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nnt;m C:\Sistemp\Med!:\Psion5CD1\Med5\MedC:\Sistemp\Bis.txt!:\Psion5CD1\Med5\Bis.txtMed5 51.2 kBP Table1 ColA1 ColB1 AAugmentin Doses: Infant up to 3 months : 25mg/kg tds Child under 6 yrs : Augmentin 125/31 SF Suspension. 5mls tds. Child 6 - 12yrs : Augmentin 250/62 SF Suspension. 5mls tds. Above 12 yrs : 250/125 (375mg) tablets. T tds. Adult serious infections : 500/125 (625mg) tablets. T tds. BBack from ITU Checkup: Post op day 1 (PO#1) Return from ITU / HDU Operation Drains & lines. ?Oxygen. ?Monitor Neuro:- Awake & Talking. ?Pain. CVS:- Pulse, BP, JVP, Apex, HS. Well Hydrated. Warm Peripheries. Chest:- Trachea, RR, BS, Added Sounds. Abdomen Fluid Balance:- - Crystaloid in & Urine out - Colloid in & Colloid out (Eg. from drains) - Total fliud balance Bloods: - FBC: WBC, Hb, Plat, Hct. - U+E: Na, K, Urea, Creat. - ABG's: pH, pO2, pCO2, HCO3, BE (Base Excess), O2 Sat. Plan: Physio, FBC, Dax, CXR, ECG JBiochemistry Normal Values (Plasma) : Acid Phosphatase (Total) 1 - 5 IU/l Acid Phosphatase (Prostatic) 0 - 1 IU/l ACTH < 80 ng/l Albumin 35 - 50 g/l Alkaline Phosphatase (Alk Phos) 30 - 300 U/l Alanine Aminotransferase (ALT) 5 - 35 U/l Amylase 30 - 170 U/l Anion Gap 12 - 18 milli-eqiv/l Aspartate Aminotransferase (AST) 7-40 U/l Bicarbonate 23 - 30 mmol/l Bilirubin (Total) 3 - 17 micmol/l Calcium 2.15 - 2.65mmol/l Corrected Calcium Add 0.02 for every g/l the measured Albumin is < 40. Chloride 95 - 108 mmol/l Cholesterol 3.5 - 6.7 mmol/l VLDL 0.128 - 0.645 mmol/l LDL 1.55 - 4.4 mmol/l HDL 0.9 - 1.93 mmol/l Cortisol Midnight 80 - 280 nmol/l 9.30am 450 - 700 nmol/l Creatinine 70 - 150 micmol/l Creatine Kinase (CK) 25 - 200 U/l Ferritin Males 16 < 90 < 330 ng/ml Females 5 < 18 < 120 ng/ml FSH Follicular 1 - 10 U/l Luteal 6 - 25 U/l Male 1 - 7 U/l gGT Male 11 - 51 U/l Female 7 - 33 U/l Globulin 18 - 32 g/l Glucose (Fasting) 4 - 6 mmol/l Glycosylated Haemaglobin 5 - 8% Growth Hormone (GH) < 20 mU/l HDL Lipoprotein 0.9 - 1.7 mmol/l Iron Male 14 - 30 micmol/l Female 11 - 30 micmol/l Iron inding Capacity (TIBC) 44-70 micmol/l Lactate Dehydrogenase (LDH) 60 - 450 U/l LH Follicular 1 - 21 U/l Mid Cycle 4.5 - 70 U/l Luteal 1 - 13 U/l Male 1 - 10 U/l Magnesium 0.75 - 1.05 mmol/l Osmolality 280 - 295 milli osmols/kg Parathyroid Hormone (PTH) 0.4 - 0.9 ng/ml (0.8 - 8.5 pmol/l) Phosphate 0.8 - 1.45 mmol/l Potassium 3.5 - 5.0 mmol/l Prolactin 60 - 360 U/l Prostatic Specific Antigen (PSA) 0 - 4 ng/l Protein (Total) 60 - 80 g/l Renin (Erect/Recumbent) 2.8-4.5 / 1.1-2.7 pmol/ml/hr Sodium 135 - 145 mmol/l Testosterone Male 9 - 24 nmol/l Female 0.5 - 2.5 nmol/l Thyroxine (Free T4) 9 - 23 picmol/l Thyroxine (Total) 70 - 140 nmol/l Thyroid Binding Globulin (TBG) 7 - 17 mg/l Tri-iodothyronine (Tot T3) 1.5 - 3.1nmol/l TSH Males 0.45 - 3.8 U/l Females 0.4 - 4.8 U/l Females >51 yrs 0.40 - 5.7 U/l Triglycerides 0.8 - 1.9 mmol/l Urate / Uric Acid Male 240 - 500 micmol/l Female 170 - 450 micmol/l Urea 2.5 - 6.7 mmol/l Vitamin B12 0.13 - 0.68 nmol/l (>150ng/l) Pleural Aspirate Protein >30 = Exudate < 30 = Transudate (But take into account Plasma Total Protein) ABiochemistry Normal Values (Urine) : Amylase 100 - 600 Units/day Calcium 2.5 - 7.5 mmol/day Chloride 60 - 180 mmol/day Cortisol (Free) <280 nmol/day Creatinine 5.7 - 17 mmol/day Osmolality 350 - 1000 mosmol/kg Oxalate 0.05 - 0.40 mmol/day Protein (Total) < 150 mg (Average 10 - 90 mg) Phosphate 16 - 48 mmol/day Potassium 20 - 120 mmol/day Sodium 60 - 250 mmol/day Urea 250 - 500 mmol/day Uric Acid <= 3.62 mmol/day (Urate) ODBlood Bottle Colours: Mauve / Purple - EDTA (3mls) FBC, Retics, Red Cell Folate, Viscosity, HbA1c, HbA2, Sickle & Hb Electrophoresis, Cyclosporin, Lead, Paul Bunnell Test, Kleihauer Test, Coombs Test, Tranketolase, Carboxyhaemaglobin. Blue - Sodium Citrate (1:9) (4.5mls) Coagulation Studies : INR, KCCT, APTT, Fibrinogen, Antithrombin 3. Black - Sodium Citrate (1:4) (2.4mls) ESR only Red / Brown - Plain = No Additive (5mls) Antibiotic Assay, Cold Agglutinins, Blood Group Antibody Investigations. Mottled Red & Brown / Yellow - SST Clot Activator Chemistry - U+E, LFT, Bone, TFT, Random Glucose, B12 & Folate, Iron & Transferrin, Cardiac Enzymes, LH, FSH, Immunology, Rheumatology,Virology & Microbiology, Drug Levels - Digoxin, Carbamazepine, Lithium, Aminophylline, Phenytoin, Sodium Valproate, Vancomycin, Gentamicin. Green - Heparin (10mls) Haemaglobin Pigments, Osmotic Fragility, Renal Dialysis Dax, Cortisol, Chromosomes, Gastrin. Grey - Fluoride + Oxalate (2mls) Glucose, Alcohol, HbA1C, Lactate, Xylose Purple / Pink - Plain = No Additive (7mls) Group & Save, Cross Match bABlood Transfusion Complications 1. Immediate haemolytic reaction 2. Delayed haemolytic reaction 3. Febrile reaction 4. Anaphylactic reaction 5. Decr immunity 6. Infection transmission 7. Graft vs. Host disease. Massive Blood Transfusion :- 1. Hypothermia 2. Incr. K+ 3. Acidosis 4. Haemolytic jaundice 5. DIC 6. ARDS 7. Arrythmias 8. Citrate Toxicity uABrain Stem Death 1. Preconditions Unresponsive & ventilated, Cause of coma known & irreversible. 2. Exclusions Drug suppression, shock, metabolic, hypothermia. 3. Brainstem Reflexes Pupillary light response, corneal, vestibulo-occular, gag, motor responses. (Carried out by 2 doctors) 4. Apnoea Test Disconnect ventilator - No resp attempt even when pCO2 @ 6.65kPa ECalcium / Hypercalcaemia / Hypocalcaemia Hypercalaemia :- Clinical effects - Bones, Moans, Groans & Psychic moans. Abdo pain, N&V, Constipation, Polyuria, Depression, Anorexia, Wt loss, Polydipsia, Tiredness, Weakness, Low BP, Pyrexia, Decr consciousness, Sudden cardiac arrest, Renal calculi, Renal failure, Corneal calcification. ECG - QT interval. Causes - Malignancies, esp c Bone metastases, Chronic Renal Failure, Hyperthyroidism & Hyperparathyroidism, Milk-Alkali syndrome, Vitamin D excess, Myeloma, Sarcoidosis. Artifact - If blood sample was taken c tourniquet on. Treatment - Treat the underlying cause. If >2.8mmol/l -> 'Saline Diuresis' - 0.9% saline 4-6L/24hrs + Frusemide 40-125mg 4-6hrly. Calcitonin / Plicamycin / Bisphosphonates / Hyrocortisone. Hypocalcaemia :- Symptoms & Signs - Tetany, Depression, Perioral anaesthesia, Paraesthesia, Carpo-pedal spasm (esp on BP cuff inflation - Trousseau sign) Neuromuscular excitability (Tapping over parotid gland causes facial muscles to twitch - Chvostek's sign.) ECG - Long QT Interval. Causes - Chronic Renal Failure, Thyroid / Parathyroid surgery, Hypoparathyroidism / Pseudohypoparathyroidism, Osteomalacia, Overhydration, Pancreatitis. Treatment - Calcium Gluconate 10ml 10% over 5min Followed by 40ml over 24hrs Then oral Ca + Calciferol 2.5mg daily. Corrected Calcium Add 0.02 for every g/l the measured Albumin is < 40. (ACarpal Bone Mnemonics: She Looks Too Pretty (Proximal, Lateral - Medial) Try To Catch Her (Distal, Lateral - Medial) (Scaphoid, Lunate, Triquetral, Pisiform) (Trapezium, Trapezoid, Capitate, Hamate) Hamlet Came To Town Shouting Loudly to Polonius. Sue Licks Tims Prick, Her Cunt's Too Tight. CChlormethiazole (Heminevrin) For Alcohol Withdrawal: 9 - 12 Capsules initially Give tds & reduce by one capsule every dose, until at 4 - 6 capsules, when the drug should be tailed off more slowly over 4 - 6 days. Day 1 : 4, 4, 4 Capsules Day 2 : 3, 3, 2 Capsules Day 3 : 2, 2, 2 Capsules Day 4 : 2, 2, 1 Capsules Day 5 : 2, 2, 1 Capsules Day 6 : 2, 1, 1Capsules Day 7 : 1, 1, 1 Capsules Day 8 : 1, 1, 0 Capsules Day 9 : 1, 0, 0 Capsules Intra-Venous Comes as a 0.8% Solution (= 8mg/ml) Initially 3 - 7.5 mls/min (24 - 60mg/min) until a Shallow sleep is induced from which the patient can easily be roused. Then reduce infusion to 0.5 - 1 ml/min (4 - 8mg/min) at the lowest possible rate to maintain shallow sleep and adequate spontaneous respiration. For Status Epilepticus: Comes as a 0.8% Solution (= 8mg/ml) Initially 5 - 15 mls/min (40 - 120 mg/min) up to a total of 40 - 120 mls (320 - 800 mg). Then continue at 0.5 to 1 ml/min (4 - 8 mg/min) and adjust rate according to response. CConstants & Physical Measures: Speed of Light (c) = 299792458 m/sec ( = 186,000 miles/sec) Boltzmann constant (k) = 1.380662*10E-23 J/K Plank constant (h) = 6.626176*10E-34 J Sec Rydberg constant (RH) = 1.097373*10E7 /m Avogadro constant (L) = 6.022045*10E23 / mol Faraday constant (F) = 9.648456E10E4 C / mol Gas constant (R) = 8.31441 J / Kelvin / mol Gravitational constant (G) = 6.672*10E-11 Stefan-Boltzmann constant (sigma) = 5.670*10E-8 W / m2 / K-4 Mass of Proton (p) = 1.672648*10E-27 (1836*e) Mass of Neutron (n) = 1.674954*10E-27 (1839*e) Mass of Electron (e) = 9.109534*10E-31 (1*e) Charge of Electron \ Proton = 1.602189*10E-19 C Radius of Earth = 3960 miles ( = 6371 km) pi = 3.14159265359 (22/7 or 355/113) e = 2.7183 1 radian = 57.296 degrees ln x = 2.303 log10 x Arterial Blood Gases (ABG's): pH 7.35 - 7.45 pCO2 4.7 - 6.0 kPa pO2 >10.6 kPa HCO3 23 - 30 mmol/l O2 Sat 94-100 % BE +/- 3 mmol/l ASA Classification (American Society of Anaesthesiologists) ASA 1 - Healthy ASA 2 - Mild systemic disease ASA 3 - Severe systemic disease, not incapacitating ASA 4 - Incapacitating disease ASA 5 - Moribund, not expected to live >24hrs MATLS AVPU Scale: Alert Responding to Voice Responding to Pain Unresponsive. Cerebro-Spinal Fluid. CSF. Lumbar Puncture. Lymphocytes < 4/mm Neutrophils 0 /mm Protein 0.15 - 0.4 g/l Glucose 3.3 - 4.4 (>2.2) mmol/l (or 70% plasma level) Pressure < 200mm of CSF Chloride 122 - 128 mmol/l Lactate <2.8 mmol/l Constipation Treatment Schedule: 1. Lactulose or Senna 2. Glycerin Suppositories 3. Rectal Sodium Citrate (Micralax Enema) 4. Rectal Phosphate Enema 5. High Arachis oil enema 6. Manual evacuation {ADermatological Terminology - Describing Lesions: Colour Sharpness of edge (Well defined / Ill defined) Surface contour Geometric shape Texture (Rough, Silky, Smooth, Hard) Smell Temperature Others: Morbilliform - Like measles - A net like blotchy slightly elevated pink exanthem. Scarlatiniform - Punctate slightly elevated papules. Levido Reticularis - Exanthem - BDermatological Terminology - Describing Lesions: SURFACE CONTOUR Dome-Shaped - Like a dome Pedunculated - On a pedicle Verrucous - With an irrecular surface Umbilicated - A raised edge and sunken centre Flat topped - With a flat top! Acuminate - Spire-like CONFIGURATION Grouped - In a group! Linear - Many lesions in a line Serpiginous - In the shape of an S Arcuate - In the shape on an arc Nummular - Round / Coin like Annular - Ring like Circinate - Circular Discoid - Disk like Gyrate - Wave like Retiform / Reticulate - Net like ~EDermatological Terminology - Primary Lesions: Macule - Small flat area of altered colour or texture. Patch - Large Macule. Papule - Small solid elevation of skin ( <0.5cm in diameter). Plaque - Large Papule ( >2cm diameter but without substantial depth). Nodule - A solid mass in the skin, usually > 0.5cm in diameter, which can be observed as an elevation or be palpated. Abscess - A locallised collection of pus in a cavity. Vesicle - A circumscribed elevation of the skin , 0.5cm in diameter, containing fluid. Bulla - A vesicle > 0.5cm in diameter. Wheel - An elevated white compressible, evanescent area of dermal oedema. Often surrounded by a red, axon mediated flare. Angioedema - A diffuse swelling of oedema which extends to the subcutaneous tissue. Papilloma - A nipple like mass projecting from the skin. Petechiae - Pinhead sized macules of blood in the skin. Purpura - A larger macule or papule of blood in the skin which doesn't blanch. Ecchymosis - A larger extravasation of blood into the skin. Haematoma - A swelling of the tissues from gross bleeding. Burrow - A linear or curvilinear papule caused by a burrowing scabies mite. Comedo - A plug of keratin & sebum wedged in a pilosebaceous orifice. Telangiectasia - A visible dilatation of small cutaneous blood vessels. Poikiloderma - A combination of reticulate hyperpigmentation, atrophy, & telangiectasia. Urticaria - CDermatological Terminology - Secondary Lesions: Scale - A flake arising from the horny layer. Crust - Looks like a scale, but is composed of dried blood or tissue fluid. Ulcer - An area of skin from which the whole epidermis and at least part of the dermis has been lost. Excoriation - An ulcer or erosion produced by scratching. Erosion - An area of skin denuded by complete or partial loss of the epidermis. The dermis is spared. Fissure - A slit in the skin. Sinus - A cavity or channel which permits the escape of fluid or pus. Scar - A result of healing, where normal structures are permanently replaced by fibrous tissue. Atrophy - Thinning of the skin due to diminution of the epidermis, dermis or subcutaneous fat. It appears thin & translucent. Stria - A streak-like, linear, atrophic, pink/purple/white lesion of the skin due to changes in the connective tissue. Pigmentation - The degree or content of colour in the skin. ??? 