endogenous catecholamines such as noradrenaline, serotonin and dopamine, resulting in sympathomimetic poisoning Cocaine/coke/crack/flake/snow/stardust - Cocaine HCl salt can be injected (onset 10-60s, peak 3-5min, duration 20-60min), ingested (onset 1-5min, peak 15-20min, duration 60-90min) or snorted (onset 1-5min, peak 15-20min, duration 60-90min) - Cocaine free base form is smoked (onset 3-5sec, peak 1-3min, duration 5-15min) - Blocks presynaptic re-uptake of biogenic amine neurotransmitters (eg NE, DA, 5-HT), blocks Na channel, increases vasoconstrictor and reduces vasodilators - Cocaine use is limited to affluent persons due to its higher cost

Traumatic Spinal Injury

Complication: - spinal cord injury (if cauda equina involved, called cauda equina syndrome) - spinal shock - neurogenic shock Spinal cord injury - central cord syndrome (finding: motor impairment > sensory, UL impairment>LL, distal impairment > proximal)(cause: neck hyperextension) - Brown-Sequard Syndrome (finding: ipsilateral deficit of motor, proprioception, and vibration and contralateral deficit of pain and temperature)(cause: penetrating trauma causing complete cord hemitransection) - posterior cord syndrome (finding: loss of proprioception) Cause equina syndrome Finding: - sciatica (straight leg raise ie pain shooting to below knee when flexion 30-70º; sciatic stretch, bowstring, crossed sciatic tension) - affected b/l myotome and dermatomes (but occasionally asymmetric): saddle anesthesia, weakness, gait disturbance, absent achilles reflex, absent anal reflex and bulbocavernosus reflex - bowel or bladder incontinence or retention Spinal shock - Finding: absent BCR, motor power 0, flaccid paralysis, urinary or bowel incontinence or retention, priapism, hypothermia - d/t transient physiological spinal cord neurons hyperpolarised and unresponsive to stimuli below level of injury - Risk: spinal cord injury - Ix XRay of cervical, thoracic and lumbar spine or CT spine Ix If Nexus NSAID (ie Neurological deficit, Spinal tenderness, not Alert and orientated to time / place / person, Intoxicated or have Distracting painful injuries): cervical collar and cervical XRay Otherwise: assess neck rotation 45º to L and R However, if initial GCS<13, intubated, other body areas are undergoing CT, suspected cervical spine injury in ">65yo, focal neurology, or dangerous mechanism eg fall from >1m, axial load to head, MVA >100km/h, ejected MVA, bicycle collision": CT c-spine ≤2h of risk factor being identified Cervical spine - Lateral XRay: aligment (anterior and posterior vertebral line, spinolaminar line, and spinous process line; predental space should be <3mm in adults and <5mm in children), bone (outline, 7 vertebrae seen, and uniform cartilage spaces), and soft tissue [C2 prevertebral space normally ≤7mm C7 prevertebral space normally ≤2cm; 2-7-7-2 (MTLS); C1 to C4 prevertebral <7mm ie less than half of vertebral body and C5-7 prevertebral tissue should be <22mm ie less than vertebral body (internet)] - Open mouth view (to visualise C1 and C2): distance between the odontoid process and the lateral masses of the C1 should be equal, and margins of C1 and C2 should remain aligned - AP view: alignment of tips of the spinous processes and distances between the spinous processes and alignment of the lateral masses of the vertebra - If short neck or large shoulder: add swimmer's view to visualise C7/T1 joint. P: - If suspect spinal injury: cervical collar, spinal board, head immobiliser with straping, CT spine - If bifacet cervical dislocation: Gardner-Wel's Tong traction. - If spinal cord injury: refer ortho. Decision for steroid by ortho. Steroid if non-penetrating injury and ≤8h of injury. Eg IV Dexamethasone 10mg bolus then maintenance. If no improvement after 24h: surgical decompression within 48h Add-on: - If intubated need CT occiput to C3 because 17% of spine injury missed with open mouth view in intubated patients

