The FCEM Notebook

Revision notes and clinical resource for emergency physicians

Joanna Rowlinson

• Publisher: CRC Press
• Year: 2015
• ISBN:
  9780429586545
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

The FCEM Notebook: Revision Notes and Clinical Resource for Emergency Physicians is the essential guide to passing the Fellowship of the College of Emergency Medicine (FCEM) examination. The book contains short questions related to the FCEM curriculum along with succinct answers to allow candidates to test their knowledge. Also included are current

MUSCULOSKELETAL AND INJURY

What are the clinical findings in necrotizing fasciitis?

NECROTIZING FASCIITIS

Rapidly spreading infection of the fascia with necrosis.

Clinical features

Significant disproportionate/unexplained pain

Pain beyond margins of erythema

Swelling

Crepitus

Erythema, later purple/dusky skin discolouration

Lethargy

Pyrexia, hypotension, tachycardia

Bullae, later become haemorrhagic

Minor skin changes initially with later rapidly spreading skin changes

Offensive discharge

Skin necrosis

Anaesthesia of affected area

Lack of bleeding from deep tissues

Risk factors/associations

Diabetes	Chronic renal failure
Alcohol excess	Malignancy
Sea swimming	Chronic liver disease
Immunocompromised	IV drug misuse
Insect bites/stings	Minor skin trauma
Post op surgical wounds/invasive procedure/minor procedures

Investigation

Initially a clinical diagnosis, with surgical exploration required to confirm.

Blood cultures, blood gas, clotting screen, U&E, albumin, LFT, CRP, ESR, CK, calcium, wound swabs, cross-match blood

XR and CT may show air in soft tissues and demonstrate extent

Management

Fluid resuscitation

Antibiotics, liaise with microbiology, e.g. benzylpenicillin, clindamycin and metronidazole

Analgesia

Aggressive, prompt extensive surgical debridement

Admit to intensive care unit

Organisms

There are often mixed anaerobic and aerobic bacteria. Organisms include:

Group A streptococcus	Staphylococcus aureus
Streptococci	Clostridium perfringens
Coliforms	Proteus
Pseudomonas	Klebsiella

NOTES:

The initial skin wound can be minimal with limited skin findings and the patient appearing well, followed by a rapid deterioration and high mortality rate. Commonly misdiagnosed initially as cellulitis.

Describe the features of Kanavel sign and the significance of this sign
Give the causes of a radial nerve palsy

KANAVEL SIGN

Four components

Finger is held in slight flexion

Fusiform swelling of the finger (‘sausage-shaped finger’)

Tenderness along the course of the flexor tendon sheath

Pain on passive extension of the finger

Clinical features are found in infection of a flexor tendon sheath in the hand.

Infection usually occurs following a bite or a puncture wound. Early recognition is essential to prevent tendon scarring and loss of function. Patients require IV antibiotics, analgesia and referral for urgent incision and drainage of the flexor tendon sheath.

CAUSES OF RADIAL NERVE PALSY

Compression in axilla ‘crutch palsy’

Compression of upper medial humerus – ‘Saturday night palsy’

Humeral fracture

Elbow dislocation

Compression at wrist from tight handcuffs or watch strap

Upper arm injections in infants

What are the features of a tetanus-prone wound?
What is the UK tetanus immunization schedule?
Describe the clinical findings in tetanus

TETANUS

Tetanus-prone wounds

Wounds or burns that require surgical intervention that is delayed for more than six hours

Wounds or burns that show a significant degree of devitalized tissue or a puncture-type injury, particularly where there has been contact with soil or manure

Wounds containing foreign bodies

Compound fractures

Wounds or burns in patients who have systemic sepsis

Higher risk

Injecting drug users (tetanus-contaminated illicit drugs, especially through pre-existing skin abscesses)

Heavy contamination with material likely to contain tetanus spores (manure, soil)

Extensive devitalized tissue

UK TETANUS IMMUNIZATION PROGRAMME

Immunization given at two months, three months, four months, four years, 14 years.

CLINICAL FINDINGS IN TETANUS

Hypertonia

Painful muscular contractions, especially face (risus sardonicus), jaw (lock-jaw), back (opisthotonus), neck

Generalized mu...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Preface
• Abbreviations
• CARDIOLOGY
• DERMATOLOGY
• ENDOCRINOLOGY
• ENVIRONMENTAL MEDICINE
• GASTROENTEROLOGY
• HAEMATOLOGY
• INFECTIOUS DISEASES
• MEDICOLEGAL
• MUSCULOSKELETAL AND INJURY
• NEUROLOGY
• OBSTETRICS AND GYNAECOLOGY
• OPHTHALMOLOGY
• PSYCHIATRY
• RESPIRATORY
• SAFEGUARDING
• SPINAL
• TOXICOLOGY