A+E Flashcards
what biochemical test would you want to know the result of in the 1st few minutes after the arrival in A +E of any unconscious or semi-conscious patient?
BM
[DKA or hypo]
treatable, + life-threatening/ brain damage
Pt found unconscious in stairwell of a block of flats. Airway patent, RR 12, sats 100% on O2, pulse 92, BP 120/90, slight response to pain, pupils equal + reacting. What further examination points are relavant?
GCS
exposure - needlesticks/ injuries
examine head for injury
neuro exam
Pt found unconscious in stairwell of a block of flats. Airway patent, RR 12, sats 100% on O2, pulse 92, BP 120/90, slight response to pain, pupils equal + reacting. What other basic observation is important and why?
temp
hypothermia [found outside]
or pyrexia - sepsis - LOC from reduced organ perfusion
WHY DONT you use GCS in stroke
may not be able to speak/slurred, arm weakness etc.
Patient is opening eyes to painful stimuli only, pulling his arm away when painful stimuli is applied to his hand and making a groaning noise. What’s his GCS?
2 + 4 + 2 = 8/15
GCS
motor /6
- normal
- localizes
- withdraws
- flex
- extends
- none
eyes/4
- open spont
- opens to voice
- open to pain
- none
voice/5
- normal
- confused
- words
- incomprehensible sounds
- none
methods for applying painful stimuli to assess GCS
supraorbital pressure
jaw thrust
nail bed pressure
list possible pathological/clinical categories for the causes of a patient’s decreased level of conciousness + a few examples for each
- cardiac [hypovol, arrhythmia, MI]
- neuro [meningitis, epilepsy, stroke, head injury]
- sepsis
- metabolic: [hypo/DKA, hypo/pernatraemia, hypercalc, myxoedema, uraemia]
- other: overdose, CO, ^CO2, alcohol, NEA
Pt found unconscious in stairwell of a block of flats. Airway patent, RR 12, sats 100% on O2, pulse 92, BP 120/90, slight response to pain, pupils equal + reacting.
5 most important investigations:
BM CT head ABG/VBG ECG urine drugs screen FBC U+E CRP LP
Pt found unconscious in stairwell of a block of flats. His resps have now become shalower and RR = 8. He has pinpoint pupils. Diagnosis? + differential for pinpoint pupils
heroin overdose [/opoids/antipsychotics/ mirtaz]
pons haemorrhage
how do you manage heroin overdose?
ABCDE
naloxone
examination findings that might alert you to the posibility of heroin overdose
shallow slow resps
pinpoint pupils
myoclonic jerks
track marks
what GCS needs intubation/ventilation
<8 [can’t protect own airway]
A+E pt with base of skull fracture and large subdural haematoma. How do you prepare the Pt for transfer to another hospital/
O2, fluids defib paddles emergency drugs anaesthetist + ODP paperwork, handover
signs of base of skull fracture
racoon/panda eyes [periorbital bruising]
mastoid bruising
CSF rhinorrhoea/otorrhoea
haemotypanum [blood adjacent to tympanic membrane]
what prophylaxis do you need to give base of skull fracture pt
pneumococcal and meningococcal vaccines
how does the ABCDE approach for assessing the patient change in major trauma
CABCDE
catastrophic haemorrhage
+ C-spine
what is the pathological process behind tension pneumothorax?
air between visceral and parietal pleura
one way valve means the pneumothorax increases every time you breath in
major trauma patient in RTC, suddenly deteriorates, says he cant breathe, pulse 130 ,sats 89% on high flow, BP 93/59. What’s happened?
massive haemothorax/ tension pneumothorax
Mx of tension pneumothorax
immediate decompression with largebore cannula in 2nd intercostal space mid clavicular line
massive haemothorax Mx
large bore chest drain
IV fluid/blood replacement
becks triad of cardiac tamponade
rising JVP
falling BP
muffled HS
[+/-pulsus parodoxus]
how would you diagnose cardiac tamponade in acute setting
US - black stripe around heart indicates fluid
Mx of cardiac tamponade
emergency pericardiocentesis
thoracotomy + pericardotomy
what is cardiac tamponade
fluid in the pericardium builds up, resulting in compression of the heart.
what are the 6 life threatening chest injuries
ATOMFC Aorta/Airway obstruction Tension pneumothorax Open pneumothorax Massive haemothorax Flail chest Cardiac tamponade
benefits of splinting a suspected fractured femur?
how can you make the procedure more comfortable for the patient?
what should you check before and after splinting/?
pain relief
nerve block
pulses and neurology
what is the name of the rash typically ass. w/ allergy rn/ describe it
urticaria
wheals - raised pink circular with white centre
which systems can be affected in an allergy rn and what corresponding features should you look for on examination?
