ACRONYMS

Lactic acidosis LLTIPS L eukaemiaL ymphomaT hiamine defI nfectionP ancreatitisS mall bowel syndrome

Inhibitors S odium valproateI soniazidC holamphenicolK etoconazoleF luconazoleA lcohol bingeC iprofloxacinE rythromycinS ulphonamidesC imetidineO meprazoleM etronidazole + warfarin

Inducers C arbemazepineR ifampicinA lcoholismP henytoinG riseofluvinP henobarbS ulphonylureas + folic acid

Causes of DIC = VHOTMISS V ascular Vasculitis, large aneurysmH epatic FailureO bstetric Amn fl emb, HELLP, abruption, septic abortionT rauma Burns, rhabdo, thermia, fat emb, brain inj, decr O2M alignancy AdenoCa, lymphoma, promyelocyticI mmune Transfusion, anaphylaxisS epsis Gram –ive, viral haemorrhagicS hock / snakes ARDS, pancreatitis

Causes of ARDS = VHOTMAST V ascular fat, clot, air embolismH epatic FailureO bstetric Amniotic fluid embolism, eclampsiaT rauma Severe HI, multiple #, >8iu blood transfusion in a dayM OF ARF, DICA ltitude HAPES epsis Pneumonia, pancreatitis, G-ivesT ox Smoke, metals, NO, NH3, chlorine, SO2, aspirin, HC,

paraquat, opioids, cocaine, nitrofurantoin

Causes of pancreatitis: GETSMASHED G allstones (35-40%)E TOHT raumaS corpian bite / toxin

M umps, EBV, HIV, coxsackie, parasiticA utoimmune (SLE, Sjogrens, vasculitis)S teroidsH yperCa / lipidsE RCP (5% risk)D rugs (5%; sulphonamides, thiazides, valproate)

TTP = FARTN F everA anemia (haemolytic)R enal failureT hrombocytopeniaN euro Sx

Enhanced elimination = PAM PACAAT PALAATUrinary alkalinisation P henobarb

A spirinM ethotrexate

MDAC P henobarbA spirinC olchicine (DECONTAMINATION > RESUS)A nticonvulsants (carbamazepine, phenytoin, Na valproate)

A mitripA manita mushroomT heophylline

HaemoD P henobarbA spirinL ithiumAnticonvulsants (Na valproate, carbamaz)A lcoholT heophylline

CI for thrombolysis = ABC CHAMPAbsolute CI A ortic dissection / active bleeding

B errycarditisC NS (ICH ever / ischaemic CVA in past 6m / OT in past 2m)

Relative CI C oagulopathy / cavitatory lung disease / CPRH TN (>180 / >110)A llergy, age >80yrsM ajor trauma in past 2mP regnancy / PUD / procedures in past 3w

Simple febrile convulsion = FATGIDS F ever >38.5A ge 6m – 5yrsT ime <15minsG eneralised 1YI ntracranial pathology absentD eficit absentS ingle seizure per episode of fever

AGMA: CATMUDPILERS C O, cyanideA lcoholic ketoacidosisT ouleneM etformin, methanolU reaemiaD KAP araldehyde, paracetamol OD

I soniazid, ironL actic acidosis A Tissue hypoxia

B1 Systemic disordersB2 Drugs/toxinsC Hereditary metabolic

E thylene glycol, ETOH XSR haboS alicylates, starvation

NAGMA: USEDCARP U reterostomyS mall bowel fistulaE xtra Cl Incr KD iarrhoea

KA (resolving) Iuretics May incr KC arbonic anhydrase inhibitorsA ddisons Incr KR TAP ancreatic fistula Incr K with type 4

Metabolic alkalosis: GRORORE Cl sensitive G I lossesR enal losses Post-diureticO ther Contraction alkalosis

Post-hypercapniaCF

Cl insensitive Normal BP R enal losses Bartter, Gitelman, diuretic efeeding alklosisO verdose of base Milk alkalki, NaHCO3 ther Severe hypoK/Mg

High BP R enal losses Liddle, diuretic, RAS, CRFE ndocrine Conns, Cushings, steroids

Prolonged QRS and QTC: PAACCTT A ntihistamines DiphenhydramineA ntimalarials Quinine, chloroquineT ype Ia/c Procainamide, quinidineT CAC ocaineC arbamazepineP henothiazines Chlorprom, stemetil

Prolonged QRS only: PLAT P ropanololL AA mantadineT ype IV Diltiazem, verapamil

Prolonged QTc only: LMAO AT SS L ithiumM ethadoneA ntipsychotics HaloP, risperidone, quetiapine, droperidolO ‘s OP’s, ondansetron, omeprazoleA ntibiotics Erythromycin, clarithromycin, tetracyclineT ype III / IV Amiodarone, sotalol, Ca antS umatriptanS SRI Amitriptyline

And ethylene glycol!

IMPORTANT TRIALS

CVISIS2: 1988; 17,000; aspirin vs SK vs aspirin + SK vs placebo in MI

Aspirin+SK > aspirin / SKAspirin = SKAspirin alone + SK alone > placebo

3% decr AR mortality, 25% decr RR mortalityISIS1 + 3: beta-blockers in MI

50% decr infarct size, reinfarct, mortality30% decr ICHDecr short term mortality with TL; decr cardiac ruptureWorsens Sx with large infarct / LVF

CLARITY-TIMI / COMMIT: clopidogrel in MIImproved hospital and 30/7 outcome

CURE: clopidogrel + aspirin vs aspirin in MI

20% decr death / MI / CVA in 3-12/12 in clopidogrel+aspirin vs aspirin alone

1% incr bleeding rate

SYNERGY: heparin + aspirin vs aspirin in MI

Decr reinfarct / mortality by 33% in heparin+aspirin vs aspirin alone

GUSTO: thrombolysis in MI

5% decr AR mortalityPIOPED: investigation of PE diagnosis

Clinical assessment and VQ scan established diagnosis in only minority of patientsCTPA: 83% sens, 96% spec, 92-96% PPV, 10% inconclusiveVQ: 98% sens, 10% spec, >50% inconclusive

+ive (13%) 88% likelihood of PE; 96% PPV if mod/high pre-test probIntermediate 15-30% likelihoodLow prob 4-12% likelihood-ive (14%) <5% likelihood; NPV 96%

NSNINDS: tPA vs placebo for NIHSS scores / mortality / probability of favourable outcome in CVA

600 patients; multiple centre RCT; industry sponsored; poorly matched50% treated <90mins; no control over post-TL trtimproved outcome at 3-12/12

13% absolute increase in minimal / no disability

3% decr mortality: 17% mortality tPA (21% placebo)

6% ICH tPA (0.6% placebo) – 50% were fatal

ECASS: tPA vs placebo for TL <6hrs600 patients; multiple centre RCT; industry sponsored; post-hoc analysis; well matchedtPA no significant improvement in outcomes; increased mortality27% ICH tPA (17% placebo)

ECASS II: tPA vs placebo for TL <6hrs800 patients; multiple centre RCT; industry sponsoredNo statistically significant change in outcome; increased ICH

ECASS III: tPA vs placebo for TL 3-4.5hrsMultiple centre RCT; industry sponsored

Better NIHSS score at 90/7 tPA and decr mortality; but incr ICH

CAST + IST: aspirin in CVA prevention post-TIA20-30% decr risk of CVA

TOXSalt Lake Study: HBO in CO poisoning

Good study; high FULow no. suicides, high no. chronic exposurePoorly matched groups, corrected for in analysis

20% decr cognitive sequelae at 6/52 and 6/12 (25 vs 45%, 20 vs 38%)

Alfred Study: HBO vs 48hrs 100% O2 in CO poisoning50% lost to FU; only severely poisoned studied, poor methodsNo benefit

IDEarly goal directed therapy (Rivers et al, NEJM, 2001): RCT; severe sepsis

Improved survival 16% compared to controlMay not be applicable to Australasia as have lower mortality rates than USA

Endpoint: CVP 8-12CVO2 >70%MAP 65-90

UO >0.5ml/kg/hr

If low MAP / CVP 500ml (10ml/kg) N saline Q5-10minly + watch for improved / worsened CV status

If MAP not achieved Commence NAD + insert CVL/ALEndpoint: PWP 15-18

MAP 90-110HR 80-120

If CO not achieved (ie. CVO2 <70%, UO low, incr lactate) - CONTROVERSIALCommence dobutamine (controversial; may decr BP and incr HR)Aim HCt >30% (transfuse; controversial)

Aim Hb >7

APC in sepsis: 6% decr mortality (controversial)Use if severe sepsis with dysfunction of >2 organ systems / APACHE >2524mcg/kg/hr INF for 96hrs

CORTICUS (NEJM, 2008): hydrocortisone in septic shock No improved survival or reversal of shock, but did speed up reversal of shock in those who did survive11% decr mortality if relative adrenal insufficiencyControversial – recommended if septic shock requiring vasopressors200-300mg hydrocortisone per day

SAFE study (NEJM 2004): saline vs albumin in ICU in critically ill patients RCT, double blindedNo significant difference in mortality, survival time, organ dysfunction, duration of mechanical ventilation / dialysis, hospital / ICU LOSDecr mortality in albumin in severe sepsis (statistically insignificant)Incr mortality in albumin in trauma

Dopamine vs NAD in shock (NEJM, 2010)No significant difference in outcomeDopamine: Incr adverse events, incr mortality in cardiogenic shock

Low dose dopamine for renal protection (Lancet, 2000)Not recommended

NAD + dobutamine vs adrenaline in septic shock (Lancet, 2007): No difference

RSBiPAP in COPD (Bronchard et al):

Decr mortality; NNT 10 (no effect on mortality when CPAP for CCF)

Decr ETT; NNT 5Decr hospital and ICU LOS

RESUS

CRASH-2 trial (2010, The Lancet): tranexamic acid 1gLarge RCT trial of effects of tranexamic acid on death and transfusion requirement in trauma

patients with, or at risk of, significant haemorrhageDecr death if given <3hrs of trauma (incr risk if given after >3hrs)

CONTROL trial: factor VIIa in blunt traumaIncr mortalityNo improvement of any clinically significant outcomes5% incr VTEOnly as last resort after control of bleeding obtained

Permissive hypotension: if uncontrolled haem and early intervention can control bleedingAim: SBP 60-80, MAP 40CI: Controlled haem, evidence of end organ failure (eg. MI), HIUnclear effects on mortality and organ failure in long term

ARDS-net: TV 6ml/kg (decr mortality rate 10%, from 40% 30%)Permissive hypercapnia (aim pH >7.2 and adequate PaO2)RR 18-22PIP <30Allow mod hypercapniaTitrate PEEP to FiO2Elevate head of bed 45degProne ventilation improves oxygenation but no survival benefit

HACA (Hypothermia after Cardiac Arrest, NEJM, 2002)Cooled for 24hrsAt 6/12 Favourable neuro 55% vs 40% Ability to live independently and work parttime

Death 40% vs 55%Trend to sepsis, bleeding and pneumonia in hypothermia groupNNT 6-7

Melbourne Study (Bernard et al, NEJM 2002)Cooled for 12hrsGood neuro outcome 50% vs 25% Discharge to home or rehabMortality 50% vs 70%

ILCOR Recommendations (2002) If unconscious (absent response to verbal commands; GCS <6; motor <4)Initial rhythm VF

Out of hospital ROSC within <60mins

TESTS AND SCORES

Trauma Score GCS RR SBP CRT Resp effort<12 = serious

Revised Trauma Score GCS RR SBPLow score = badCons: poorly predictive of mortality

CRAMS Score Circ Resp Abdo Motor Speech<8 = badPros: good for pre-hospital triage

Injury Severity Score Head+neck Abdo+pelvis Chest Face Extremities External<9 = minor >25 = severe >35 = very severeCons: doesn’t account for age / co-morbidities; retrospective; bad for penetrating

New Injury Severity Score Just 3 worst injuries of abovePros: better mortality prediction

CHADS2: 1 for CCF / HTN / Age >75yrs / DM2 for CVA / TIA / thromboembolism

0 = aspirin = 2% risk/yr of CVA 1.5%/yr ARR 1Y prevention; 2.5%/yr ARR 2Y20% decr risk CVA

1 = aspirin / warfarin = 3% risk2 = warfarin = 4% risk 60% RRR

2.5%/yr ARR 1Y prevention, 8.5%/yr ARR 2Y1%/yr =haemorrhage

3 = 6%4 = 8%5 = 12%6 = 18%

ABCD2 score: 1 for Age: >60yrs 2 for:

BP: >140/90Clinical: speech disturbance unilateral weakness

Duration: 10-60mins >60minsDM

0-3 = 1% 2/7 risk = 15% 1/52 risk = do CT head and carotid USS within 48-72hrs; OP FU4-5 = 4% 2/7 risk = 20-25% 1/52 risk = admit6-7 = 8% 2/7 risk = 25-30% 1/52 rsik