Pregnant trauma

Complication: preterm labour, placental abruption, amniotic embolism, DIVC, uterine rupture, fetomaternal haemorrhage, pregnancy loss, fetal distress, higher risk of abdominal injury in chest trauma, higher risk bladder injury, supine hypotensive syndrome, delayed gastric emptying, Rh issoimmunisation Ix: - FBC, RP, GXM, Coag- If mother Rh negative: Kleihauer-Betke stain for fetal blood. XRays forms to be signed by both ED and O&G specialists P: insert RT early (to decompress stomach and bowel and prevent aspiration). Lower index of suspicion for hypovolaemia (as physiological vasodilation and increased blood volume by 50% in pregnancy). If supine hypotensive syndrome: displace uterus to left manually or left lateral position esp >20w if no CI. Assess abdo, uterine contraction and vagina externally only. If fitting, assume eclampsia until proven otherwise. Refer O&G for fetal assessment. If >20-24w, CTG min 4h. Rh Ig as needed. CT abdo limited to upper abdomen above fundus with fetal shielding. If cardiac arrest and pregnancy >20w: consider perimortem C-section <4min of arrest. Add-on: physiological maternal hyperventilation causes hypocapnoea. Normal PaCO2 consider respiratory compromise. physiologically widened SI joint and pubic symphysis max 8mm

Hypertensive Emergency (2018 CPG)

Complications: - Acute HF [P: ↓SBP <25% ≤1h ➝ ↓BP≤160/100 ≤6h. Aim symptom resolution (NB BB or CCB can exacerbate HF)(use GTN➝hydralazine➝MgSO4) - ACS [P: ↓SBP<25% ≤1h ➝ ↓BP≤160/100 ≤6h (alt ↓DBP ≤15%/110 ≤60min ➝ ↓BP to normal ≤48h)(consider type A aortic dissection as cause of CS; avoid selective BB if cocaine abuse suspected] - acute aortic dissection [P: ↓SBP ≤120 ≤20min, ↓DBP <80 ≤1h and ↓HR <60 ≤1h (give BB before vasodilators eg nitroprusside or nicardipine to prevent reflex tachycardia or inotropic effect)] - preeclampsia [P: ↓SBP<140 ≤1h. (CI: ACEi, ARB, nitroprusside)] - *hypertensive encephalopathy* (aka reversible posterior leukoencephalopathy syndrome)(p/w severe HTN; *headache* of insidious onset; N&V; *visual Sx*, papilloedema, retinal haemorrhage; *hyperreflexia*, confusion, seizures; haematuria and proteinuria)(diagnosis is by exclusion when mental status improves after BP is lowered)[P: ↓BP <25% ≤1h (avoid nitroprusside as can cause intracranial oedema)] - acute hypertensive nephrosclerosis (aka malignant nephroscleoris)(d/t fibrinoid necrosis of glomerular arterioles)(Ix: Cr↑, eGFR<60, haematuria)(P: ↓BP<25% ≤24h Long term BP control reverses the kidney impairment) - Sympathetic crisis or phaeochromocytoma [P: ↓BP until symptom resolution (avoid BB monotherapy except labetalol)] Ix: CXR, ECG, RP, UFEME P: - IV Labetalol 20mg (take from 1 vial of 25mg/5cc only 4cc) over 2min. After 10min, 40-80mg PRN up to 200mg. Then IVI 20mg/4cc/h, every 30min, double up to 160mg/32cc/h (1m-11yo: IV 