airway: stridor, swollen lips + tongue
lungs: wheeze, ^RR, cyanosis, low sats
skin: rash
circulatory: low BP, Pale, clammy
brain: reduced consciousness
what is the mechanism of anaphylactic rn.s
IgE, IgG, complement > mast cell degradation >histamine release
vasodilaiton
contraction of bronchial muscles
Tx for anaphylaxis
ABCDE o2 fluids chlorphenamine [piriton] adrenaline 0.5mg [0.5ml of 1 in 1000] hydrocort salb if wheeze
when is adrenaline indicated in anaphylaxis
extremes of each system: stridor/wheeze, hypoTN, drowsy
what can cause a delayed deterioration in anaphylaxis
digestion of food
delayed histamine response
best route for adrenaline in anaphylaxis
IM
risks of giving IV adrenaline
palpitations, SOB, N+V, MI, arrhythmia
what is a biphasic rn in anaphylaxis?
not v common, recurrence of anaphylaxis after tx, several hrs later
follow-up /discharge plan after anaphylaxis admission
epipen [adrenaline] 3-5 days pred PO antihistamine salb inhlaer R/V w/ allergist
risks of someone else picking up epipen and accidental needle stick
finger ischaemia
[vasoconstrictor]
32 yr old female presents with 3 day history of L side CP, worse on inspiration + cough, sharp at times, feels SOB, occasional dry cough. Only DH is marvelon. Smokes 20/day, drinks 20-30 units/week.
Give 4 differentials.
PE
MSK pain
LRTI
pneumothorax
what examianation findings would be suggestive of MSK chest pain
tenderness on pressure
tender shoulder movements
32 yr old female presents with 3 day history of L side CP, worse on inspiration + cough, sharp at times, feels SOB, occasional dry cough. Only DH is marvelon. Smokes 20/day, drinks 20-30 units/week.
List 4 useful tests
CT pulmonary angiogram D dimer ABG ECG CXR FBC U+E LFT clotting
what is a d-dimer
fibrin degradation product
list 5 clinical findings suggestive of DVT
dilated superficial veins swollen >3cm tender on back pain pitting
scoring system for PE, + what factors it takes into account
wells
Clinical signs/Sx of DVT Heart rate > 100 Immobilization [3 days] /surgery in last 4 weeks Previous PE /DVT Hemoptysis Malignancy
pt started on warfarin. What range should INR be?
2-3
how long warfarin for PE?
3-6/12
if recurrent, lifelong
Mx of large PE
O2 if hypoxic morphine w/ antiemetic LMWH/fondaparinux fluid bolus if low BP consistent low BP -> noradrenaline/dobutamine IV thrombolysis [alteplase] long term anticoag
Sx of PCM overdose
none/
vomiting
RUQ pain
later:
jaundice, encpehalopathy, AKI
how long does it take for PCM toxicity to occur?
hepatic enzymes ^ at around 24 hrs,
then jaundice, hepatomegaly at around 48hrs
why do you do bloods at 4hrs in PCM overdose if toxicity takes 24 hrs? why not sooner?
PCM levels, to predict future toxicity
time for digestion/absorption from GI tract
liver is main site of PCM toxicity, what other organs are commonly affected in serious toxicity?
brain
kidney [AKI]
which pt.s are at particular risk of liver damage in PCM overdose?
malnutrition/ low BMI alcohol carbamaz pre-existing liver disease HIV [reduced hepatic glutathione]
in PCM overdose, in what circumstances should you start the NAC as soon as poss, prior to seeing PCM levels?
8-24 hrs post ingestion
suspicion of large overdose
ingestion time unknown
staggered
PCM overdose - important Qs to ask patients about the overdose and the events surrounding it, to assess risk of further overdose
intention previous overdoses note/finances in order any further plans who rang the ambulance
see pt 11 hrs after PCM overdose, what bloods should you take?
U+E LFT PCM level clotting/INR glucose
see pt 11 hrs after PCM overdose, should you give charcoal?
no, give if presenting <4 hrs since overdose
see pt 11 hrs after PCM overdose, when should you start NAC?
immediately >8hrs since ingestion
Pt receiving NAC for PCM overdose, flushed and vomited. Obs normal. what should you do?
rash is common SE - continue, chlorphenamine + antiemetics, observe. Can reduce to 1/2 rate. Dont stop unless anaphylaxis w/ shock [BP here is normal].