Stroke screening tools: ROSIER scale, FAST, CPSS, LAPSS, MASSStroke assessment scale: NIH: correlates with infarct vol, weighted to ant circulation, allows comparison over time, measures level of impairment

TIMI risk score >0.5mm ST deviation>2 angina in past day>3 cardiac RF>50% prev stenosis>65yrsAspirin in past weekIncr cardiac markers

0-1 = 5% risk death / MI / urgent revasc at 2/522 = 8%3 = 13% Intermediate Early invasive therapy good4 = 20%5 = 25% High6-7 = 40%

Pros: not dependent on physiology; validated; applicable to allCons: doesn’t weight RF’s; 0 score still has 2% risk

Grace Score ST changes Estimate of in-hospital and 6/12 mortalityAgeBiomarkersHRSBPCrKillip class

Cardiac arrest

Pros: more preciseCons: more difficult; RF’s not involved

Duke Criteria 2 major 2x +ive blood culture of typical MO >12hrs apart Staph aureus, strep bovisIntracardiac mass Strep viridians, enterococcusPeriannular abscess HACEKPartial dehiscence of prosthetic valveNew regurg on echo

1major, 3 minor IVDU / congenital heart disease5 minor T >38

Vascular phenomena (organ emboli, mycotic aneurysm, splinter haem, Janeway)Immunological phenomena (GN, Osler’s nodes, Roth spots)+ive blood culture / echo not fitting major criteria

Modified Jones Criteria 2 major Carditis / new murmur 66%Chorea 10-30%Migratory polyarthritis 60-70%Erythema marginatum 10%Subcutaneous nodules Uncommon

1 major, 2 minor PMH RFT >38Incr titre of antistrep abIncr ESR / CRP >30Long PRArthralgia

SMART-COP S BP <90 Predicts deterioration, need for ICU/vasopressorsM ultilobar 0-2 = low riskA lb <35 3-4 = mod riskR R 5-6 = high risk (33%)T achy >125 >7 = high risk (50%)C onfusion 92% sens, 62% specO 2P H <7.35

CORB C onfusion Predicts deterioration, need for ICU/vasopressorsO 2 <90% >1 = severeR R >30 80% sens, 68% specB P <95

CURB-65 C onfusion Predicts 30/7 mortality / ICU admissionU r >7 0 = 0% 0 – 1: can send homeR R >30 1 = 1% 2: borderline

B P <90 2 = 7.5%>65yrs 3 = 20%

4 = 40%5 = 60%

Pneumonia Severity Index History NH res, CCF/CVA/CRF, Ca, liverOE T, HR >125, RR >30, BP <90Ix BSL >14, Hct <30, PaO2 <60, Ur >11, Na <130, pH <7.35

Pleural effusionPredicts mortality; class I – V; admit class III and over; 30% mortality class V

NYHA CCF: I Sx on abnormal exertionII Sx on ordinary exertion 10%/yr mortalityIII Sx on less than ordinary exertion 20%/yr mortalityIV Sx at rest 40-50%/yr mortality

Killip Classification I No CCF 5% mortalityII Bibasal rales + S3 15-20% mortalityIII Frank pul oedema 40% mortalityIV Cardiogenic shock 80% mortality

Brugada’s VT criteria Absent RS in any precordial lead 100% specRS >100 in any precordial lead >95% specAV dissociation (<25% sens) Notched QRS (40% sens, >75% spec)

Fusion beatsCapture beats

Wellen’s VT criteria RBBB V1 L sided incr rabbit ear in V1V6 RS ratio <1 QS wave

LBBB V1 RS >60ms R wave >30ms Notched downslope of SV6 RS ratio <1 Any Q wave

Other VT criteria QRS >120-140RBBB + QRS >140LBBB + QRS >160Concordance of QRS 20% sens, 90% specLAD/RAD

Well’s Criteria for DVT 1 for RF’s Ca <6/12 Recent POP / decr movement Bedridden >3/7 / major OT <4/52

Leg Tender veinsEntire leg swollenCalf swelling >3cm compared to oppositePitting oedemaCollateral superficial veins

-2 for alternative diagnosis more likely0-2 = low risk>2 = high risk

Well’s Criteria for PE 1 for haemoptysis RED = in PERCCa

1.5 for HR >100 Bedridden >3/7 / OT <4/52PMH PE / DVT

3 for Sx of DVTPE most likely diagnosis

0-1 = 3-4% risk2-6 = 20% risk7+ = >60% riskSubjective; extensively validated

Revised Geneva Score 1 for >65yrs2 for haemoptysis; OT/leg # in 1/12; active Ca3 for HR 75-94; unilat leg pain; prev DVT/PE4 for Leg pain on palpation / unilat oedema5 for HR >95

0-2 = 8% risk4-10 = 28% risk11+ = 74% riskMore objective; less validated

PERC Criteria EpiD Age <50yrs Sens 97.5%History No haemoptysis Spec 22%

No OT / trauma in 1/12PMH No PMH PE/DVTDH No OCPOE HR <100

SaO2 >95%No unilateral leg swelling

SADPERSONS

PSYCH EXAM ADDMIS A ppearanceD isorders of thoughtD isorders of perceptionM ood and affectI nsightS Cognitision

ASA CLASS: 1 = healthy, no medical problems2 = mild systemic disease3 = severe systemic disease, but no incapacitating4 = severe systemic disease that is constant threat to life5 = moribund, expected to live <24hrs irrespective of operationE = emergency

SAN FRAN SYNCOPE RULE History SOBPMH PMH CCFOE SBP <90 at triageInvestigation Not in SR

New ECG changesHct <30

1 = 12% serious outcome <1/52; 95% sens, 60% spec; similar to physician judgement but 10% more sens

MMSE 10 points Orientation9 points Language (objects, if and but, paper, close eyes, sentence, pentameter)5 points Attention + calculation (serial 7’s / world)3 points Recall (recall registration words)3 points Registration (3 words, rpt back)

>25 = normal 21-25 = mild <20 = cognitive impairment <9 = severe

GCS Eye 1 None2 To pain3 To voice4 Open spontaneously

Verbal 1 None2 Sounds3 Inappropriate words

4 Disorientated5 Appropriate

Motor 1 None2 Decerebrate (extension) Pons3 Decorticate (flexion) Midbrain4 Withdraws5 Localises Forebrain6 Obeys commands

SGARBOSSA CRITERIA Concordant STE >1mm Up UpDiscordant STE >5mm Up DownConcordant STD >1mm Down Down

OTTAWA ANKLE RULES Pain near malleoli + inability to WB 4 steps immediately and in ED Tender post / inf lat / medial malleolus

100% sens, 40% spec; decr XR by 30%

OTTAWA FOOT RULES Pain in mid-foot + inability to WB 4 steps immediately and in ED Tender base 5th MT and navicular

100% sens, 80% spec

OTTAWA KNEE RULES Pain in knee + inability to WB 4 steps immediately and in ED >55yrs Tender head of fibula / patella Active knee flexion <90deg

100% sens fo significant #, 50% spec; decr XR by 25%

NEXUS CRITERIA Neuro deficit Sens 99.6%ETOHXtra injuriesUnconsciouns / decr LOCSore on palpation

CANADIAN C SPINE High risk: OLD >65yrsNEURO SX ParaesthesiaMECHANISM: fall >1m / >5 steps / axial load / >100kmph /

rollover / ejection / >55kmph / death at scene / bike collision / motorized rec vehicle

INJURIES: sig closed HI, neuro Sx, pelvic #, multiple limb #Low risk: Rear ended

Sitting in EDAmbulatory at any timeDelayed neck painNo tenderness

CANADIAN CT HEAD High risk: OLD >65yrsNEURO SX GCS <15 2hrs post

Vomiting >2xINJURIES Open / depressed skull #

BSF Med risk: MECHANISM: fall >1m / >5 steps / car v ped / ejection

Amnesia >30mins

Rule Of Nines Adult Child 1yr oldLeg 18% each 13.5% (+0.5% per yr each)Arm 9% each SameTorso 18% front, 18% back Same

Head 9% 19% (- 1% per yr)Perineum 1%Neck 1%

Ranson’s Criteria On arrival A ge >55yrsA ST >250L DH >350-700B SL >10W BC >16

@ 48hrs P aO2 <60H ct drop >10%

C a <2 U r rise >5B E >4

E stimated fluid sequestration >6L0-2 = 1% mortality 3-4 = 15% mortality 4-5 = 40% mortality 6-7 = 100% mortality

Glasgow Scoring System A ST >200A lb <32L DH >600B SL >10W BC >15P aO2 <60C a <2U r >15

>3 = severe

Apache Score AgePhysiology T, MAP, HR, GCS

pH, Na, K, Cr, AA gradient, PaO2WBC, Hct

Chronic Health Chronic organ insufficiencyImmune compromiseARF

Done at admission only >7 = severe = 11-18% mortality65% sens, 76% spec

Light’s Criteria: 1+ ofPleural chol : serum chol >0.3Pleural protein : serum protein >0.5 99% sens for exudatePleural LDH : serum LDH >0.6 65-85% specPleural chol >1.1Serum alb - pleural alb >1.2Pleural LDH >2/3 upper limit of normal for serum LDH

Exudate TransudateProtein >30 <30WBC High Low

Complicated parapneumonic effusion/empyema: pH <7.2 or 0.15-0.3 less than serumGlu <2.5LDH >1000LoculatedOngoing sepsis despite ABx

Empyema Turbid with WCC >1000MO on gram stain

Transudate ExudateIncreased hydrostatic pressure

CHFConstrictive pericarditisSVC obstruction

Malignancy – primary or metastatic; 38% lung, 17% breastInfection

PneumoniaViral, fungal, mycobacterial, parasiticContiguous infection

PE (80%)Decreased oncotic pressure

CirrhosisNephrotic syndromeHypoalbuminemia

Connective tissue diseasesSLE, RA

InflammationUremiaPancreatitisSarcoidosisHemothorax

Iatrogenic / otherPeritoneal dialysis

Iatrogenic / otherPost-cardiac surgeryPost-radiotherapyDrugs – amiodarone

“Classic” exudates that can be transudatesMalignancyPE (20%)SarcoidosisHypothyroidism

Severity of Asthma Mild PEFR, FEV1 >75% SaO2 >95%Mod PEFR, FEV1 >50-75% SaO2 90-95% HR 100-120 PhrasesSevere PEFR, FEV1 <50% SaO2 <90% HR >120 WordsExtremis Can’t do SaO2 <90% HR >140/low Can’t do

Severity of COPD Mild FEV1 <80%Mod FEV1 <60%Severe FEV1 <40%

DRUG DOSES I FORGETO+GTocolysis: Salbutamol 100mcg/hr and increase until contractions stop Nifedipine 20mg stat rpt Q30min if ongoing 20mg TDS MgSO4 20mmol over 30mins

GTNCI: >34/40, fetal distress, placental abruption, infection, pre-eclampsiaDelay delivery by 24-48hrs in 80%

Betamethasone 11.4mg IM Q24h x2; if <34/40; decr risk of ARDS by 50%

AntiD: 250iu if <13/40, 625iu IM if >13/40

PPH Oxytoxcin 10iu IV stat 40iu over 4hrs or Ergometrine 250-500mcg IV/IMMisoprostol 500-1000mcg PR or Intramyometrial 250-500mcg PGF2a

MgSO4 in eclampsia: 40mmol over 15mins 20mmol rpt x2 Q15min if seizing 10-30mmol/hr INF

Monitor Mg levels and for SE’s (lethargy, decr reflexes, flushing)CaGlu is antidote

BP: Hydralazine 5-10mg IV over 5-10mins rpt Q20min 5-60mg/hr INFNifedipine: 10mg PO rpt Q30min 10mg PO Q4hrlyLabetalol 20mg 40mg 80mg to max 200mg 1-2mg/hr INFMethylodopa: 250mg PO Q6hNitroprusside: 0.1-5mcg/kg/min INF

PID: Sexy: Ceftriaxone 250mg IM stat (clinda if penicillin allergy)Azithromycin 1g PO single dose OR Doxycycline 100mg BD 2/52 (roxy if BF)Metronidazole 400mg BD 2/52

Severe: Ampicillin 2g IV Q6h IVGentamicin 5mg/kg OD IVMetronidazole 500mg BD IV

TOXToxic doses

ACEi Can have 2-3x dose and it’s fine

ETOH 2-5g/kg coma>4mmol/L 0 order kineticsWithdrawal: 5-10mg PO 6-8hrly

10-20mg PO 1-2hrly5mg IV stat Rpt up to 20mg in 30mins

Then Q30minlyWernickes Thiamine 500mg IV

Ethylene 1ml/kg lethalETOH if >3mmol/LETOH 1g/kg in 5% dex 150mg/kg/hr

Aim ETOH 20-30mmol/L / 100-150mg/dLHaemodialysis if >4-8mmol/L (until <3mmol/L)CNS CV renalPyridoxine 100mg IVThiamine 100mg IVNaHCO3

