…or a damaged nail fold edge Nail avulsion and inspection of the nail bed, with suture of any nail bed laceration Contraindications There are no…

…oxygen, and the ability to lay the patient down. Injection Needle Angle Maximum volume per site : : : : Deltoid, adult 23–25 G, 25 mm 90° 1…

…transmitted infection — although chlamydia and gonorrhoea can be tested on urine or a self taken vaginal sample without a speculum. Routine gynaecological examination of asymptomatic…

…never happens, and to make sure the catheter does not become the patient's next focus of infection. Indications Infusion of vesicant solutions: vasopressors, concentrated…

…edges are held apart. A wound through the full thickness of the dermis, particularly over joints and in cosmetically sensitive areas. Superficial wounds with well…

…the day of the test can therefore be given dexamethasone. That is the practical key: the patient does not have to be left unprotected for…

…range of about 15–40 Hz , and adjust the gain so that the atrial deflections are clear without clipping. 4. Estimate the depth of insertion…

…of thyroid disease; repeat it once the patient has recovered. Pitfalls Haemolysis raises the potassium, LDH and AST and lowers the haptoglobin. A tourniquet left…

…PH) is a heterogeneous pathophysiological disorder characterized primarily by elevation of pulmonary arterial pressure. It may arise from pulmonary vascular disease, left sided cardiac disease…

…left side so that the fluid collects in the left flank. Have the patient empty the bladder first. Procedure Choice of insertion site The left…

…Injection of contrast media into the ventricle will instead reveal that the apical portion of the left ventricle is dilated (hence the term apical ballooning…

…tree after selective intracoronary contrast injection under fluoroscopy. The procedure is performed by advancing guidewires and diagnostic catheters from a percutaneous arterial access site to…

…preferably anteroposteriorly : one anteriorly over the praecordium to the left of the sternum, the other on the back between the left scapula and the spine…

…emergency. Infection can progress rapidly, while the typical local signs of inflammation may be faint or absent. Take cultures immediately, but never let sampling, imaging…

…question): A fracture of the bone to be punctured, or a major injury proximal to the puncture site. A joint prosthesis or orthopaedic metalwork in…

…or soft tissues over the puncture site — use another approach or refrain. Bacteraemia without suspicion of joint infection (relative; aspiration can seed a sterile joint)…

…chloride available. Infection in the area to be biopsied. Hypersensitivity to local anaesthetics. Areas at high risk of unsightly or hypertrophic scars: the sternum, the…

…out a possible donor on your own on grounds of age or medical history — contact the transplant coordinator and let the assessment be made there…

…the rest. Support your working hand against the patient's zygoma or the bridge of the nose. 4. Approach tangentially from the periphery , never through…

…scalpel until pus appears. Take a culture from the wall of the cavity before irrigating. 5. Let the pus drain out. Empty it with gentle…

Echocardiography The echocardiographic examination The use of echocardiography has increased dramatically during the past few decades. Advances in echocardiography have been propelled by breakthroughs in…

…should include: palpation of peripheral pulses; auscultation for carotid, femoral, and abdominal bruits; bilateral brachial blood pressure measurement; cardiac auscultation; inspection of the legs and…

…not an alternative to it. See the separate guide to joint aspiration and injection. Indications Condition Injection site Comment : : : Subacromial bursitis, rotator cuff syndrome The…

…in particular that exceeds the patient's normal variation and requires a change of treatment. Common precipitants are viral infection, bacterial infection and air pollution…

…in some individuals the infection may be severe and deadly. Importantly, COVID 19 has caused an unprecedented number of severe and deadly infections among young…

…condition and should be managed urgently. The risk of cardiogenic shock is high and pharmacological interventions are often futile. A transcutaneous pacemaker is often necessary…

Procedurer The insertion itself is rarely the difficult part — it is the confirmation of the position that determines whether the tube is safe. A misplaced…

…foreign materials pose a high risk of infection. Approximately 20% of all endocarditis affect people with valve prostheses and among other cases 18% show significant…

…and respiratory acidosis, or a markedly increased work of breathing with impending exhaustion. Threatened airway obstruction: inhalation injury, anaphylaxis, deep neck infection, an expanding haematoma…

…local practice Relative Skin infection, herpes zoster or burns over the puncture site Relative Mechanical ventilation with a high PEEP (an increased risk of pneumothorax…