Mx of acute stemi incl. Ix.s
ECG 12 lead cannulate + take blood for trop, FBC, glucose, lipids, U+E O2 IF LOW SATS CXR aspirin ticagrelor morphine [+metoclop] BIVALIRUDIN BB PCI [within 120mins] TPA thrombolyiss
contraindications to IV TPA thrombolysis post-MI [if you cant get them to PCI within 120 mins]
prev intracranial haemorrhage ischaemic stroke <6/12 cerebral malig AV malf recent major trauma/surg/head injury recent GI bleed bleeding disorder A dissection liver biopsy/LP <24hrs
what do you give a pt with STEMI who present >12hrs after Sx onset?
fondaparinux
causes of cardiogenic shock
MI arrhythmia PE tension pneumo tamponade myocarditis endocarditis aortic dissection
Mx of broad complex tachycardia
O2 sedate and DC shock correct electrolytes amiodarone if known SVT/BBB: adenosine torsades -give Mg2+
mx of narrow-complex/ supraventricular tachycardia
O2 [if sats<90]
unstable - sedate + DCCV
correct electrolytes
amiod
stable + regular -vagal manoevres
adenosine
[verapamil]
mx of bradycardia
O2 if hypoxic correct electrolytes unstable:atropine transcutaneous pacing Isoprenaline adrenaline
mx of acute asthma
O2 salb neb ipratropium neb hydrcort iv/ pred PO MgSO4 IV
ICU: aminophylline, ventilation, IV salb,
what Ix.s do you want to do in acute asthma
PEF
ECG for arrhythmias
ABG
Mx of acute COPD
salb neb ipratropium neb controlled O2 IV hydrocort + PO pred amoxi/clarith/doxy if infection physio aid sputum
Iv aminophylline
CPAP
resp stimulant doxapram
intubate/ventilate
mx of large PE
O2 if hypoxic morphine [w/ antiemetic] fondaparinux/ LMWH fluids/ vasopressors if hypovol consider alteplase long term anticoag
for a pt with acute upper GI bleed who is shocked, what drug can you add to your management if you suspect oesophageal varices to be the cause? [e.g. known liver disease]
terlipressin
acute Mx of convulsive status epilepticus
and what Ix.s would you take alongside your management?
ABCDE
open and secure airway +/- adjuncts
O2
suction
bloods: FBC, U+E, LFT, glucose, Ca2+, tox screen, anticonvulsant levels
LORAZ, + repeat
[buccal midaz/ rectal diaz]
THIAMINE [alc/malnourished]
GLUCOSE
fluids
PHENYTOIN infusion
ECG
after 1 hr, anaesthetist RSI, intubate + vent
Mx of raised ICP
correct hypotn
elevate bed head
if intubated, hyperventilate to achieve low CO2 [leads to cerebral vasoconstriction]
mannitol
if oedematous tumour -dex
in a fitting patient , what is another possible cause other than epilepsy in a female patient?
eclampsia
you give IV loraz to fitting pt, what SE are you most worried about?
resp arrest
what is the risk of phenytoin infusion in fitting pt and when would you not give it?
brady
brady or heart block
what are the causes if status epilepticus
epilepsy eclampsia hypoglyc alcohol drugs CNS infection/ lesion HTNive enceph
medical complications of status epilepticus
brain damage arrhythmia tachy resp failure aspiration asystole vomiting hyperkalaemia apnoea HTN
ecg criteria for thrombolysis in MI
ST elevation in adjacent leads
LBBB
post changes [ST dep, tall R waves V1-3]
in head injury, primary traumatic brain injury occurs at the time of impact. What neurophysiological/ anatomical consequences cause secondary injury mins-days later?
^ICP cerebral oedema expanding haematomas seizures infection
assessing a patient using ABCDE, what aspects should be paid particular attention to if the patient has sustained a head injury?
GCS [and changes to this]
pupils
C-spine protection
neuro examination
in a trauma patient, low BP together with inappropriately low pulse rate indicates injury to what aspect + what level of the spinal cord?
sympathetic
cervical
patient presenting with head injury and reduced GCS. What imaging do you need to arrange within 1st hour of injury?
CT head
following head injury, what aspects of your patient’s presentation might warrant an urgent CT head?
reduced GCS open /depressed /basal skull fracture focal CNS deficit fit [post-injury] >1 vomit
LOC + coagulopathy
when would you add cervical spine CT to head CT in head injury patient?
intubated [?could exacerbate C-spine injury] GCS <13 dangerous mechanism of injury focal CNS deficit upper/lower limb parasthesia
elderly patient presents with unwitnessed fall + poor history. Doesnt know if she banged head. Takes warfarin. GCS 15, no focal neuro deficits. What Ix does she need?
CT head within 1 hour
risk of ICH is higher for patients on warfarin or clopidogrel?
clopidogrel
give 3 aspects of medical management of head injury
avoid hypoTN [syst >90]
dont overload [cerebral oedema]
dont use glucose [damages brain tissue]
avoid hypoxia/hypercapnia > hypervent
opiates
mannitol
IV loraz/buccal midaz for seizure
raise head
avoid ^glycaemia/ pyrexia
