😱SHOCK FOR DUMMIES

- Pre HO Medicorp KB

Cardiogenic Shock
- Pt concious
- BP < 90/60
- Most common cause : Myocardial Infarction
- Kena buat ECG - Contohnya nampak ada changes, ST Elevation
- Principle of treatment ;

1. Tx underlying cause(eg Myocardial Infarction)

Thrombolytic Therapy
✅PCI
✅Streptokinase -100 mega unit/ 100 cc /Hour

2. Symptomatic TX (eg : Chest pain)

🌸Pain Killer
IV Morphine 2-2.5mg every 5 min
(Targeted pain score 0-1) - well controlled pain
No maximum dose for morphine
(As long as sedation score 0-1, no limit to give morphine)

(If sedation score 2,3 can give IV Fentanyl 50 mcg - 100 mcg)

❗️kena optimize pain control, sebab boleh worsen MI kalau sakit persistent.
Nak pain score 0- 1.

🌸Oxygen?
Precaution to use, sebab can cause worsen necrosis, oxidative stress to
heart.
Unless if spo2 drop, can start with 1L first, then 2L per minute

🌸 Nitrates
- ? Contraindicated in cardiogenic shock

🌸 Inotropes

Example : Dopamine, Dobupamine, Noradrenaline

🌸Choice drug in MI?

BP : Stroke Volume x Total Peripheral Resistance

✅1st line inotropes in cardiogenic shock, dopamine

✅Other type of shock, 1st line - noradrenaline.
***
Haemorhagic shock

What if patient that post op (eg laparotomy), suddenly BP drop?

🌸Check Temp
- Fever : Septic shock

🌸Check Hb
- HB low: Haemorrhagic shock

What to do as HO (if haemorrhagic shock?)

🌸Prepare patient
🌸Form
🌸Symptomatic
🌸Blood tx - after d/w MO
Berapa pint? Whole blood ke pack cell?
✅Pack cell.
Hb aim > 10, 1 pint akan membuat HB naik sampai 1 - 1.5
Sambil awaiting pack cell?
(Sejam biasanya blood bank nak prepare blood)
- Can give IV bolus normal saline : 20cc/kg/Hour

***
🍎HYPOVOLUMIC SHOCK
Example in case :
1. DKA
2. Burn

DKA
- CBS >11 (Capillary blood sugar)
- PH < 7.3
- HCO3 < 15

IX
- UFEME
- ABG

Why dalam DKA BP drop?

Fluid enter intracellular due to hyperlgycemia in cell. So treatment underlying
cause is by reduce high glucose.

Inotropes of choice?
IV Noradrenaline.

If patient burn?
Loss circulating volume due to burn.
Tx underlying factor?
- Put pt on dressing, pt on antibiotic
- Prevent infection
- IV NS 20 cc/ KG/ Hr

🍎Septic shock : Tx same as hypovolemic shock but + Antibiotic

**
🍎Apa beza allergic reaction/anaphylaxtic/ anaphylaxis shock

🌸Allergic : Urticaria (skin n mucus membrane)

🌸Anaphylaxtic : urticaria (skin n mucus membrane n systemic( respiratory +/-

cardiovascular)

🌸Anaphylaxic shock : anaphylaxtic n BP drop

- Tx : IM Adrenaline : 0.5 mg at lateral tigh, wait for 5 min, if sx resolve, tak
perlu buat apa-apa
- If not resolve, give second dose but in contralateral side
- If still not resolve : IV Adrenaline ( only can be given if planned by specialist)

❗️IV adrenaline most case use if patient yang case asystole je

🌸Symptomatic tx

- IV Hydrocort 200mg
- T Prednisolone 30mg (Both same efficacy)
- IV Piriton / Syr Piriton
- IV Ranitidine (help reduce hypersensitivity and GI symptom)
- Inotropes : IV Noradrenaline : need to give only if pt given IM Adrenaline
already.

If pt on triple inotropes, refer anest.

***
🍎SPINAL SHOCK

Cause cth: MVA - vetebral injury and fracture

BP okey?
Boleh tunggu turn for operation.

Tapi some case BP can drop.

Why in spinal shock BP boleh drop?
- Sebab injury to nerve innervate blood vessel
- Spinal cord f(x) nya maintain blood vessel tone
- Treatment by IV Noradrenaline : help in vasoconstrict and increase BP
Ecg for dummies

Rate : kita kira berapa kotak besar diantara R-R, then lepas dapat tu baru 300
divide by kotak besar.
Eg : 300/5 : 60 bpm.