Meths 0.5-1ml/kg lethalMost potent cause of incr OGETOH as above until <6mmol/LHaemodialysis if >15mmol/LPyridoxine and thiamine as above+ folate 50mg IV

Iso 4ml/kg coma

Incr OG as above, but minimal AGMA despite high ketosisHaemodialysis if >65mmol/LETOH not used

Carbamazepine Delayed onset 2Y to anticholinergicNa blockade SO TREAT AS TCA ODCharcoal, MDAC, NaHCO3 (cardiotoxicity), haemodialysis

Na val >200mg/kg comaBlood probs: decr plt/WBC (BM failure) decr BSL/Ca/phos

incr NH/LFT (liver failure) incr Na/MetHb, AGMACharcoal, MDAC, WBI if SR, haemodialysis (>1-1.5g/L)

Phenytoin 100mg/kg risk of comaNa blockade (IV)Charcoal, MDAC

Type I antihis Anticholinergic, anti adrenergic, anti serotonin, Na and K blockadeNaHCO3, MgSO4, inotropes, benzos for seizures

Olanzapine >300mg comaAnticholinergic, anti adrenergic

Clozapine Anticholinergic, seizures, agranulocytosis, myocarditisQuetiapine >3g severe

Na and K blockade, seizuresRisperidone Anticholinergic, Na and K blockade, anti serotonin, EPSE

Chlorprom >5g severeAnticholinergic, EPSE, seizures

Haloperidol Na and K blockade, EPSE, seizuresThioridazine Anticholinergic, Na and K blockade (severe)

Na channel Citalopram, venlafaxineQuetiapine, haloperidol Risperidone, thioridazinePropanolol

Aspirin >300mg/kg severe >500mg/kg fatalCharcoal, MDAC, WBI if SRNaHCO3 if symptomatic / level > 2.2 / pH <7.1HaemoD if can’t UA / UA doesn’t work / level >4 despite trt / level >4 chronic / level > 6

acute / severe

Propanolol As per TCA HypoG, hyperK

Verapamil >15mg/kg toxic HyperG, hypoK, ketoacidosis, lactic acidosis, AGMANifedipine >2mg/kg toxic

TCA >10mg/kgOlanzapine 40-100mg mod >300mg comaQuetiapine >3g severe

Chlorprom >5g severeNa valproate 400-1000mg/kg severe >1g/kg MOFCarbamazepine 20-50mg/kg mod >50mg/kg severe

Aspirin 150-300mg/kg mod >300mg/kg severe

Colchicine >0.5mg/kg mod >0.8mg/kg severeParaquat 20-40mg/kg death in 5/7-wks

>40mg/kg death in 1-5/7>50mg/kg death in <3/7

Isoniazid >10g >15g fatal

Fe 20-60mg/kg mod 60-120mg/kg severe >120mg/kg lethalLi >40mg/kg

Ethylene glycol 2ml/kgMeths 30ml of 40%Isopropanol 2.5ml/kg of 70%

Propanolol >1gDigoxin >10mg (>4mg in children)Diltiazem 5mg/kg (>10tabs in adults, >2 tabs in children)Verapamil 16mg/kg (>10tabs in adults, >2tabs in children)

Theophylline >110mmol/l

Trt: Syrup of ipecac 15-30mlGastric lavage: 200ml (10ml/kg) warm waterCharcoal: 25-50g (0.5-1g/kg)WBI: 2L/hr (25ml/kg/hr)Intralipid: 1ml/kg 20% over 1min 10ml/hr INFMDAC: 50g (1g/kg) PO 25g (0.5g/kg) Q2hUrinary alkalinisation: 1mmol/kg NaHCO3 IV bolus 2.5-25mmol/hr

OP Pralidoxime 1-2g in 100ml N saline slow IV over 15mins 0.5-1g/hrEndpoint: plasma cholinesterase >10%

Atropine 1-2mg double dose Q2-3min until dry secretions

Fe Desferrioxamine 5-15mg/kg/hr (can cause hypotension)Indication: >90mmol/L, 60mmol/L + Sx, severe toxicityEndpoint: Sx gone, Fe normal, AGMA normal, urine normal

Cy Hydroxycobalamin 5g in 100ml N saline over 15mins rpt if no improvementEndpoint: improved LOC, CV status, metabolic acidosis Safe

Dicobalt EDTA 300mg in 20ml dex over 1-5mins rpt if no improvementEndpoint: as above Bad SE’s esp if not poisoned

Amyl nitrite 300mg over 2-3mins INH Na thiosulphate 12.5g IV over 10mins rpt if needed

Endpoint: as above Safe

Lead Succimer 10mg/kg PO TDSDimercaprol 3-4mg/kg IM Q4hNa Ca EDTA 25-75mg/kg

Isoniazid Pyridoxime 5g IV over 3-5mins (or same dose as isoniazid) rpt Q15min until seizures Controlled

Morphine Naloxone 2/3 of wake up dose INF per hourDOA 20-60mins

MetHb Methylene blue 1-2mg/kg IV over 5mins rpt at 1hr if needed

Digibind: Acute: mg ingested x 0.8 x 2 = no ampoules

Chronic: (mmol/L level x kg) / 100 = no ampoules ?NG????

CaGlu in HFl poisoning: 60ml 10% IV if systemic10ml 10% up to 40ml with KY TOP Q15min then 6x/day0.5-1ml/cm 10% SC (not in hands / feet) – not diluted

10ml 10% with 40ml N saline + heparin IV regional - large10ml 10% with 40ml N saline IA regional over 4hrs (gold standard)1.5ml 2.5% in N saline NEB

Ca antagonist poisoning: 60ml 10% CaGlu over 15mins 20ml/hr INF Endpoint: Ca >25mg glucagon stat 1-5mg/hr1iu/kg actrapid in 50ml 50% dex 0.5-1iu/kg/hr actrapid in 10% dex1ml/kg 20% intralipid over 1min 0.5ml/kg/min INF

Dystonic reaction (EPSE) DB Benztropine 1-2mg IV rpt at 15mins if needed 1mg PO TDS

SS SC Cyproheptadine 8mg PO TDS Chlorpromazine 50-100mg IV

NMS NB Bromocriptine 2.5mg PO TDSDantrolene

MH MD Dantrolene 1mg/kg IV 1mg/kg QID IV

Fe OD stages 0-3hrs 3-12hrs 12-48hrs 2-5/7 weeks

GIVariceal haem: Octreotide: 50mcg stat IV 50mcg/hr INF for 48hrs

Terlipressin: 2mg IV Q6h

Gastro: Paedialyte 25ml/kg/hr for 4hrs

Liver failure: Mannitol 0.3-0.4g/kgLactulose 20g PO / 300ml PR

Appendicitis 1g Ampicillin QID + 5mg/kg gentamicin OD + metronidazole

Cholecystitis 1g ampicillin QID + 5mg/kg gentamicin OD (+ metronidazole if gallstones)

Gastro Norfloxacin 400mg (10mg/kg) PO BD 5/7 – E coli, Yersinia, salmonella, shigellaDoxycycline – choleraMetronidazole 400mg (10mg/kg) PO TID 7-10/7 – C diff, giardiaVancomycin 125-250mg PO QID 10/7 – severe C diff

Erythromycin 500mg (10mg/kg) PO QID 5/7 – campylobacter

H pylori Pantoprazole 40mg BD + amoxicillin 1g BD for 5/7 pantoprazole 40mg BD + amox + clarithromycin 500mg BD for 5/7

SBP Ceftriaxone 2g IV OD / cefotaxime 2g IV TDSCeftazadime / cefazolin / vanc intraperitoneal

RSAsthma Salbutamol 10mcg/kg (500mcg) over 2mins rpt at 10mins 1-20mcg/kg/min

MgSO4 25-50mg/kg IV over 20minsAminoP 6-10mg/kg (500mg) over 1hr 0.5-1mg/kg/hr infusion

CVEsmolol 500mcg/kg bolus 50-100mcg/kg/min infusion (thyroid storm)

HTN: GTN 1-20mcg/min titrated up 5mcg ever 5mins max 200mcg/min METHBLabetalol 10-20mg 40mg 80mg 1-10mg/hr infusionEsmolol 500mcg/kg bolus 50mcg/kg/min titrated to max 300mcg/kg/minNa nitroprusside 0.1-10mcg/kg/min CYANIDEHydralazine 5-10mg IV over 5-10mins 5mg/hr INF

AF: Amiodarone 2-5mg/kg over 10mins 50% reversion in 24hrs, 90% in 48hrsFlecainide 2mg/kg over 30mins 200-300mg PO 60% reversion in 3hrs, 80% in 8hrsDigoxin 500mcg IV 250mcg Q4-6h up to 250mcg/dayVerapamil 1mg rpt to 10mg IVMetoprolol 5-10mg over 2mins

MI Aspirin: 300mgClopidogrel: 300mg for TL, 600mg for PCIUFH: 60Iiu/kg 12iu/kg/hr INF aiming APTT 1.5-4x normalLMWH: 0.75-1mg/kg SC BD (give 30mg IV bolus if <75yrs)Metoprolol: 50mg PO BDReteplase: 10iu IV over 2mins 2nd dose 30mins laterSK: 1.5million IU over 1hr

PE: UFH: 80iu/kg IV 18iu/kg/hr INFLMWH: 1mg/kg SC BDr-tPA: 10mg IV bolus 90mg IV over 2hrsSK: 250,000iu IV over 30mins 100,000iu/hr for 24hrs

IE: ampicillin 2g IV Q4hFluclox 2g IV Q4h (not needed if subacute)Gent 5mg/kg IV ODIf prosthetic / IVDU: ceftriaxone + vanc + gent

RF: penicillin 10mg/kg BD for 10/7

SVT: adenosine 6, 12, 18 (0.1mg/kg, 0.2mg/kg, 0.3mg/kg); reverts 90%; 15% recurVerapamil 5mg IV slowly; 80% reversion, 95% with 10mgFlecainide 2mg/kg IV over 30-45mins

TdP: 20mmol MgSO4 over 1-2mins 10-20mmol/hr

VT: Amiodarone 150mg IV over 5-10mins 600mg/24hrs 30% effective in 1hrProcainamide 100mg IV 50mg/min until reversion 75% effectiveSotalol 1.5mg/kg over 3mins 65% effectiveLignocaine 1.5mg/kg IV over 5mins 20-30% effective

Product Dose Effect

Rbc 2u (15ml/kg) Hb 20g/l, Hct 6%

Plt (single) 1u (5ml/kg) Plt 50,000/mcl

FFP 4u (15ml/kg) 1 unit = 3-5%

Cryoppt 10u (1u/5kg) Fibrinogen 75mg/dL

NSSeizure: midaz 0.15mg/kg IV/IN/IM

phenytoin 18mg/kg over 30minsPhenobarb 18mg/kg over 30minsLevetiracetam 20mg/kgNa valproate 20mg/kg over 3-5minsThiopental 2-5mg/kg 2-5mg/kg/hr

Migraine: paracetamol, nsaid, aspirinMaxalon, chlorprom, stemetilsumitrip

chlorprom 12.5-25mg IVEffective in 85%SE: decr BP, sedation

Stemetil 12.5mg IVEffective in 80%SE: phlebitis, akthesia

Maxalon 1 10mg IV70-80% effective

Droperidol 2.5mg IV slow80-100% effectiveSE: QT prolongation

Sumitriptan 100mg PO / 6mg SC60-75% effective; use in mod-severeCI: vascular disease, preg, HTN, MAOISE: MI, HTN, arrhythmia, chest pressure, dizziness

Dihydroergotamine: 1mg IV over 3mins Q8h85% effective

CI: preg, sepsis, vascular disease, HTNSE: vasoC, ischaemia

Lignocaine: DOA 40mins (2-5hrs with adrenaline)5mg/kg plain, 7mg/kg with adrenalineUse phentolamine to reverse adrenaline effectToxicity: dizziness, tinnitus, perioral tingling, decr LOC, agitation, nystagmus, muscle twitches, seizures, decr BP, arrhythmia

Prilocaine: 6mg/kg plain, 8mg/kg with adrenaline; 3mg/kg for Bier’s blockBupivacaine: DOA 6hrs

2mg/kg plain, 3mg/kg with adrenalineSE: most cardiotoxic

EMLA: prilocaine + lignocaine; onset 45mins; effective in 65% childrenSE: local allergy 5%; vasoC; CI <6/12 as systemic absorption + risk of MetHb

