TC's emergency medicine wrap up 4

1. T C ’ S P O T P O U R R I
T H E M E M E E D I T I O N

2. W H A T I S A M E M E ?

3. F E A S T S T U D Y
• I’ve mentioned it before
• Essentially found shocked
septic kids in Africa did worse
with fluid boluses over
maintenance fluid
• Comment from the floor was
“yeah but they’ll all have
malaria and the fluid will make
their cerebral oedema worse”
• Fair enough

4. S H U T U P F E R G I E
• The non-anaemic and non-malaria patients were
analysed
• Found to have the same poor outcomes with fluid
boluses over maintenance fluids as the anaemia and
malaria kids
• Regardless of whether albumin or crystalloids given

7. S G A R B O S S A C R I T E R I A
• Smith modified Sgarbossa rule:
• At least one lead with concordant STE (Sgarbossa criterion
1) or
• At least one lead of V1-V3 with concordant ST depression
(Sgarbossa criterion 2) or
• Proportionally excessively discordant ST elevation in V1-V4,
as defined by an ST/S ratio of equal to or more than 0.20
and at least 2 mm of STE. (this replaces Sgarbossa criterion
3 which uses an absolute of 5mm)

9. S E V E R E C U T A N E O U S A D V E R S E
R E A C T I O N S
• Drug hypersensitivity syndrome is the same as DRESS
• SJS/TEN
• Acute generalised exanthematous pustulosis (AGEP)
• drug induced erythroderma
• Severe, unexpected reaction to a medicine(s)
• high fever, a morbilliform skin rash
• inflammation of one or more internal organs including the liver, kidneys, lungs
and/or heart
• It generally starts two to eight weeks after taking the responsible medicine.

10. C U L P R I T S
• Allopurinol
• AEDs esp. carbamazepine, phenobarbitol, phenytoin
• Sulfonamides
• But really anything

12. M E A C U L P A

16. wire
left in
Individual
Factors
Patient
Factors
Task
Factors
Education
and
Training
Team and
Social
Factors
Working
Conditions
Equipment
and
resources
Communi
cation
Organisati
onal and
strategic
Factors

19. C H O I C E S R A N K R A T E
1 8 G I V C 8 . 5 F R R I C 0 0 : 4 6
6 F R S H E A T H 7 F R R I C 1 : 0 0
8 . 5 F R R I C 8 . 5 F R S H E A T H 1 : 0 5
1 4 G L U M E N C V C 1 4 G I V C 1 : 3 0
7 F R R I C 6 F R S H E A T H 2 : 1 0
1 6 G I V C 1 4 G 1 3 . 3 C M I V C 2 : 1 0
2 0 G I V C 1 6 G I V C 2 : 2 0
1 4 G I V C 1 8 G I V C 4 : 2 3
8 . 5 F R S H E A T H 1 4 G L U M E N C V C 5 : 2 0
1 4 G 1 3 . 3 C M I V C 2 0 G I V C 6 : 4 7

20. C O U N T R Y W E E K
• 13yo playing football, someone stepped on his foot
while trying to spin round
• pain

22. T I L L A U X F R A C T U R E
• Salter Harris III distal tibia epiphysis
• Caused by an avulsion of the anterior inferior tibiofibular ligament
• Mechanism of injury is thought to be due to an external rotation force
• 12-14yo
• A period of time exists when the lateral physis is the only portion not
fused
• An additional fracture in the posterior distal tibial metaphysis in the
coronal plane would result in a…?

24. B A R B A R A
• 70yo lady
• sore right knee
• normal XR with GP
• moderate effusion, ROM ~70º
• No PMHx

25. P L A N ?

27. W H A T A R E Y O U L O O K I N G
F O R I N T H E S Y N O V I A L
F L U I D ?

31. C O U R S E
• D/C with NSAIDS and Dx with pseudogout
• Recalled 2 days later after bacteria grown
• Sent home by ED as patient feeling ok
• No bloods done
• Back 5 days after initial presentation with obvious
septic joint

34. • Unwitnessed arrest
• Initial non-VF Rhythm
• Lack of bystander CPR
• >30 min to ROSC
• >30 min of CPR
• Evidence of unresponsive hypoperfusion and microcirculatory failure:
• pH <7.2 and Lactate >7
• Age >85
• End-Stage Renal Disease (ESRD
• Non-Cardiac Causes: Cardiac arrest due to drugs, drowning, acute stroke, terminal cancer and trauma,
just to name a few non-cardiac causes, are likely to result in poor outcomes post-resuscitation.
Unfavourable for Cath

37. A V O I D
• All STEMI criteria patients
• excluded if sats <94%
• There was an increase in the rate of recurrent myocardial infarction in
the oxygen group compared with the no oxygen group (5.5% versus
0.9%; P=0.006)
• An increase in frequency of cardiac arrhythmia (40.4% versus 31.4%;
P=0.05).
• At 6 months, the oxygen group had an increase in myocardial infarct
size on cardiac magnetic resonance (n=139; 20.3 versus 13.1 g;
P=0.04).

39. P L U G F O R A C H A R I T Y
• I’ve belonged for ~5years
• “Medics Beyond Medicine”
• For doctors who want to connect with people with
mental and physical disabilities rather than just see
them in a clinical setting
• Generally revolves around outings
• Recently featured on channel 9 news

42. • Emma and Dave volunteered their time
• “Daniel” here has myotonic dystrophy as seen by the
tell tale baldness pattern
• “Chris” has a rare chromosomal abnormality that
means he has a compulsion to wear a cap in an
inappropriate setting

43. A G E A D J U S T E D D - D I M E R
• Wells score ≤4
• Age ✷ D-dimer (0.01mg/L)
• ie a 70yo will have an acceptable D-dimer <0.7mg/L
• Validated in multiple studies
• I think we should use it

44. C E N T O R
• History of fever
• Tonsillar exudates
• Tender anterior cervical adenopathy
• Absence of cough
• The Modified Centor Criteria add the patient's age to the criteria
• Age <15 add 1 point
• Age >44 subtract 1 point
• -1, 0 or 1 points - No antibiotic or throat culture necessary (Risk
of strep. infection <10%)
• 2 or 3 points - Should receive a throat culture and treat with an
antibiotic if culture is positive (Risk of strep. infection 32% if 3
criteria, 15% if 2)
• 4 or 5 points - Treat empirically with an antibiotic (Risk of strep.
infection 56%)
• The presence of all four variables indicates a 40 - 60% positive
predictive value for a culture of the throat to test positive for
Group A Streptococcus bacteria. The absence of all four
variables indicates a negative predictive value of greater than
80%

45. W H A T A N T I B I O T I C
• Phenoxymethylpenicllin
• Cheap, proven
• Never been a resistant GABHS to penicillin
• Good anaerobic cover just in case the patient has…

47. F U S O B A C T E R I U M
N E C R O P H O N U M
• lemierre’s syndrome
• Thrombus of the internal jugular
• Sepsis
• Mortality of ~5%
• Not sensitive to macrolides