🌸Rhythm : susah siket yang ni, biasanya tengok di lead no II, sama macam
Rate sebab panjang siket, lagi jelas nak tengok any abnormality.

Sinus Rythm adalah : P followed by QRS. Kalau P kemudian takde QRS atau
QRS tanpa P, bukanlah Sinus Rythm namanya. Benda lain pula tu.

Boleh jadi Sinus Tachy, kalau laju sangat heart rate, macam 150bpm tapi still
nampak P, QRS nya.

🌸Axis :

Biasa boleh tengok di lead I dan II

Prominent Q atau S ke arah negative ⬇ ️atau positive ⬆ ️

Left axis deviation ingat mnemonic ni - They LEFT Each Other

I - ⬆️

II - ⬇️

Right axis Deviation

(They have RIGHT to see each other)

I ⬇️

II ⬆️

- Adalag specific significant kenapa ada axis changes sekian dan sekian,
boleh cari ya.

🌸 Wave
P- R interval biasanya 3-5 small box ( kalau prolong mungkin heart block)

QRS : tak boleh lebih 3 small box

(If broad QRS maybe in case Ventricullar Fibrillation or Ventricullar
Tacycardia)

ST Elevation
More than 2 small box ( 1mm) in 2 contagious lead indicate infarction.

ST depression
More than 1 small box (>0.5mm) in 2 lead indicate ischemic.
T wave
T inversion di AVR, VI normal, tapi kalau significant dan banyak di lead lain
mungkin ischemia atau infarct.

Tall tented in HyperKalemia

Flatten in Hypokalemia

Location ECG Changes

(Ada orang ajar saya, kalau ingat kedudukan lead di chest masa pasang lagi
senang nak ingat ecg changes, tapi saya suka hafal gambar je)

II, III, AVF : Inferior MI

V1, V2 : Septal MI
V3, V4, Anterior MI
V5,V6,I, AVL : Lateral MI

Ada yang changes V3-V6, I, AVL : anterolateral.

Ada yang changes inferolateral.

If more than 6 lead ada ST elevation, tu dah dikiran Extensive MI.

1. Apa beza treatment unstable angina, non stemi dan STEMI? Kan
semuanya ACS?

🌸Biasanya unstable angina ubatnya sama je dengan non stemi, cuma

tempoh berapa hari SC Fondaparinux yang berbeza.

UA : SC Fondaparinux/Arixtra 2.5g OD x3/7

NSTEMI : SC Fonda 5/7
STEMI : PCI atau Thrombolysis
Patient STEMI akan masuk CCU, for cont cardiac monitoring.

🌸In ward, biasanya pt given

- double antiplatelet
- statin
- Beta blocker - if HR permissible
- Ace i - If no renal impairment
- Ca Channel Blocker
- PPI

🌸Cth ubat
- T Cardiprin 100mg OD / Aspirin
- T Plavix 75 mg OD / clopidogrel
- T Atorvastatin 40mg ON /statin
- T Ramipril 2.5mg ON /ACE-i
- T Felodipine 5mg OD /CCB
- T Pantoprazole 40mg OD /PPI
- T Vastarel MR 35 mg OD/Trimetazidine
- T Bisoprolol 2.5mg OD/BB

2. Kalau patient ada SVT, Atrial Fibrillation, Heart Block, VF, kena buat apa?
Kena prepare in mind yang MO akan suruh prepare ubat apa?

🌸SVT :
1. Buat carotid massage first
2. Prepare adenosin - to put in large vein, push then need flush with normal
saline- because easily hydrolyze
3. IV Adenosine 6mg —> 12mg
4. Kena prepare cardiac monitor - heart may stop temporarily or bradycardia

🌸Atrial Fibrillation
1. IV Amiodarone

🌸Heart Block
- Patient akan masuk CCU
- Ada certain case Dr bagi Atropine
- Kena put on external pacemaker
- Patient akan sakit, so kena bagi sedation
- Kalau still persistent brady HR <40, mungkin akan kena masuk Temporary
Pacemaker : macam masukkan IJC, tapi connected to battery
- Then mungkin ada certain case cardiologist akan suruh bagi Isoprenaline
infusion
- Then kalau family member boleh bayar akan change temporary pacemaker
to permanent pacemaker hampir 10K atau berbelas K harganya.

🌸Pulseless Ventricular Tachycardia/

Ventricullar Fibrillation
- Defibrillation

🌸Ada certain Ventricullar Tacycardia, cardologist order to give amiodarone.

