A-E Approach - Medical Emergencies Flashcards
Approach to any trauma case
Primary survey - cABCDE
PPE Does the patient look unwell 'How are you?' -normal response => ABC ok -abnormal response => ABC assessment needed
Ask for monitoring - pulse oximetry, ECG monitor, BP, HR, nasal capnography
Ask for 2 large bore IV cannulas and take bloods
How would you restrict the CSpine
Ask someone to hold patient’s head with 2 hands to keep head steady
Apply collar around patient
-measure the distance between the chin and shoulder and adjust height
Fix with blocks and tape above and below head
How would you assess the airway
- what are you looking for
- how would you manage airway emergencies
Is it patent => patient can speak, identify themselves, tell you what happened, ABCD likely to be ok
Are they making any sounds => airway compromise
-Stridor
-Wheeze
-Snoring
-no sounds
Give O2, aim for high sats but get someone to check records for CO2 retention
Basic temporary maneouvres -jaw thrust, chin lift Assess and address immediate causes of airway obstruction -suction -swelling, edema -remove foreign objects carefully -anaphylaxis Temporary airway adjuncts -conscious - nasopharyngeal airway -unconscious - oropharyngeal/laryngeal mask airway
GCS U8 => call anaesthetist, prepare for intubation
-prepare for cricothyroidotomy if intubation not possible
Anaphylaxis
- identification
- management
Itchy rash
Swollen lips, mouth, neck
2222 crash call
Lie patient down
Remove allergen
Ask for monitoring of HR, BP, RR, temp, SaO2, ECG
IM adrenaline 0.5mg anterolateral thigh
Airway => secure it
Breathing => 15L NRM, salbutamol 5mg neb for wheeze
Circulation => 2 large core IV cannulas
If no response
- repeat adrenaline every 5mins
- IV 500ml Hartmans/saline and repeat to support BP
How would you assess breathing
- what are you looking for
- lifethreatening breathing problems related to trauma
- lifethreatening medical breathing problems
Ask for monitoring - SaO2, BP, HR, RR, ECG, nasal capnography
O2 high flow NRM
Ventilation - bag valve mask if needed
Inspect
- pallor - central cyanosis
- RR - first thing to change in deterioration
- effort - accessory muscle use
- symmetry - asymmetry (lung pathology), paradoxical mv (flail chest)
- signs of injury - wounds, fractures
- JVP elevation
Palpate, percuss
- tracheal deviation, hyperresonance => TENSION PNEUMOTHORAX!
- displaced apex beat
- tenderness from injuries
Auscultate
-air entry, any additional sounds
Trauma
- open/tension pneumothorax
- massive hemothorax
- cardiac tamponade
Medical
- tension pneumothorax
- lifethreatening asthma
- COPD exacerbation
- pulmonary edema from acute heart failure
- pulmonary embolism
- COVID pneumonitis
Open, tension pneumothorax, massive hemothorax, cardiac tamponade
- identification
- management
Tracheal deviation + hyperresonance => treat as TENSION
-5ICS MAL needle decompression + high flow O2
Hyperresonance + reduced lung sounds => treat as open
-3 way dressing over trauma site + chest drain + high flow O2
Reduced air entry + dull chest + asymmetrical chest mv => massive hemothorax?
-chest drain insertion 5ICS MAL + O2
High JVP, low BP, penetrating chest wound => cardiac tamponade?
- rule out TP
- rapid transfer to Trauma Center => pericardiocentesis
Life threatening asthma
- identification
- management
PEAK FLOW - U30%
15L high flow O2 NRM
Salbutamol nebs
Pred 50mg 5 days
Prep for intubation
15L high flow O2 NRM => Venturi for CO2 retainers once sats improve
Salbutamol nebs
Pred 30mg 5 days
ABx if infective
T2RF or patient tiring => intubate!
