A&E Flashcards
What blood tests do you want in a suspected septic patient? What additional investigations should be done?
FBC U&Es ABG/ VBG LFTs Glucose Lactate Coagulation CRP \+ Blood cultures
X-rays:
- CXR
- US
- CT
Special tests:
- swabs
If a person has sepsis and indwelling catheter where should blood cultures be taken from?
2 sets should be taken.
One Peripherally
One from catheter
During sepsis aggressive fluid resuscitation is given, what is the patient at risk of developing?
Non-cardiogenic pulmonary oedema
What drugs can be added in a septic patient to increase the MAP? What drug should myocardial dysfunctional patient receive? and what is last drug choice if the first two are not working?
Adrenaline
Dobutamine
Dobutamine recommended for myocardial dysfunction
Hydrocortisone IV can be used as last resort
Why may a patient who has experienced trauma have coagulation defects?
Depletion of clotting factors
Fluids
- dilute clotting factors
Hypothermia
- reduces effectiveness of clotting
Why are IV fluids not recommended for a trauma patient?
Disrupts the initial clot
- new pressure disrupts clot
Haemodilution
Cooling of patient
- making coagulopathy worse
What things should always be recorded following a head injury?
GCS
Pupil size and reactivity
Lateralizing signs
Decorticate/ decelebrate signs
What is Cushing’s triad?
Signs of Herniation of the cerebellar tonsils through the foramen magnum.
resulting in brainstem compression.
Rising blood pressure
bradycardia
Intermittent respiration
What are some signs of urethral injury?
Blood at penile meatus
Perineal ecchymosis
Scrotal haematoma
High riding prostate
Known pelvic fracture
What are the trimodal causes of death following from major trauma?
Immediate:
- massive blood loss
- neck fracture
- intracranial bleed
- aortic sheering
- airway obstruction
Early:
- ATOMFC
- Airway compromise
- tension Pneumo
- Open pneumo
- Massive haemothorax
- Flail chest
- Cardiac tamponade
Late:
- P.E
- Sepsis
What history do you want about someone when they come in from the ambulance crew?
AMPLE
- Allergies
- Medication
- PMH, Pregnancy?
- Last meal
- Events
What can be done to stabilize the C-spine prior to placing the in a collar?
Bimanual inline stabilization
Name two other injuries/ complications to consider in burns victims:
Inhalation injury
Carbon monoxide poisoning
How is frostbite treated?
Rapid heating with moist heat >40 degrees
In a patient with major trauma, a C-spine injury is suspected until proven otherwise, when can the collar be removed?
Negative radiological findings
Absent pain from spinal origins
- which can be sensed without distraction of other painful stimuli
What are some signs of C-spine fracture seen on clinical examination?
Cervical spine tenderness
Subcutaneous emphysema
Tracheal deviation
Laryngeal fracture
Focal neurology
Outline the Ottowa rules for x-raying the ankle:
X-ray if:
- any pain over the lateral aspect of ankle across fibula
- any pain over the medial aspect of ankle across the tibia
- Unable to weight bare or walk more than 4 steps in ED
What are the ottowa rules for the knee?
x-ray if:
- tender over the patella
- tender over the fibula
- unable to flex knee to 90degrees
- unable to weight bare
- > 55 years
What is the injury called that can occur to the thumb which is due to excessive valgus rotation? what ligament is damaged and what is the complication?
Game keeper’s thumb
Ulnar collateral ligament
Stener lesion
- where the adductor pollicis gets caught
In a patient that attends A&E due to a fall, what are the essential investigations that should be done?
Cardiovascular examination
- lying and standing BP
Full neurological examination
- vision
- cerebellar signs
MSK examination
What is a finding on ECG which can be indicative of an M.I coming very soon, in which ST elevation will be seen?
Depression or elevation of the aVR lead
and/ or
Hyperacute tall T waves
Wellen’s syndrome which see biphasic T wave changes in anterior leads. suggest of critical LAD stenosis
What are the cut offs for ST - elevation:
> 2mm in V1-3 in males
1.5 in V1-3 in females
**note these would an anterior
> 1mm in any other leads
**note these would be inferior
What are the progressive changes seen in the ECG for an M.I
Hyperacute T waves
ST elevation
Q waves / and inverted T waves
What investigations should be done into aortic dissection:
ECG: rule out ACS *may see inferior ST elevation
CXR - widening of mediastinum
D-dimer - very unlikely to be aortic dissection if low
CT Angio of chest/ abdo/ pelvis is definitive
*if patient is unstable a TOE can be done
What investigation is worth ordering in someone who has overdosed on benzodiazepines to assess how well they have been oxygenating?
ABG or VBG
they tend to develop a type 2 respiratory failure
What is the substance that is often in cocaine and how does it affect the patient?
Levamisole
- anti-worming agent
Mimics HIV and necrotic skin lesions
What are the signs and symptoms of cocaine overdose and how are they managed?
Hyperthermia
ACS/ chest pain
Rhabdomyolysis
Seizures
Management:
- Benzodiazepines (this can help vasospasm as well)
- GTN + Aspirin
- Dantrolene - if >40 degrees
- Cyproheptadine
What is the serious ECG pattern seen with digitalis toxicity?
Bidirectional Ventricular Tachycardia
Where would you see fluid in the abdomen if present during a fast scan?
Pouch of Morrison
- between liver and kidney
Between kidney and spleen
Around the bladder
Pouch of Douglas
- especially for gynae
What signs may be seen on a lateral elbow x-ray other than direct fracture to the bone which suggest fracture?
Sail sign
- displacement of fat pad.
- very true posteriorly
What are the stages of iron toxicity and what is the treatment?
stage 1:
- N&V
- Abdominal pain
- Haematemesis
Stage 2:
- apparent recovery
Stage 3:
- lethargy
- seizures
- shock
- Coagulation abnormalities
Stage 4:
- liver failure
Stage 5:
- pyloric scarring
Treatment:
- gastric lavage
- deferoxamine
**remember children are at high risk of this
On a CXR you see many radiopaque pills in the stomach, what is it likely to be?
Iron tablets
What is the fluid resuscitation dose given for DKA in children and what rate is the insulin infused at?
Saline - 10mls/kg
Insulin dose: 0.1units/kg/hour
What are the complications of DKA?
Cerebral oedema
- GCS/ behaviour changes
- give mannitol
ARDS
Hypoglycaemia
Hypokalaemia
Aspiration pneumonia
VTE
How many shocks can be given in someone who is hypothermic?
3 shocks then no more before they are >30 degrees
What are some findings of severe DKA requiring HDU input?
pH <7.1
Ketones >6
GCS <12
Cerebral oedema on presentation
