Acute Flashcards
ABCDE - Airway
Is the airway patent?
* If they can talk to you = yes
* Sounds of obstruction = added sounds / silence / cyanosis
If not patent;
1. Jaw thrust (avoid healt tilt due to risk of C spine injury)
2. NPA - do not do this is suspecting basal skull fracture
3. OPA - only it patient is unconcious
4. If these fail = ET intubate + call anesthetist
ABCDE - Breathing
Observations:
* RR
* Sp02
* Assess for any obvious cyanosis
Examination;
* Feel - for tracheal deviation / chest wall movements
* Percuss chest
* Ausculate chest + denote breath sounds
Action;
1. 15L non-rebreathe 02 - almost all pts should get this
2. Aim to keep sats 94-98%
3. Request ABG + CXR
4. Needle decompression if tension pneumothorax is present
ABCDE - Circulation
Observations;
* Pulses - rate, rhythm, character
* CRT
* BP
Examination;
* Cardiac examination - look for JVP then auscultate the heart sounds + check for oedema.
Interventions;
1. Gain IV access
2. Bloods + blood cultures
3. 12 lead ECG
4. Measure Urine output
5. Give IV fluids if hypovolemic - 500ml bolus over 15 mins
6. If haemorrhaging - stop the bleed / TXA
ABCDE - Disability
Assesment;
* GCS / AVPU
* Pupillary size + reactivity
* Glucose
* Urine dipstick
Interventions;
* Consider oral glucose/detrose if needed, naloxone if indicated
* Head CT id indicated
ABCDE - Exposure
- Temerature
- Check skin for swelling (+ roll patient over)
- Calf swelling
- Bleeding
- Signs of infection
- Abdominal palpation
- Fuller examination of relevant systems
Anaphylaxis
Common causes = foods, insect venom, latex, antibiotics, anaesthetic, contrast, NSAIDs, vancomycin
Sx; Sudden onset + rapid progression of;
* Airway problems - stridor, swelling of throat/tongue
* Breathing = respiratory wheeze + SOB/dyspnoea
* Circulation = Hypotension + Tachycardia
* Generalised pruritus
* Widespread erythematous / urticarial rash
Management;
1. IM Adrenaline - 0.5mg repeat every 5 minutes
2. IV fluids bolus 500ml
3. Chlorphenamine 10mg (adults) - IM or slow IV
4. Hydrocortisone 200mg
Monitor. & Beware for biphasic anaphylaxis (recurrence within 72hours)
Cardiac Tamponade
= Accumulation of blood (or fluid or gas) in the pericardial space.
Causes = Trauma / post surgery / CABG / Malignancy / post MI / Renal failure / Aortic dissection / Pericarditis
Features: **Beck’s triad **
1. Hypotension
2. Raised JVP
3. Muffled heart sounds
Additional = SOB / Tachycardia / Chest pain / Pulsus paradoxus / Abdo pain
Investigations;
1. ECG = electrical alternans (alternating amplitude/axis of the QRS complexes)
2. Echocardiogram
Management = Thoracotomy (definitive management) / Urgent needle pericardiocentesis can be done in peri-arrest to buy time
Main differences between Cardiac Tamponade + Constrictive pericarditis
Tamponade = Absent Y descent on JVP.
Constrictive pericarditis = X + Y are both present on JVP. Kussmaul’s breathing more common. Also won’t have pulsus paradoxus.
Tension pneumothroax Features
Pt typically presents wth sudden onset;
1. Dyspnoea
2. Tachypnoea / ARDS
3. Tachycardia
4. Hypotension
Signs on examination;
* Absent breath sounds + Hyper-resonance to percussion - on the affected side
* Tracheal deviation - *away from the affected side *
* Distended neck veins
Management of suspected tension pneumothorax
Clinical diagnosis - can get CXR to confirm it but do not wait for this it patient is deteriorating.
- High flow 02
- Immediate decompression (IV cannula into 2nd intercostal mid-clavicular line)
- Axillary chest drain
Triangle of safety for chest drain
5th intercostal space, mid-axillary line between latissimus dorsi + pec major.
Open pneumothorax
A.K.A traumatic pneumothorax (Occurs when there is a large open wound to the chest)
This is when the pleural cavity pressure = Atmospheric pressure.
