Difficult meningitis scenarios were reviewed. The best resource to read is Harrisons textbook of internal medicine.
Acute meningitis presentations - bacterial, viral and encephalitis vs
subacute presentations of bacterial brain abscess
Viral meningitis does not cause somnolence / drowsiness
Bacterial meningitis progresses to confusion
Encephalitis often presents with bizarre behaviour
Meningism, kernigs and neck stiffness are late signs and only present in <20% of adults and fewer children. mortality once meningism is present is 20-30% -- so don't use this to rule out meningitis!!!
Best resource for difficult types of meningitis eg TB, cryptococcal, syphillis is Nelsons textbook of paediarics or UTD.
see tables attached below
This is a massive topic in the EM syllabus. Detailed discussions were completed on :
Stroke syndromes - aca amca pca etc, lateral medullary syndrome - anatomy, ct findings, mri and correlation with clinical features
A good resource for this is Harrisons
Acute thrombolysis guidelines and current literature =such as acem policy on acute stroke, - detailed knowledge of the stroke protocol is needed - suggested reading includes UpToDate or stroke review articles
knowledge of HIHSS scoring and modified ranking evaluation is important
Medical management and hypertensive management in stroke situations.
A review of the topic of headache was completed in the webinar focussing on:
Classification - Primary (migraine, cluster etc) vs Secondary headache (infection, ich, mass, trauma, etc)
Key dangerous causes to exclude eg sah, ich, mass, infection, trauma, face, ear, throat, Giant cell arteritis, teeth, sinus.
International headache classification and definitions
evidence based pharmacology for migraine management incl details of which drugs in which types of patients - detail from UTD required.
This webinar introduced the topic of neurology and started with an exam favourite - seizures.
The approach to seizure classification - organic (trauma, infection, metabolic, toxin, ins lesion) vs idiopathic epilepsy (and its types eg generalised, myoclonic etc) and definitions around provoked and unprovoked seizures.
A consultant approach to managing:
Airway and critical threats
diagnosing the cause of the seizure
done in a seemless and simultaneous fashion.
A detailed approach to RSI and ongoing sedation in the SE patient
An appreciation of the important pivotal clinical features to look for followed by investigation approach.
The topics of first seizure approach vs second seizure is important.
A detailed review of status epileptics and drug knowledge is important and should be reviewed in Up To Date.
The table in Rosens on special seizure situations eg hyponatraemia / eclampsia and departures from standard therapy.
This was a jam-packed session on surgical conditions common to the exam (and the floor!!)
We reviewed a good approach to abdominal plain film and CT abdomen referencing Rabi et al and CT radiology teaching atlas.
useful for obstruction, perforation, volvulus patterns, toxic megacolon
1.assess general gas pattern - caecum, tvs, descending, air in rectum, small bowel pattern in middle.
2.free air pattern? RUQ air? gas around organs? air on both sides of bowel wall ? ligament teres or falciform lig signs?
3. obstruction patterns- fluid levels, large bowel or small dilated , ileocecal valve competent? cecal or sigmoid volvulus
CT / CTA
abd wall - free air beneath
liver and liver kidney area (hepatorenal space)
spleen and kidney (splenorenal space)
gallbladder - thickening
cecum - tvs - descending - sigmoid colon - rectum - in axial profile
bowel wall thickening - infection, inflammatory, ischemia, cancer, ibs
gas in gallbladder
gas in portsplenic circ
pneumatosis intestinalis (air in bowel wall)
sma ischemia on cta
bush on trauma cta - bleeding
Using the above summary tool for assessment we reviewed films ct and uss on the following topics.
The 'analysis' part of the question was the image analysis and the knowledge component was review of causes, classification, symptoms etc using the guide above
we did a rapid 1 min of sections using
risk factors, 5 points on clinical review, severity assessmnt, complications
checking for all of these on the scan
Gallstones - colic vs acute cholecystitis vs cholangitis
Tokyo guidelines 2013
Pancreatitis - focussed on severity scoring for prognosis and disposition
- BISAP vs ransons vs CT severity index vs apache vs sirs score
BISAP = renal f + SIRS + age + effusion
BUN > 25 mg/dL (8.9 mmol/L)
Abnormal mental status with a Glasgow coma score < 15
Evidence of SIRS
> 60 years old
Bowel wall thickening DD:
infection - clostridium, shigella, campylobacter, e coli (has related toxin producing), yersinia
inflammatory - UC / chrohns / vasculitis / sle
neoplasm - primary adenocarcinoma / mets / sec to nodes form lymphoma
ibs - low on the list
Click here Today we covered some key areas in surgery for the acem exam.
The 4 key patterns of presentation include
embolic - AF or ventricular aneurysm related - 50% of all MI
low flow states
each of these have a specific risk factor profile which are distinct
recognising aetiology, sensitive or specific findings on clinical assessment, and diagnosis on CTA is important, as well as severity grading or assessment of complications such as infarction and organ failure is key.
Management options of
laparotomy for bowel resection or
vs angiography for clot retrieval or local papaverine is considered
diagnostic criteria - 2 of 3 - lipase Elevation, clinical features, imaging findings
classification -oedematous vs necrotic
severity assessment - based on organ failure
prognostic scores : be ale to compare and contrast
- BISAP - renal function, effusion, gcs, sirs, 60 yo
ransons, apache, sirs,
have some knowledge of imaging of the pancreas
Toxic megacolon was covered in detail, reviewing the 2 common presentations from IBD or clostridium difficile. Imaging diagnosis of tvs colon > 6 cm and
diagnostic criteria including systemic illness and anaemia, wcc elevation, sirs
the treatment options varied with underlying cause
associations of metabolic alkalosis, hypokalaemia, dysmotility agents
Clostridial infecting and predictors or risk factors for clostridial such as antibiotic use, COPD, hospital admission were discussed in detail.
Lastly we covered MCQ golden rules:
read the question
assess if you have the knowledge in an area, or not
your gut feeling is only good if you have reviewed the area concerned
always study the topic highlighted in the mcq
know why an option is correct and why incorrect
good resources for MCQ:
de Alwis Emergency medicine mcq
Dunn mcq's / Tintinalli mcq's