0.25-0.5mg/kg up to 20mg. Then IVI 0.5-1mg/kg/h initially, then maintenance 0.25-3mg/kg/h)(onset ≤5min; duration 3-6h; keep patient supine during and 3h after procedure; caution in HF, asthma, heart block, severe PVD, on verapamil or diltiazem)(ED: IVI Labetalol 100mg in 50cc NS run 2ml/h) - IVI GTN 5mcg/min (take from 1 vial of 50mg/10cc only 6cc/30mg, diluted into 50cc with NS, which results in 30mg/50cc, ie 0.6mg/1cc, give 0.5cc/h), increase q3-5min by 5-10mcg/min (0.5-1ml/h) to max 400mcg/min (40ml/h)(onset immediate; duration 3-5min; preferred in ACS and APO) - IVI Isosorbide dinitrate 2-20mg/h (take 1 vial of 10mg/10cc, diluted into 50cc, which results in 0.2mg/cc, give 10cc/h)(onset 3-15min; duration 1h; preferred in ACS) - IV Hydralazine (vial: 20mg/1cc; take 1cc dilute into 4cc NS; serve 5mg/1cc) 5-10mg over 5-10min. After 20-30min, repeat PRN. Alt IVI 0.2-0.3mg/min initially, then maintenance 0.05-0.15mg/min (in O&G: when MAP<125, IVI 5mg/h; ie 0.083mg/min; ie take 40mg/2cc dilute into 40cc NS; ie 1mg/1cc; serve 5mg/5cc/h; after q20min, titrate up by 1mg/1cc/h up to 10mg/10cc/h ie 0.166mg/min)(1m-11yo: IV 0.1-0.5mg/kg up to 10mg. After 4-6h, repeat PRN. IVI 12.5-50mcg/kg/h up to 3mg/kg/d)(onset 10-30min; duration 3-8h; caution in ACS, CVA and dissecting aneurysm. Unpredictable BP lowering effects. Preferred in pregnant women with bradycardia, APO, heart block or BA) - IVI Nicardipine 5mg/h up to 15mg/h. After response achieved, ↓ to 3mg/h (children IV bolus 0.5-5mcg/kg over 1min then IVI 1-4mcg/kg/min)(onset: 5-10min; duration 1-4h; caution in acute HF and ACS) - IV Esmolol 80mg over 30sec. Then IVI 150mcg/kg/min up to 300mcg/kg/min (children IV 250-500mcg/kg over 1min, then IVI 50-200mcg/kg/min for 4min. May repeat sequence)(onset 1min; duration 10-20min; used in perioperative situations and tachyarrhythmias) - IV Na Nitroprusside 0.3-1.5mcg/kg/min initially (use only with D5W). After q5min, titrate up by 0.5mcg/kg/min PRN. Usually 0.5-6mcg/kg/min, up to 8mcg/kg/min. Discontinue if no response after 10min. May continue for a few hours if there is response (children IV 0.25-0.5mcg/kg/min, after 15-20min, may be repeatedly double up to 6mcg/kg/min)(onset seconds; duration 1-5min; caution in HF. Require intraarterial BP monitoring. Lower dosing adjsutment for elderly and those already on anti-HTN) After 24h of stable BP, change to oral anti-HTN by weaning IV therapy over 1-2/7 Add-on: - IV Phentolamine (α-adrenergic antagonist)(if phaeochromocytoma)(alt Prazosin) - IV Phentolamine 5-10mg/kg/min (if sympathomimetic agents or sympathetic overactivity)(if life threatening, give 2.5-5mg bolus)(alt nitroprusside). If taken Amphetamine, add IM Chlorpromazine 1mg/kg - IV Fenoldopam (if malignant nephrosclerosis)(alt dialysis) - IV Propranolol 1mg over 1min, repeat q2min until given 0.1mg/kg or up to 10mg