5ADermatology - Rx of Dermatitis: In incresing strength - Mild : 1% Hydrocortisone Moderately potent : Eumovate (0.05% Clobetasone Buyrate) Potent : Betnovate (0.1% Betamethasone) : Loicoid R (Hydrocortisone Butyrate) Very Potent : Dermovate (0.05% Clobetasone Proprionate) BNF - 13.4 IADigoxin Loading Doses: Available as 500mcg in 2mls Vial Loading Dose = 0.5 to 1mg over 24 hours (Eg. 500mcg, 250mcg, 250mcg over 24 hours) Maintenance Dose = 250 - 500mcg/day. To work out total loading dose: Oral - 6*1.5*PtWt in KG / 0.63 I/V - 6*1.5*wt in Kg (Dont divide by 0.63) Cockroft Furmula to work out GFR: 140-Age? AECG Lead Positions & Colours Right Arm - Red Left Arm - Yellow Left Leg - Green Right Leg - Black V1 - 4th ICS to Right of Sternum V2 - 4th ICS to L of Sternum V3 - Between V2 & V4 V4 - 5th ICS at MCL V5 - AAL at the level of V4 V6 - MAL at the level of V4 CGeriatric Depression Scale (GDS) : (Yesavage 1988) 1. Are you basically satisfied with your life? N 2. Have you dropped many of your activities & Interests? Y 3. Do you feel that your life is empty? Y 4. Do you often get bored? Y 5. Are you in good spirits most of the time? N 6. Are you afraid that something bad is going to happen to you? Y 7. Do you feel happy most of the time? N 8. Do you often feel helpless? Y 9. Do you prefer to stay at home, rather than going out and doing new things? Y 10. Do you feel that you have more problems with memory than most? Y 11. Do you think that it is wonderful to alive now? N 12. Do you feel pretty worthless the way do are now? Y 13. Do you feel full of energy? N 14. Do you feel that your situation is hopeless? Y 15. Do you think that most people are better off than you? Y A responce the same as the one marked after the question is given a mark of one. A score greater than 5 probably indicates depression. AGlasgow Coma Scale (GCS): Eye Opening: 4 - Spontaneous 3 - To Speech 2 - To Pain 1 - No Eye Opening Best Verbal Response: 5 - Orientated 4 - Confused Conversation 3 - Inappropriate Speach 2 - Incomprehensible Sounds 1 - No Response Best Motor Response: 6 - Obeys commands 5 - Appropriate locallising response to pain 4 - Withdrawal response 3 - Abnormal flexion response (Decorticate Rigidity) 2 - Extension response (Decerebrate rigidity) 1 - No Response @Haematology Normal Values: Haemaglobin (Males) 13 - 18 g/dl (Females) 12 - 17 g/dl Haematocrit (Males) 0.40 - 0.54 (Females) 0.35 - 0.47 MCV 82 - 97 fl MCH 27 - 32 pg MCHC 30 - 35 g/dl Platelets 150 - 400 *10E9/l Reticulocytes 0.2 - 2.0 % Serum Iron 14 - 32 micmol/l TIBC 50 - 72 micmol/l Serum B12 150 - 900 ng/l Red Ce ll Folate 100 - 450 micg/l Serum Folate 3 - 20 micg/l Differential Count:- RBC 4.0 - 6.5 *10E12/l Total WCC/WBC 4.0 - 11.0 * 10E9/l (100%) Neutrophil 2.0 - 7.5 *10E9/l (40 - 75%) Lymphocytes 1.3 - 3.5 *10E9/l (20 - 45%) Monocyte 0.2 - 0.8 *10E9/l (2 - 6%) Eosinophils 0.04 - 0.44 *10E9/l ( <1 - 3%) Basophil 0.01 - 0.1 *10E9/l ( <1%) Prothrombin Time (PT) 10 - 15 secs Thrombin Time (TT) 15-19 secs APTT 27 - 39 secs Fibrinogen 2 - 5 EIndications for Skull X-Ray Post Head Injury: 1. Loss of Consciousness or Amnesia at any time. 2. Neurological Symptoms or Signs 3. CSF Leak / Blood loss from nose or ear 4. Suspected penetrating injury. 5. Alcohol Intoxication - Indic for Admiss alone. 6. Difficulty in assessing the patient (Young / Epilepsy) [Scalp laceration alone is not an indication for SXR] Criteria for Hospital Admission after Recent Head Injury: 1. Confusion or Depression of level of consciousness at the time of examination. 2. Skull Fracture 3. Neurological Signs or Progressive Headache or Vomiting 4. Difficulty in assessing the patient (Alcohol / Young / Epilepsy) 5. Other Medical Conditions (Eg. Haemophilia) 6. The patient's social circumstances or the lack of responsible adult / relative supervision. Indications for Consultation with a Neurosurgical Unit: 1. Fractured skull in combination with Either - Confusion or other depression in level of consciousness Or - Focal Neurological Signs Or - Fits 2. Confusion or other neurological disturbance persisting for more than 4 hours. (Even if there is not skull fracture) 3. Coma continuing after resuscitation 4. Suspected open injury of the vault or base of the skull. 5. Depressed fracture of the skull 6. Deterioration of neurological condition. (fall of GCS 2 points) Write in Notes: No LOC / F / F / D / N / W / P / R / O / Amn No LOC / Faints / Fits / Dizziness / Numbness / Weakness / Paraesthesia / Rhinorhoea / Otorrhoea / Amnesia. BIndications to Thrombolysis: 1. Regional ST segmnt Elevation. 2. Appropriate Hx of Chest Pain with LBBB Contraindications to Thrombolysis: 1. Recent Hx of Bleeding or Peptic Ulcer 2. Hx of Coagulopathy or Anticoagulation. 