Pulmonary edema
- identification
- management
Crepitations on auscultation + high JVP
=> IN PREHOSPITAL SETTING, GTN spray, adequate O2
Position - sit up O2 - high flow 15L NRM Diuretic - furosemide 40mg IV Morphine if distressed Antiemetic - metoclopramide if morphine given Nitrates - GTN
Identify and treat cause
- fluid overload => furosemide
- arrythmia => depends on type
- aortic/mitral regurg => valve replacement
- ACS => PCI
- tamponade => pericardiocentesis
- HTN crisis => BP control
Pulmonary embolism
- identification
- management
Hard to say for sure just from observations
-high HR, low SaO2
IN PREHOSPITAL - FOCUS ON OXYGENATION AND TRANSPORT TO A&E
Wells score 4+ => CTPA within 4hrs
-if not, DOAC
Wells score U4 => DD + DOAC
-DD +ve => CTPA within 4hrs
Circulation assessment
-what are you looking for
Assume hypovolemic shock until proven otherwise
Ext bleeds - floor, femur, CAP
-ext bleeds - compress and apply pressure
Skeletal bleeds
-pelvic binder
-long bones - traction, reduction, splinting
If actively bleeding, MASSIVE HEMORRHAGE PROTOCOL
Quick CV exam
- peripheral cyanosis
- temp
- CRT
- JVP
- palpate radial and carotid pulse
- HR, BP
- auscultate
2 large bore IV cannulas in peripheries/IO access (humeral head, proximal tibia)
-FBC, U&E, LFT, CRP, ABG, coagulation profile, cultures, G&M
500ml warmed Hartmanns/NaCl if low BP => auscultate for pulmonary edema
-if no response => get senior input
What are the main types of shock
- how would you identify them
- how would you manage them in a prehospital setting
Most likely - hypovolemic => IV crystalloid
-no JVP
Obstructive
- high JVP, lung fields clear
- cardiac tamponade => pericardiocentesis
- PE => O2, thrombolysis if cardiac arrest
- TP => needle decomp
Distributive
- no JVP
- anaphylaxis => remove allergen, adrenaline
- sepsis => sepsis 6
Cardiogenic
- high JVP, pulmonary edema
- arrythmia => antiarrythmics, DC cardioversion, pacing
- MI => aspirin, GTN, PCI transfer
- HF => GTN, CPAP, diuretics
Disability assessment
- what would you do
- how would you do this
Look - AVPU
Listen - oriented in TPP
Do
- BMs
- GCS
- pupil responses - unequal pupils => head trauma
- limb mv and sensory testing
- reflexes
- temp
- Head CT if head trauma suspected
DKA
- core features
- investigations
- management
- complications
Core features - within hours
- polydipsia, polyuria => dehydration
- abdo pain, N+V
- confusion, blurry vision, fatigue
Investigations - confirm diagnosis
Bedside - capillary glucose/ketones, urinedip, ABG
-glucose 11mmol+
-acidotic pH or HCO3 U15
-capillary ketones 3mmol+ or urinary ketones
Management 1. RAPID REHYDRATION - saline 2. INSULIN 3. K INFUSION 4. REASSESS PATIENT AND IDENTIFY CAUSE Bedside - Hx, head to toe exam, ECG, MSU Bloods - FBC, glucose, U&E, LFT, osmolality, CRP, cultures Imaging - CXR 5. MONITOR and VTE prophylaxis -capillary glucose, ketones, ABG for pH, K and glucose
Possible causes - 4Is
-infection, infarction, intoxication, ignorance
Complications
- arrythmias
- cerebral, pulmonary edema - from rapid rehydration
HSS
- core features
- investigations
- management
- complications
Core features - over days
- polydipsia, polyuria
- N+V, dizzy, confusion
Investigations - confirm diagnosis
- hyperglycemia - 30mmol+
- hyperosmolality 320mmol+
- hypovolemia
Management 1. RAPID FLUID RESUS - saline 2. INSULIN TO CORRECT GLUCOSE -at a lower rate than DKA 3.REASSESS PATIENT AND IDENTIFY CAUSE Bedside - Hx, head to toe exam, ECG, MSU Bloods - FBC, glucose, U&E, LFT, osmolality, CRP, cultures Imaging - CXR 4. MONITOR AND VTE PROPHYLAXIS -capillary/blood glucose, osmolality