AnGEL cream: amethocaine; onset 20minsSE: local reaction 15%

TAC: tetracaine adrenaline cocaineSE: less effective <4yrs; CI’ed in places where adrenaline CI’ed; toxicity if used on MM’s (so use lower dose)

LAT/ALA: lignocaine + adrenaline + tetracaine; cheap; as effective as TAC; less toxic; onset 20- 30mins

Thrombolysis for CVA: tPA 0.9mg/kg 10% as bolus, 90% over 60mins

GBS IVIG 2g/kg for 5/7

MG Crisis Edrophonium 1 1 2mg IV slow pushNeostigmine 0.5-2mg IV

Trt Pyridostigmine 60-90mg PO Q4hPred 100mg/day

ENVIRONMENTALAMS/HACE: Acetazolamide 250mg PO BD Same dose prophylaxis

Dexamethasone 8mg stat 4mg Q6h PO/IM/IV 4mg PO BD for prophylaxisHAPE: Nifedipine 10mg SL stat 20-30mg SR BD Same dose prophylaxis

ORTHOSeptic arthritis: 2g IV fluclox QID

1.2g IV penicillin QID+ gent if <6yrs / IVDU

Bier’s block 3mg/kg 0.5% prilocaineInflate cuff 100mmHg over SBP

IDOndansetron 0.15mg/kg IV/PO Decr LOS, IV use, vomiting, hospitalization

No effect on readmission

Herpes simplex: Acyclovir 200mg 5x/day for 5/7 or 400mg TDSHerpes zoster: Acyclovir 400mg 5x/day for 10/7Neonatal / encephalitis: 10mg/kg IV TDS for 2/52

Kawasaki disease: IVIG 2g/kg over 12hrsAspirin 30-50mg/kg/day until fever gone 3-5mg/kg OD for 6-8/52

OM Amox /aug 15-25mg/kg TDS POCefaclor 10mg/kg QID PO

Epiglottitis Ceftriaxone 25mg/kg for 5/7 (+/- vanc)

Ludwig’s angina Benpen 1.2g IV Q6hr or Clinda 450mg IV Q8hMetronidazole 500mg IV BD

Nec fasc Meropenem 1g IV TDS + clindamycin

Fournier’s Ceftriaxone 2g IV + metronidazole 500mg IV + gentamicin 5mg/kg IV

Meningitis 10mg (0.2mg/kg) dexamethasone IV Q6h for 4/7 within 1hr of ABx halves incidence of audio/neuro complications decr risk mortality in adults

Rifampicin 10mg/kg BD x4 for contact prophylaxis / ceftriaxone IM / cipro

Brain abscess Fluclox 50mg/kg Q4h + cefotaxime 50mg/kg QID + metronidazole 7.5mg/kg TDS

<3/12 Unknown source Amoxicillin 50mg/kg QID (covers listeria and Grp B strep in <3/12)+ cefotaxime 100mg/kg stat 50mg/kg QIDor ceftriaxone 100mg/kg IM if no IV access+/- 10-20mg/kg acyclovir TDS

>3/12 Unknown source Cefotaxime 100mg/kg stat 50mg/kg QID

<3/12 Meningitis Amoxicillin 50mg/kg QID+ cefotaxime 100mg/kg stat 50mg/kg QIDor ceftriaxone 100mg/kg IM if no IV access

>3/12 Meningitis Cefotaxime 100mg/kg stat 50mg/kg QIDIf suspect pneumococcus: vancomycin 12.5mg/kg QIDIf suspect listeria: keep amoxicillin

Adult Meningitis Ceftriaxone 2g + benpen 1.8g

<3/12 Pneumonia Amoxicillin 50mg/kg QID+ cefotaxime 100mg/kg stat 50mg/kg QIDor ceftriaxone 100mg/kg IM if no IV access

>3/12 Pneumonia Amoxicillin 30-50mg/kg TDSWell pneumoniae Amoxicillin 30mg/kg TDS PO 5-7/7Complicated pneumonia Augmentin 30mg/kg TDS (or cefuroxime 30mg/kg TDS)Unwell pneumonia Fluclox 50mg/kg QID

+ cefotaxime 50mg/kg QID or clindamycinAtypical pneumonia Roxithromycin 4mg/kg PO BD

<3/12 UTI Amoxicillin 50mg/kg QID+ gentamicin 5-7.5mg/kg OD (if CNS not excluded, use cefotaxime)

>3/12 UTI Gentamicin 5-7.5mg/kg OD (or cefuroxime)If well, ceftriaxone then discharge on augmentin

Gastro Na <120 3% saline at 1ml/kg/hr

Na 120-150 0.45% saline + 2.5% dex over 24hrsNa 150-160 0.45% saline + 2.5% dex over 48hrsNa >160 0.45% saline + 2.5% dex over 72hrsPer stool 10ml/kgPer vomit 2ml/kgNG rehydration 25ml/kg/hr (or 100ml/kg over 4hrs) or 5ml/min

ENDOCRINEDKA 1L N saline 1L over 1hr 1L over 2hrs 1L over 4hrs 1L over 10hrs

Change to 0.45% saline + 5% dex once BSL <15Aim decr glu by 5/hr, osm by 1-2/hrAdd KCl once K <5 and UO – 10mmol/hr if K 4-5, 30 if 3-4, 40 if <3If BSL decreasing too fast, used 0.45% saline + 10% dexActrapid 0.1iu/kg/hr (max 6iu/hr) 0.05iu/kg/hr once BSL <12NaHCO3 if pH <7, HCO3 <5, severe hyperK0.5-1g/kg mannitol if cerebral oedema5-10ml/kg 3% saline over 30mins if cerebral oedema

Thyroid storm Esmolol 500mcg/kg 50mcg/kg/min infusion (if concern of COPD/CCF)Propanolol 0.5-1mg/min to max 10mgPropylthiouracil 900-1200mg PO loading 300mg/dayHydrocortisone 100mg IV

GUPriapism Terbutaline 5-10mg PO 500mcg SC

Pseudoephedrine 60-120mg POAdrenaline 1:100,000 2-3ml

METABOLICHyperK Salbutamol 5mg nebs rpt Onset 15-30mins DOA 2-4hrs

Ca resonium 15-30g PO Q4-6h Onset 1-2hrs DOA 4-6hrs10iu actrapid in 50mls 50% dex Onset 15-30mins DOA 2-4hrNaHCO3 1mmol/kg over 15-3mins Onset 5-30mins DOA 1-2hrsCa Glu 10-20ml of 10% over 5mins Onset 1-3mins DOA 30-60mins

Hypertonic (3%) saline 25-100ml/hr (1-2ml/kg/hr) via CVLIndication: Coma, seizure, decr LOCEndpoint: Na >125 / Sx resolved

RESUSCooling 32-34deg for 12-24hrs passively rewarm over 8hrs at 0.25-0.5deg/hr

30ml/kg 4deg N saline over 30mins

Paeds resus Adrenaline 10mcg/kg including in neonatesAmiodarone 5mg/kgMgSO4 0.1-0.2mmol/kgNaHCO3 1mmol/kgAtropine 20mcg/kg (min 100mcg, max 1mg)Sux Neonate: 3mg/kg; child: 2mg/kgNaloxone 0.1mg/kg

NUMBERS I FORGETRESUSCardiac arrest: no CPR: no long term survival if time to shock >8mins

CPR: no long term survival if time to shock >12minsDefib: 95% success if <30secs; 25% success if 2minsOut of hospital: 35% survive to hospital, 5% survive to dischargeIn ED: 70% survival

ETCO2 is 5 less than arterial; correlates well with coronary perfusion p and survival from cardiac arrest; if <10mmHg, survival unlikelyCardioversion: 0.8% risk of VF with sync cardioversion; 15% risk of asystole with VF

Propofol Cons resp depression in 50-60%Apnoea in up to 20%Ventilation needed in 1.5% (intubation in 0.02%)SBP drop by >20 in 15%Pain on injectionNo analgesiaMyoclonic jerks + hypertonicity (rare)Propofol-infusion syndrome (rare)

Pros Onset 20secs; offset 9minsAmnesia, bronchoD, anticonvulsant, antiemetic

Ketamine Cons HTN, incr HRSalivation, bronchorrhoea, tearingLaryngospasm 1-2.5%Transient resp dep if rapid IV adminVomiting 8%Incr ICPMovement; ataxia during recoveryDysphoric and emergence phenomena

CI URTI, LRTI, CF, <3/12, incr ICP, glaucoma, penetrating eye inj, HTN , CCF, aneurysm, porphyria, thyrotoxicosis, IHD

Pros Catatonia, amnesia, analgesiaPreserveation of resp and airway reflexesBronchoDOnset 40secs (8mins IM); offset 10mins (30mins IM)

NO Cons Little sedationOnset 5mins; rapid offsetVomiting 5-10%Dysphoria 1%Apnoea 1-2% children <2yrs – resolves when stop gasDizzinessMild CV depressant, pul vasoC

CI Pneumothorax, bowel obstruction, severe, HI, severe COPD, decompression illness, recent drive, FiO2 >0.5 needed; intoxicated; decr LOC; prolonged use in pregnancy

Pros No resp depressionAnxiolysis; analgesia

Sux CI Burns (9-66 days from inj, if >20% TBSA)Neuro conditions (10/7 – 6/12 from SC inj, UMN lesion, peri nerve inj, peri neuropathy, tetanus, muscular dystrophy, CVA)Congenital neuropathy Crush injMalignant hyperthermia

Cons Incr IGp, IOp, ICPMuscle fasciculationsHyperK (3-5mins after injection; lasts 10-15mins; by <1)

Thio Cons No analgesiaHypotension, arrhythmiasApnoea, trismusPhlebitis, emergence delirium

Pros Amnesia, anticonvulsantOnset 40secs; offset 10-30mins

Etomidate Cons No analgesiaMyoclonus in 20%VomitingPain on adminResp depressionEmergence phenomenaAdrenocortical suppression and seizures if infusion

Pros No CV depressionOnset 15secs, offset 10mins

Fentanyl Cons Chest wall rigidity if >5mcg/kgHypotension if BP maintained by sympathetic toneDecr HR, resp depression

Pros Onset <1min; offset 30-60minsLess hypotensive as no histamine releaseAnalgesia

PAEDSPaediatric Formulae

Weight (>1y) (Age + 4) x2

Weight (<1y) [Age (months) + 9] / 2

ETT

Age/4 + 4

Neonate 3mm

6/12 3.5mm

12/12 4mm

ETT length

Age/2 + 12 to lips

Age/2 + 15 to nose

Neonate 10cm

6-12/12 12cm

BP(Age x 2) + 85

Neonate = 60mmHg

Ventilation rate

Infants 20/min

1-8y 15/min

>8y 12/min

Defib 4J/kg

Cardioversion 0.5J/kg, 1J/kg, 2J/kg

NG and IDC 2 x ETT

Chest tube 4 x ETT or 2 x NG

Bronchiolitis RSV in 40-70%Adenovirus rare but causes more severe diseaseRapid Ag test 85% sens, 99% spec40% are admitted

Croup Parainfluenza I 50%

CHANGES IN ELDERLY15% decr TBW, 40% decr ECF, decr CI, incr SVR, decr ability to incr HRDecr muscle, incr fat, decr plasma proteins, decr bone densityDecr pul compliance, incr diaphragmatic breathingDecr GFRDecr 1st pass, decr p450, decr GI motility and gastric acid secretionDecr immunity

STATISTICS

Precision Measure of accuracy of testFalse negative FN = 1 – sensFalse positive FP = 1 – spec Sens TP / (TP + FN)

TP rate = fraction of people known to have disease who test positiveSpec TN / (TN + FP)

TN rate = fraction of people known to be disease free who test negativeAccuracy (TP + TN) / N

Proportion of all test results that are correct (sens and spec)PPV TP / (TP + FP)

The probability a positive test actually signifies presence of diseaseNPV TN / (TN + FP)

The probability that a disease will not be present if the test is negative

NSReflexes: C5-6 Biceps

C7-8 TricepsC8 FingerL3-4 KneeL5-S1 AnkleS1 Plantar

CVA: 75% 50% unknown 80% anterior25% lacunar 20% posterior20% embolic 80% MCA territory5% atherosclerotic2% dissection (10-25% if young/middle aged)

10% mortalityThrombolysis <3hrs (<6-12hrs in MI)

NIHSS 4-25 for TL; <1/3 MCA involvement; plt <100; PT <15; <80yrs2% decr mortality if <90mins; benefits at 3-12/12; NNT 83% risk of death from TL

Trt BP >220/120 (BP >185/110 if for TL)Aim 10-15% decr in 24hrs

ICH: 25% 50% ICH, 50% SAH80-90% 1Y: putamen > thalamus > pons > cerebellum, brainstem, BG; central on CT10-20% 2Y: peripheral on CT