3. Recent Head Injury, or Cerebrovascular Disease 4. Severe Renal or Liver Failure 4. Suspected Dissecting Aortic Aneurism 5. BP > 180 Systolic or 105 >Diastolic 6. Following CPR 7. Proliferative Diabetic Retinopathy 8. Pregnancy 9. Pulmonary cavitation 10. Acute Pancreatitis & Severe Diabetes Mellitus 11. Recent Surgery or Trauma. (1 Week) 12. Systolic BP < 95 (Strep) 13. Previous Administration of Strep > 5 days or < 1 year. 14. Known reaction to Strep. `CVP Normal Range: 0 - 8 (Measured from sternal angle) 4 - 12 (Measured from mid-axillary line) ECG Notes: Net upward deviation of QRS on ECG goes along axis vector. Net downward deviation of QRS on ECG goes back along axis vector. LAD : +ve deviation in I, & -ve deviations in II & III RAD : +ve deviation in III, & -ve deviation in I. Infusion Pump Types: Baxter - For infusions from a Bag (Volumetric Pump) Imed - For infusions and TPN (Volumetric Pump) Becton Dickinson - 50mls (Syringe Driver) Vickers - 50mls (Syringe Driver) Graseby - 10mls (Syringer Driver) PInfusions - Adrenaline Infusion: 2mg in 100mls 5% Dextrose to run at 10mls/hr. YAInfusions - Diamorphine Infusion Pump: 40-120mg Diamorphine + 50-100mg Cyclizine +/- 5mg Haloperidol in 8mls water for injection to run at 1-4mm/hr in a Graseby Pump. 48mm per syringe 8mls per syringe 48mm = 60mg 1mm = 1.25mg Max Dose 10mg in 4 hours / 60mg in 24 hours. Can Substitute 6.25-15mg Methotrimeprazine (Nozinan) for Cyclizine. $AInfusions - Dobutamine Infusion: Comes as 250mg in a 20ml vial 250mg Dobutamine made up to 50 mls with N/Saline (=5mg/ml) To run at 2.5 - 10 mcg/kg/min through a central line. 250mg Dobutamine in 250mls 5% Glucose or N/Saline (=1mg/ml) to run at x mls/hr. (Av Range 6 - 35 mls / hour) 8AInfusions - Dopamine Infusion: a) Comes as 200mg in a 5ml vial b) Dilute 200mg Dopamine in 50mls of N/Saline (4mg/ml = 4000mcg/ml) c) Renal Dose = 2.5 - 5.0mcg/kg/min d) Therefore Infusion rate = 2.5 * 72 * 60 = 2.7mls/hr 4000 (2.5 = Dose, 72 = weight, 60 = Minutes.) (Must be given by a central line) AInfusions - Heparin Infusion: x units of Heparin in 48mls N/Saline to run at 2mls/hr. (Do KPPT a few hours after starting) (x = Up to 48000 Units / day) Comes as - 1000U in 1ml Vial 5000U in 1ml Vial 25000U in 1ml Vial Pump Hep = 1000U/ml 10000U - 0.4mls/hr 12000U - 0.5mls/hr 15000U - 0.65mls/hr 20000U - 0.85mls/hr 24000U - 1.0mls/hr 30000U - 1.25mls/hr 40000U - 1.65mls/hr 48000U - 2.0mls/hr AINR Ranges 2 - 2.5 : Prx of DVT and PE in those at risk (Long Term) 2 - 3 : Prx in Surgery (Lower limb, Abdo), Rx of DVT's and PE's (3-6 Months) Prx of thromboembolism after MI's (3-6 Months) TIA's (Long Term), Atrial fibrillation (Long Term) Mitral Stenosis with Embolism (Long Term) Tissue Valves (3 Months) 3 - 4.5 : Rx of recurrent DVT's, PE's (Long Term) MI's & other Arterial Disease (Long Term) Mechanical Valves (Life Long) CABG's (Up to 2 Months) AInsulin Sliding Scale: Treatment of Diabetes - I/V Insulin Sliding Scale 50units Human Actrapid in 50mls N/Saline Titrated against BM Stix level. BM Stix Rate (Units/hr = mls/hr) 0.0 - 4.0 0.5 4.1 - 7.0 1.0 7.1 - 11.0 2.0 11.1 - 17.0 4.0 17.1 - 27.0 7.0 >27.0 10.0 Infuse 500mls of 5% Dextrose over 8 hrs if [Glucose] goes <4.0 mmol/l. Rx of Hyperkalaemia - 10U of Insulin in 50mls of 50% Glucose to be given over 15 mins. Insulin comes in 10ml Vials where 1ml contains 100U of Insulin. YALung Function Tests: FEV1 - Forced Expiratory Volume in 1 second VC - Vital Capacity FEV1/VC - A measure of Airway Obstruction Peak Flow - Maximum rate of expulsion of air TLC - Total Lung Capacity RV - Rresidual Volume Diffusion: TLCO = KCO * VA (Transfer Factor = How good at Gas exchange) KCO - Rate of uptake of CO. VA - Alveolar Volume Infusions - GTN / Nitronol Infusion: 50mg of GTN in 50mls N/Saline to run at 0 - 5mls/hr titrating to angina pain and respiration. 50mg of GTN in 100mls N/Saline to run at 0 - 10mls/hr titrating to angina pain and respiration. NInfusions - Isoprenaline Infusion: 1mg in 50mls N/Saline to run at 0-8mls/hr Infusions - Lignocaine infusion: Initially give 100mg iv as bolus over 2mins Then make up infusion of 1g in 500mls N/saline (=2mg/ml or 0.2%) Run at :- - 120mls/hr for 30 mins - 60mls/hr for 2 hours - 30mls/hr from then on. Infusions - Mannitol Infusion: Available as 50g in 250mls of Infusion fluid (=250mg/ml or 20%) Available as 50g in 500mls of Infusion Fluid (=100mg/ml or 10%) Dose is 1g/kg (Often 50g) given over 20 mins bInfusions - Morphine Sulphate Infusion: 50mg Morphine in 50mls N/Saline to run at 1 to 10 mls/hr Infusions - Omnopon Infusion: Available as - Omnopon 20 = 20mg in 1ml Omnopon 10 = 10mg in 1ml 40mg Omnopon in 40mls N/Saline to run at 0-10mls/hr Titrate to pain and respiration Infusions - Pethidine Infusion: 200 - 500mg Pethidine in 50mls N/Saline (=4 - 10mg/ml) to run from 1 - 10 mls/hr depending on patient requirements. fInfusions - Salbutamol Infusion: 5mg in 500mls 5% Glucose to run at 3 - 20mcg/min More if necessary. WInfusions - Streptokinase Infusion: 1.5m units in 100mls N/Saline to run at 100mls/hr CManagement of Arhythmias: Ectopic Beats - Rarely require Treatment. Reassure. If troublesome, try Beta-blockers. Atrial Fibrillation - If ventricular rate is too high, control c Digoxin. If doesn't work, add a Beta-blocker or Verapamil. Consider synchronised d.c. shock. Consider anticoagulation in valvular or myocardial disease. Atrial Flutter - Synchronised d.c. shock. Digoxin. Paroxysmal SVT - Vagal Stimulation - Carotid Sinus massage, Squatting, Jendrassic manouevre. If above fails, give Adenosine. Consider Digitalisation or a Beta-blocker, or Verapamil. Acute Arrhythmias assoc c MI - Lignocaine 100mg i/v If bradycardia & hypotension - Atropine (0.3 - 1mg) Ventricular Tachycardia - If very rapid c circulatory collapse - d.c. shock. If above not effective - give Lignocaine. Torsade de Pointes - Give i/v Magnesium Sulphate. (Risk factors: Long QT interval, Drug induced, Hypokalaemia severe bradycardia, & genetic predisposition) SAMini Mental Test Score (MTS): 1. Name 2. Age 3. DOB 4. Address 5. Time - Current Year / Day of Week / Time of Day 6. Place - Where are we? 7. Person - What I am ? / What is she ? 8. Long Term Memory - When was 2nd world war ? 9. Short Term Memory - Who is the Monarch / Prime Minister ? 