3. Macam mana nak access dan history taking if patient presented with fever?
In more systematic way?

🌸Fever?
CNS?
- Ada orang perasan awak ada meracau atau tak sedar?
URTI?
- Batuk? Sesak nafas?
CVS?
Skin lesion?
GI? Loose stool? Vomiting? Diarrhea?
UTI? Dysuria, frequency, urgency?

4. Apa differential diagnosis Fever, SOB, chest pain?

🌸Fever
- Dengue
Infection
Bacterial - Leptospirosis, Meliodosis
Parasit - Malaria
Viral - Dengue

🌸SOB
- Pneumonia
- COPD
- Asthma
- Lung ca
- TB
- Chronic Lung Disease
- Pulm Embolism
- Pneumothax/ Hemothorax
- CCF/MI/ Cardiomyopathy
- Pleural Effusion
- Anemia
🌸 Chest Pain
- ACS
- Pulm Embolism
- Pneumothorax
- Aortic disection
- Pericarditis
- GERD
- Pancreatitis
- Gastritis - epigastric

6. Kenapa patient before CT contrast kena bagi NAC- N acetyl cystein?

🌸Protective to renal, contrast can worsen renal function.

7. Macam mana nak baca ABG?

https://www.facebook.com/100002501025636/posts/2003040653122616/

8. Macam mana nak baca ECG?

9. Location ECG changes indicate infarction dan ischemic di mana?

https://www.facebook.com/100002501025636/posts/2001607976599217/

10. Apa itu safety triangle - for chest tube insertion?

🌸Superior- base of axilla

Ant - lateral border of pectoralis major
Post - lateral border latismus dorsi
Inferior - nipple line, at 5th intercostal space,

🌸above inferior rib, sebab below superior rib ada neuromuscular bundle-
prevent injury

11. Masa pleural tapping nak hantar sample untuk investigation apa?

MTB CNS
Biochemical - protein, LDH, glucose
FEME
CNS
PCR

12. Macam mana nak tengok chest tube functioning ke tak?

🌸Fluctuation and bubbling dalam under water sealed patient during

breathing, if not obvious can ask patient to cough

13. Kenapa ada patient yang dalam list meds nya Spirinolactone 150 mg?
High dose ni untuk apa?

🌸Medication for portal hypertension

14. Kenapa ada patient ACS kita bagi SC fondaparinux, kenapa ada yang kita
bagi IVI Heparin?

🌸Kalau EGFR less than 30 kita bagi IVI Heparin rather

than sc Fondaparinux
15. Femoral catheter - bila masa guna triple lumen, double lumen?

🌸Double lumen - biasanya for the access patient untuk dialysis

🌸Triple lumen - ada lumen tambahan incase nak masuk medication ke

(patient that have difficult peripheral vein)

16. Macam mana nak tahu nak cucuk kat mana masa insert femoral catheter?
Mana most medial, vein or artery?

🌸Ingat VAN

🌸Most medial adalah Vein,

Then Artery then Nerve.

Palpate Artery, then about 1-2cm medially adalah vein, cucuk ke arah
umbilicus.

17. Kalau nak cucuk intramuscular at buttock? Which area to poke? To

prevent sciatic nerve injury?

🌸Imagine buttock tu ada 4 petak, cucuk kat upper outer quadrant

18. Kalau patient ada syphilis biasa kita bagi ubat apa?

🌸IM Benzathine Penicillin 2.4 Million Unit weekly for 3 week.

19. Apa formula corrected calcium, apa significantnya?

🌸Ada some calcium yang bind to albumin, once hypo albuminemia, secara
direct total calcium akan kelihatan low. Padahal kalau kira corrected calcium,
mungkin normal je bagi dia.

Corrected Ca : Calcium + (0.02 (40- Albumin)

Ambil blood calcium pt, result menunjukkan calcium 1.3, tapi sebenarnya dia
hypo albumin, tup-tup lepas kira corrected calcium, dapat 2.0, normal lah
sebenarnya calcium tu bagi dia.

Unless kalau kira formula corrected calcium ni, still dapat nilai yang rendah.
Tu baru kita boleh cakap yang memang calcium dia low.

Double check balik ya😉

Correct if there any mistake.
paramedic note, [25.12.18 01:06]
Susah sangat nak faham ABG, beberapa bulan kerja pun macam tak berapa
nak faham, tahu2 nak tunjuk result kat MO je...😂

Sebenarnya depend kepada case juga kenapa kita ambil ABG ni, atau VBG.