40% mortalityOT if <1cm from surface + <60yrs

Cerebellar haem >3cmHydrocephalus / marked mass effect

Endarterectomy if: >80% stenosis (50% decr RR disabling CVA / death)70-80% stensosis (25% decr RR)

Trt BP >190/120 Aim 160/90 / MAP 110

SAH: 70% ruptured Berry aneurysm: <50% aneurysms rupture; <50% AVMs have symptoms15% perimesencephalic50% mortality from initial bleed; 33% good recovery; 33% severe neuro deficitWarning bleed in 50%LOC in 66%CT head 97.5% sens at 12hrs; 95% 12-24hrs; 85% 1-2/7; 75% 2-3/7; 50% >1/52

LP >100,000 RBCRebleed 20% (50% mortality); vasospasm 30% (30% mortality)

Trt SBP >180/120Aim pre-haem BP / SBP 120 – 180 / MAP 110

CV

Norms: CO 5.5L/min; SV 70ml; EF 65%; EDV 130ml

Infective endo: native: mortality 25%; worse acute; better subacuteStaph aureus in normal (30% in normal, 66% in IVDU)

Prosthetic: mortality 50% Strep viridans in abnormal (50-60%)

Mitral in normal; triscuspid in IVDU

AF: 2/3 cardiovert within 24hrs40% due to IHD

0.1% risk if lone AF <60yrs1.5% if low risk and anticoagulated4.5% if low risk and uncoagulatedPost-cardioversion: 55% in SR @ 1yr

90% success <48hrs, 50% success >48hrs1-5% risk of embolism

Warfarin: 2.5%/yr ARR 1Y, 8.5%/yr ARR 2Y60% RRR CVA1%/yr haemorrhage

Aspirin: 1.5%/yr ARR 1Y, 2.5%/yr ARR 2Y20% decr risk CVA

Syncope: 1% ED visits; 5% hospital admissions; 2% incidence >80yrs40% unknown20% vasovagal10% cardiac (exertional = HOCM, AS)10% postural (abnormal = decr SBP >20mmHg, or SBP <90)situationalcarotid sinus sens (abnormal = decr SBP >50mmHg, or ventricular pause >3secs)pacemaker failureECG finds cause in 5%; blood tests in 2.5%

MI: Prox LAD Mortality 70% aVRAnt-septal Mortality 10% V1 CHB, RBBB, Mobitz IILateral Ventricular ruptureInferior Mortality 5% RV in 1/3; CHB; papillary muscle ruptureRV Mortality 25-30% CHB

Circulation balanced 60-65%; R dominant 20-25%; L dominant 10-15%15-30% silent15% with initial normal ECG’s develop criteria on serials10% incr sens if RV and post leads12% in hospital mortalityIrreversible damage in 20-40mins1/3 have no RF’s

Risk stratification: 40% V low <2% chance of MI / death in 6/1255% Low 2-10% chance 30% reclassified as high risk5% High >10% chance

Normal ECG + trop: 1% risk MINormal ECG + trop + <40yrs, no PMH, no RF 0.1-0.2% risk MI

Trop T 99% sens 75-90% spec Detectable 2-12hrs Duration 14/7Trop I 95% sens 82-95% spec Detectable 2-12hrs Duration 7/7Tot CK 90% sens 90% spec Detectable 4-8hrs Duration 4/7CKMB Higher Higher Detectable 4-8hrs Duration 2/7CKMB mass 95% sens 99% spec

Reperfusion in general: 2.5% decr AR mortality47% decr RR mortality5-10% incr improvement of LVEF

PCI: 6-7% dec AR mortality, 90% reperfusion rate<1hr since Sx Available <60mins1-2hr since Sx Available <90mins3-12hr since Sx and offsite Available <120mins>12hrs If unstable

Large infarct: anterior / RV / inferior plus significant ST depression / LBBBCardiogenic shock / severe CCF (Killip >3) and <75yrsCI to thrombolysisAs rescue therapy if TL fails

Best if: >70yrs, late, large, anterior / RV, CCF, prev CABG

TL: 5% decr AR mortality, 60-80% reperfusion rateToo late for PTCA / PTCA not available>30mins pre-hospital transfer time<6-12hrs since Sx (<3hrs in CVA)

tPA best if: <75yrs; decr BP; indigenous; >4hrs delay; ant MI; CI to SK2% decr AR mortality compared to SK

Aspirin: 1Y prevention for AMI: not recommended2Y prevention for AMI: decr ARR serious vascular events 8% 6.7%

decr ARR CVA 2.5% 2%decr ARR coronary evetns 5% 4%

In unstable angina: 50-70% decr MI / deathIn MI (ISIS2): 3% decr AR mortality same as reperfusion therapy

25% decr RR mortality

Clopidogrel: In MI (CURE): 20% decr mortality (with aspirin)1% incr bleeding rate

Heparin: In MI: 33% decr mortality (with aspirin)

GTN: In MI: 35% decr mortality

BB: In MI: 50% decr mortality, infarct size, reinfarct rate30% decr ICH

Statins: 30% decr coronary events over 5yrs15% decr CVA

PE: 10% mortality rate5x incr risk during pregnancyDVT in 30-50% patients50% no RF’s, 15-30% trauma, 10-25% Ca, 5-15% immobilizationSOB most common SxD dimer ELISA 95% sens

Qualitative 80-85% sensUSS leg 60% sens, 93% specTTE 60-70% sens, 90% specTOE 80-97% sens, 88-100% specThoracic USS 75% snes, 95% specCXR Abnormal in 70-85%ECG Abnormal in 70-90%Risk stratification High = massive 40-50% PA occluded >15% short term mortality

Mod = submassive RV dysfx 3-15% short term mortalityLow = non-massive No RV dysfx 3% short term mortality

TL indications in PE: CV compromise / cardiac arrest likely 2Y to PEPE <5/7>40% pul vascular occlusionRV dilation / hypokinesis / RVSP >40mmHgSignificant co-morbidities: COPD, CCF, prev PEFloating thrombusHR:SBP >1Incr tropECG showing RV strainSevere hypoxia

Pericardial tamponade: 15-60ml normal200ml tamponade200-250ml must be present to be seen on CXR2L can be tolerated if slow accumulationPulsus paradoxicus = decr SBP >10-20mmHg on inspirationCancer most common cause of chronic; SOB most common SxEcho: >2cm effusion depth

RA / RV / LA collapseDilated IVC with lack of collapse

Pericarditis: 25% Idiopathic25% CaECG abnormal in 90%Pericardial effusion in 40%Incr trop in 50%

CCF: If Sx 2yr mortality 35%, 6yr mortality 65-80%ACEi: 40% decr mortality; decr re-hospitalisationBB: decr disease progression / hospitalization; incr survival / cardiac performanceMorphine: 10% incr mortality, hospital LOS, need for ventilationCPAP: decr need for intubation / ICU

No change in hospital mortality / LOSDiuretics: No study has ever shown benefit

HTN: Mild 140-159 90-99Mod 160-179 100-109Severe >180 >110Malignant >180 >120 + evidence of end organ damageAim <110 or 25% reduction in 12-24hrs

WPW: 95% orthodromic, 5% antidromic

ECG changes K >10 VF, asystole, sinus arrest, brady, CHB9 Sine wave7-8 Loss of P waves Wide QRS, S+T waves merge

Idioventricular rhythm, BBB6.5-7 Small P waves, ST depression

Blocks6-6.5 Long PR, long QT5.5-6 Peaked T waves3.5 – 5 NormalDecr Long PR, T wave flat/inverted, ST depression

U waves (mimic long QTc)VF, VT, atrial arrhythmia

Ca Incr Short QT; peaked wide T waves; J wavesDecr Long QTc

Mg Incr Long PR, wide QRSCHB

Decr Long QTcTdP, AF, SVT

dsd

RSNIV: Decr need for intubation by 25% overall

CPAP decr need for intubation by 90% in APO Incr survival to dischargeDecr ICU LOS, intubationLess evidence in pneumonia, ARDS, asthma, children25% don’t tolerateIndication: type II resp failure pH 7.25-7.35

paO2 <60 on FiO2 50%paCO2 >50RR >24Incr WOB

Type I resp failure RR >30CPAP Improved compliance, FRC, VQ

Decr preload + afterload incr CODecr intrapul shunting

BiPAP Decr WOB, afterload

Pneumothorax: 1Y: 50-85% re-expansion rate without intervention0.1% risk non-smoker, 12% smoker

2Y: 30-65% re-expansion rate without intervention>70% smokers30-50% recurrence rate; 20% recurrence within 1yrCXR 90-95% sens; sliding lung 95% sens, comet tail >95% sensO2 4x incr reabsorption

Asthma PaCO2 >40 = bad = likely if PEFR <200 / <30% predictedFEV1 <1L / <25% predicted

CXR Will detect 100-300ml fluid on PA/AP 75-100ml on lateral decubitus 800-1000ml on supineUSS 100% sens for >100ml; can detect 5-50ml

Decr pneumothorax from 15% to 5% when used to guide drainage

Pleural effusion Removing >500ml/hr will cause re-expansion pul oedema if >1.5L removedDrain if deeper than 1cm on USS

O+GPre-eclampsia: >160/>110 x1 or >140/>90 x2

+ >300g/24hrs + generalized oedema or other end organ damage

In 5-7% pregnancies30% recurrence in next pregnancyFetal and maternal mortality 2%Trt >170/110Aim <160/110

Eclampsia Fetal mortality up to 30%

Beta-hCG: Urine: >20iu/L 95-100% sens; <1% false negativesBlood: >5iu/L Sens 100%+ >50% in 2/7 suggests viable pregnancy (decr from 12/40 onwards)

+ <50% in 2/7 suggests ectopic - <35% in 2/7 suggests ectopic - >35% in 2/7 suggests miscarriage

Fundus height: 12/40 Symphysis pubis16/40 Half way20/40 Umbilicus

TVUS: 4.5-5/40 Gestational sac5.5-6/40 Yolk sac6/40 Fetal pole and cardiac activity

Bad Empty gestational sac with diameter >18-20mmGestational sac >16mm / CRL >6mm without cardiac activity

TVUS zone 1500-2400 Works from 5/40TAUS zone 3000-6000 If >6/40 and nothing seen TVUS

Ectopic In 2% pregnancies25-30% ectopic pregnancy rate in subsequent pregnancies80% ampullary

PID: 10% infertility after 1st episode, 20% after 2nd, >50% after 3rd

Changes in preg CV Can lose 30% blood vol before decr BPUterus decr CO 10-30% when compresses40% incr CO; 15-20 incr HR by term; 10-15 decr BP and MAP in 2nd trimester but

normalizes by 20/40; decr DBP>SBP; 20% decr SVR; 50% incr plasma vol; 100x incr uterine blood flow; split S1; loud S3; SM; LAD

Haem 20-30% incr RBC vol; 30% incr RBC mass; decr Hct; incr WBCRS 20-30% incr O2 consumption; 40% incr TV; 25% incr MV; 20% decr FRC; 25% decr

RV; no change in VC / RRGI 2-3x incr ALP; decr alb 5GU 50% incr GFR and CrCl; glycosuria in >50%

APH In 2-5% pregnancies30% placenta preaevia Painless profuse PV bleeding

Bright redNon-tender soft uterusMaternal shock (mortality 0.03%) Fetus OKUSS 95% sens

20% placental abruption Painful PV bleeding or may be concealed (1-2L)Dark red bloodTender tense large uterusMaternal shock (<1% mortality) Fetal shock (15-35% mortality)USS 25% sens

Uterine rupture PV bleedingPalpable fetal parts; small uterusHigh maternal morbidity High fetal morbidity

Vasa praevia Painless small amounts PV bleeding

Mother OK 75% fetal mortality

PPH 1Y >500ml in 1st 24hrs / >1L after CSMassive = >50% circulating blood vol in <3hrs / >150ml/min2-5% of SVDTone, trauma, tissue, thrombin

2Y From 24hrs – 6/52

Perimorbid CS Immediate 70% survival10mins 15% survival20mins 2% survival with poor outcome

RENAL / URORenal stone: 90% opaque 70% CaPhos (O), 15% struvite; 10% urate (L); 1% cysteine (partially O) CTKUB: 97% sens and spec

IVP: 80-85% sens, 95% specUSS: 65-93% sens, 90-95% spec AXR: 50% sens

Renal failure Mild GFR 60-90ml/minMod GFR 30-60Severe GFR <30Failure GFR <15

CAPD >100 WBC>50% neutrophilsUsually staph

Na deficit (135 – Na) x 0.6 x kgH20 deficit ((Na – 140) / 140) x 0.6 x kg

GIUpper GI bleeding: 60% PUD (25% duodenal ulcer, 20% gastric ulcer, 25% gastritis)

