The ECG provides some information about the site and extent of myocardial damage in acute myocardial infarction, particularly in STEMI. The ECG changes that may occur in NSTEMI are less-clearly related to the site of myocardial damage than the changes in STEMI.

• A septal infarct shows changes in the V1 - V2 leads, and typically involves the left anterior descending artery.
• An anterior infarct shows changes in the V3 - V4leads, and typically involves the left anterior descending artery.
• A lateral infarct shows changes in leads V5 - V6, I, aVL, and typically involves the left circumflex artery or diagonal branch of the left anterior descending artery.
• An anteroseptal infarct shows changes in the V1 -V4 leads and typically involves the left anterior descending artery.
• An anterolateral infarct shows changes in leads I,aVL, V3 - V6 (and reciprocal changes in leads II, III,aVF) and typically involves the left anterior descending or the left circumflex artery.
• An inferior infarct shows changes in leads II, III, aVF(and reciprocal changes in leads I, aVL) and typically involves the right coronary artery.
• A posterior infarct shows reciprocal changes inleads V1 - V3 and requires placement of posterior leads (V7 - V9) to identify ST-elevation - it typically involves the right coronary artery or the left circumflex artery.

• This is the most important drug for treatment of anaphylaxis and works best when given as early as possible after the onset of the reaction:
  - As an alpha-receptor agonist, it reverses peripheral vasodilation and reduces oedema. As a beta-receptor agonist it dilates bronchial airways, increases the force of myocardial contraction, and suppresses histamine and leukotriene release.
• The intramuscular route is best for most individuals; the best site for IM injection is the anterolateral aspect of the middle third of the thigh.
• For adults, the initial dose is 0.5 mg =500 micrograms = 0.5 mL of 1:1000adrenaline. After the initial dose of adrenaline, further doses can be given at about 5 min intervals according to the patient's response.
  If features of anaphylaxis persist despite 2 doses of IM adrenaline, the refractory anaphylaxis algorithm should be followed, and an adrenaline infusion started with expert support.
• Nebulised adrenaline may be effective as an adjunct to treat upper airway obstruction caused by laryngeal oedema, but only after treatment with IM (or IV) adrenaline and not as an alternative. Recommended doses are5 mL of 1 mg ML (1:1000) adrenaline.
• Adrenaline remains the first line vasopressor for treatment of anaphylaxis. Consider other vasopressors and inotropes (e.g. noradrenaline, vasopressin ,metaraminol and glucagon) when initial resuscitation with adrenaline and fluids has not been successful. Only use these drugs in specialist settings where there is experience in their use.

• Anticholinergic agents are the treatment of choice because they block cholinergic receptors and are thought to balance the cholinergic and dopaminergic activity: intravenous (IV) or intramuscular (IM) procyclidine 5-10mg or benztropine 1-2mg(IV/IM) are the drugs of choice.
• If symptoms are due to an acute dystonic reaction, there should be an improvement within 5minutes of IV administration and 20 minutes if given IM.
• Patients would be expected to be symptom-free by 30 minutes. A second dose can be given if there has been no response after 10 minutes following IV administration (30 minutes for IM). However, if there continues to be no improvement, an alternative diagnosis and cause should be sought.

• Acute dystonia is essentially a clinical diagnosis based on a careful history and characteristic clinical presentation.
• Anticholinergic agents are the treatment of choice because they block cholinergic receptors and are thought to balance the cholinergic and dopaminergic activity: intravenous (IV)or intramuscular (IM) procyclidine 5-10mg or benztropine 1-2mg (IV/IM) are the drugs of choice. If symptoms are due to an acute dystonic reaction, there should be an improvement within 5minutes of IV administration and 20minutes if given IM.
• Patients would be expected to be symptom-free by 30minutes. A second dose can be given if there has been no response after 10minutesfollowingIVadministration(30minutes following IV administration (30minutes for IM). However, if there continues to be no improvement, an alternative diagnosis and cause should be sought.
• Benzodiazepines are GABA agonists; they inhibit and antagonise excitatory dopaminergic neurons. They can be helpful in refractory cases of dystonia(e.g. diazepam 2.5-10mg IV).
  Prophylaxis is required for 48 to 72hours to prevent recurrence of symptoms: oral procyclidine 5mg TDS is appropriate.
• In practice, patients are usually given prophylaxis for up to a week. Patients should receive advice about the potential for recurrence of dystonia if prophylaxis is not adhered to.

• For patients with adverse features : - Use synchronised cardioversion, Under conscious sedation or general anaesthesia
  - Ensure defibrillator is set to deliver a synchronised shock (to coincide with the R wave)
  - Start with 120 – 150 J for broad-complex tachycardia
  - Start with 70 – 120 J for narrow-complex tachycardia or atrial flutter For atrial fibrillation (AF) start at maximal defibrillator output
  - For AF and atrial flutter use anteroposterior defibrillator pad positions where practicable
  - Increase shock energy in increments if initial attempt fails and perform up to three attempts
  - If cardioversion fails to terminate the arrhythmia, and adverse features persist, give amiodarone300 mg IV over 10 – 20 mins and attempt further cardioversion. The loading dose of amiodarone can be followed by an infusion of 900 mg over 24 h, given via a large vein.

