Aproach to ICB

    Intracranial bleed is one of the commonest pathology that can be seen in trauma patient. It can be further divide into mild, moderate and severe which is in other way reflect to GCS itself. It will be mild head injury if the GCS more than 12, mmoderate if the GCS 9-12 and severe if GCS less than 8. It can be suspected if the any of follows happen

• Any period of loss of consciousness (LOC)
• Any loss of memory for events immediately before or after the accident
• Any alteration in mental state at the time of the accident
• Focal neurologic deficits, which may or may not be transient.

    I also find that CT head Canadian rules might be help in suspecting ICB as it includes age as 1 of the criteria which diagnosis is a little bit tricky for peadiatric age groups. It includes, GCS dropping post trauma, opened or depressed skull fracture, any signs of basal skull fracture, persistent vomiting or vomiting more than 2, age less than 2 or more than 65. It will be safer to do CT brain for those who are under alcohol or drugs influence for the diagnosis making.

    

Intracranial bleed can take 2 form which is
      
Extradural haemorhage, usually related to skull fracture which may tear branches of middle meningeal. Characterize by concave lesion in CT brain and not travel along the sutures

Subdural  haematoma, usually related to poor outcome as the brain might be injured together. Characterized by convex lesion and bleed travel along the sutures in the CT brain

Bismillahirrahmanirrahim...
At last...dapat juga aku mempunyai blog sendiri...this blog was fully dedicated to all my colleagues in medical field with hope that we can share our experience in improvising our clinical care..

Being posted in ED (emergency department, sajer jer pki term nie berbanding A&E,sounds macho to me...waqaqa)  made me learn so many thing and realize that experience that i gain during my previous posting still not enough.

ED basically been divided into 3 zone, red, yellow and green..each zone had different kind of patient which had been triage earlier at our triage center. In green zone, patient usually will come with vary vague symptoms such as dizziness, body weakness, headache (u'll cracking ur head for the diagnosis...huhu) and etc...Not only that, some of them will come just for the sake for MC (dush..i think this is much more headache for me)

Unlike in yellow zone, or semi-critical area, usually patient who are been triage here are trully sick. Those who are unable to ambulate, having high pain score, breathlessness will be triage here. I rarely had problem managing case here as most of them had clear-cut diagnosis and most of the time will be admitted to the ward..

Last will be red zone ( i like to be here as most of the action will be here), here the cases are more severe such as patient in shosck, polytrauma, severe SOB, severe chest pain and etc..

Thus, working here make me realize that fast decision and action should be done in coping with number of patient ( termasuklah kerenah diorg and kluarga diorg yang berbagai). So one of the way is by having mneumonic (dulu mase student, tak pernah kisah nk pk pasal mneumonic huhu..) Hmm, kesimpulannya aku nak kongsila beberapa mneumonic yang aku ada, which is i think really help me a lot during clerking. Thanx to Dr Amin (EP in HSA,JB) for giving me this mneumonic and for his guidance


Central Nervous System

Altered conciousness
(AEIOU TIPS)
Alcohol
Encaphalopathy
Infection
Opiod
Uremia
Trauma
Insulin
Psychosis
Syncopal

Causes of pin-point pupil
(PP)
Pontine pathology
oPiod

Unequal Pupil
(HANTU)

Causes of vertigo
(VOMITS)
Vestibulitis
Ototoxic drugs
Meniere's disease
Injury
Tumor
Spin (BPPV)

Central Vertigo
(CVA)
Cranial nerve lesion
Vertical Nystagmus
Ataxia and other sign of cerebellar lesion

Peripheral Vertigo
(DRFLIP)
Deafness
Ringing / tinnitus
Fatigability
Latency
Insidous
Positional

Causes of Syncopal (San Francisco)
(CHESS)
CCF
Haematology e.g haematocrit < 30, anemia
ECG
SOB
Systolic less than 90