20% Mallory Weiss tear7-10% Variceal: most common cause of rebleed

PUD: 30% duodenal, 15% gastricH pylori most common cause; ELISA IgG 85% sens, 80% spec; Urease 90-95% sens; Faecal Ag >90% sens and spec; trt success 85%NSAID’s 2nd (20% have Sx)Duodenal = 90-95% have H pyloriGastric = NSAID (70% have H pylori)H pylori: 10-20% get PUDbleeding stops spontenously in 80%5-6% mortality20% haemorrhage, 20% penetration, 5% perf, 2% GOO

GORD: omeprazole help Sx in 80%; H2 better at helping Sx than omeprazole

20-50% have H pylori

Varices: bleeding stops spontaneously in 20-30%10-15% haemorrhage/yr25-40% mortality (15-20% 6/52 mortailty)20-30% recurrence (most common cause of rebleed in upper GI bleeding)SB tube: 50% recurrence; controls bleed in 80%; 30% complication rateSclerotherapy: 40% complication rateLigation / sclero: stops bleeding in 80%Octreotide: stops bleeding in 80%TIPS: controls bleeding in 90%

Lower GI bleed 20% bleeds; 5-10% mortality80% stop spontaneously60% due to diverticular disease; 10-20% no cause; 12% angiodysplasia; 2% Ca

90% GI FB’s pass sponteanously; 80% are paeds; cricopharyngeal narrowing at C6 most common site of obstruction in paeds, distal oesophagus most common in adultSBP: WCC >500-1000; neut >250; low glu; high protein; G stain and culture 70% sens

Enterobacter (63%; eg. E coli (30%), klebsiella (10%)) > strep pneumonia, enterococci, anaerobes (5%), staph aureus (10%), pseudomonas (5%)10% >1 MO30% ascitic patients develop SBP in 1yr

Ages for diseases: <1/12 Nec enterocolitis<3/12 Volvulus / malrotation, feeding intolerance, incarcerated hernia,

testicular torsion2-6/12 Pyloric stenosis6-18/12 Intussusception18-24/12 Kawasaki disease1-3yrs Croup (most 18m)1-7yrs Epiglottitis (most <2yrs)4-6yrs HSP5-8yrs Bacterial tracheitis

Abdo USS: 90% sens for 250ml96% sens for 500ml95% spec

Ascites: Transudate <30g/L protein CCF, cirrhosis, constrictive pericarditisExudate >30g/L protein Ca, infection, venous obstruction, pancreatitis, lymphatic Obstruction

Blood Ca>300 WBC ?infectionLactate SBPAmylase Pancreatitis

Liver failure: Jaundice seen when bil >4070% unconjugated = 2, 30% conjugated = directFulminant >75% mortality

Onset of encephalopathy within 2/52Acute Onset of encephalopathy within 8/52

Bad prognosis: Hep C/D/E, idiosyncratic drug reactionGood prognosis: Hep A, paracetamol

Adults 50-70% paracetamol20% no cause13% idiosyncratic drug reaction

8% Hep B (more in developing world)<5% Hep A4% Hep C

Paeds <1yrs 40% metabolic25% other15% neonatal haemochromatosis15% viral hepatitis

Paeds >1yr 45% unknown25% Hep C/D/E10% Hep A10% drug related5% Hep B

Appendicitis 20% fetal loss in preg30% retrocaecal, 30% pelvicAnorexia most common Sx; pain migrates to RIF in 50%50-75% have classical SxMcBurney’s point = 1/3 way from ASIS/umbilicus; appendix is medial and inf to pointUSS 80-90% sens, 90-100% spec – diameter >6cm, target sign, wall thickness >2mmCT + MRI 90-95% sens, 95% specAcceptable negative laparotomy rate 10-20%

Biliary Gallstones present in 10-20%; symptomatic in 20%Ca is most common cause of CBD obstructionCholecystitis >90% gallstones, 10% acalculus (anaerobes and coliforms)Bacteria present in 50% cholecystitis (75% G-ive, 15% G+ive, anaerobes rare)Acalculus cholecystitis >50% mortality70% cholesterol stones (radiolucent); 30% pigment stones (radio-opaque)Murphy’s sign 85-95% sens, 85% specUSS 90-95% sens, 95% spec for gallstones

90% sens, 80% spec for cholecystitis – GB >4x8cm, wall >4mm, CBD >10mmCT Lower sens

Diverticulitis Occurs in 10-25% people with diverticular diseaseUsually anaerobes and G-ive rodsSignificant bleeding usually R sided; 5-15% bleedCT 97% sens, 100% spec

Volvulis Sigmoid 2/3, elderly; sigmoidoscopy 90% success rate, but 90% recurrenceCaecal 1/3, young; mortality 10-40%

Obstruction SBO >2.5cmLBO >5cm>5 AF levels abnormalAXR 75-80% sens, 50% specUSS 95% sens and specCT 90% sens, 95% spec

Elderly AP 10% mortality; 40% initially misdiagnosedCholecystitis most common cause

Hernias Inguinal: 75%; 2/3 indirect, 1/3 direct; 3%/mth strangulation; cough impulse above and medial to symphysis pubis; most common inc in women

Indirect: lat to inf epiG art; frequent strangulationDirect: med to inf epiG art

Femoral: 20%/mth strangulationMed to inf epiG art; below and lat to pubic tubercle

Ischaemic colitis >50% mortality

Pancreatitis Mortality 2-10%ETOH most common cause; gallstones most common cause in womenBacteria present in 20% (50% in cholecystitis)CRP >150 at 48hrs is predictor of severityLipase Incr earlier (in 4-8hrs), for longer (1-2/52)

95% sens and specDoes not correlate with severity

Amylase Incr later (2-12hrs), for shorter (1/52)80-90% sens (less sens with ETOH), 75% specDoes not correlate with severity

CT 80-95% sens

GURenal colic 90% stones radio-opaque (25% gallstones)

90% pass spontaneously70% Ca phos / oxalate (radio-opaque)10-15% struvite – infective staghorn10% urate (radiolucent)1% cysteine (partially radio-opaque)Narrowest part is VUJ : 1-5mm4mm = 90% pass5mm = 80% pass5-8mm = 15% pass>8mm = 5% passHaematuria absent in 5-10%; gross haematuria in 30%CT KUB 97% sens and specAXR 50% sensUSS may miss if <5mm / mid-ureter

ENT

OM Incr cure rate by 10%, decr duration fever by 1/7No effect on rate of complications

Pharyngitis Decr duration Sx by 0.5 days, decr severity Sx, decr infectious period from 2/52 to 1/7Decr risk RF by 70%Decr risk OM by 70%Decr risk quinsy by 85%Decr risk sinusitis by 50%No effect on risk of post-strep GN

Ludwig’s angina 50% failure rate for RSI

TOXConcerning dosesMetformin >10gDigoxin >10mg (>4mg in children)Fe >60mg/kg >60mmol/L (>90mmol/L is high risk)LithiumParacetamol >200mg/kgAspirin >300mg/kg >2.2mmol/L for alkalinisation

DecontaminationCharcoal: 45% decr absorption at 30mins, 40% at 1hr, 15% at 2hrsSyrup of ipecac: decr absorption 30% if in 1st hrGastric lavage: 25% decr absorption if at 30mins, 10% if at 1hr

Fe OD Markers of toxicity: WCC >15, BSL >8, AGMA

METABOLICNa deficit (mmol/L) = (0.6 x kg) x (desired Na – actual Na) 90% DM is type IIHONK: pH >7.3, HCO3 >15, AG normal, BSL >600, ketones +, osm >320DKA: pH <7.3, HCO3 <15, AG high, BSL >250, ketones +++, variable osmHONK: N saline resus replace with 0.45% saline over 48-72hrs add 5% dex when BSL <15DKA: N saline resus replace with N saline over 24hrs 0.45% saline + 5% dex when BSL <15HONK: 0.05iu/kg/hr DKA: 0.1iu/kg/hrHONK mortality: 15-45% DKA mortality: 5-15%

TRAUMA

Hyphema: rebleeding in 3-5/7 in 30%FAST: 96% sens for >800ml FF

90% sens for >250ml FF95% spec100% sens, 96% spec for need for laparotomy in hypotensive patientinsufficient sens to rule out significant inj in stable patient

USS chest: 90% sens, 95% spec for haemothoraxSliding lung sign 95% sens, 90% specAbsent comet tails >95% sens, 60% spec

USS AAA: ED doc 90-100% sens, >95% spec for >3cmUSS IVC: normal 15-20mm with 5mm decr during insp

Hypovolaemia: <14mm, with >40% collapse on inspirationHypervolaemia: >20mm, without any insp collapse

Burns: Minor Mod MajorFull <2% 2-10% >10%Partial <15% 15-25% >25% (-5 if <10 / >50yrs)

Burns unit >10% TBSA adult>5% TBSA child>5% full thicknessSpecial areas

Brooke-Parkland: 2-4ml/kg/% burn (+maintenance if child)1st half in 8hrs, 2nd half in 16hrsAim UO 0.5-1ml/kg/hr

Penning’s criteria: C1 10mmC2 5mmC3-4 7mm <50% width C4 in childrenC5+ 20mm

Haemothorax Small <350mlMod 350-1500mlLarge >1500ml (>15ml/lg)Massive >300ml/hr for 2hrs

>600ml/6hrs >4ml/kg/hr

Thoractomoty Stable >200ml/hr for >2hrs>1500ml overall

Unstable >100ml/hr for >2hrs>1000ml overall

Compartment syndrome: 1-10mmHg Normal<15mmHg Safe20-30mmHg Cause damage>30mmHg Emergency fasciotomy

Boehler’s angle: <20deg = fracture

DPL: 1L (10ml/kg) saline; 98% sens; 1% complication rate; 15% false +ive>20ml frank blood>100,000 RBC/ml if blunt>5000 RBC/ml if penetrating>500 WBC/ml if <3hrs since injbile / food

ORTHOJt aspirate: Normal WCC <200, <25% PMN

Inflamm WCC 2000-50,000; >50% PMNSeptic WCC >25,000; >85% PMN

Septic arthritis: 15% mortality50% staph, 40% grp A strep in adults

ENVIRONMENTALHeat stroke T >40, altered LOC, anhydrosis, MOF

Mortality 10-50%

Decr T by… Incr T by…Blanket 0.5-2deg / hrIce packs 0.04-0.08deg / min

Ice/warm water immersion 0.15-0.25deg / min 4-10deg / hrEvaporative 0.3deg /minHumidified O2 1-1.5deg / hrGastric lavage 0.5deg / minPeritoneal lavage 2-4deg / hrThoracic lavage 3-6deg / hrHaemodialysis 2-3deg / hrCPB 7-10deg / hr

Hypothermia: Severe <28; mod 28-32; mild 32-35check pulse for 60secs (instead of 10)1x shock + drugs withhold until >30deg then 2x interval between drugs until

35 degHeat IVF to 42 degUse 5% dex as energy substrateRapid rewarm to 30deg then slower45% survive with normal function, 15% with severe brain inj100% good outcome if GCS >8 at 2hrs>90% if GCS >3 at 2hrsGood prognosis: witnessed

<5mins to retrieval<5mins submersionGCS >5 on scene<10mins to CPR<10mins to first resp effort = <10% significant neuro deficit<30mins to spontaneous breathingSaO2 >94%ROSC pre-hospital / no resp arrestPupillary response / motor response to pain on arrivalCold water

Bad prognosis: above + male<3yrs >10-25mins submersion>25mins resusFixed dilated pupils at 6hrsGCS 5 on arrival = 80% risk death / severe deficitVT/VF on initial ECG / asystoleMetabolic acidosis pH <7.1 on arrival

Altitude High >1500m (4900ft) AMS begins >2500m HAPE begins >3500mMost can acclimitise up to 5500mChanges Incr RR, HCO3 diuresis, pul HTN, incr lung vol

Incr SV, incr BP, incr CO, peri vasoCIncr RBC (days-wks), incr EPO (hrs), incr 23DPG

Burns >20% fluid shifts, recommend IVF + IDC + NGT>40% recommend stress ulcer prophylaxis>50% potentially fatal>60% decr CO>80% full thickness unsurvivable50deg 5mins55deg 30secs60deg 5secs70deg 1secAdmit burns unit: Partial thickness >20%

Partial thickness >15% if chemical

Partial thickness >10% if <10yrs / >50yrsFull thickness >5%Other major burn criteria

AGE Occurs within 5-20mins of ascent, or in waterDCS 50% within 1hr, 90% within 6hrs

