Nota Perubatan

Author: notaperubatan

  • Blood Gas — Arterial Blood Gas (ABG) & Venous Blood Gas (VBG)

    Equipment

    Have you seen this syringe before? This is not a normal 1 cc syringe, but this is a heparin-prefilled 1 cc syringe, for blood gas samples. With this syringe, we don’t need to coat the wall of syringe with heparin manually.

    PS: not all hospital / all departments have this priviledge

    Sampling

    How to use a blood gas analyser?

    • Sometimes, as MO / HO, we have to run the blood gas by ourselves, especially in NICU / labour room / ED (some hospitals only allow certain staff to operate those machines as those machines can get spoilt easily if not handled properly)
    • The video shows how a blood gas analyser machine works in general. If you notice, it only uses a little of blood, the remaining is not required. Usually I only send about 0.5 mL of blood to lab for ABG / VBG. You don’t need to fill up the whole 1.0 mL syringe to get blood gas result, if your ice is not enough, the blood at the top part will clot, then you have to retake the blood gas.
    • If you are not sure how to run the machine, ask for help, don’t do it alone.

  • Back to Basic — Taking a Comprehensive Consent

    Mnemonic: LED TO REASON

    ⭐️ Lead in: introduce yourself to the patient & identify the correct patient

    ⭐️ Explore: how much does the patient know so far regarding his / her condition

    ⭐️ Diagnosis

    • Explain the diagnosis to the patient: based on history, physical examination and initial investigations

    ⭐️ Treatment/Procedure

    • Propose a treatment / procedure to the patient (e.g. ODGS, colonoscopy, right below knee amputation)
    • Indication of the treatment / procedure (e.g. to remove tumor, to identify the underlying cause of anaemia, to remove source of infection)
    • How is it done? (e.g. including under local / regional / general anaesthesia)

    ⭐️ Options: discuss all the options other than the proposed treatment / procedure, including that of doing nothing

    ⭐️ Results:

    • Explain likely outcome in terms of pain, mobility, work, diet and return to normal activities (e.g. usually patient will stay in the ward for how long?
    • How long it takes?
    • How fast the result is available?

    ⭐️ Eventualities, e.g., the possibility of needing to remove the testicle in a hernia operation

    ⭐️ Adverse events

    • Examples e.g. myocardial infarction, stroke, pulmonary embolism, bleeding and specific organ damage, vomiting
    • What can be done to minimize? (e.g. antiemetic agents for chemotherapy)

    ⭐️ Sound mind: ask if they have understood

    ⭐️ Open question: check if further clarification is needed

    ⭐️ Note: document everything discussed in the case note

  • Reticulocytes

    Introduction

    Reticulocytes are young, larger red blood cells (contain RNA) signifying active erythropoiesis

    Normal Range

    0.8 – 2%

    Causes of raised reticulocytes count

    • Haemolysis (Examples: severe NNJ due to ABO incompatibility, other forms of haemolytic anaemia in adults)
    • Haemorrhage
    • B12 / folate / iron given to bone marrow that lack these vitamins

  • Common Workups

    WorkupItem

    Anaemic workup

    – FBC
    – FBP
    – Iron studies (Serum iron, ferritin, UIBC, TIBC, TSAT)
    – Vitamin B12, Folate (Indicated if the anaemia is macrocytic)

    =====
    Sometimes in patients with underlying autoimmune disease / haemolytic anaemia is suspected, further test should also be sent. Haemolytic workup:
    – Reticulocyte count
    – LFT (bilirubin, especially indirect bilirubin would be raised) 
    – LDH
    – Coombs test
    – Coagulation profile 

    Note: Send these BEFORE first transfusion if possible, otherwise the report will not be accurate

    Hepatitis screening

    Usually we send: 
    – HBsAg
    – Anti-HCV

  • Killip Classification

    Killip 1:

    • No clinical signs of heart failure

    Killip II: Mild heart failure

    • Crepitations heard at lower third / less of the lungs
    • Elevated JVP
    • S3 heart sound

    Killip III

    • Frank acute pulmonary oedema: crepitations heard more than one-third of the chest

    Killip IV Cardiogenic shock + pulmonary oedema

    • Hypotension (SBP <90 mmHg)
    • Evidence of peripheral vasoconstriction (oliguria, cyanosis, sweating)

  • N-Acetylcysteine (NAC)

    Introduction

    The most widely used antidote for paracetamol poisoning. Its efficacy as a specific antidote for paracetamol poisoning relies mainly on its ability to stimulate glutathione synthesis. Glutathione is essential in the metabolism of NAPQI (toxic paracetamol metabolite

    4 possible modes of action:

    • Increased glutathione availability
    • Direct binding of NAPQI
    • Provision of inorganic sulfate
    • Reduction of NAPQI back to paracetamol

    Dosing

    Paracetamol Toxicity

    • 150 mg/kg NAC diluted in 200 ml of 5% dextrose IV over 15-60 minutes., then
    • 50 mg/kg NAC diluted in 500 ml of 5% dextrose IV over 4 hours, then
    • 100 mg /kg NAC diluted in 1000 ml of 5% dextrose IV over 16 hours
    • 150 mg/kg in 100 ml of 5% dextrose over 15 minutes, then
    • 50 mg/kg in 250 ml of 5% dextrose over 4 hours, then
    • 50 mg/kg in 250 ml of 5% dextrose over 8 hours, then
    • 50 mg/kg in 250 ml of 5% dextrose over 8 hours.
    • 150 mg/kg in 3 ml/kg of 5% dextrose over 15 minutes, then
    • 50 mg/kg in 7 ml/kg of 5% dextrose over 4 hours, then
    • 50 mg/kg in 7 ml/kg of 5% dextrose over 8 hours, then
    • 50 mg/kg in 7 ml/kg of 5% dextrose over 8 hours

    References / Further Reading

    1. https://litfl.com/n-acetylcysteine/

  • Safety Triangle

  • Dark and Bright Areas on Different Imaging Modalities

    Modality Bright on Image Dark on Image
    X-rays // Radiography Opacity Lucency
    CT scan Hyperdense Hypodense
    MRI Hyperintense Hypointense
    Ultrasound Hyperechoic Hypoechoic / Anechoic
    No matches found.

  • Atrial Fibrillation (AF)

    ECG Features

    • Absence of P wave
    • Irregularly irregular R-R interval
    • Narrow QRS complex

  • Glasgow Coma Scale (GCS)

    • 4: Opened spontaneously
    • 3: Opened to speech
    • 2: Opened to pain
    • 1: No response
    • 5: Orientated to time, place, and person
    • 4: Disorientated
    • 3: Inappropriate words
    • 2: Incomprehensible words
    • 1: No response
    • 6: Obeys commands
    • 5: Moves to localize pain
    • 4: Flexion and withdrawal from pain
    • 3: Abnormal flexion (decorticate)
    • 2: Abnormal extension (decerebrate)
    • 1: No response

    Minimum sore: 3
    Total score: 15

    Notes

    • Consider intubation if GCS ≤8
    • How can a HO easily remember GCS?
      • Take care of patients in acute cubicle, where you would need to assess GCS almost every day 😀
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