Cardiovascular system

TIMI Scoring
(ACS)
Age > 65 y.o
on Aspirin before
Cardiac Risk
Chest Pain
Cardiac biomarker
history of Stenoisis
St depression/elevation

Causes of ST depression
(STDMI)
Systemic eg hypovolemia, dehydration
Thrombosis
Dynamic e.g prinzmetal, post PCI
Mechanical e.g valve replacement
Inflammatory e.g SLE

Causes of T inversion
(INVERT)
Infarct
Normal e.g young, Black
Ventricular hypertrophy
Ectopic foci
RBBB/LBBB
Treatment e.g Digoxin

Causes of ST elevation
(ABCHELLP)
AMI
Brugada Syndrome
Carditis (pericarditis)
Hyperkalemia
Early benign repolarization
LVH
LBB
Prinzmetal angina

Early Mx of MI
(MONA)
MOrphine intravenously
Oxygen
Nitrate sublingual 0.5mg stat
Aspirin 300mg stat

Contraindication for thrombolytic therapy
(I AM A CSI)
Ischaemic stroke >3hours or less than 3months
Atriovenous malformation in the brain
Malignancy or tumor in the brain
Active bleeding (menses is exclusion)
Closed facial or head injury
Suspected Aortic dissection
ICB

Causes of hypotension
(HADIAH)
Hypovolumia
Autonomic dysfunction
Drugs
Idiopathic
Acidosis
Hypopituitary

*exclude causes of shock before thinking other causes of hypotension such as cardiogenic, anaphylactic, sepsis, hypovolumia and etc

Causes of AF
(PIRATES)
Pulmonary causes eg pneumonia, pulmonary embolism
Ischemia
Rheumatic Fever
Atrial myxoma
Thyrotoxicosis
Essential hypertension
Sepsis


Gatro-intestinal system

Causes of epigastric pain
(DAPPOM)
DKA
AAA
Pancreatitis
Perforated Viscus
Obstruction
Mesentric ischemia

Avogadro scoring
(MANTRELS)
Migrating pain - 1 marks
Anorexia - 1 marks
Nausea - 1 marks
Tenderness - 2 marks
Rebound tenderness - 2 marks
Elevating temperature - 1 marks
Leucocytosis - 2 marks
Shifting pain - 2marks

Criteria managing UGIB
(BLEED)
Bleeding ongoing
Low sytolic BP <100mmhg
Elevated PT
Erratic Mental Status
Disease comorbidity


Aproach to trauma

Nexus criteria for cervical protection
(NSAID)
Neurological deficit
Spinal tenderness
Altered mental status
Injury above cervical
Distracting pain

Canadian CT- Head rules
(GOAVA)
GCS dropping within 2 hours
Opened / depressed skull fracture
Any Sign of basal skull fracture
Vomiting more than 2 / persistent vomiting
Age more than 65 or less than 2 years old

*may consider CT head in pt under alcohol or drug influence

6 hidden injury in the chest
(ATOMFC)
Airway obstruction
Tension pneumothorax
Open Chest wound
Massive Haemothorax
Flail Chest
Cardiac Tamponade

Secondary survey
(PATMED)
Pulmonary contussion
Aortic Dissection
Tracheo-esophageal injury
Myocardial contussion
Esophageal ruptured
Diaphragmatic injury

Miscellanous

Organophospates intoxication
(DUMBELS)
Diarhea
Urination
Mydriasis
Bronchorhea/bronchospasm
Emesis
Lacrimation
Salivation

Contraindication for Charcoals
(CHARCOALS)
Caustic / corrosives
Heavy metal e.g iron, leads
Alcohol
Rapid onset e.g cyanide
Cloride base
Other insoluble in water
Aliphatic hydrocarbon e. paraffin,methyl
Laxative

Early direct goal therapy in sepsis
(UMMC)
Urine >0.5ml/kg/hour
MAP > 65
McVO2 > 65% or Scvo2 > 70%
CVP 8-12mmhg

Please inform me if i'm wrong and i'll apreciate if we can proceed with discussion. Thank you