Digoxin poisoning

Complications: - N&V and anorexia - Hallucinations - Sinus bradycardia or arrhythmia Ix: take digoxin level at ≥6h after ingestion (ideally at 12h after ingestion) Risks: - low K and Mg - Erythromycin, spironolactone, verapamil or diltiazem, or amiodarone use increases digoxin levels. P: - If ingested in last 1h, give Activated charcoal 50g (1g/kg up to 50g) po/ng - Consider digoxin Fab fragments or haemodialysis - If sinus bradycardia, withhold next dose until HR>60. If severe sinus brady, give atropine or cardiac pacing

On Burns (MTLS)

Complications: - hypovolaemia from increased cellular permeability - myocardial depression (risk: burn>50% TBSA) - thrombosis d/t haeomoconcentration - anaemia from extravasation and destruction of RBC - hypothermia - infection - acidosis - rhabdomyolysis, myoglobinuria, renal failure - hypermetabolic and catabolic response lead to hepatic failure - eschar formation with respiratory or circulatory compromise Types: - thermal (skin and inhalational). - chemical (skin, inhalation or mucous membrane) - electrical (Ix: CK-MM, ECG, 24h telemetry and spinal Xray) - radiation Depth - 1º/superficial: epidermis. Finding: red, swelling, pain. Heals 3-6d without scar. - 2º/partial thickness: dermis. Superficial dermis finding: red, blister, pain; heals 1-3w, scarring unusual. Partial dermis (skin appendages destroyed) finding: white with erythematous area, dry, waxy, less elastic, reduced blanching to pressure, less painful; healing >3w with scarring and contracture. - 3º/full thickness: fat. Finding: white, charred, tan, thrombosed vessels, dry and leahtery, do not blanch, and analgesia. Does not heal; severe scarring and contractures. P: tangential shaving to remove dead dermis layer by layer until bleeding - 4º: muscle, bone, joint. Finding: carbonisation Size (take 2º and above only): - Rule of 9. Child: thigh lesser and head more. - Rule of palm. Patient's palm is 1% - Lund and Browder chart Initial: remove burned clothing. Cool saline 12ºC 15-30min. If ≤3h: cover with wet towels (if after 3h: cover with dry towels or cling wrap) Inhalational injury - Supraglottic (finding: brassy cough, stridor, hoarseness, soot in sputum, facial burns eg singing of eyebrow and nostrils)(d/t immediate oedema of pharynx and larynx)(risk: high temp) - Subglottic (finding: wheezing, cough, bronchospasm)(d/t injury to lung parenchyma by superheated steam, aspiration of scalding liquid or toxic inhalant or chemical) - RR unreliable due to toxic combustion products may cause depressant effects - May be assoc with cyanide (finding: high lactate, low compensated CO2)(Ix: cyanide level not available in HKL)(cyanide forces cells to undergo anaerobic metabolism)(P: hydroxycolamin) or CO poisoning (finding: depressed LOC, cherry red skin, apnoeic)(Ix: if moderate to severe burns: take HbCO level as pulse oxymetry and ABG not reliable)(P: high flow O2 mask. If HbCO>10%, humidified 100% oxygen >24h. Hyperbaric O2) - P: O2. Airway protection KIV ETT. If bronchospasm: bronchodilator. Judicious fluids to avoid APO. Avoid steroids. Further study: NO, heparin, NAC nebulisation. Shock - late onset - d/t hypovolaemic, distributive and cardiogenic components - Ix: Hct, electrolytes, DXT, Ca, alb, osmolality - P: if >15-20% TBSA: fluid resus (if paeds/elderly: >10%). Use balanced crystalloid ie sterofundin or hartman. Use parkland formula (alt Brooke or Evans) ie If >14yo: 2ml/kg body weight x % TBSA. If <14yo: 3ml/kg body weight x % TBSA + maintenance (1/2 NSD5). If electrical burn: 4mlg/kg/TBDS (ATLS 10th edition). Rate: give half in 8h and remainder over 16h. Aim UO 0.5ml/kg/h (if paed 1ml/kg/h)(if rhabdomyolysis 3-4ml/kg/h). Overresusciation SE ARDS, abdominal, extremities and orbital compartment syndrome, multiorgan failure Analgesia. IV Morphine 2-3mg q10min (if paeds 0.1mg/kg). KIV regional block. If anxious: BZD Secondary survey - Treat wound. Do not rupture blister as risk infection. If <10%: cover with moist sterile dressing eg Jelonet NS dressing with Aquacil. If >10%: cover with dry dressing to avoid hypothermia. If 2º burn or more: IM ATT, SSD cream or bacitracin cream. No need prophylactic IV abx. - If circumferential thoracic or limb eschar compromising ventilation or perfusion: incision lateral to chest or limb down to subcutaneous layer. - If moderate to severe burn: RT for RT feeding - Ranitidine or PPI to prevent stress ulcer If chemical burn, electrical burn, comorbidities, affecting "face, eyes, ears, hands, genitalia, perineum, major joints", circumferential chest burn, >10% partial thickness, any 3º burn, <10yo or >50yo: refer burn unit