Kalau patient resporatory problem, kita hantar ABG.

Cth
PH 7.25 (7.35-7.45)
PO2 60 (80-100)
PCO2 60 (35-45)
BE
Lact
HCO3 22 (22-26)
Ni kiranya patient ni ada respiratory acidosis, sebab PCO2 tinggi, Bicarb
(HCO3) normal je.

Acidosis boleh disebabkan oleh, high po2 atau low hco3 ( sebab co2 boleh
buat acidic, hco3 buatkan jadi basic), kurang hco3 buatkan blood jadi lebih
acidic.

Kalau patient ESRF kita nak tengok HCO3, sebab indication nak dialyse
adalah persistent metabolic acidosis.

In DKA pun kita nak tgk pt acidic tak, mostly berkaitan dgn metabolic.

So, poin nya... depend what case sebenarnya nak tengok ABG ni.

Susah kalau tiba2 tak tahu case, pastu nak baca ABG.

Dan biasanya anest selalu ambil ABG sebab nak adjust dan weaning down
oxygen.

Kalau tak okey guna non invasive ventilation po2 levelnya, mereka kena
intubate, kemudian nak adjust Fio2 tu depend tahap ABG yang diambil...
memang saya tak pandailah yang ni.

Pernah anest ajar, kalau patient COPD atau old age ke, kita tak expeck PO2
cantik sangat, base on age dia mungkin bagi dia dah okey dah sekian po2.

Formulanya 100- age/3

Cthnya : 100- 86/3 = 100-28
Po2 72 dah cukup okey dah untuk age dia, tak perlu lah nak aim 80 ke atas.

Kena banyak lagi bab-bab ABG ni, oxygenation bagai😅

Boleh faham basic2 macam ni dah syukur sangat sebenarnya.

https://t.me/sayadoktorjunior
PART 1 - MUST KNOW ORTHO
Question plus answer

1. Which patient we put POP, which patient we put backslab? Apa beza?

🍎Full cast POP usually we do after CMR to keep stabilize fracture that we
already reduced, kalau letak backslab no pointlah kita reduce bersungguh2,
nanti ia akan tertarik balik la kan?

Radius/ ulnar fracture yang no need operation biasanya kita letak full POP, for
conservative mx, then pt boleh balik.

Back slab we use for temporary immobilize je, contohnya letak kat ED,
sementara nak menunggu turn op beberapa hari tu kita boleh guna backslab.

Above Elbow backslab

Above Knee
Below Knee
Boot slab
U Slab
Volar slab
Sugar Tong
Itulah contoh jenis2 slab

2. DM bagi antibiotic apa?

🍎IV Unasyn to cover polymicrobial usually kita bagi, tapi tengoklah juga
result tissue CnS atau Pus CnS yang kita dapat masa pt underwent wound
debridement dalam OT tu organism apa, then kita change antibiotic base on
sensitivity.

3. NF Bagi antibiotic apa?

🍎Empirically - penicillin, Clindamycin, Metronidazole

Kalau strep atau clostridium - Penicillin G

Polymicrobial - Meropenam etc
(Depend on sensitivity)

4. Cloxacillin cover apa? Gentamicin? Unasyn? Cefuroxime? Rifampicin?

🍎IV Cloxacillin 1g QID - more on gram positive ( cellulitis biasa bagi ni)

Iv Cefuroxime 750mg TDS/ Tab Cefuroxime 250 BD - more on gram positive,

patient prophylaxtic nak masuk OT kita bgi ni, post op plating pun kita bagi,
mungkin sampai seminggu?

IV unasyn Diabetic Foot Ulcer

Tab Rifampicin 300mg BD - good for bone penatrating- boleh bagi utk Pt
Osteomyelitis, but need to monitor RFT weekly, ask orange color urine to
know compliance.

5. Why irrigate with a lot normal saline in open fracture?

🍎Bagi stat dose antibiotic as soon as possible, then irrigate to Reduce

Bacterial Load.

6. Sciatic nerve branch? Post op nak check apa? Foot drop disebabkan nerve
mana yang affected?

🍎Sciatic Nerve ada dua branch

- Common Peroneal Nerve (Give branch to Deep Peroneal Nerve (supply ms
anterior compartment leg n sensory 1st web spacs ) and Superficial Peroneal
Nerve- supply lateral compartment leg and dorsum foot exept 1st web space)

- Tibial Nerve

Foot drop - injury to common peroneal nerve

7. Calceneum pin insertion medial ke lateral? Nak avoid nerve apa? High
tibial pin?

🍎Calceneum pin must inserted from medial to lateral - 1/4 posterior from tip
med malleolus tu calceneum... to avoid neurovascular bundle over medial
side. Ada tibial nerve, tibial artery.