Possible causes - 4Is
-infection, infarction, intoxication, ignorance
Complications
- arrythmias
- cerebral, pulmonary edema - from rapid rehydration
Hypoglycemia
- core features
- investigations
- management
Early presentation
- hunger, fatigue
- shaking, pale, sweating
- headache, dizziness
Late presentation
- confusion
- slurred speech, blurred vision
- fainting, seizures, coma
Investigations - BG U3.5
Management
Unconscious - IM glucagon once
Conscious, unsafe swallow - glucose gel in mouth
Conscious, swallow - 15-20g fast acting carbs (5 glucose tablets) AND long acting carbs
Monitoring
- check cap glucose every 10mins and repeat treatment until glucose within range
- determine and address cause
Sepsis
- core features
- management
Abnormal temp
High RR, HR
Low BP
Confusion
Take
- lactate
- blood cultures
- urine output
Give
- fluid
- O2
- ABx
ACS
- core features
- management
Dull chest pain => left shoulder, neck, jaw
5mins+
Cold, clammy, N+V
Pain on rest
Aspirin Clopidogrel GTN Morphine O2
Exposure
Look - rashes, abnormalities, bleeds
Listen - AMPLE Hx, collateral Allergies Medications Past medical history Last meal Events leading to injury
Do - abdo exam, rule out abdo pathologies
-document findings and what has been done
Anaphylaxis
- core features
- management
Recent exposure to allergen
- drugs (ABx, NAC, IV contrast)
- foods (nuts, eggs, shellfish)
- animals (stings
- latex
2222 => medical emergency Airway - secure it -call anaesthetics early -ADRENALINE 0.5ml IM Breathing - 15L NRM + salbutamol NEB if wheezing Circulation - 2 wide bore cannulas -IV fluid resus until BP ok -Hydrocortisone IV, chlorpheniramine IV -ECG monitoring Bloods - FBC, U&E, CRP, mast cell tryptase (confirm anaphylaxis)
Sepsis
- core features
- risk factors
- management
Suspected infection
Fever
Systemic response => life threatening organ dysfunction
Risk factors
- extremes of age
- recent surgery/trauma
- IC
- indwelling catheters, lines, IVDU
Investigations => FIND SOURCE AND COMPLICATIONS -FBC, INR, VBG (lactate) -blood cultures -cap glucose -urine dip, culture CXR
Management - SEPSIS 6
GIVE O2, ABx, FLUIDS
TAKE LACTATE, CULTURES, FLUID OUTPUT
Seizure
- common causes
- A-E management
- management after recovery
A -recovery position -maintain airway - jaw thrust, suction, nasopharyngeal -10mins - IV lorazepam (repeat in 10mins) -30mins - IV phenytoin 60mins - GA in ICU B -15L NRM C -secure IV access and monitoring -Bloods - FBC, LFT, U&E, Ca, PO4, Mg, antiepileptic drug levels -VBG - lactate -ECG - prolonged QT D -capillary glucose => glucose IV -alcohol dependence => Pabrinex 2 pairs IV E -full exam
Neuroloogical - epilepsy, SOL, meningitis/encephalitis, head trauma
Metabolic - hypoglycemia. electrolyte abnormalities
Drugs - OD, alcohol withdrawal
Febrile
Eclampsia
Assess for underlying cause -Hx -multisystem exam Treat underlying cause Refer to neuro/seizure team Driving advice, ask patient to inform DVLA
Approach to arrythmias
- possible causes
- core features
- management for specific arrythmias
A-E
Pulseless => cardiac arrest, call crash team
Tachyarrythmia => synchronised DC cardioversion
Bradycardia => pacing + ATROPINE 500mcg IV
3lead monitoring
Identify and treat cause - electrolyte abnormalities, ACS, hypoxia, sepsis, drug toxicity
VT => amiodarone 300mg IV
Torsades de pointes => MgSO4 2g IV
Broad complex tachycardia
