Advanced

Life Support
Check for Danger

Check for Responsiveness

Send for help and Defibrillator

Open Airway- Head Tilt, Chin Lift, Jaw Thrust
Normal breathing- Rescue Breath 8-10 breaths / minute

Start CPR 100 compressions /min
- Adult: 30 compression : 2 breaths
- Children: 15 compressions : 2 breaths

Attach Defibrillator & Reassess rhythm & Shock 200J / 4J/kg

Shockable (Ventricular fibrillation or Pulseless Ventricular tachycardia)
- 1st Defibrillation -> CPR 2mins -> Reassess rhythm ->
- 2nd Defibrillation -> CPR 2mins & Adrenaline 1mg/ 10mcg/kg -> Reassess rhythm ->
- 3rd Defibrillation -> CPR 2mins & Amiodarone 300mg/ 5mg/kg -> Reassess rhythm ->
- 4th Defibrillation -> CPR 2mins & Adrenaline 1mg/ 10mcg/kg

Non Shockable (cardiac arrest)
- CPR 2mins & Adrenaline 1mg/ 10mcg/kg -> Reassess rhythm ->
- CPR 2mins -> Reassess rhythm ->
- CPR 2mins & Adrenaline 1mg/ 10mcg/kg

Correct underlying cause
- Hyperthermia, Hypothermia
- Hyper/ Hypo electrolytes
- Hypoxia
- Hypovolaemia

Anaphylaxis
Stop administration, Remove trigger
High flow oxygen and lie supine

Look for life threatening problems
- Airway- Stridor, Obstruction
- Breathing- Dyspnea, Sat <92%, Wheeze
- Circulation- Pale, Low blood pressure

Cardiac Arrest
- Start CPR -> IV/IO assess with Adrenaline 1mg -> 2L IV saline -> Repeat IV Adrenaline every 5mins

Shock/ Bronchospasm
- Intramuscular Adrenaline 0.3-0.5mg -> IV saline -> Repeat IM Adrenaline 5mins

Foreign body airway obstruction

Responsive
- Mild obstruction- Encourage coughing
- Severe obstruction (conscious)- 5 back blocks -> 5 chest thrusts

Non-Responsive
- Severe obstruction (unconscious)- CPR 30 compressions -> open airway & remove FB -> ventilate

Arrhythmia
ABCDE approach, Oxygen and IV access
Monitor HR, BP, Sat O2, ECG

Check evidence of adverse signs -> unstable
- shock, syncope, myocardial ischemia, heart failure

Unstable Tachycardia
- synchronized DC shock up to 3 attempts
- Amiodarone 300mg IV over 10-20mins
- Repeat shock
- Amiodarone 90mg over 24hr

Unstable Bradycardia (risk of asystole- recent asystole, Mobits II AV block, Complete Heart Block)
- Atropine 500mcg repeat up to 3mg
- Adrenaline 2-10mcg per min / Dopamine
- Transcutaneous pacing

Stable Tachycardia

Regular Narrow Complex- Supraventricular Tachycardia
- Vagal manoeuvres (Valsalva maneuver, Carotid sinus massage, cold stimulus)
- IV adenosine 6mg -> 12mg -> 12mg -> B-blocker or Calcium Channel Blocker

Irregular Narrow Complex- Atrial Fibrillation
- B-blocker or Calcium Channel Blocker
- Digoxin or Amiodarone for heart failure
- Anticoagulate > 48 hrs > Cardioversion

Regular Broad complex- Ventricular Tachycardia
- Amiodarone 300mg IV over 20-60mins
- Amiodarone 900mg over 24hr
- (watch out SVT with BBB)

Irregular Broad complex- Polymorphic VT (torsades de pointes)
- Magnesium 2g over 10min
- (watch out AF with BBB, Pre-excited AF)

Stable Bradycardia
- Observe

Pregnant Abdomen Examination

General inspection
- Comfortable
- Abdominal striations or Linea Nigra
- Scar from Previous Caesarean Section
- Fetal movements over 24 weeks

Measure fundal height
- From pubic symphysis to top of the bump
- Length in cm corresponds to how far in weeks

Check the lie of the baby
- Use both hands on each side of her bump and gently press
- Longitudinal, Transverse or Oblique

Check the presentation
- Place both hands at the base of the uterus, just above pubic bone
- Cephalic / Breech (how much engagement)

Auscultating babys heart
- best heard over babys shoulder
- Use Doppler ultrasound or Pinard stethoscope
- Heart rate between 120-140

For completeness
- Check blood pressure
- Perform urinalysis
- CTG for babys heart

Discussion regarding glucosuria/ proteinuria or elevated blood pressure
- Gestational Diabetes and Pre-eclampsia



Examine the hand motor function for

Radial nerve

Wrist extension

Median nerve

Active opposition of thumb and forefinger

Ulnar nerve

Abduction of fingers

Emergencey Procedure

Tension pneumothorax Needle decompression
Second intercostal space at midclavicular line
Chest drain

Fifth intercostal space at midaxillary line

Plastic Hand

Collateral ligament injury
Central slip extensor tendon -> boutonniere
Volar plate injury
Joint Dislocation
(Dorsal PIPJ most common)
Extensor tendon injury at DIP (mallet finger)
FDP tendon injury (jersey finger)
Distal Phalanx Fracture
Middle Phalanx Fracture

