Pulmonary Embolism Fast Facts: Wells Score Menmonic

Clots can form due to many reasons that we all are aware about. Let's do a quick review of certain facts for this deadly diagnosis.

• Pulmonary Emboli arise from Proximal DVT (Above the Knee)
• Distal DVTs in itself does not a risk for PE unless they migrate upwards.
• Pregnancy PEs are from Pelvic Veins (Risks last upto 2 months post delivery)
• PE = Alveolar Dead Space Ventilation
• ~ 50% Lung involved will lead to Pulmonary HTN
• Massive PE =  >70% Lung Involvement (10% will die in first 1 Hour)
• Recent Surgery in last 4 weeks poses a risk (mostly it is Orthopedic Surgery: 70% Risks in Knee Surgery)
• Unexplained DVT: 15 - 20 % of these will develop malignancy in next 2 years 

Anatomy Fast Facts MRCEM Part A Section 3

Anatomy Lower Limb: MRCEM FAST FACTS

MRCEM FAST FACTS PART A: HEMATOLOGY SECTION 1

Watch the Video on Hematology Fast Facts for MRCEM Part A.
If you have any suggestions or comments, Kindly list them below.

Good Luck

Physiology Fast Facts for MRCEM Part A

Unfortunately, I have not had enough time to prepare the Videos or slides for Physiology Section for Part A. So, I have tried to put up a link that gives us high yield concepts in Physiology that are often tested in the exam and are often useful at bedside.

Hopefully, by next sitting, I shall be able to put the video up. Till then, Good Luck & Study Well!!!

Download Link:

Physiology High Yield Notes

(Credit: At A Glance Series)

This Book has been recommended by past students as a good learning resource for the Physiology Section for MRCEM Part A

MRCEM Part A Fast Facts : Microbiology

MRCEM FAST FACTS Part A: Pharmacology

MRCEM FAST FACTS PART A: Biochemistry

MRCEM Fast Facts Series Part A: Resuscitation

Clearing a Cervical Spine clinically (Mnemonic)

1st step is to look for high risk factors: PAD65

Paresthesias in Extremities, Age more than 65, Dangerous mechanism of injury (high speed, axial load, 1metre or 5 stairs, bicycle, recreational vehicle)

If any of these, get an imaging
If none of these, go to step 2

2nd Step is to look for Low risk factors: PARTS

Delayed onset of neck PAIN,
Ambulatory at any time
Simple Rear End Collision
No Midline Spinal Tenderness, or
Sitting in the ED

If any of these present, no Imaging, go to step 3

Lateral movement of neck 45 degrees

If movement possible, remove the collar

Stroke/TIA: Scales & Recommendations

Rosier Scale:   Diagnoses Stroke
NIHSS:             Rates Severity of a stroke
ABCD2:           Predicts Stroke in TIA

Rosier Scale:

Negative Symptoms:
LOC/Syncope      -1
Seizures                 -1

Positive Symptoms: (FALSE Memonic)
Assymetric Weakness of Face     1
                                            Arms    1
                                            Legs     1
Disturbance in Speech                 1
                           Eyes (Vision)      1

Total Score -2 to 5
Score of > 0 is Stroke in absence of Hypoglycemia with a Sensitivity of 93% and Specificity of 83%

ABCD2 for TIA:

Age > 60                        1 point
BP   > 140/90                1 point
C/f
Unilateral Weakness   2 points
Slurred Speech only (no weakness)  1 point
Duration
> 60 minutes                      2 points
>10 minutes and < 60 minutes 1 point
<10 0="" minutes="" nbsp="" p="" points="">DM

Score: 0 to 7
< 4                   Aspirin and Secondary prevention
                        Imaging or Brain and carotids and consultation in 1 week

> 4                  Aspirin and Secondary prevention
                        Imaging or Brain and carotids and consultation in 24 hours

C/I to Thrombolysis in Stroke:

Age: <18 or="">80
BP: >185/110 or bleeding disorders
CNS: Neoplasm, AVM, Past Bleed, Recent Stroke
Duration: > 4.5 Hours
NIHSS: <5 or="">25

(Victoria Stacey 2012)

Toxicology Hints

Raised Anion Gap (MUDPILES)

Methanol
Uremia
DKA
Paraldehyde
INH, Iron
Lactic Acidosis
Ethanol, Ethylene glycol
Salicylates
=================================================================

Whenever presented with Acidosis, Calculate the AG. After Calculating the AG, Measure Serum Osmolality and Osmolar Gap

OG = Measured Osm -  Caculated Osm

Calculated Osm = 2 Na+ + Glucose + Urea
OG more means present of other osmoles

Raised OG

Alcohols (Methanol, Ethanol, Ethylene Glycol, Isopropanol), Mannitol, Ketones
=================================================================

Oral Charcoal DOES NOT help in:
(BOIL A PC)

Boric Acid
OPC
Iron
Lithium
Alcohols/Acids/Alkalies
Petroleum products
Cyanide

=================================================================

GI Symptoms (Nausea, Vomiting & Diarrhoea) with Visual disturbances in an elderly is a hint towards digoxin toxicity.
Patient on digoxin & frusemide/erythromycin --- more chances of toxicity
Erythromycin/Phenothiazines prolongs QT interval and can precipitate Torsades