Crystalloids and Colloid

Crystalloids - Balanced salt solution administered IV - Isotonic: NS, HM, D5, D5W1/4NS - Hypotonic: HS - Hypertonic: D10, mannitol, 3%NS, HSD5 - Adv: easily available (eg cheaper, more shelf life), doesn't disturb coagulation - Disad: three quarters of crystalloid enter the interstitium (UpToDate)(replacement ratio is 1 pint blood:4 pint crystalloid)(O&G 1:3, ED 1:5); more risk of APO; If large amount of crystalloids given, watch out for dilutional coagulopathy and hypothermia NS 0.9% (contains NaCl 150mmol/L) - Cons: no K; if large volumes >3L can cause hyperchloraemic metabolic acidosis and hypernatraemia Hartman's/Ringer's solution: [contains Na 131mmol/L, K 5mmol/L, Ca 2mmol/L, Cl 111mmol/L and lactate (turned into bicarbonate in liver 29mmol/L)] - Pros: potential benefit if >2L crystalloid needed (UpToDate)(avoids hyperchloraemic metabolic acidosis and hypernatraemia); may be more useful for burn patients - Cons: have not consistently been proven to be superior, especially when smaller volumes eg ≤2 L are administered (UpToDate) D5: 50g/L of glucose, little calories of 200kcal/L, no electrolytes Colloid - Pros: contains large insoluble molecules, therefore faster plasma volume expansion and initial resuscitation than colloids [however meta-analyses failed to demonstrate a consistent clinically meaningful benefit derived from this (same mortality rates between resus with crystalloid and colloid)(UpToDate)]. Improved rheology (flow). Stays in intravascular space (ratio of replacement 1:1), ↓risk of APO - Cons: allergic risk [gelatin (eg gelafundin) > dextran > HES (eg Voluven)], dilution of coagulation factors, expensive eg Voluven RM60/bag.

Name some situations where mouth to mouth pose a safety issue to the rescuer?

Cyanide, organophosphate, azide or phosphine poisoning.

Reduced consciousness, LOC or collapse

Danger: if unsafe environment, move casualty to safety Response (AVPU): 1) Shout and tap an uninjured part. "Are you alright". Look for dysarthria, aphasia or stupurous answers about the month and age 2) poor obeying of command to open and close eyes or grip and release hands 3) poor response to repeated, strong or painful stimulation 4) unconscious Send for help if if unconscious: - Ask someone to call 111 for *help* or activate the Emergency response system and return immediately to confirm call made. If no help beside you and nearest contact <4min away: recovery position and get help first (as 2/3 of adult cardiac arrest is secondary to VF and if defibrillated within 90sec, 80% survival, which drops by 10%/min thereafter)(cf only 10% of child arrest is secondary to VF) Airway: - Head tilt and chin lift (jaw thrust esp if trauma), after that, remove obvious causes of airway obstruction Breathing: - check for breathing for 10sec - If breathing movements with airflow: recovery position - If breathing movements without airflow: firm jaw thrust - If no *breathing* movements: assume cardiac arrest (see cardiac arrest) Causes of reduced consciousness but normal breathing with airflow: 1. Local brain issue - Brain tissue: Meningitis (nuchal rigidity), neurosyphillis, Wernicke encephalopathy (Sx: gradual onset opthalmoplegia and ataxia), Hypertensive encephalopathy (Sx: DBP >120 and papilloedema), neoplasm, seizure postictal phase - Basal skull fracture - Vessel: stroke, basilar migraine (Sx: headache, previous similar attacks, preceding visual disturbance, vertigo, confusion) or cerebral vasculitis (Sx: fever) (Ix: ANA, RF, C3 and C4) 2. Systemic issue affecting brain - Metabolites: hypoglycaemia, HHS, DKA, electrolyte imbalance - Oxygen: hypoxia - Hormones: myoxoedema coma (precipitated by infection, MI or stroke in a person with hypothyroidism) - Toxins: acute toxic metabolic encephalopathy (i.e. delirium)(Sx: in liver failure, asterixis, ascitis, dilated superficial vein), recent medication changes, alcohol intoxication, opioid overdose (Sx: cocaine - narcotic but also blocks noradrenaline reuptake, therefore a stimulant, causing pupil dilation; heroin - narcotic causes pinpoint pupil and bradypnoea) - Withdrawal: delirium tremens - Syncope Ix: ABG, FBC, RP, LFT, ESR, TSH, D-dimer, UFEME, urine C&S, tracheal C&S, blood C&S, CXR, post intubation and CT brain depending on indications P: - GCS<10 inform MO, transfer acute, determine cause, KIV intubation and referral to anaes - (coma) iv D10W 100ml (over 1-3min) + iv thaimine 100mg + iv naloxone 0.1-0.4mg (up to 2mg) (NB not flumazenil as may precipitate seizures and arrhythmias in combined BZD and TCA overdose). - (hyperventilating and profound hypocarbia) sedate, intubate and ventilate with or without muscle relaxant (to prevent cerebral vasospasm and resultant infarction)