Management;
* Cover with sterile dressing securing 3 sides to the chest wall, leaving one side free. (allowing air to escape but not enter)
* Insert chest drain
* Surgery
Massive Haemothorax
Accumulation of blood in the pleural space following trauma.
Sx;
* Hypovolemic shock - hypotension + tachycardia + prolonged CRT
* Dull percussion of the chest wall (unlike tension pneumothorac which is hyper-resonant)
* Reduced breath sounds on affected side
* Collapsed neck veins
Management = IV fluids + Large bore chest drain. + Surgical thoractomy if >1500ml of blood comes out
Fat embolism
Presence of fat globules in the lung parencyhma + peripheral circulation.
Cause = typically occurs after trauma - mainly associated with long bone or pelvic fractures.
Sx;
24-72 hours post injury with;
1. Respiratory distress - Dyspnoea + tachypnoea + Hypoxia
2. Neurological abnormalities - confusion + focal neurological signs + seizures
3. Petechial rash
May mimic DIC with coagulation abnormalities, may have renal changes and you may see soft fluffy exudates with macula oedema scotoma
CXR = snowstorm appearance
Management of severe burns
- IV fluids (parkland formula)
- Urinary catheter
- Analgesia
- Send to burn unit if complex burn involving perineum, hands or face.
- Surgical excision/skin grafting
Mrs smith
Causes of Atrial Fibrillation
Mitral regurgitation
Sepsis
Mital stenosis
Ischemic heart disease
Thyrotoxicosis
HTN
Atrial fibrillation ECG
Absent P waves.
Narrow complex tachycardia
Irregularly irregular rhythm
Peri-arrest tachycardia Management
- ABCDE - give 02, Obtain IV access, Monitor ECG, BP, sats + Identify and treat reversible causes.
- If any life threatening feeatures = Synchronised DC shock (up to 3 attempts). If unsuccessful - give IV Amiodarone 300mg over 10-20 mins, then repeat the shock.
Broad-complex tachycardia - no life threatening Fx;
1. If regular rhythm - assume VT and give loading dose Amiodarone 300mg IV, followed by a 24hr infusion
2. If irregular = seek expert help (could be AF with BBB or Tdp - which needs magnesium 2g)
Narrow-Complex tachycardia (<0.12ms) - no life threatening Fx;
1. Regular = vagal manouevre followed by IV Adenosine 6mg to start, then 12mg, then 18mg. - IF this does not work consider Atrial flutter and give rate control
2. Irregular rhythm = AF so try cardioversion with flecainide or amiodarone or Electrical cardioversion
Initial Management of ACS
Initial management = Aspirin 300mg, 02, Morphine + Nitrates (GTN x2), gain IV access, do bloods, do ECG.
Use GRACE score to calculate 6 month mortality risk.
* High risk = Urgent coronary angiogram + PCI
* Intermediate risk = Early coronary angiogram + PCI (<72hrs)
* Low risk = Medical management
BATMAN
Medical management of ACS (low risk)
Beta-blockers
Aspirin 300mg stat dose
Ticagrelor 180mg stat (or clopi)
Morphine
Anticoagulant (e.g fondaparinux)
Nitrates
Secondary prevention after ACS
Aspirin
Antiplatelet (ticareglor/clopi)
Atorvostatin 80mg
ACEi
Atenolol
Aldosterone antagonist - if HF present
Assesing the extent of burns
**Simple rule **= the palmar surface is around 1% of TBSA - this is good for measuring small burns but no good for ones >15% TBSA.
Wallace’s rule of 9s;
* Head & neck = 9%
* Anterior chet = 9%
* Each arm = 9%
* Anterior abdomen = 9%
* Posterior abdomen = 9%
* Each anterior part of the leg = 9%
* Each posterior part of the leg = 9%
Lund & Browder chart = a more reliable way of assesing the extent.
Depth of burns
- First degree = superfifical epidermal. Red, glistening skin + Painful. No blisters. will heal in 7 days.
- Second degree - Superficial dermal = Pale pink + painful, blistered and weeping/wet. 2-3 weeks to heal with minimal scarring.
- Second degree - deep dermal = Typically white, may have patches of non-blanching erythema. Reduced sensation. Painful to deep pressure. No CRT. 3-8 weeks to heal with scarring.
- Third degree - full thickness = White (waxy) or Brown (leathery) or black in colour. No blisters & no pain. Requires surgical repair and grafting
- Fourth degree = sub dermal = includes subcut fat, muscle and sometimes bone. Requires reconstruction and sometimes amputation.