TCA OVERDOSE

Remember the actions of TCAs:

• SNRI
• Anticholinergic: All D's (Dry Mouth, Dry skin and hyperthermia, DIlated pupils, Depressin of Respiration, Disorder Heart Rhythm,  Delayed Gastric Emptying, Distended Bladder) and Agitation (Remember the atropine psychosis in OPC Poisoning)
• Alpha 1 Blocker: Hypotension
• Na+ Channel Blocker: Wide PR, QRS, QT

Fatal Dose: 15 mg/kg

Management:

Approach in ABCDE Method:

Airway: Nasal Oxygen

Breathing: Assisted Ventilation

Circulation: IV Access (Lab workup: Venous blood Gas for Acidosis, FBC, U & Es, Renal Functions, Acetaminophen levels), EKG, Vitals, Monitoring, 

IV Fluids

Antidotes:

If taken within 2 hours: Give Oral Charcoal 50 gms

Correct Acidosis: With NaHCO3

50 ml of 8.4% over 15 minutes, then 500 ml of 1.8% over 4 hours (Give HCO3, even if pH is normal, try to keep pH > 7.5, if QRS > 100, monitor hypokalemia)

IV benzodiazepines for convulsions (Avoid phenytoin -- Na+ Channel blocker)

Treat Arrythmia with fluids and NaHCO3, avoid Antiarrythmic Class 1a and 1c -- Na+ Channel Blockers

HD if required,

Refer TOXBASE

Refer ITU

ACETAMINOPHEN (PARACETAMOL) OVERDOSE

A very common OSCE scenario presented as:

• Obtaining History
• Management
• Psychiatric Assessment
• Assessing Capacity
• Assessing Mental Status

OBTAINING HISTORY:

Hi, My Name is Dr ABC, one of the ED Registrars who will be taking care of you today. May I know you name please? How old are you? And what do you do for your living?

Are you having any discomfort or pain? I want to assure you that I would provide you with every assistance, including pain killers to make you more comfortable.

If attendant is present, ask her name and relationship?

Ask the patient if she wants him/her to be present or can they wait outside in the Lobby?

If unstable, begin resuscitation.

I would like to ask you what brought you here today?

 Current Symptoms:

 Do you have any pain in abdomen? Vomiting? 

Event:

What have you taken? Do you have any packets or labels? Exactly when did you take it? How many tablets? Did you take anything else along with it,.... like any other medications or drugs, or alcohol?

Psychiatry:

Why did you take the overdose? Did you want to kill yourself or was it a cry for help?

Did you plan about doing it? Like trying not to be found? Closure of bank accounts? Suicide note?

How do you feel now?

Did you come here by yourself or under duress?

Did you try hurting yourself before too?

Assess risk of severe depression by asking about Sleep, Loss of interest, Guilt feeling, memory and concentration, appetite, psychomotor symptoms.

Assess Suicidal risk by asking SAD PERSONS Score: (Male 1945, single without social support and feeling hopeless and has a plan)

Social History:

Smoking, drugs, alcohol, Social support, Schooling, Stress at work or home

Medical illness:

Do you have any other medical illnesses? like liver disease, kidney disease or infections

Do you take any medications routinely? 

Are you allergic to any medications?

Have you been diagnosed of any psychiatric illnesses like depressions?

Management:

Bloods for CBC, U & Es, glucose, Coagulations Panel, group and type, LFTs, Serum Acetaminophen level, VBGs, lactate. Urine Toxicology screen

Ask for a nomogram

If less than one hour of intake, 50 gm of Charcoal PO

IV NAC

Hospitalize

Psychiatric referral

If denies NAC/treatment:

• Assess Capacity : Understand what is proposed, retain, weigh the benefits and risks involved, make a decision and communicate it
• If capacitated and no risk of repetition discharge (0 - 4 SAD PERSONS)
• If Capacitated, but risk of repetition of self harm (4+ SAD PERSONS), use section under Mental Capacity Act and hold.
• Explore Needle phobia
• Offer Oral Methionine

HYPERKALEMIA (HARD) & INDICATIONS OF DIALYSIS (AEIOU)

Causes: (HARD)

H     Hemolysis
A     Addisson's Diseases
R     Renal Failure/Rhabdomyolysis
D     Drugs: ARBs/Spironolactone and nephrotoxic agents

In an OSCE, first place the patient on monitored bed, cannulate, and get repeat samples for U & E, Creatinine, Calcium, and venous blood gases. Ask for an EKG to look for tall T waves.

Ask history of any Infections, injuries or renal disease, cardiac symptoms like chest pain/palpitations.

Background medical diseases like HTN, CHF, DM, Multiple myeloma, SLE
Drugs like ACEI, ARBS, Spironolactone, NSAIDS, Aminoglycosides, Amphotericin, recent contrast media imaging.