Charges for Foreigners

Specialist clinic registration RM120 Daycare registration RM250 3rd class admission - Medical ward deposit RM1400. Surgical ward deposit RM2800 - Daily charge RM260 - For malaysians, max total per admission is RM500 2nd class admission - Deposit RM5000 - Daily charge 8 bed sharing RM280 1st class admission - Deposit RM11000 - Daily charge 4 bed sharing RM300 - Daily charge 2 bed sharing RM340 - Daily charge single room RM420 Daily charge includes food, bed, and inpatient charges (doctor consultation, nursing care, and ward medications). It does not include investigations and treatment. SPIKPA ie Skim perlindungan insurans kesihatan pekerja asing max RM10,000 setahun UNHCR membawa kad USJR dapat 50% diskaun (protected by SUHAKAM) Pengurangan or pengecualian bayaran kupon warganegara tanpa jaminan: ward 3 + kategori tak mampu (i.e. letter from DUN, penghulu, penggawa, or HO referral to pegawai kerja sosial perubatan) Change beds: final charge is based on most expensive bed GeneXpert test service no longer offered to foreigners at IPR. UNHCR card holders can have GeneXpert tested at International Organisation for Migrants (free and result available same day) at Tawakal Hospital (http://www.iom.int) Senarai Penyakit Berjangkit for which medical care is free for foreigners living/working in Malaysia (with ≥3 month visa) the moment a doctor diagnoses the penyakit berjangkit and submits the lampiran III form (waiving of medical fees)[whereas lampiran I(i) and I(ii) gives contacts of patient free medical workup] - yellow fever, Ebola, Cholera, Malaria, Plague, Typhoid and tuberculosis (first line drugs only) Deposit can be postponed (until patient is awake or waris is found) if admitting specialist provides a Lampiran A1.

Paracetamol Poisoning

Stage I (2-24h): non specific Sx mainly GI (N&V, malaise) Stage II (24-96h): RUQ tenderness, elevated AST, ALT, bilirubin, PT, renal injury possible Stage III (>96h): recovery Complication: coma, lactic acidosis, coagulopathy, acute tubular necrosis, ARDS, thrombocytopenia, pyroglutamic acidosis, hyperamylasaemia Potentially toxic dose: >150mg/kg/24h (if malnourished, chronic alcoholic or on isoniazid: 100mg/kg)(if assume 50kg, potentially toxic dose is 7500mg ie 15 pills)(in repeated supratherapeutic doses, even though we know that half life in therapeutic dose is only 2h and can be prolonged in overdose, clinical toxicology course 2019 says in repeated supratherapeutic doses, NAC is indicated as long as >150mg/kg in the past 24h) Ix: - TDM PCM level at ≥4h of ingestion - FBC, RP, LFT, AST and coag, VBG, DXT P: - If <2h of ingestion: activated charcoal 1g/kg max 50g - If massive overdose ie ingested >1g/kg: gastric lavage - NAC. If "PCM level at 4h above nomogram line (150 line)(if panadol extend, also check at 8h)", "potentially toxic dose ingested ie >150mg/kg but present >8h after ingestion", "potentially toxic dose ingested, present 4-8h after ingestion and TDM PCM level only available >8h later", massive overdose (ie >1g/kg), or "present >24h but with detectable serum PCM level (ie >10mg/L) or elevated ALT/AST": NAC 150mg/kg in D5 200ml (if children 3ml/kg) for 15-60min, after that 50mg/kg in D5 500ml (if children 7ml/kg) for 4h, after that 100mg/kg in D5 1L (if children 14ml/kg) over 16h (continue until improving ALT or recovering encephalopathy). SE NAC include anaphylactoid reaction (6-23%; stop infusion, antihistamine ± steroid, restart NAC at slower rate; if life threatening NAC hypersensitivity, change to oral methionine 2.5mg QID x4doses, if children <6yo oral methionine 1g QID 4 doses) - If presented >24h after ingestion of a potentially toxic dose, no SSx of hepatotoxicity, no deranged LFT and no detectable PCM level: repeat LFT 24h later. - If Cr>300, PT>100, pH<7.3: liver transplant (King's college criteria) Add-on: - Therapeutic dosing PCM level peaks 0.5-2h after ingestion, half life around 2h.