Parkland formula
= Used for burns with >15% TBSA.
Total fluid require in 24hrs = 4ml X TBSA X Weight (kg)
50% given in first 8 hours, then 50% in next 16.
Crystalloid only (e.g hartmann’s)
After 24hrs start colloid fluids (Albumin/FFP) at 0.5ml X TBSA X Weight followed by a maintenance (dextrose-saline) at 1.5ml
Smoke inhalation injury
Features;
* Face/neck burns
* Singeing of eyebrows + nose hairs
* Carbon deposits + inflammation in oropharyngx
* Carbon particles in sputum
* hoarse voice
* Carboxyhb >10%
* SOB, Stridor, dribbling etc
Management = ET intubation if stridor. Flexible bronchoscopy can help assess damage.
If CO poisoning = hyperbaric 02
salbutamol if bronchospasm.
IV fluids
A unilaterally dilated pupil which is sluggish to react to light in pt with head injury may indicate what
3rd nerve compression (may be due to tentorial herniation)
Can also cause a bilateral dilated pupil if its a bilateral 3rd nerve palsy
Causes of bilateral pupil constriction
Opiates
Pontine lesions
Metabolic encephalopathy
Red flags for head injury requiring urgent CT scan
- GCS <13 on initial assesment
- GCS <15 2 hours post injury
- Suspected open/depressed skull fracture
- Sign of basal skull fracture - panda eyes, CSF leak, battle sign
- Post-traumatic seziure
- Focal neurological deficit
- 1+ episode of vomitting
Other red flags (requiring CT in 8 hours) = Age >65, Bleeding disorders, Anticoagulation, Dangerous mechanism of injury, 30+ Minutues of retrogade amnesia.
Anti-cholingeric overdose
Agents = Carbamazepine / Antihistamines / TCAs
Sx;
* Urinary retention, bowel retention
* Hyperreflexia
* Hyperthermia
* Dry mouth
* Warm skin, Anhydrosis etc
O/E = Tachycardia, Tachypnoea, Mydriasis
Management = IV bicarb if arrythmia, seizure or acidosis. (if they go into VT may require amiodarone)
TCA overdose
Common. Usually amitryptyline or Dosulepin.
Features = Dry mouth, Mydriasis, Urinary retention, blurred vision, tachycardia.
Severe overdose = Arrythmias, seizures, Acidosis. ECG may show QT prolongation and widening of QRS.
Management = IV bicarbonate & treat the arrythmia (but treat anything which prolongs depolarisation e.g amiodarone or flecainide)
Cholingeric overdose
E.g nerve agents, Organosphosphates (pesticides)
Features = opposite of anticholingerics so Miosis, Sweating, Diarrhoea, Musle weakness, tremor etc.
Can cause Cardiac arrest.
Management = Atropine for bradycardia.
Amphetamines/Cocaine overdose
Features = Tachycardia + Tachypnoea + Hypertension + Mydriasis.
Think - activation so hyperthermia, diaphoresis, hyper-reflexia, inc bowels etc.
Management = Benzodiazepines.
*Note - cocaine can cause SEVERE vasoconstriction resulting in stroke, MI, aortic dissection, ischemic colitis, QRS widening and QT prolongation.
Benzo overdose
benzo’s enhance GABA.
Features = CNS depression, Mydriasis, Nystagmus, Diplopia + Bradycardia + hypotension + hypothermia + resp depression.
Management = Supportive management - give Flumazenil if severe.
Paracetamol overdose
Causes acute liver failure.
Features;
* Jaundice + RUQ pain + Raised PT time
* Hypoalbuminemia
* Hepatic encephalopathy
* Hepatorenal failure
Management;
1. If ingested in past 1 hour or >12mg = Activated Charcoal
2. N-acetylcysteine - transfuse it slowly
3. Liver transplant if sevre
Aspirin / Salicylate overdose
= Leads to a mixed Respiratory Alkalosis (due to hyperventilation) + Metabolic acidosis
Features = Hyperventilation + **Tinnitus ** (v early sign) + Sweating + Hyperthermia + N&V + Coma/Seizures
Management = Charcoal if <1hour. IV bicarbonate to help with acidosis.
2. Haemodialysis if >700mg/L or acidosis fails to improve or pulmonary oedema or seizures.