Electrical >1000V = threshold for severe injVertical = 20% mortality Horizontal = 60% mortalityLightning = 10-30% mortality1mAmp tingling2-10mAmp pain10mAmp paralysis / tetany100mAmp – 1Amp VF, rest arrest, burns>10Amp asystoleLow volt AC VF, rhabdo, ARF, deep tissue burnsHigh volt AC / DC / lightning asystole, superficial burns

IDNeedlestick inj: Transmission: Hep B: E+ive, 40%; E-ive 5% (2-30% risk)

Hep C: 2-10% (<2% risk)HIV: 0.3%

Gloves decr by 50%Prophylaxis decr seroconversion by 80%Full 4/52 course tolerated by 35%

HIV transmission: 0.8% anal receptive 3-15% prev in homos0.6% shared IVDU 1% prev in IVDU0.3% needlestick0.1% vag / insertive anal <0.1% prev in heteros<0.1% MM exposure

Hep B transmission 15% sex

Hep C transmission 15% sex

HIV: PCP occurs in 60%

Malaria Falciparum >90% within 2/12; more resistanceVivax 50% within 2/12; most common; can be delayed monthsMost common cause of fever in traveller

Dengue 4-10/7 incubation

Risk of SBI: <4w and well <5%

<4w + ill 13-21%<4w + bronchiolitis: 3-10% so do septic screen

<6w 15% overall Height of fever irrelevant this young

6w – 3m well <5%

6w – 3m ill 13-21%4w – 2m + bronchiolitis: 3-5% so do urine

6w – 3m 6-10% overall if any fever3m – 6m <1%6m – 2yrs <1% (incr if higher fever)Overall <2yrs 3%

Seizure + well 0.3% SBISeizure + ill 15-18% SBI

UTI (paeds) 3-8% with no source have UTI<3/12 30% systemic sepsis>3/12 5% systemic sepsis85% E coli, 6% proteusNitrites 40% sens, 99% specWBC 50-90% sens and spec (dipstick 75% sens)Bacteria 50-90% sens, 10-90% specMSSU >5-10 WCCCatheter >1-5 WCCSPA >0 WCC

Meningitis (paeds) 5% mortalityFND in 15% (30% pneumococcus)Decr LOC 15% (more pneumococcus)Seizures 30%

Meningitis 60% strep pneumonia FND prominent16% N meningitides14% grp B strep

CSF Bacterial WCC 200-10,000 PMN 100-10,000 MMN <100 Pro >1 Glu lowViral WCC 100-700 PMN <100 MMN >100 N NPartial Trt WCC 200-5000 PMN 10-100 MMN >100 Either EitherTB WCC 100-500 PMN high early MMN high late Pro >1 Glu low late

Protein incr 0.01 per 1000 RBC

Opening p Adult 7-18cm 22-25G, 12cm8-18yrs 7-20cm 22-25G, 6cm1-8yrs 1-10cm 2cm

SIRS = >2 of T <36 or >38HR >90 HR >160 infants, HR 150 childrenRR > 20 or PaCO2 <32 RR >60 infants, RR >50 childrenWCC <4 or >12 or >10% bands

Organ dysfx SBP <90 / 40 below normal / MAP <60BE < -5Lactate >2UO <30ml/hrFiO2 >0.4 or PEEP >5Cr >160Decr LOC

Severe sepsis = SIRS + organ dysfx

Lactate good for risk stratification: >2 = 4% mortality, >4 = 28% mortalityIncr mortality by 8%/hr for delay in ABx

Septic shock = severe sepsis + uncorrectable hypotension

Unknown source Fluclox + gentRS Ceftriaxone + azithromycinGI Ampicillin + gent + metronidazoleUTI Ampicillin + gentSkin Fluclox

Febrile convulsion 4% incidence; 35% recurrence3% go on to epilepsy (same as general population)

Nec fasc Mortality 25-35%Clostridium perfringens most common causeB fragilis and E coli in Fournier’s

Kawasaki IVIG 2g/kg IV over 12hrsAspirin 30-50mg/kg/day until fever gone 3-5mg/kg OD for 6-8/52

ENDOCRINEDM: Type I 10% DM

90% immune mediated; 10% unknown50% concordance in twins>80% loss islet cells for features of DM

Type II 80% DM100% concordance in twins

MODY 2-5% DM

DKA Fetal mortality 30-50%; mortality 5-15% (1% in children); 70% mortality if cerebral oedemaAcetoacetate on ketostix urine testB-HB on blood; more in alcoholic ketoacidosisB-HB converted to acetoacetateAcetone on breath test5-10L fluid deficit; 5-10mmol/kg Na deficit; 3-5mmol/kg K deficit

DERMATOLOGY

EM minor No MM involvedEM major 1MM involved

SJS Epidermal detachment <10% BSA>1MM involvedMortality 10-15%

TEN Epidermal detachment >30% BSAMM often involvedMortality 25-35%

TSS Toxic T >38.9

Shock SBP <90S Rash desquamation; involvement 3+ systems

SSSS No MM involvement

FACTS I FORGETDISCHARGE PLANNING Diagnostic certainty

SHPredictors of early readmission – reliance on others, assistance neededSymptom control

PO intakeMental stateTest mobilityTime of dischargeCommunicationCheck contact detailsOrganise OP FUDischarge medicationStatutory requirements (eg. Work certificate)Discharge info and letterTransportation

DERMATOLOGYKawasaki disease Fever >5/7 + 4/5 of 100%

MM involvement: cracked lips, strawberry tongue 90%Bilat conjunctivitis with perilimbic sparing 80%Polymorphous generalized rash 99%Peripheral redness and oedema 85-95%Cervical lymphadenopathy 60-98%

Do echo at 2/52 6/52 1yrMI is leading cause of death; mortality <1%

Measles Fever >38Rash – erythematous maculopapular1 of: cough / coryza / conjunctivitis / Koplick spots

Mortality 10-15%; 50% due to pneumonia

ENVIRONMENTALPIB Funnel web, mouse spider

All snakes inc seaCone shellBlue ringed octopus

Redback 20% envenomation rateFemale bite Severe pain (in mins/delayed), erythema, sweating, piloerection lactrodectism (severe pain, sweating, piloerection) maybe weakness, N+V+AP 2 vial AV IM (serum sickness 10-15% for all AV)

Funnel web 10-25% envenomation rateMale bite pain + fang marks within 30mins, autonomic storm NCPO, spasms, paralysis, coma PIB, 1 vial AV rpt

Mouse spider <5% envenomation rateMod localNon-specific general PIB, funnel web AV

White tail Local painRecluse spider Blue ulcer necrotizing arachnidism, metHbBlack house Necrotising arachnidism

Box Jelly Immediate severe painCardiotoxicity collapse in water cardiac arrest, arrhythmia, HTN /decr BPMuscle spasms + paralysis vinegar, 1-6 vials AV, MgSO4

Carybdeid Mild localIrukandji Syndrome on beach sympathetic storm HTN, CCF, NCPO, collapseSevere generalized pain vinegar, MgSO4, anti-HTN

Blue bottle Severe local in water hot water

Blue ringed Paralysis collapse on beach PIB

Stone fish Severe pain hot water, 1-3 vials AV, ABx, ADT

Sea snake Paralysis in 2-6hrsMyolysis + ARF PIB, 1-3 vials AV

Brown snake 60% snake deaths, 70% snake bitesCardiotoxicitiy early collapseEarly severe coagulopathyThrombotic microangiopathy ARF PIB, 2 vials AV

Tiger snake 25% snake deathsCardiotoxicity early collapseEarly coagulopathyLate neurotoxicity, severe myolysis, ARF PIB, 2 vials AV

Black snake Marked localCoagulopathy, neurotoxicity, myolysis, ARF PIB, 1 vial AV

Taipan 10% snake deathsEarly collapse, coagulopathy, neurotoxicity, myolysis PIB, 1-3 vials AV

Death adder 5% snake deathsEarly neurotoxicity PIB, 1 vial AV

IDLive attenuated BCG Avoif if immunosuppressed

MMRVZVPolio

Notifiable disease Campylobacter, chlamydia, gonorrhea, hep A+E, flu, legionella, listeria, MMR, syphilis, salmonella, VZV

TRAUMABrown Sequard Ipsilateral motor, position, vibratory

Contralateral pain, TCentral Upper > lower bilaterallyAnterior Bilat motor weaknessHuman bites:Staph aureus Eikenella

Dog bites• Staphylococcus Streptococcus Haemophilus species• Eikenella Pasteurella Proteus Klebsiella species• Enterobacter species• Capnocytophaga canimorsus – overwhelming sepsis in immunocomp• Bacteroides Moraxella Corynebacterium Neisseria Fusobacterium Prevotela Porphyromonas

• Cat bites – 60-80% get infected• Staphylococcus Streptococcus • Pasteurella Actinomyces Propionibacterium Bacteroides • Fusobacterium Clostridium Wolinella Peptostreptococcus species• Bartonella cat scratch disease regional lymphadenopathy after 7-12/7

Marine assocStaph, strepG-ive rods esp Vibrio

Tetanus ProphylaxisHx Clean Dirty

Td TIG Td TIG

<3 or unknown ✓ No ✓ ✓

Immunised

≤ 5y No No No No

5-10 y No No ✓ No

>10 y ✓ No ✓ No

HBsAg+ HBsAg- Unknown

Unvaccinated HBIg (400iu IM) + vacc Vacc Vacc

Vacc + responder (anti-HBs >10) No Rx No Rx No Rx

Vacc + non- responder (anti-HBs <10) HBIg (400iu IM) + vacc Booster If hi-risk,Rx as H

Source Mx

HIV - Nil else

Likely/confirmed + PEP 4/52 (ideally <24-36h) 2 drugs standard3 drugs if hi-risk

Unknown Usually no PEP 2 drugs if hi-risk

O+GSafe in preg: cephalosporins, azithromycin, nitrofurantoin, penicillins

Maxalon, ondansetron, stemetil, promethazineHeparin

Not safe in preg: fluroquinolones (ie. Ciprofloxacin), sulphonamides (eg. Cotrim), tetracyclines (eg. Doxy), gent, metronidazoleOral hypoglycaemicsWarfarin, thrombolysisNSAIDs, aspirinStemetilPhenytoinAmiodarone, ACEi, AII receptor antagonistsLithium

Most common cause of vulvovaginitis: bacterial vaginosis

GIH pylori: PUD: PUD in 20%; most common cause; duodenal > gastricNSAIDS: PUD: Symptoms in 20%; endoscopic evidence in 50%; 2nd most common cause; gastric > duodenalOmeprazole: GI bleed: Decr LOS, active bleeding at endoscopy, need for OT

No effect on transfusion, recurrence, mortalityPUD: Heal earlier

H2 antagonists: GORD: Better at treating Sx than omeprazolePUD: Heals 85% duodenal in 4-8/52, 70% gastric in 8/52

80% relapse at 1yr if no maintenanceMisoprostol For NSAID related diseaseSucralfate Better in smokersBismuth cmpds For H pylori related diseaseOctreotide: Varices: Decr active bleeding; transfusion need by 33%; as effective as

sclerotherapyGastroscopy: GI bleed: Decr rebleeding by 60%, mortality by 45%, emergent OT by 65%SB tube: Varices: Controls bleeding in 70-90%

50% recurrence; 25-30% complication rateBanding/sclera: Varices: stops bleeding in 80-90%

40% complication rate for sclerotherapyTIPS: Varices: Stops bleeding in 90%; 25% decr 1yr mortality, 50% decr

rebleedingAngio+embo: Varices: Stops bleeding in 80%Complications: PUD: Haem 20% (most common), penetration 20%, perf 5%, GOO 2%

Hepatitis Acute Previous Chronic Carrier Immune A IgM anti HAV No No IgG anti HAV

HAV RNA . B IgM anti HBcAg 5-10% 1-10%

HBsAg Anti HBsAgHBsAg >6/12 HBsAg IgG anti HBsAgHBeAg Anti HBeAg HBeAg (phase 2)HBV DNA IgG anti HBcAg IgG anti HBcAg

Anti HBeAg (phase 3) Hep B DNA .

C HCV RNA 75-85% (less in kids) 0.2-1% - IgG anti HCV .

D HDV RNA 5-10% co, 80% super Low - IgM anti HDV IgG anti HDV .

