14.03.26 Placement notes

ARDS

• • Definition

    • Type 1 respiratory failure

    • Non-cardiogenic (i.e. PAWP <16 mm Hg)

  • Diagnosis: Berlin criteria

    • Lung injury of acute onset, within 1 week of an apparent clinical insult and with progression of respiratory symptoms

    • Bilateral opacities on chest imaging not explained by other pulmonary pathology

    • Respiratory failure not explained by heart failure or volume overload

    • Decreased arterial PaO2/FiO2 ratio:

      • Mild ≤ 39.9 kPa

      • Moderate < 26.6. kPa

      • Severe < 13.3 kPa

  • Causes

    • Primary pulmonary (SARS, barotrauma)

    • SIRS (e.g. Pancreatitis)

PCA prescription

• • Morphine PCA, IV

  • 50 mg in 50 ml 0.9 % NaCl

  • 1 mg bolus; 5 minute lockout

  • No background

Notes

• Marjolin's ulcer

  • Aggressive ulcerating SCC presenting in an area of previously traumatized, chronically inflamed, or scarred skin

  • e.g. At a long-standing venous ulcer

• Gallbladder polyps

  • > 1 cm with / co-occurring gallstones in people over 50 => Risk of development to adenocarcinoma

• CXR in pancreatitis

  • ARDS

  • Alelectasis (due to pain; risk of pneumonias)

  • Perforation (alternative cause of raised amylase / late complication)

• Antibiotics (meropenem, imipenem) are sometimes used in pancreatitis for prophylaxis, but not much evidence base

• Evidence of end-organ dysfunction in SIRS

  • Poor or altered cerebral function

  • Hypoxemia (PaO2 less than 10 kPa)

  • Elevated plasma lactate

  • Oliguria (< 0.5 ml/kg body weight.h)

  • Hypotension

  • Raised bilirubin

  • DIC

• Infection + 2 criteria + organ dysfunction = Severe sepsis

• Infection + 2 criteria + lactate >4 or SBP <90 or MAP <70 after 30 ml/kg fluid bolus = Septic shock

• Conditions associated with berry aneurysms (cf 85% of SAHs):

  • Adult polycystic kidney disease, Ehlers-Danlos syndrome coarctation of the aorta

• Acute anterior uveitis occurs in as many as 30% of patients at some time during the course of ankylosing spondylitis (esp. with HLA-B27 allele)

• HBeAg: Secreted version of HBcAg; Marker of active replication and infectivity

• Hyperactivity and short stature are associated with Perthes disease

• Low platelet count and raised transaminase level is typical of dengue fever

• Hypercalcaemia, renal failure, high total protein = myeloma

• Conn's syndrome is the likely diagnosis - a renin:aldosterone ratio would be an appropriate first-line investigation

• Bilateral INO

• Young: MS

• Old: Stroke

• Cluster headache prophylaxis: Verapamil

• Osteochondritis dissecans: Pain after exercise, Intermittent swelling and locking