…Time to onset of action 1 to 2 minutes Duration of action 10 to 30 minutes Delivery IV Dose Bolus injection : 5 to 15 mg…

…Etiologies of tension pneumothorax include: Traumatic injuries (blunt force, lacerations, gunshot wounds) Asthmatic episodes Iatrogenic events (e.g., during central venous catheter insertion) Underlying lung…

…Relative — avoid forced manoeuvres An ongoing respiratory infection with a risk of transmission Until symptom free Haemoptysis of unclear cause Until investigated Relative obstacles also…

…Alternative route : Central venous administration of adenosine is suitable in the intensive care unit or coronary care unit. Adenosine injection must be administered quickly (1…

…primary infection, low risk of recurrence vancomycin 125 mg × 4 PO 10 days Clostridioides difficile, high risk of recurrence fidaxomicin 200 mg × 2 PO 10…

…of seizures, delirium tremens, infection, trauma and metabolic disturbance. 4. Monitoring at the appropriate level of care , with readiness for respiratory support. 5. Treatment of…

…level of consciousness, the pupils, tone, clonus and seizures. Give glucose in hypoglycaemia and a benzodiazepine for toxicological seizures E Temperature, skin, smell, injection marks…

…Use of cannabis, electronic cigarettes or other inhaled products. Readiness to attempt cessation. Depression, schizophrenia, schizoaffective disorder, HIV infection or other circumstances that may affect…

…spread of infection A small or uncooperative child Movement causes injury Preparation and equipment Otoscopy: an otoscope with a charged battery and clean disposable specula…

…What usually ruins the examination is not the technique but the handling of the specimen — an aspirate that clots before the smears are made is…

…of the medulla result in the blood pressure lowering effect. Effects Potent blood pressure lowering effect. Pain relief. Delivery IV, IM, PO, transdermal Dose Injection…

…larger , since a mask that is too small leaks and gives a poorer seal. Procedure Insertion of the laryngeal mask 1. Check the mask, remove…

…the threshold, but the threshold varies between regions. Infection of the skin over the puncture site. Marked haemodynamic instability — stabilise the patient first. CT before…

…Palpate the pulses and measure the ankle brachial index with Doppler. 4. Culture only in the presence of clinical signs of infection — all chronic wounds…

…done without losing time. 7. Perform urgent CT of the brain and CT angiography from the aortic arch to the vertex. 8. Contact the thrombectomy…

…a small amount of lidocaine without adrenaline (epinephrine). 3. Puncture 1–2 cm proximal to the wrist crease at an angle of 30–45 degrees…

…proton pump inhibitor with concomitant NSAID use or a history of ulcer, not routinely Infection Consider Pneumocystis prophylaxis with high doses over a long period…

…slowly. Rapid injection increases the risk of nicotinic effects with paradoxically increasing weakness. 6. Assess the chosen finding continuously during the window of effect, 40…

…undiluted syringe of 10 mg/mL makes small adjustments impossible. Procedure Intravenous titration in acute severe pain Practical points during titration: Give the injection slowly…

…caused by a dysregulated host response to infection. Clinically this usually corresponds to an acute increase in the SOFA score of at least 2 points…

…clinical site of action—the coronary artery perfusing the AV node—before the drug is eliminated. A flush should immediately follow the bolus injection to…

…In patients undergoing percutaneous coronary intervention, even mild baseline renal dysfunction is associated with worse outcomes. The risk of death at 1 year is increased…

…ancestry Previous muscle disease or a personal or family history of muscle disorders Acute infection Renal or hepatic impairment Hypothyroidism Vitamin D deficiency Concomitant interacting…

…a high risk of hypoglycaemia 8–12 mmol/L The critically ill patient in intensive care According to the local protocol Avoid tight targets in…

…The Wells criteria for pulmonary embolism: Criterion Points : : Clinical signs of deep vein thrombosis 3 Pulmonary embolism is the most likely diagnosis 3 Heart rate…

…value of these techniques rests on their ability to characterize the anatomy responsible for a stenosis, define plaque morphology, identify occult lesions, and optimize percutaneous…

…eGFR of 30 40 mL/min for lower urinary tract infection. At an eGFR <30 mL/min the antibacterial effect is lost. Dosed independently of…