E HEV Ag NoIgM anti HEV IgG anti HEV IgG anti HEV

HAEMATOLOGYClotting probs retroperitoneal bleeding, intra-articular bleeding, delayed bleedingPlt probs mucocutaneous bleeding = gum, petechiae, purpura, epistaxis, GI/GU bleed, menorrhagia, bruisingDIC incr DD, decr plt (most common lab finding), incr INR, decr fib

Absolute Relative

Bleed

Active bleeding or diathesis

Sig closed HI <3/12

Face trauma <3/12

Recent bleed <4/52

Surgery <3/52

Active PUD

Anticoagulant use

Non-comp vasc punc site

CPR >10min

ICH

Prior ICH

Ischemic CVA <3/12

Cerebral vasc lesion

Malig lesion 1° or 2°

Severe/poorly controlled HT

HT >180/110 on presentation

Ischemic CVA >3/12

Dementia

OtherAortic dissection

PericarditisPregnancy

TOXICOLOGY

WBI: SR prepsAgents that don’t bind charcoalFe (>60mg/kg)Li (>40mg/kg)Lead, arsenic, SR verapamil/diltiazem, SR KCl (>2.5mmol/kg), body packers, pharmacobezoars

Intralipid: LAPropanolol, verapamilTCA

MDAC: Carbamazepine / phenobarb coma, phenytoin, valproate

AspirinTheophyllineQuinine

NaHCO3: Phenobarb comaAspirinMethotrexate

Haemodialysis: Carbamazepine / phenobarb, valproic acidAspirinTheophyllineMetformin, alcohols

Lithium (>6mmol/L acute OD, >2.5mmol/L chronic)Charcoal haemP: Carbamazepine / phenobarb, phenytoin

Aspirin, paracetamolTheophyllineAmanita

DRUGSNO max 70:30; onset 4-5mins; MAC 1.02 (weak)

Pros: analgesia, amnesia, no decr RR or airway reflexesCons: diffusion hypoxia at high doses; mask intolerance; vomiting 5-10%; dysphoria 1%; apnoea 1-2% <2yrs, 1:300 otherwiseCI: pneumothorax, bowel obstruction, gastric distension, severe HI; severe COPD, decompression illness, >50% O2 needed, decr LOC, pregnancy

BLOODSUr Incr Renal failure, CCF, dehydration, catabolism, sepsis, OT, steroids, starvation, GI bleed

Decr Preg, severe liver disease, low protein diet, anabolism, Ur cycle defectsCr Incr Decr GFR, incr muscle mass, catabolism, muscle disease

Decr Elderly, decr muscle massUr:Cr Incr Prerenal, sepsis, GI bood, dehydration, CCF, RAS, steroids, tetracyclines

50-100 Renal, acuteDecr Renal, chronic; hepatic failure, muscle trauma, preg, trimethoprim

CVJVP Raised R heart failure, fluid overload, decr HR, SVC obstruction

Paradoxical Cardiac tamponade, constrictive pericarditisLarge a Tricuspid stenosis, pul HTN, pul stenosis, CHB, flutter, HOCM, ASAbsent a AFSystolic wave TR

Apex Tapping MSProlonged ASTriple HOCM

Heave Large RV / LAThrill Severe ASS1 Loud MS, TS Tachy

Soft MR LBBB, 1st deg HB, MIS2 Loud AS HTN

Soft AR MISplit S1 RBBBSplit S2 Increased PS, MR, VSD RBBB

Fixed ASD

Reversed AS, coarctation LBBBS3 Rapid diastolic filling; CCF, AR, MR, VSD, PDA, MI, maybe physiologicalS4 Poorly compliant V; AS, PS, MR, pul HTN, HTN, MIEjection click ASMid-systolic click MV prolapseOpening snap MSPSM MR, TR VSDESM AS, PS ASDLate systolic MV prolapseEarly diastolic AR, PRMid diastolic MS, TSContinuous PDA, coarctation, venous humInspiration Incr R murmursExpiration Incr L murmursHOCM Incr by Valsalva and standing; decr by squatting, hand grip, leg elevation; SMAS Loud reverse split S2, S4, ejection click, ESM, large a wave, narrow pulse p, slow rising

pulse, sustained displaced apex beat, thrill if severe, LVH on ECGAR Soft S2, S3, early diastolic murmur (+/- SM), Corrigan’s sign, Quinke’s sign, Traube’s sign,

Duroziez’s sign, water hammer pulse, wide pulse p, Austin Flint murmur, displaced apex beat, LVH

MS Loud S1, opening snap, mid diastolic murmur, tapping apex beat, small pulse p, thrill; RAD; RV strain; P mitrale, AF

MR Soft S1, incr splitting S2, S3, S4, PSM, small vol pulse, RAD, LV strain, P mitrale, AFMV prolapse Mid-systolic click, late systolic murmur

Anti-arrhythmics: IA Procainamide, quinidine, disopyramide Wide QRS, QTIB Lignocaine, phenytoinIC Flecainide Wide QRS, PRII Beta-blockers Long PR; HBIII Wide PR, QRS, QTIV Ca antagonists Long PR

OK in WPW: Flecainide, procainamide, verapamil (if narrow complex)Not OK in WPW: Adenosine, BB, Ca antagonists, dig

Cyanotic heart disease TOFTotal anomalous venous drainageTGATruncus arteriosusTricuspid atresia

ECG Hypothermia Decr complex size; Osborn wave (esp II, III, aVF, precordial); HB’s; AF, VF, asystole, prolonged PR, long QRS and QT, STE

Hyperthermia Long QTc; AF, SVT, RBBB

RESPIRATORYCavitating lung lesions:Cancer: SCC; HodgkinsAutoimmune: granulomatosis, sarcoidosis, Wegener’s, RA, progressive massive fibrosisVascular: septic emboli, pul infarctInfectious: Staph aureus

Klebsiella

G-ives, anaerobesFungi, aspiration, 2Y TBInfected bullae / cysts

Trauma: traumatic cystYoung: bronchogenic cyst, laryngotracheal papillomatosis

Abscess Staph aureus (esp if immunocompromised)KlebseillaG-ive, anaerobes (esp if immunocompetent)Fungi (aspergillus, cryptococcal), aspiration, 2Y TB

Aspiration Staph aureus, strep pneumoniaKlebsiellaG-ives, anaerobesE coli, enterobacter, H influenza, pseudomonasCXR initially normal in 25%; 40% who aspirate get pneumonia

Empyema/effusion Staph aureus, strep pneumonaie (esp effusion)

Empyema KlebsiellaPseudomonas, nocardia, TB

Effusion G-ives, anaerobesMycoplasma, HibCCF, trauma, PE, Ca (more likely if large), autoimmune, renal failureR = ovarian CaL = pancreatitis, chylothorax, CCF

Round pneumonia Strep pneumonia, staphLegionellaCoxiella

Interstitial lung disease: A-SHITFACED A typicals Viral, atypicals, radiationDiffuse, tiny, haze S arcoidosis

H istiocytosisI diopathicT umour Mets, lymphangitisF ailureA utoimmune SLE, RA, scleroderma, granulomatosisC ollagen vascular diseaseE nvironmental Asbestosis, silicosis, coal, farmerD rugs Methotrexate, amiodarone

Pul fibrosis Upper zone SETCARP S ilicosis, sarcoidosisGround glass, reticular E osinophilic pneumoniaLinear and nodules T BDirty looking C oal, CF

A spergillosis, ank spondR adiation

P CP, pneumoconiosis

Lower zone BADRASH B ronchiectasis

A spirationD rugs Methotrexate, nitrofurantoin,

hydralazine, amiodarone, paraquat, smoke inhalation

R AA stebestosS clerodermaH amman Rich, histiocytosis

Honeycomb BIGHIPS B leomycinI diopathicG ranulomasH istiocytosis

I nterstitial pneumoniaP neumoconiosisS arcoidosis

Pul nodules: CAVIE C ancer AdenomaNeoplasia Mets Colon, breast, renal, testicular,

melanoma, TCCAdenoCa Central SCC, small cell

Peri Large cell, bronchoalveolarA utoimmune Granulomatosis, RA, Wegener’s, silicosisV ascular AVM, haemartoma, PE, infarctI nfection Round pneumonia

Miliary TBVaricella pneumoniaFungal Histoplasmosis, aspergilloma

E nviro Pleural plaques

Pleural masses MALLETS M esotheliomaA denoCa, asbestosisL ymphoma, leukaemiaE mpysemaT hymomaS plenosis

NEUROLOGYMCA Contralat face+arm >leg hemiplegia + sensory loss

Honomynous hemianopiaDom: aphasia, agnosia (Broca’s and Wernicke’s)Non-dom: spatial neglect, dressing apraxia

ACA Contralat leg > arm hemiplegia + sensory loss Disorder of conjugate gazeConfusion, personality changeDom: aphasiaNon-dom: neglect, confusion

Opthalmic Amaurosis fugax

PCA Ipsilat cranial nerve III deficitContralat sensory loss NO MOTOR LOSSHonomynous hemianopia, quadrantanopia

VertebroB Ipsilat cranial nerve deficitContralat body signsCerebellar signs

Lat med S Ipsilat VII, IX, X Horner’s syndrome, ipsilat facial numbness, dysphagia, dysarthriaContralat loss pain and T in body NO MOTOR LOSSDisorder of conjugate gazeCerebellar signs

Wallenberg Ipsilat facial loss of pain and T, weaknessContralat loss pain and T in body, weaknessCerebellar signs

Int capsule Contralat motor loss NO SENSORY LOSS

Thalamus Contralat sensory loss NO MOTOR LOSS

UMN acute UMN chronic LMN Spinal cord NMJWasting None Mild SevereTone Decr Incr DecrFasciculations No No YesReflexes Incr Incr Decr Loss at level Normal

Incr below levelPlantar Up Up None

Fatiguable

ILCOR changes

Major 30 chest immediately

Minor AED ASAP – now BLS skillChange op Q2minAnnual BLS trainingEmphasis on signs of life rather than vitalNo finger sweepChest compressions only OKPlace hand over centre of chestPrecordial thump de-emphasised

Major No interruptions – push hard, push fastCompress chargingChange Q2minNo atropineETCO2

Minor 100/minDrug IV/IO not ETTSingle shocks200JUSS for checking heart activityAvoid hyperoxiaHypothermia for surivivorsPrecordial thump for witnessed collapseAngioplasty post ROSC

CT head: Lat ventricle 3rd ventricle quadrigeminal cistern, suprasellar cistern 4th ventricle

Ring enhancing lesions:MetsRadiation necrosisTuberculomaHaematoma (resolving)AneurysmMultiple sclerosisPrimary brain tumour (glioblastoma, CNS lymphoma, cystic astrocytoma)Abscess toxoplasma, TB cryptococcus, candida Staph aureus, strep prevotella, pseudomonas anaerobes, bacteroides

neurosyphilis

A. Synovial FluidNormal Class I Class 2 Class 3 Class 4

Type of fluid Normal Non-inflamm Inflammatory* Purulent HemorrhagicAppearance Clear

Light yellowClearLight yellow

Cloudy-opaque Dark yellow

Cloudy-opaqueDark yellow-green

CloudyPink-red

Volume (ml) <3.5 >3.5 >3.5 >3.5 >3.5Viscosity High High Low Low VariableWbc/L <200 200-2000 3000-100,000 >40,000 >2000PMNs <25% <25% 50% 75% 30%Gram + culture Neg Neg Neg Usually positive NegGlc:serum = = < << =Differentials N/A Degenerative

TraumaAVNNeuropathicHPOAEarly inflamm

RheumatoidGoutPseudogoutReiter’sAnk spondPsoriaticSarcoidIBDSclerodermaRh feverTB, viral

PyogenicS. aureusGonococcus(25% G+C only)

TraumaFractureBleeding diathesisHemophiliaNeuropathicHemangiomaBleeding neoplasm

*pseudogout = pos birefringence; gout = neg birefringence; RA = phagocytic PMN inclusions; Reiters = phagocytosis of leucs by macrophages

B. CSFParameter Normal Bacterial Viral TB / FungalPressure cmH2O 7-20 Very high N / slightly high Very high in TBWcc/mm3 <5

neonates <30>200up to 20,000

<1000 <1000

Predominantcell type

Lymphocytes0 PMNs

PMN(10% lymphocytes)

Lymphocytes(50% PMN initially)

Lymphocytes

Glucose 0.6 x serum0.8 in neonates

Low0.3 x serum

Normal or high Low / N

Protein 15-45 mg/dl90 in infants

High > 50 Normal or high High

Organisms 0 80% +ve60% if pretreated

0 80% +ve ZN90% crypto Ag

C. Abdominal ParacentesisTraditionally classified as transudate vs exudateMore useful is serum-ascites albumin gradient (SAAG)

Transudate ExudateSAAG High (>11g/l) Low (<11g/l)Protein < 30g/l > 30g/lpH > 7.3 < 7.3LDH Low HighGlucose Normal LowWCC <1000 /l > 1000 /lCauses Portal HT present:

CirrhosisHeart failureConstrictive pericarditisBudd-Chiari or veno-occlusive disease

Non-portal HT etiology:MalignancyInflammatory / InfectionPancreatitisLymphatic obstruction

Bacterial peritonitis likely if: (ADHB RMO Handbook 2005) Wcc > 500 x 106 / L Predominantly neutrophils