Hypothermia

Sx: - <34C Complications: - Vasodilation and hypotension - VF - Hypothermia induced diuresis Ix: rule out VF and hypoglycaemia. Request cardiac monitoring and glucose level. Cause: hypoglycemia P: - Give IVF - Give hot air blankets (alt warm packs to armpits, groin or neck. Also, immersion in warm baths avoiding limbs) - If <30C, give warm NS iv 42-44ºC (alt oesophageal rewarming tubes, extracorpoeral rewarning, peritoneal lavage, or warm humidified oxygen 42-46ºC). Aim 35ºC

Chemical Burns

Sx: - Hydrofluoric acid (P: 10% Ca gluconate gel topically, iv or intraarterially and consider burn excision), oxalic acid and phosphorus: hypocalcaemia - Petrol: systemic endothelial damage, bronchospasm (P: bronchodilator) - Cresol: methaemoglobinaemia and haemolysis - Formic, picric, tannic acid: renal and hepatic damage P: - Remove any excess dry chemicals by brushing with a cloth, after that, irrigate with running water for at least half an hour (except if burnt by sodium, potassium and lithium: wash with mineral oil), if alkali, irrigate for at least 1h

Hyperthermia

Sx: ≥40C Complications: - neurological complications - tubular necrosis - heat exhaustion (Sx: hypotension) - heat stroke (Sx: dry skin) Cause: - direct heat - malignant hyperthermia (Sx: muscle rigidity) (P: hyperventilate with 100% oxygen at flows of 10L/min to flush volatile anesthetics. Give postsynaptic muscle relaxant dantrolene iv 2-5mg/kg) P: - Paracetamol 15 mg/kg po qid - Water mist spray - If heat exhaustion, raise legs and give IVF - If heat stroke, give ice packs (alt cool IVF, ice water bath, or gastric lavage with iced saline)

Intraosseous access

Used if unconscious Used in paeds after 2 failed IV attempts in major trauma patients (MTLS) Must be sterile Size of needle: based on weight Location: 2 finger breath medial and inferior to tibial tuberosity Check: aspirated blood (can be used for blood Ix, GXM, blood gas). Flush no resistance/swelling. Needle firmly in place. Duration: 48h max CI: burns (risk of cellulitis), bone problems eg fracture

Ketamine

White powder or pills which can be insufflated (onset 5-15min, peak 45-60min, duration 1-3h), ingested (onset 5-20min, peak 90min, duration 4-8h) or rarely injected. Aka special K, K, vitamin K and kit kat Ketamine binds to NMDA receptors, biogenic amine uptake complex, sigma receptor and Act receptor which may be responsible for its clinical effect. Finding: - CNS: altered mental status, slurred speech, anxiety, hallucinations, distorted body image, nystagmus, psychomotor agitation makes the patient at risk of self injury - CVS: palpitations, HTN, tachycardia - ENT: chronic rhinitis, epistaxis and septal perforation - Seizures or respiratory arrest may occur. Death is rare following ketamine abuse of overdose - hyperthermia, rhabdomyolysis - ketamine associated abdominal pain (further study needed)(occurs in 21% of ED cases) - chronic use: memory, learning and attention problems. If use 1-4years: ketamine associated lower urinary tract destruction (finding: dysuria, frequency ie voiding q15min, urgency, urge incontinence, painful haematuria, hydronephrosis, impared renal function) Ix: - urine toxicology (false positive in dextromethorphan use) - ECG, CXR, FBC, RP, LFT CK as clinicalyl indicated P: - adequate fluid to maintain urine output - titrate dose of BZD to control agitation - observe 4-6h for effect of ketamine to wear off - supportive care - prevent secondary injury