Treatment:

1. 10 ml of 10% Calcium Gluconate slow IV push
2. 50 ml of 50% Dextrose with 10 Units HAI over 10 minutes
3. Nebulized Salbutamol
4. Kayexalate PO or Enema
5. NaHCO3 can also be used
6. Lastly, HD and ICU care should be recommended for refractory hyperkalemia.

Treat Underlying cause:

Hydrate with IV Fluids

Stop all nephrotoxic drugs

Treat infections with antibiotics

Monitor UO

Note the Indications for Dialysis in Acute Renal Failure: AEIOU

• Acidosis (Metabolic Acidosis with pH < 7.2)
• Electrolyte disturbances: Refractory hyperkalemia
• Ingestions
• Overload (Fluid Overload: CHF)
• Uremia: Pericarditis/Encephalopathy

(Source: Trivedi, 2011)

Ottawa Knee Rule: Mnemonic

WAIT get an X Ray of Knee if:

W     Inability to bear weight (4 steps) both immediately and in ED
A      Age greater than or equal to 55
I      Inability to Flex Knee to 90 degrees
T     Tenderness isolated to patella or head of fibula

Succinyl Choline (Suxamethonium)

A great drug of choice for paralysis in RSI, but carries it's own list of side-effects and C/I.

Dose: 1.5 mg/kg IV

Side Efects (BAHAMAS)

Bronchospasm
Anaphylaxis
Hyperkalemia
Arrythmias (Brady and Tachy)
Malignant Hyperthermia
Apnea (especially in inadequate pseudo-cholinesterase)
Secretions (Salivation)

Contraindications (CNBC Eye)

Crush Injuries
Neurological: Spinal Cord Injury, Myotonic dystrophy
Burns
Chronic Renal Failure
Eye (Penetrating injury of the eye)

(To know more about Anesthesiology Visit www.gasexchange.com)

Lower Back Pain

A frequently tested topic in the OSCE part of the MCEM Examinations

History taking
Examination

Remember if the station involves history, go about in these steps:

Hi, My name is Dr.                                , one of the emergency department registrars. May I know your name please? How old are you? And What do you do for your living?

I understand that you have back pain.... I would like to give you some medications for your pain. Well,... I have been asked to take a history about your pain, Is that Okay with you?

Ask SOCRATES of pain, Past similar complaints, Allergies, Past Medical & Surgical History, Medications, Urinary and GI habits, Social history.

Remember to look for REDFLAGS: TUNA FISH

T     Trauma, Tuberculosis
U     Unexplained loss of weight, Night sweats
N     Neurological Deficits, Bowel & Bladder incontinence
A     <20 and="">55
F     Fever
I      IVDU
S     Steroid use or immunosuppressed
H    History of Cancer, early morning stiffness

Ask for Physical examination to be performed, and certain tests like FBC, U & E, CRP, X ray and/or MRI

Thank the patient and Examiner

1. For OSCEs asking for physical examination, remember the following things:

Hi, My name is Dr.                                , one of the emergency department registrars. I understand that you have back pain.... I would like to give you some medications for your pain. Also, I would like to do a physical examination on you. Is that Okay with you?

Before I begin, I would like to know/obtain the vital signs of my patient.

The examination of spine consists of:

1. Range of movements of spine
2. Neurological examination of the lower limb
3. Nerve Stretch tests: SLR, Femoral Stretch tests
4. Gait

Read the question carefully, as they may just ask you to perform specific components. Look for the following videos for further idea about the examination.

(Video Credits: Dr Claire B. & Dr Simon C.)

MCEM Part A Recommended Study Plan

Resources:

Curriculum for Part A from CEM

Revision Notes for MCEM Part A by Mark Harrison

Get Through MCEM Part A

Online Qbank: MCEMEXAMPREP.CO.UK, PASSMCEM

Step 1:

Define a study plan to complete one reading of Mark Harrison over 45 days

A dedicated study time of about 25 hours per week to get the task accomplished

Step 2:

Using the curriculum and a standard textbook of Anatomy, complete the anatomy revision in next 15 days

A dedicated study time of about 25 hours per week to get the task accomplished

Anatomy Text Books recommended for reference:

1.                  Snell’s Clinical Anatomy

2.                  Netter’s Anatomy Atlas

3.                  BD Chaurasia Anatomy (India)

Step 3:

Retrospectively Solve the online question bank (mcemexamprep) and note down additional points in the Revision Notes Book

Study Time: 45 Days

Step 4:

Assess yourself by solving passmcem and mock tests from mcemexamprep

Study Time: 15 Days

Step 5:

Be confident and realize the fact that you have to just get 140 questions right to pass this exam, you are not expected to achieve a 99 percent. Do not get intimidated by the passing rate. So breathe easy, and go ahead.

Give it your best shot…

GOOD LUCK

(N.B: The author have recommended the resources for learning based on past examinees' experience and is in no way having any conflicts of interest or promoting the recommended products)

NEXUS Criteria for C-Spine Injury Mnemonic

NEXUS Criteria For Cervical Injury:

N    Neuro Deficit
E     EtOH/Intoxication
X    eXtreme distracting Injury
U    Unable to provide history (Altered LOC)
S    Spinal tenderness (midline)

Courtesy: Academic Life in EM Blog