10. Count from 20 - 10 backwards. SAModes of Death: Asphyxia Asthenia Brain Failure Cachexia Cardiac Failure (Not further qualified) Debilty Exhaustion Heart Failure (Not further qualified) Hepatic Failure Hepatorenal Failure Kidney Failure Liver Failure Liver & Kidney Failure Renal Failure Respiratory Arrest Shock Syncope Uraemia Vagal Inhibition Vasovagal Attack KAMRSA Eradication Therapy: Hibiscrub for all washes Bactroban Nasal Cream tds Sterzac Powder to Groin & Axilla tds Give 7 days of treatment, followed by 2 days free. Then swab 3 times every alternate day. (6 days) If all three swabs are clear, then is free from MRSA. If any swab is positive, then re-start eradication schedule. BMyotomes: Shoulder Abduction & Lateral Rotation - C5 Shoulder Adduction & Medial Rotation - C6/7/8 Elbow Flexion - C5/6 Elbow Extension - C7/8 Forearm Pronation - C7/8 Forearm Supination - C6 Wrist Flexion & Extension - C6/7 Finger Flexion & Extension - C7/8 (Long Tendon) Intrinsic Muscles of Hand - T1 Hip Flexion - L2/3 Hip Extension - L4/5 Knee Extension - L3/4 Knee Flexion - L4/5 Ankle Dorsiflexion - L4/5 Ankle Plantar Flexion - S1/2 Ankle Inversion - L4 Ankle Eversion - L5/S1 Big Toe Extension - L5/S1 Big Toe Flexion - S1/2 +ANaloxone: Available as 400mcg in a vial Give 0.4 - 2mg every 2 - 3 mins as a bolus depending on clinical response. (Up to a maximum of 10mg). If a long acting opioid has been taken - set up a Naloxone Infusion. 400mcg Naloxone in 100mls N/Saline (4mcg/ml) to run according to clinical response. 9ANotes on Antibiotics : Gentamicin - Doesn't cover Gram +ves Augmentin - Covers Staphs more than Amoxycillin alone. Ciprofloxacin - Doesn't cover Pneumococci. Pneumonia: OK - Amoxycillin Sick - Amoxycillin + Erythromycin Continuing - Add Flucloxycillin / Rifampicin Very Sick - i/v Cefuroxime + i/v Erythromicin 7AOperation Codings - Abdominal Wall & Peritoneum: Peritonitis c Peritoneal Washout - Major Intraperitoneal Abscess - Major Laparotomy - Major Inguinal Hernia - Inter Femoral Hernia - Inter Incisional Hernia - Inter Recurrent Hernia - Inter Obstructed / Strangulated Hernia - Major Intraabdominal Hernia - Major Mental State Examination (MSE) Appearance Speech Abnormal Beliefs Abnormal Experiences Orientation Short & Long Term Memory Concentration Insight Muir & Barclay Formula Burns Rehydration Formula: Wt * %Burn / 2 = Colloid Fluid in 1st 4 Hours This gives an underestimate. Some units give Crystalloid and don't divide by 2. Operation Codings - Anus: Perianal Abscess - Minor Fissure - Minor Fistula - Inter Warts - Minor Anal Repair - Major Sling - Major Haemorrhoidectomy - Inter Operation Codings - Bladder & Urethra: Cystoscopy - Minor Vesicocolic Fistula - Major Cystectomy - Major Urethral Dilatation - Minor Operation Codings - Bowel: Bowel Obstruction - Major Appendicectomy - Major Colostomy - Major Colostomy Closure - Inter Colectomy - Major Sigmoidoscopy - Minor Colonoscopy - Inter Dilatation of Stricture - Inter Rectal Polyp - Minor jOperation Codings - Breast: Biopsy - Minor Lumpectomy - Inter Mastectomy - Major Microdochectomy - Inter Operation Codings - External Genitalia: Circumcision - Minor Vasectomy - Minor Hydrocoele - Inter Orchidectomy - Inter Undescended Testis - Inter Torsion - Inter Operation Codings - Liver, Gallbladder & Pancreas: ERCP - Inter Liver Abscess - Major Cholecystectomy - Major Pancreatectomy - Major Hepatectomy - Major AOperation Codings - Skin & Subcutaneous Tissues: Rodent Ulcer (BCC) - Inter Melanoma - Major Squamous Cell Carcinoma (SCC) - Inter Block Dissection - Major Sebaceous cyst - Minor Abscess - Minor Pilonidal Sinus - Inter Wound Curettage - Inter Nail Avulsion - Minor Radical Nail Excision - Inter Ganglion - Inter Split Skin Graft (SSS) - Minor Excision Benign Lesions - Minor Lipoma - Minor Lymph Node Biopsy - Inter /COverdose Levels: Alcohol Levels: Legal Limit - 80mg% blood (mg/100mls) or 17.5mmol/l Legal Limit - 35mcg% breath (mcg/100mls) Legal Limit - 107mg% urine (mg/100ml) Intoxication - > 150mg% or 33mmol/l Coma - > 300mg% or 66mmol/l Death (Resp failure) - > 400mg% or 115mmol/l Alcohol Estimate = 5 * (Measured Osmolality - Calculated Osmolality) (Where Calculated Osmolality = 2 (Na + K) + Urea + Glucose ) Aspirin / Salicylate <4.3 : Increase Oral Fluids Salicylate >4.3 : Charcoal / Alkaline Diuresis / Urinary Alkalinazation Treatment level in adults is 120mg/kg Treatment levels for Paracetamol: Time Normal Risk Increased Risk (mmol/l) 4hrs 1.32 0.66 8hrs 0.66 0.33 12hrs 0.33 0.15 16hrs 0.15 0.08 Children are allowed 150mg / kg before blood paracetmol levels need to be taken. |BPaediatric Analgesia Doses: Paracetamol / Calpol 2 Months : 60mg for post-immunisation pyrexia 2-3 Months : 10mg/kg qds (5mg/kg if jaundiced) 3-12 Months : 60-120mg qds 1-5 Years : 120-250mg qds 6-12 Years : 250-500mg qds Ibuprofen 20mg/kg/day in divided doses (Not recommended for children under 7kg / 4-6 months) (Junifen is 100mg / 5mls) Sedation of Children: Promethazine / Phenergan Elixir (1mg/ml) Under 2yrs - Not recommended 2-5yrs - 15-20mg 5-10 - 20-25mg Trimeprazine = Alimemazine (Vallergan Syrup = 7.5mg / 5ml) (Vallergan Syrup Forte = 30mg / 5mls) 2mg/kg for Children between 2 - 7 yrs. Under 2 yrs - Not recommended. &FPaediatric Growth Assessment Norms - Boys : (3rd < 10th < 50th < 90th < 97th Percentile) Age Weight (Kg) Height (cm) Birth 2.8<3.1< 3.5 <4.0<4.4 46<48< 50 <53<55 1 Month 3.4<3.7< 4.4 <5.1<5.4 50<52< 54 <57<59 2 Months 4.0<4.4< 5.2 <6.0<6.4 53<55< 58 <60<62 3 Months 4.6<5.0< 5.9 <7.0<7.4 56<58< 60 <64<66 4 Months 5.3<5.7< 6.6 <7.9<8.4 58<60< 63 <66<68 5 Months 5.8<6.3< 8.6 <8.6<9.2 60<63< 66 <68<70 6 Months 6.3<6.8< 7.8 <9.2<9.9 63<65< 68 <70<72 8 Months 7.1<7.6< 8.7 <10.3<11.0 66<68< 71 <74<76 10 Mnths 7.8<8.4< 9.5 <11.0<11.9 67<69< 74 <77<79 12 Mnths 8.3<9.0< 10.0 <11.7<12.6 71<73< 76 <80<82 15 Mnths 8.9<9.6< 10.9 <12.5<13.5 74<76< 80 <83<85 20 Mnths 9.6<10.4< 11.9 <13.6<14.6 78<80< 84 <87<89 2 Years 10.2<11< 12.6 <14.6<15.6 81<83< 86 <90<92 3 Years 11.5<13< 15 <17<18 87<89< 94 <99<101 4 Years 13<14< 16.0 <19<20.5 93<96< 102 <107<110 5 Years 14<15.5< 18.5 <21.5<24 99<102< 108 <114<117 6 Years 16<17< 20.0 <24<27 105<108< 115 <121<125 7 Years 17<19< 23 <27<31 110<113< 120 <128<131 8 Years 19<21< 25 <30<34 116<119< 126 <134<137 9 Years 21<23< 27 <33<39 120<124< 132 <139<143 10 Years 23<25< 30 <37<43 125<129< 137 <145<148 11 Years 25<27< 33 <42<48 130<134< 142 <150<154 12 Years 27<30< 37 <46<53 135<139< 147 <155<159 13 Years 30<33< 41 <51<59 140<144< 152 <160<164 14 Years 36<39< 49 <59<66 148<153< 161 <169<173 15 Years 43<47< 56 <68<74 156<160< 169 <176<181 