Welcome 2015

It seems ages since I was revising for my FFICM and set this blog up–though its only a matter of months–and this site has stood a bit stagnant. So, the first few months of this year will be do or break for this site. I hope build better coverage of the curriculum onto the site. I have quite a few revision notes that I will be looking over and editing for public consumption.

2015 has brought in other big changes for me. Later this week, I’ll be travelling to West Africa to help with the Ebola crisis for 7 weeks. While Ebola has been largely viewed and managed as a Public Health crisis, it is very much a critical illness. What an Intensivist can add to the situation has yet to be seen. I’ll be documenting my experiences on my other blog.

If you have any spare Christmas pennies, I’d be grateful if you could send them over to the guys at MSF who are doing a sterling work over in West Africa.

Drowning

Definition

Drowning is defined as respiratory impairment due to submersion in liquid. Often associated with hypothermia, trauma and result in multi-organ failure.

  • The aspirate is either hypertonic (sea water) or hypotonic (fresh water) leading to pulmonary oedema; the water may carry bacteria or particulate matter.
  • Initial assessment: precipitating event (alcohol/drugs), water type and temperature, known medical history, ABCDE.

 

Resources


paper Drowning, Carter & Sinclair. CEACCP (2011)

 

Extracorporeal Membrane Oxygenation

Classification

  • veno-arterial ECMO (VA-ECMO): gas exchange and haemodynamic support
  • veno-venous (VV-ECMO): gas exchange
  • arterio-venous ECMO (AV-ECMO): gas exchange (mainly CO2 removal; no pump)

Resources


paperExtracorporeal membrane oxygenation in adultsMartinez & Vuylsteke, CEACCP 2012

 

ECGs

ECGs are frequently presented to candidates sitting the OSCE element of the exam, a systematic approach is essential.

  • Name, date, calibration (1mv=1cm, 0.2s=1cm [small square 40 msec])
  • Rate = 300/number of big squares between Q-Q
  • Rhythm AF, tachy (>100), brady (<60), sinus, heart block
  • Axis normal = -30° to +110°

P              peaked, tall Dright atrial hypertrophy

notched, broad Dleft atrial hypertrophy

P-R          >5 small squares

I degree block: prolonged PR interval

                II degree block:

                                Wekeneback: sequential ­ of PR interval

Mobitz typ II: fixed PR, dropped QRS (2:1, 3:1…)

                III degree block: disassociation of P and QRS

QRS        wide (<2.5 small squares)

MarroW Dright bundle branch block

WilliM Dleft bundle branch block

Q             1mm wide, 2mm/25% of R-wave

D old MI

Normal in lead I, aVL V6

ST           raised: 1mm 2xconsangious limb-leads, 2mm chest-leads

Depression: myocardial ischemia

Reverse tick: digoxin effect

Saddle shaped elevation: acute constrictive pericarditis

T              peaked hyperkalaemia

Flat, prolonged, hypokalaemia

Ischemia, infarction

Normal in III, V1-2 (and V3 in Negroes)

U             Normal/Hypokalaemia

 

MI: Hyperacute T-waves, ST-elevation T-wave inversion, Q-waves. Inf. (II, III, aVF) Ant. (V1-4), Lat. (I, aVL,V5-6) Post. look at V1-2. New LBBB.

PE: S-I (deep S-waves in I), Q-III (Q-waves in III), T-III (inverted T-waves in III). More generally a sign of R-heart strain.

Hyperkalaemia: tall tented T, wide QRS

Hypokalaemia: flattened T, prominent U, (muscle weakness, cramps, tetany)

 

Resources


On the webECG Wave-Maven – is a resource with many “barn-door” ECGs, presented in a quiz format; large database, expert explanations.

Echocardiography

Bedside Critical care Echo (POCUS – Point of Care UltraSound) deserves it’s own page, while not featured prominently on the exam, it is becoming a standard of care on most units. There are lots of pages out there, here are a few I’ve found helpful

Resources


guideline Joint Statement: Appropriate Use Criteria for Echocardiography (2011) – this statement considers the evidence and utility of performing echo in specific situations.

On the webVirtual Transthoracic Echocardiography – this page shows high quality, interactive 3D images which will help you understand what your seeing on echo and also gives a few tips.

podcastMatt and Mike are constantly putting new podcasts out, they carry several lectures on the physics of ultrasound alongside the use of ultrasound of other parts of the body.