…because of the cosmesis, often with antibiotic prophylaxis. Deep puncture wounds , where the base cannot be inspected or irrigated clean. Wounds with retained foreign material…

…is decided before the needle goes in: the choice of site, the use of ultrasound throughout the puncture, and maintaining maximal barrier precautions without shortcuts…

…complete heart block without current symptoms, alternating bundle branch block in acute anterior infarction, and before drugs or procedures with a known risk of bradycardia…

…bacterial CNS infections states that CT must not be performed before lumbar puncture in suspected bacterial meningitis — not even with a reduced level of consciousness…

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

…the puncture went. Indications Unexplained cytopenia in one or more cell lines. Suspected acute leukaemia, myelodysplastic syndrome or myeloproliferative neoplasm. Work up and staging of…

…disease. Contraindications Infection of the skin or soft tissues over the puncture site — use another approach or refrain. Bacteraemia without suspicion of joint infection (relative…

…choose a new site if in doubt Cellulitis over the insertion site Change the puncture site Preparation and equipment Ultrasound with a curved array probe…

…the puncture site. An arm with an arteriovenous fistula, previous axillary clearance or lymphoedema. A limb with paresis or marked swelling. A vein suspected of…

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

…The indication rests on the clinical picture together with echocardiographic signs of tamponade — not on how wide the rim of fluid looks. With ultrasound guidance…

…signs of inflammation may be faint or absent. Take cultures immediately, but never let sampling, imaging, the blood count or contact with the patient's…

…the overall picture : exercise capacity, symptoms, blood pressure response, heart rate response, arrhythmias and recovery. A patient who stops at a low workload with a…

…with the clinical picture, medication, fluid balance, renal function, electrolytes and supplemental oxygen [1]. Distinguish between: Acidaemia and alkalaemia , which describe the current pH of…

… cellulitis instead gives a diffuse oedematous picture without a demarcated fluid collection. Ultrasound also shows the depth of the cavity and its distance to vessels…

…often visual, auditory or tactile hallucinations with a relatively clear level of consciousness and preserved orientation 12 to 48 hours Withdrawal seizures, usually generalised tonic…

…the ratio between the body's exchangeable sodium and potassium and the total body water. In hypotonic hyponatraemia the amount of water is too great…

…care Intermediate–high Stable Yes Raised Admission with monitoring. Be prepared for rescue thrombolysis Intermediate–low Stable One of the two positive Admission Low Stable…

…The picture on the right shows color Doppler located across the mitral valve and the left atrium. The main advantage of color Doppler is that…

…analysis of three phase 3 trials, tenecteplase was non inferior to alteplase with respect to an excellent functional outcome, without an increased risk of symptomatic…

…adrenaline never replace intramuscular adrenaline [1,2]. Delayed administration of adrenaline is associated with more severe and more protracted reactions, biphasic courses and fatal outcome…

…1. Assess vital signs and level of consciousness immediately. 2. Check oxygen saturation and capillary glucose. 3. Exclude immediately treatable threats without delay: hypoxia, hypoglycaemia…

…occur Mixed picture of DKA and HHS Overlap is common. Treat as mixed DKA and HHS if the patient has marked hyperosmolality together with significant…

…The grading must not be used mechanically. A patient with a plasma potassium of 6.2 mmol/L, new bradycardia and acute kidney injury may…

…by Whipple's triad : 1. Symptoms or signs consistent with hypoglycaemia. 2. A documented low plasma glucose during the symptoms. 3. Resolution of the symptoms…

…with a subungual haematoma — manage it as an open fracture. The anatomy of the nail apparatus The terminology is hard to follow without a picture…

…produce post ischemic stunning. In the absence of infarction, contractile recovery can occur rapidly after reperfusion, with recovery generally occurring within one week. By contrast…

…permitted when assessing dietary electrolyte intake, because it can increase blood pressure and may affect interpretation of the clinical picture. A 24 hour urine collection…