16 Years 47<51< 61 <72<78 160<164< 172 <181<185 @Paediatric Growth Assessment Norms - Girls : (3rd < 10th < 50th < 90th < 97th Percentile) Age Weight (Kg) Height (cm) Birth 2.7<3.0< 3.4 <3.9<4.2 47<48< 50 <52<54 1 Month 3.3<3.5< 4.1 <4.7<5.1 50<52< 54 <56<57 2 Months 3.8<4.2< 4.8 <5.5<6.0 53<54< 57 <59<60 3 Months 4.4<4.8< 5.5 <6.4<6.9 55<57< 59 <62<63 4 Months 4.9<5.4< 6.3 <7.1<7.7 58<59< 62 <64<66 5 Months 5.4<6.0< 6.8 <7.8<8.4 60<61< 64 <66<68 6 Months 5.9<6.5< 7.4 <8.5<9.1 61<62< 66 <68<70 8 Months 6.6<7.3< 8.3 <9.5<10.2 64<66< 69 <72<74 10 Mnths 7.3<7.9< 9.1 <10.4<11.0 67<69< 72 <75<77 12 Mnths 7.8<8.4< 9.7 <11.2<11.8 69<71< 74 <78<80 15 Mnths 8.4<9.0< 10.5 <12.1<12.7 72<74< 78 <81<83 20 Mnths 9.2<9.9< 11.5 <13.2<14.0 77<78< 82 <86<88 2 Years 9.7<10.4< 12.3 <14.1<14.9 80<81< 85 <89<92 3 Years 12<13< 15 <17<18 86<88< 93 <98<100 4 Years 13<14< 17 <19<20 92<95< 100 <106<108 5 Years 15<16< 19 <22<24 98<101< 107 <113<116 6 Years 16<17< 21 <25<27 104<107< 113 <120<123 7 Years 18<19< 23 <28<31 109<112< 119 <126<129 8 Years 20<21< 25 <32<35 114<118< 125 <132<136 9 Years 21<23< 28 <35<40 119<123< 130 <138<141 10 Years 23<25< 31 <40<45 125<128< 136 <143<147 11 Years 25<28< 34 <45<51 130<134< 141 <149<153 12 Years 30<32< 40 <51<57 138<141< 149 <157<160 13 Years 37<40< 48 <60<67 145<149< 157 <164<168 14 Years 42<45< 53 <65<72 149<153< 161 <168<172 15 Years 45<47< 55 <67<74 150<154< 162 <169<173 16 Years 46<48< 56 <68<75 151<155< 162 <170<173 APaediatric Normal Values: Age Pulse Respirations Newborn 110 - 170 30 - 50 11 Months 100 - 140 26 - 40 2 Years 80 - 130 20 - 30 4 Years 80 - 120 20 - 30 8 Years 70 - 110 18 - 24 Adolescent 60 - 110 12 - 20 Age Blood Pressure 6 - 12 Months 90/61 (+/- 25/19) 2 - 3 Years 95/61 (+/- 24/24) 4 - 5 Years 99/65 (+/- 21/15) 6 Years 100/56 (+/- 15/8) 8 Years 105/67 (+/- 16/9) 10 Years 109/58 (+/- 16/10) 12 Years 113/59 (+/- 18/10) APaediatric Rehydration in Dehydration : 1. Restoration of circulation - - Drinking - NaCl / Albumin 4.5% / FFP / PPF @ 10mls/kg over 15-30mins (20mls/kg if shocked) - Repeat i/v infusion *2 as necessary 2. Investigations. (U&E. ABG if necessary) 3. Refer on. DPotassium / Hyperkalaemia / Hypokalaemia Hyperkalaemia :- Causes - Haemolysis, Myonecrosis, Metabolic / Lactic acidosis, Diabetic Ketoacidosis, Renal failure, Low insulin, Diarrhoea, Excess i/v K+ replacement, K+ sparing diuretics, Addisons disease, Sodium depletion, Anorexia, Massive blood transfusion. ECG - String sign - Tall 'tented' T-Waves, Flat P, Widened QRS, -> VF. Treatment - < 6.5mmol/l -> Calcium Resonium. > 6.5mmol/l -> 10U of Insulin in 50mls of 50% Glucose to be given over 15 mins. 10ml 10% calcium gluconate slow i/v 1L Normal saline over 1hr + 40mg Frusemide i/v Hypokalaemia :- Clinically - Muscle weakness, Hypotonia, Cardiac arrhythmias, Cramps, Tetany. ECG - Small / Inverted T-Waves, Prominent U-Wave, Prolonged PR interval, ST depression. Causes - Diuretics, Vomiting, Diarrhoea, Purgative abuse, Intestinal fistula, Villous adenoma of rectum, Carbenoxolone, Insulin + Glucose, Renal tubule failure, Pyloric stenosis, Alkalosis, Low intake of K+, Hyperaldosteronism, Cushing's Syndrome, Conn's Syndrome, Steroid / ACTH Rx. Treatment - If >2.5 -> Oral Potassium Supplement If <2.5 -> 20mmol KCl in >200ml over >1hr (Not if oliguric) kAPreparation for ERCP: Venflon in R arm. Non-Jaundiced Patients - 750mg Ciprofloxacin po 2 hrs pre-ERCP Jaundiced Patients - Adequate hydration pre-ERCP, if necessary intravenous. 750mg Ciprofloxacin po or 2 hrs pre-ERCP and continued bd 3 days. If necessary, to be given i/v. Urinary catheter inserted Pre-ERCP and urine output monitored hourly for 12 hours. Operation Codings - Neck & Mouth: Salivary Calculus - Inter Excision Submandibular Gland - Inter Parotidectomy - Major Thyroglossal Cyst - Inter Thyroid Nodule - Inter Thyroidectomy - Major Parathyroidectomy - Major Operation Codings - Spleen, Adrenal & Kidneys: Splenectomy - Major Any Adrenal Procedure - Major Any Kidney Procedure - Major Operation Codings - Stomach: Oesophagogastrectomy - Major Gastectomy - Major Gastroscopy - Minor Perforated Peptic Ulcer - Major Operation Codings - Vascular: Aorta - Major Embolectomy - Major Ligation of Artery - Inter Varicose Veins - Inter Hickman Line - Inter lPaediatric - Traction in Children: 5lbs for children <= 5yrs Add 1 lb per year, up to a maximum of 10 lbs. Paediatric Child Fitting / Epilepsy : 0.2 - 0.5mg/kg PR Diazepam Followed by - 0.2mg/kg iv Diazepam OR Lorazepam 2mg i/v (into large vein) Followed by - 0.25mls/kg Paraldehyde i/m in Arachis Oil 1:1 Phenytoin: Available as 250mg Phenytoin in a 5ml Vial Status Epilepticus: - Loading Dose : 10 - 15mg/kg over 10 mins (Eg. 500mg) Maintenance Dose : 300 - 400mg/day I/V in Divided Doses |BProtocols - Myocardial Infarction (MI). 1. ECG 2. I/V Access 3. Bloods for FBC, U+E, Glucose, Random Cholesterol, CE's. 4. Aspirin 150mg S/L 5. Diamorphine 5mg i/v & thereafter prn. 6. Streptokinase 1.5MU in 100mls N/Saline to run over 1 hour / or 7. TPA (10mg bolus over 2 min, then 50mg over 1 hour, then 40 mg over 2 hours) 8. If pain continues - GTN Infusion. 9. Consider Heparin (Yes - After TPA. No - After Strep) 10. ACE Inhibitors 3 days post MI in Pt's with Clinical or Echocardiographic evidence of LV Dysfunction. (SAVE Trial). (Titrate up to maximum dose of 50mg tds). 