High tibial pin - insert from lateral, to avoid common peroneal nerve near head
fibula

8. Skin traction? Berapa maxima berat untuk letak pemberat? Nak bungkus
sampai mana? Apa yang kena monitor? Kawasan masa yang mudah nak
kena pressure sore?

🍎Skin traction - not more than 5% body wight

Bandage up to distal part of fracture.
Usually some hosp prefer non adhesive type because can irritate pt skin,
tercabut kulit😅

Put some orthoban to prevent pressure sore.

Post application must monitor distal circulation chart( crt, dpa pta palpable or
not, able to move ankle and toes)
Most importantly pressure sore- if pt pun on backslab, check at bony
prominence - medial/ lateral malleolus, calceneum and head of fibula (deep
peroneal nerve kat situ)

9. Skeletal traction? How much weight?

🍎Not more than 10% body weighy

10. Fat embolism syndrome nak check macam mana?

🍎Pt can have SOB, tachycardia, drowsiness, Fever suddenly.

Check petichae over armpit, conjunctiva and chest.

GURD Criteria - nanti saya tulis ye.

11. Median, radial and ulnar nerve nak check di point mana?

🍎Median - medial to distal phalanx index finger

Radial - anatomical snuff box
Ulnar - tepi little finger

12. OK sign nak test hand untuk nerve apa?

🍎Can do O ( index and thumb) - Median Nerve opponen pollicis

Able to extend wrist - Radial Nerve
Able to extend medial 3 finger - Ulnar Nerve

13. Open fracture management?

- 🍎ABCD
- Secure bleeding
- Large bore branulla - iv fluid
- Analgesic
- IV cefuroxime(+IV Gentamicin, + IV Flagyl) - depend on severity and dirty
- ATT injection
- Irrigate with a lot NS/ water for irrigation
- Immobilize - backslab/skin traction/ splinting/ to reduce pain
- External Fixator first until wound closure
- Dressing
- Once open fracture become close fracture, can do internal fixation

14. Neck of femur fracture? Apa beza total hip athroplasty, bipolar and
unipolar? In which patient and which operation? Premorbidly? Age factor?

🍎Old age >6yo usually can do orthosynthesis, if young patient <65yo can try
screw first, to give time, if anything happen, can proceed with orthosynthesis
later.

Must ask premobidly able to ambulate or socially active or not because can
affect mx

15. LRINEC Score NF?

🍎( L leucocyte R RBS I infective parameter CRP, E Enemia HB C Creatinine)

Total White Cell

Glucose
Na
Creatinine
Hb
16. NF vs Cellulitis?

🍎NF - Not well demarcated margin, purplish, bullae, aggresive worsen,

crepitus

17. DFU - examination/history/classification/ pharmaco/ non pharmaco/

surgical tx

18. Plating/ internal fixation?

🍎Plating yang biasa saya tengok - plating fibula, tibia plateau fracture, radius/
ulnar butress plating.

Internal fixation more on lower limb

- Midashaft tibia fracture, femur fracture

19. Interlocking nail, plating, butress plate, cerclage, tension band wiring.

🍎Tension Band Wiring - Patella fracture, malleolus fracture

Screw - small fracture, malleoulus, head fibula fracture

K Wire - Small bone fracture MCB, MTB.

Spring plate - Acetabulum fracture

20. Clavicle fracture can be mx consevatively?

🍎Can be manage conservatively usually by just use armsling, but in certain

condition can do plating (hook)- eg pt also had lower limb fracture, need to
use crutches to ambulate, so need to operate clavice for early mobilization.
Pernah juga tengok patient had bilateral clavicle fracture also need to operate.

21. Septic arthritis? Kocher criteria? xray

changes? ROM?

🍎One of orthopedic emergency

KOCHER criteria

Pt will have fever

Increase Total White Cell
ESR/CRP increase
Unable to weightbear

Limited ROM join

X Ray - Increase in join space

22. Asia chart

23. L2,L3,L4,L5,SI ?

🍎Power lower limb. (To know which spine level affected)

L2 Flex Hip
L3 Extend Knee
L4 Dorsiflex ankle
L5 Dorsiflex Big Toe
S1 Plantarflex Ankle

24. Superficial peroneal nerve? Deep peroneal nerve supply which area? -
answer in no 6

P/s : Please double check the answer ya.