…prophylaxis. Deep puncture wounds , where the base cannot be inspected or irrigated clean. Wounds with retained foreign material or devitalised tissue that cannot be removed…

…in: the choice of site, the use of ultrasound throughout the puncture, and maintaining maximal barrier precautions without shortcuts. The most common serious error is…

…where the pads would go. Transvenous pacing: the relative contraindications are the same as for a central venous catheter — coagulopathy, infection at the puncture site…

…the roots of the cauda equina. If in doubt: choose a level lower, never higher. 3. Mark the puncture site, clean in wide circles and…

…close to the upper border of the rib, never at the lower border where the neurovascular bundle lies, and the drainage is stopped for coughing…

…that clots before the smears are made is unusable, no matter how well the puncture went. Indications Unexplained cytopenia in one or more cell lines…

…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…

…straightforward: ultrasound to find the fluid, an insertion site in the left lower quadrant lateral to the rectus sheath, and a cell count plus albumin…

…analysers — check locally. Contraindications Peripheral venous cannula: Infection, burns or trauma at the puncture site. An arm with an arteriovenous fistula, previous axillary clearance or…

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

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

…where one exists, but a neutropenic patient who is clinically unwell must be managed as an emergency even at a lower temperature. Suspect neutropenia in…

Procedurer The value of the exercise test lies not in ST depression alone but in the overall picture : exercise capacity, symptoms, blood pressure response, heart…

…moment of sampling, but does not by itself identify the cause. The result must always be weighed together with the clinical picture, medication, fluid balance…

…heterogeneous area whose contents move under pressure; cellulitis instead gives a diffuse oedematous picture without a demarcated fluid collection. Ultrasound also shows the depth of…

…and several syndromes can overlap [1,4]. Time after a clear reduction or the last intake Common clinical picture : : 4 to 12 hours Tremor, sweating…

…and a postictal state. 3. Check a repeat plasma sodium if the result is unexpected or does not fit the clinical picture. 4. Where possible…

…do it. Otherwise the echocardiographic findings plus the clinical picture are sufficient for a treatment decision. Systemic thrombolysis is the first line treatment in high…

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

…non inferior to alteplase with respect to an excellent functional outcome, without an increased risk of symptomatic intracerebral haemorrhage or death [3]. Acute overview 1…

…Isolated urticaria, localised angio oedema or itching without compromise of the airway, breathing or circulation is usually an allergic reaction but not in itself anaphylaxis…

…and level of consciousness immediately. 2. Check oxygen saturation and capillary glucose. 3. Exclude immediately treatable threats without delay: hypoxia, hypoglycaemia, circulatory failure, sepsis, stroke…

…high osmolality Blood ketones are preferable to urine ketones. The principal ketone body in DKA is beta hydroxybutyrate, whereas ordinary urine dipsticks mainly measure acetoacetate…

…start cardiac monitoring at a plasma potassium above 6.0 mmol/L, and at lower values if the rise is rapid, the patient has symptoms…

…for example after relatives have given carbohydrate or glucagon. In a person without diabetes, a hypoglycaemic disorder is defined primarily by Whipple's triad : 1…

…it as an open fracture. The anatomy of the nail apparatus The terminology is hard to follow without a picture, and several of the steps…

…When present, the clinical picture may include: Symptoms attributable to chronic LV systolic dysfunction and HF Angina, although its absence does not exclude ischemic cardiomyopathy…

…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…