11. Beta Blockers (ISIS1 - Usually Atenolol) }CProtocols - Status Epilepticus : Secure airway + Give Oxygen If Hypoglycaemia - 50mls 50% Glucose If Alcoholic - 250mg Thiamine iv (Ampules 1 & 2 of Pabrinex) If Brain Tumour - Dexamethasone 20mg iv Institute Anti-epileptic Therapy: Premonitory Status - Diazepam 10-20mg iv/pr Repeat in 15 mins if continues. Early Status (up to 30mins) Lorazepam 0.07mg/kg up to maximum of 4mg bolus. Repeat in 10mins if continues. Established Status (>30min) Loading dose of Phenytoin 15mg/kg administered at 50mg/min iv With ECG & BP monitoring. Next if fails Chlormethiazole 0.8% Infusion Loading with 40-100mls over 10mins Followed by infusion at the lowest rate to prevent convulsions. (Often rate = 1-4mls/min & continued for 12 hrs). Monitor Resps. Next if fails Phenobarbitone 10mg/kg iv at max rate of 60mg/min. Refractory Status Needs General Anaesthesia c Propofol or Thiopentone on ITU. qARadiology - Magnetic Resonance Scans (MRI) T1- Anatomical: White = Fat, Proteinaceous fluid, Bone marrow Black = Other fluids, Tendons, Ligaments, Fibrocartilage T2 - Incr contrast between normal & abnormal tissue. White = Inflammation, Neoplasms, Pus, All fluids Black = Ligaments, Tendons, Fibrocartilage Gadolinium - Incr contrast between tissues in T1&T2. ARenal Colic Management: Do an IVU / IVP Admit if: Septic / Pyuria High Creatinine Pain not under control No filling down to the level of obstruction. ??? Incomplete filling down to the level of obstr by 1 hour It doesn't matter about the size of the stone. FResearch Article Critique Checklist Introduction :- Is the study relevant & important to our practice? Is the work useful & original? Does it add to the fund of useful knowledge? Was the study setting similar enough to our working environment that, assuming the results are valid, they may be extrapolated to our practice? Methods : Was the architecture or design of the study appropriate to answer the questions posed in the introduction? Is the connection between the hypothesis & the instruments used clearly justified? Is the relationship between outcomes & measures plausible? Are the instrments used appropriate to the study & have they been validated previously? Are the population & the population sample defined & recognisably similar to that seen in practice? Are the recruitment definitions & inclusion / exclusion criteria clearly stated? Is the sample size sufficient to answer the questions posed, & has there been an attempt to estimate the required numbers in advance? Results :- Is the response rate adequate? Are drop-outs well described, & is there any reason to think that they differ materially from responders? Are the tables & figures clear? Have stastistical tests been applied appropriately? Are p-values or confidence intervals used? Where statistically significant differences are found, are they sufficient to be clinically important? Discussion :- Does the discussion show an awareness of the methodological limitations of the study design? Are problems or difficulties acknowledged? Are the conclusions drawn justified by the results presented? Is a comparison drawn with other published work? Do the authors speculate too far beyond the evidence presented? CSodium / Hypernatraemia / Hyponatraemia Hypernatraemia :- Causes - Water loss in excess to Sodium Incr cortisol - Conn's Syndrome, Diabetes insipidus, Osmotic diuresis, Iatrogenic - Incorrect fluid & electrolyte replacement (Esp Coma) Clinically -> CNS depression. Treatment - Water orally if possible. If [Na] >150mmol/l = 5litres 5% Dextrose over 24hrs. Hyponatraemia :- Causes - Na & H2O lost from Kidneys - Addisons Disease, Renal Failure, Diuretic Excess. Osmotic Diuresis (Glucose / Urea) Na & H2O lost from Gut - Diarrhoea, Vomiting, Fistula, Villous adenoma, Small bowel obstruction. Na & H2O lost from Elsewhere - Cystic Fibrosis, Burns, Heat exposure, Trauma. Others - SIADH, Water excess, Severe Hypothyroidism, Nephrotic syndrome, Heart failure, Cirrhosis. Treatment - [Na] <110mmol/l = 200ml 5% NaCl over >6hrs. [Na] >110mmol/l = Fluid restriction 1L/24hrs. BSurgical Risk Factors (Preoperative) Must Stop :- MAOIs, Tricyclics, Lithium, Phenothiazines. Change to IVI :- Fluids, Insulin, Steroids, Digoxin, Warfarin-Heparin. Oral contraceptive pill :- On OCP -> 0.96% risk of DVT No OCP -> 0.5% risk of DVT. Perioperative MI :- Within 3 months = 33% mortality 3-6 mnths = 10% mortality >6mnths = 5% mortality. Smoking :- Stopping 24-48hrs Preop -> Decr CarboxyHb Stopping 6wks Preop = Incr immunity, Incr cilia, Decr bronchoconstriction. Hypertension :- Distolic BP 90-105mmHg = 2x risk of ischaemia. URTI :- 16x Incr risk of laryngospasm, apnoea, bronchospasm, at time of surgery; 20x incr. risk if infection 3-4wks before surgery; therefore postpone surgery for 4wks after URTI. ASuture Materials: Absorbable :- Plain Catgut (Monofilament) Chromic Catgut (Monofilament) Polyglycolic Acid - Dexon (Braided) Polyglactin - Vicryl (Braided) Polydioxanone - PDS (Monofilament) Non-Absorbable Silk (Braided) Linen (Braided) Wire - Stainless steel (Monofilament) Nylon - Ethilon (Monofilament) Polypropylene - Prolene (Monofilament) Expanded Polytetrafluoroethylene - ePTFE fETherapeutic Drug Monitoring: Digoxin: Sample 6 - 8 hrs post dose Half Life 36 - 51 hrs Steady State 7 - 14 days Therapeutic Range 1 - 2 mcg/l Comment - Prolonged in Renal failure & CCF Carbamazepine: Sample - Immediately pre-dose Half Life 5 - 27 hrs Steady State 2 - 4 Weeks Therapeutic Range 4 - 12 mg/l Effects of Toxicity: Reversible Blurring of Vision, Dizziness. Dose: 100mg od / bd - Up to 1.2g daily in divided doses. Notes: Start at low dose and build up. Sodium Valproate: Sample - Immediately pre-dose Half Life 6 - 17 hrs Steady State 3 days Therapeutic Range 50 - 100 mg/l Phenytoin: Sample - Immediately pre-dose Half Life 20 - 50 hrs Steady State 2 - 4 weeks Therapeutic Range 5 - 20 mg/l Theophylline: Sample 6 - 8 hrs post dose Half Life 4 - 16 hrs Steady State 2 days Therapeutic Range 10 - 20 mg/l Comments - Prolonged in CCF & Cirrhosis Lithium: Sample 12 hrs post dose Half Life 18 - 36 Steady State 3 - 4 days Therapeutic Range 0.6 - 1.0 mmol/l Toxic Levels >= 1.5 mmol/l Comments - Prolonged in Renal Failure Gentamicin: Sample 1 hr post dose & immediately Pre-Dose Therapeutic Range :- Peak levels should be <10mg/L Trough levels should be < 2mg/L Comments - Prolonged in Renal Failure Vancomycin Sample 1 hr post dose & immediately Pre-Dose Therapeutic Range :- Peak levels should be <30mg/l Trough levels should be <10mg/l *ATo Put in Urinary Catheter: 1. Catheter Set (Kidney dish, Small pot, Cotton wool buds, Swabs & Lap Cover) 2. Catheter 3. Urine Drainage Bag 4. Local Anaesthetic Gel (Instillagel) 5. Syringe 6. Sterile N/Saline to blow up Baloon 7. Sterile Gloves 8. Sachet of N/Saline for Cleaning around Urethra !ATranslators / Interpreters / Liguists :- Institute of Linguists 24a Highbury Grove London N5 2EA Tel : 0171 359 7445 The London Interpreting Project (LIP) 20 Compton Terrace London N1 2UN Tel : 0171 359 6798 Language Line 18 Victoria Park Square London E2 9PF Tel : 0181 981 9911 |Protocols - Amiodarone Treatment : a) 200mg tds for 3 days (Loading Dose) b) 200mg bd for 3 days c) 200mg od from then on Protocols - Any operation involving insertion of metalwork: 1.5g Cefuroxime at induction 750mg Cefuroxime tds 8hrs postop and thereafter. Protocols - Warfarin Treatment : Start with 10mg, 5mg, & 5mg, taking INR every day. Adjust dose according to INR values on a sliding scale. Tablet Colours: 1mg - Brown 3mg - Blue 5mg - Pink Radiological Order of Ossification of Childs Elbow: CRITOE Capitellum - 2yrs Radial Head - 4yrs Internal Condyle - 6yrs Troclea - 8yrs Olecranon - 10yrs External Condyle - 12yrs Nutrient arteries to shafts of limbs: From Knee I Flee, To Elbow I grow Synacthen Stimulation Test: t=0mins - Take Blood for Serum Cortisol Then give 250 g Synacthen i/m. t=30mins - Take Blood for Serum Cortisol t=60mins - Take Blood for Serum Cortisol HUnit Conversions: LENGTH 1 cm = 0.394 ins 1 metre = 1.09 yards ( = 39.4 ins) 1 km = 0.621 mile 1 inch = 2.54 cm 1 foot = 30.48 cm ( = 12 ins) 1 yard = 0.9144 m ( = 3 feet) 1 mile = 1609.344 m ( = 1760 yards) 3 feet = 1 yard 6 feet = 1 fathom (= 2 yards) 22 yards = 1 chain 10 chains = 1 furlong ( = 220 yards) 8 furlongs = 1 mile 1 nautical mile = 1852 m 1 light year = 9.4607*10E15 m 1 parsec = 3.26 light years (= 30.857*10E15 m) 1 sq foot = 0.0929 sq metres 1 sq yard = 0.8361 sq metres 1 acre = 70 yards square ( = 4840 sq yards) ( = 0.4046 ha) ( = 4 roods) 1 hectare (ha) = 10000 sq m ( = 2.47 acre) 1 sq km = 100 hectares 1 sq mile = 640 acres ( = 259 ha) ( = 2.59 sq km) VOLUME 1 gallon = 4.546 litres ( = 8 pints) 1 pint = 0.568 litres (4/7th of a litre) 1 litre = 1.761 pints ( = 0.220 gallons) 4 gills = 1 pint 2 pints = 1 quart 4 quarts = 1 gallon 2 gallons = 1 peck 4 pecks = 1 bushel ( = 8 gallons) 8 bushels = 1 quarter 36 bushels = 1 chaldron 1 oz = 28.3495 grams 1 lb = 0.4536 kg 1 kg = 2.205 lbs ( = 35.3 oz) 1 ton = 1016 kg ( = 2240 lbs) 1 tonne = 1000 kg 1 dram = 27.344 grains 16 drams = 1 ounce ( = 437.5 grains) 16 ounces = 1 pound ( = 7000 grains) 14 pounds = 1 stone 2 stone = 1 quarter 4 quarters = 1 cwt (hundred weight) (= 8 stone) ( = 50.80 kg) 20 cwt = 1 ton ( = 160 stone) TEMPERATURE Celsius - Fahrenheit : Multiply Temp (in C) by 9/5 & add 32. Fahrenheit-Celsius : Subtract 32 from Temp (in F) & multiply by 5/9. Celsius - Kelvin : Add 273.15 to the Temp (in C). 0 C = 32 F, 5 C = 41 F, 10 C = 50 F, 15 C = 59 F 20 C = 68 F, 25 C = 77 F, 30 C = 86 F, 35 C = 95 C 37 C = 98.4 F, -40 C = -40 F, 100 F = 37.77 C VELOCITY 1 mph = 1.6093 kmph 1 foot/sec = 0.3048 m/s FUEL CONSUMPTION 1 gallon/mile = 2.825 litres/km 1 mile/gallon = 0.354 km/litre ENERGY 1 joule = 0.239 calories ( = 2.778*10E-7 kW hr) ( = 0.738 ft lb) 1 kW hr = 3.6*10E6 joules 1 calory = 4.187 joules 1 ft lb = 1.356 joules PRESSURE 1 pascal = 1.450*10E-4 lb/sq in ( = 1 Newton / sq metre) 1 atmosphere = 101.3*10E3 pascals ( = 760 mm Hg) 1 millibar = 100 pascals 1 torr =133.3 pascals ( = 0.01934 lb/sq in) 1 lb/sq in = 6895 pascals MONEY 20 shillings = 1 pound 1 shilling = 12 old pence @Viva's: Answering a Question D - Definition In - Incidence I - Incidence, Age, Sex A - Age C - Cause Surgeon's - Sex P - Presentation (Hx & Ex) Gown - Geographical P - Pathology Physicians - Predisposing factors D - Diagnosis Might - Macro-Pathology I - Investigations Make - Micro-Pathology C - Complications Some - Sx, Sgx, Sequellae R - Treatment (Rx) Treatment - Treatment P - Prophylaxis / Prognosis Progress - Prognosis Causes of Disease: Body Systems: C - Congenital Neurological I - Idiopathic Endocrine I - Infective Cardiovasular I - Inflammatory Respiratory N- Neoplastic Gastrointestinal T - Traumatic Genitourinary O - Others (Vascular, Drugs Bones Obstetric, Iatrogenic) Joints D - Degererative Skin P - Psychiatric / Psychosomatic Connective Tissue A - Autoimmune Haematological M - Metabolic Immunological E - Endocrine )AWeber Classification of Lateral Malleolar Ankle Fractures : Weber A - Below the Syndesmosis - Rarely ever need fixation. Weber B - At the Syndesmosis - Only need fixation if there is talar shift or if Medial Malleolus is avulsed. Weber C - Above the Syndesmosis - Almost always need fixation. cADr. Jason Wolfe The author of this file. This file is freely distributable, but the copyright remains my own. If you find any mistakes, or just simply want to talk, then contact me by email. Updates are available from my website. I hope you all find it useful. email - jwolfe@clara.net www - http://www.jwolfe.clara.net (2nd Version - 18th July 1998) Triple Therapy for Helicobacter Pylori: Omeprazole 20mg bd for 6/52 Amoxycillin 1g bd po for 1/52 Clarithomycin 500mg bd o for 1/52 Tumour Markers: Gut Hormones Screen: Ca19.9 Glucagon Ca 125 Gastrin Ca 15.3 Pancreatic polypeptide CEA Neurotensin AFP VIP bHCG PTHRP (if hypercalcaemic) Viva - Describing a bone in MRCS Exam: Hold in anatomical position Relevant bony landmarks Relevant soft tissue landmarks Relevant articulations Arterial & Nerve supply Development of bone Clinical relevance Viva - Examining a Lump : Site Colour Tenderness Pulsatility Size Consistency Temperature Punctum Shape Contour Tethering Fluctuation Transillumination Local Lymph Nodes "DATA.APP?@ Table1 General This SIS-file is designed from BISON Software. Bison Software doesn't accept any liability for the function of the programme to be installed. Please pay attention to the comment in the README file of the author. Before installing this software please make a B A C K U P of your Psion Series 5. Have a lot of fun! Diese SIS-Datei wurde von Bison Software erstellt. Bison Software bernimmt keinerlei Garantie f r die Funktion des zu installierenden Programmes. Bitte beachten Sie die Hinweise in der README Datei des Autors. Bevor Sie das Programm installieren machen Sie ein B A C K U P Ihres Psion Serie 5. Viel Spa