- Suspect trigeminal neuralgia if the person has pain in the distribution of the trigeminal nerve (usually in the cheek or lower jaw) that is:

• Severe — often described as electric shock-like, sharp, or shooting.

• Unilateral — trigeminal neuralgia is bilateral in only 3%of people.

• Short-lived — lasting a few seconds to minutes and stopping suddenly.

• Recurrent — the person may experience many attacks a day, with a refractory period between each attacks a day, with a refractory period between each attack.

• Episodic — the pain may go into remission for weeks or months before returning.
  Provoked by factors such as light touch to the face ,eating, talking, or exposure to cold air.

This fracture affects the radius within 2.5cm of the wrist, such that the distal fragment is angulated to point dorsally. It usually results from a fall onto an outstretched hand. Osteoporosis contributes to an
increased frequency in post- menopausal women.

Colles’ fractures produce characteristic clinical deformity (sometimes likened to a ‘dinner fork’). Check for scaphoid tenderness, distal sensation, and pulses in all cases.

X-ray appearances include one of more of the following:

• Posterior and radial displacement (translation) of the distal fragment
•  Angulation of the distal fragment to point dorsally (the articular surface of the distal radius normally has a 5° forward tilt on the lateral wrist X- ray)
• Angulation of the distal fragment to point more radially (the articular surface of the distal radius is normally tilted 22° towards the ulnar side on an AP wrist X- ray)
• Impaction, leading to shortening of the radius in relation to the ulnar

• Ventricular fibrillation and pulseless ventricular tachycardia are less common in children but may be seen in sudden collapse, in hypothermia, in poisoning from tricyclic antidepressants and in those with cardiac disease.
• If ventricular fibrillation or ventricular tachycardia is identified, an asynchronous shock of 4J/kg should be given immediately and CPR immediately resumed without reassessing the rhythm or checking for a pulse.
• Appropriately sized adhesive defibrillation pads should be used. Recommended sizes are 4.5 cm for children <10 kg and 8-12 cm for children > 10 kg. One pad is placed over the apex in the mid-axillary line, whilst the other is put immediately below the clavicle just to the right of the sternum.
• If an automated external defibrillator (AED) is being used, a standard adult shock should be given in children over 8 years, and attenuated paediatric paddles should be used with the AED in children under 8 years old.
• For the infant less than 1 year, a manual defibrillator that can be adjusted to give the correct shock is recommended.

- Diagnosis of Guillain-Barre Syndrome is made by pattern recognition.

• The classic presentation is a progressive symmetrical muscle weakness affecting lower extremities before upper extremities, and proximal muscles before distal muscles, accompanied by paraesthesias in the feet and hands. The paralysis is typically flaccid with areflexia and progresses acutely over days, with 73% reaching a lowest point within 1 week and 98% by 4 weeks.

• About 89% of patients experience pain, which typically begins in the back and legs. It occurs at onset and during disease course.
• Facial, oropharyngeal, and extraocular weakness may also occur. These cranial nerve deficits often occur after trunk and limb involvement but precede them in 15% of cases.
• Mild dysautonomia occurs in 70% and causes sinus tachycardia, labile blood pressure, postural hypotension, urinary retention, ileus, and very rarely life-threatening cardiac arrhythmia.
• Up to 30% of patients will develop respiratory muscle weakness requiring mechanical ventilation.
  The progressive phase is followed by a plateau phase ofpersistent, unchanging symptoms lasting a variableduration before recovery begins.

• First-degree AV block:
  -Prolongation of PR interval (>0.2s)
• Second-degree AV block Mobitz type I :
  -Progressive prolongation of PR interval after each successive P wave with eventual dropped
  ventricular conduction
• Second-degree AV block Mobitz type I :
  - Constant (often prolonged) PR interval with random intermittent dropping of ventricular conduction
• Second-degree AV block Mobitz type II :
  - Alternate P waves not conducted to ventricles; alternate P waves not followed by QRS complex
• Second-degree AV block (2:1 type) block :
  - Complete dissociation between atria and ventricles; no relationship between P waves and QRS complex

- Unconscious

• If the choking child is, or becomes, unconscious place him on a firm, flat surface. Call out, or send, for help if it is still not available; do not leave the child at this stage.

- Open airway

• Open the mouth and look for any obvious object. If one is seen, make an attempt to remove it with asingle finger sweep. Do not attempt blind or repeatedfinger sweeps – these can push the object moredeeply into the pharynx and cause injury.

- Rescue breaths

• Open the airway and attempt 5 rescue breaths. Assess the effectiveness of each breath: if a breath does not make the chest rise, reposition the head before making the next attempt.

-Chest compression and CPR

• Attempt 5 rescue breaths and if there is no response, proceed immediately to chest compression regardless of whether the breaths are successful.
  Follow the sequence for single rescuer CPR for approximately 1 min before summoning help (if this has not already been done by someone else).
• When the airway is opened for attempted delivery of rescue breaths, look to see if the foreign body can be seen in the mouth. If an object is seen, attempt to remove it with a single finger sweep.
• If it appears that the obstruction has been relieved, open and check the airway as above. Deliver rescue breaths if the child is not breathing and then assess for signs of life. If there are none, commence chest compressions and perform CPR.
• If the child regains consciousness and is breathing effectively, place him in a safe side-lying (recovery)position and monitor breathing and conscious level whilst awaiting the arrival of the help.