Metacarpal Fracture

Ulnar Collateral Ligament Injury Thumb

Subungual hematoma
Nail bed laceration

Referral Criertica

Buddy tape for 2-4 weeks

Splinted in full extension for 6 weeks
Splint at 30 flexion and progressively increase extension
weekly for 2-4 weeks
Attempt reduction
Then treat soft tissue with splint 2-4 weeks
(Dorsal- flexion, Volar- extension)
Splint DIP joint in neutral for 6 weeks
Spint finger and refer to hands
Splint fingers for 3 weeks
Attempt reduction
Then splint in extension in doral aluminium splint for 6
weeks
Then buddy tape for 6 weeks
Attempt reduction
Then ulnar cutter splint finger in 70-90 degree of flexion
for 6 weeks
Xray for stenar lesion
Refer hand if over 35 degree laxity
Stable injury for thumb spica for 6 weeks
Subungual decompression
Nail plate removal and repair

Irreducible (significant rotation), Unstable, Young
children, Intraarticular > 2/3, Tendon injury

Wrist/Hand
De Quervains AtPL, EPB
Hitchhikers- active extension against resistance
tenosynovitis in the abductor pollicis longus and Finkelsteins- pulls the thumb of the patient in ulnar deviation and
extensor pollicis brevis tendons of the wrist
longitudinal traction






Intersection Syndrome

discrete swelling at this area of intersection

Scapholunate ligament

Watsons- ulnar -> radial deviation of wrist with examiner's thumb

on the palmar surface of scaphoid

Carpal Tunnel

Phalens- pushing the dorsal surfaces of both hands together

Tinell - lightly tapping over the
nerve to elicit a sensation of tingling

DURJ instability

Piano key- ballottement of ulnar head, (prominence of ulna)

TFCC

Ulnar grind test- wrist in ulnar deviation while applying a shear

force across the ulnar complex of the wrist

Ankle
Anterior Talofibular ligament

Anterior drawer test

-Test for anterior subluxation compared
with the uninjured ankle

High Syndesmotic ankle sprain Stressing the syndesmosis and eliciting pain proximal to the ankle join

Crossed leg test
- Cross their legs with the injured leg resting at midcalf on the knees

Squeeze test
- Squeezing the lower leg at midcalf

Rotation test
- Externally rotating the ankle with the foot dorsiflexed
Calcaneofibular ligament

Inversion stress/ Talar tilt test

- Stress Calcaneofibular ligament
laxity compared with uninjured ankle
suggests ligament damage

Shoulder http://sitemaker.umich.edu/fm_musculoskeletal_shoulder/shoulder_exam_manuevers

Range of
Motion

Appley Scratch test of external rotation- over the head

Appley Scratch test of internal rotation- from the back

Rotator Cuff
Supraspinatous- Passively abduct shoulder to 90 degrees,flex to 30 degrees and point thumbs down
strength testing Drop arm- Positive if the patient is unable to keep arms elevated after the examiner releases
Empty Can- pain or weakness while provide resistance upward
Subscapularis- Test resisted internal rotation
Push off- adduct and internally rotate arm behind back and provide resistance
Rotator Cuff
Impingement

Neer- Stabilize scapula with thumb pointing down and passively flex the arm. Pain is a positive test
Hawkins- Stabilize the scapula, passively abduct the shoulder to 90 degrees, flex the shoulder to 30
degrees, flex the elbow to 90 degrees, and internally rotate the shoulder. Pain is a positive test.

Bicepital
Speed- Flex the shoulder to 90 degrees with the arm supinated. Provide downward resistance against
Tendonopathy shoulder flexion.
Yergasons- Flex elbow to 90 degrees, shake hands with patient and provide resistance against
supination.
Labral Tear

OBriens test-
Point the thumb down, flex shoulder to 90 degrees and adduct the arm across midline. Provide
resistance against further shoulder flexion and evaluate for pain. Repeat with thumb pointing up and
again evaluate for pain. If pain was present with the thumb down but relieved with the thumb up, it is
considered a positive test

Anterior
glenohumeral
stability

Apprehension and Relocation Test-

Apprehension Test
-With the patient supine, abduct shoulder to 90 degrees and externally rotate arm to place stress on
the glenohumeral joint. the patient may feels apprehensive that the arm may dislocate anteriorly
Relocation Test
-Using the examiners hand to place a posteriorly directed force on the glenohumeral joint. Relief of
apprehension for dislocation is a positive test.

Knee http://sitemaker.umich.edu/fm_musculoskeletal_knee/specific_knee_exam_manuevers

Patella Effusion

Patellar Ballottlement- Compress patella and release quickly, observe rapid rebound
(Compress suprapatellar pouch for increase effusion)

Patella Dislocation

Apprehension test- Force patella laterally by medial pressure

Cruciate ligament

Anterior Cruciate Ligament-

- Anterior Drawer- Flex knee 90 and pull tibia anteriorly
- Lachman- Flex knee 30 and pull tibia anteriorly
Posterior Cruciate Ligament-
- Posterior Drawer- Flex knee 90 and push tibia posteriorly
- Lachman- Flex knee 90 and pull tibia posteriorly
- Posterior Sag- Flex knee 90, sag of tibia means tear of PCL

Collateral ligament

Medial Collateral Ligament- Valgus force in 0 and 30 degrees

Lateral Collateral Ligament- Varus force in 0 and 30 degrees
Tenderness to palpate = First degree, Laxity at 30 = Second degree, Laxity at 0 = Third degree

Meniscal injury/tears Apley's Grind -

- prone position with the knee flexed to 90 degrees
- then axial force with tibia rotate medially and laterally
McMurrays-
Medial meniscus- (Valgus stress)
- Hand on medial jointline, apply axial force and extending and externally rotating the knee
Lateral meniscus- (Varus stress)
- Hand on lateral jointline, apply axial force and extending and internally rotating the knee