Acute and critical care Flashcards
What are the prerequisites for a blood transfusion?
2 independent G&S taken by different people at different times
What blood group is given in an emergency?
What may be given in future? Why?
O negative
O positive. Save O negative for pregnant women to prevent rhesus disease.
If you have an obese person you need to given fluids to, to what weight do you calculate their fluid requirements?
Equations?
Ideal body weight.
Males = 0.9xH(cm)-88
Females = 0.9xH(cm)-92
If you are dealing with major trauma and the patient has massive haemorrhage, what are your fluid options? Which one first?
Red blood cells (first), FFP, Fluids (crystalloids)
Given the adult therapeutic dose and time for administration of:
- Red cells
- Platelets
- Cryoprecipitate
- FFP
Red cells = 1 bag over 2-3 hours
Platelets = 1 bag over 30 minutes (max)
Cryoprecipitate = 2 bags stat
FFP = 3 bags, 30 minutes max per bag (1.5hrs)
- What does TACO stand for?
- What are the signs and symptoms?
- Time frame for diagnosis?
- Investigation?
- Management?
1)Transfusion associated circulatory overload
2) Pulmonary oedema so: dyspnoea, wheezing, cough, cyanosis, tachypnoea
Heart overload: chest tightness, rapid increase in blood pressure, distended neck veins
Peripheral oedema
3) Within 24 hours of transfusion
4) CXR
5) Treatment = diuretics, (morphine), nitrates
Prevention = Giving single units, prophylactic diuretics, regular reviewing of patient
What is major trauma?
Serious and often multiple injuries where there is a strong possibility of death or disability
What is the Golden hour? Platinum 10 minutes?
Getting patients into hospital within 1 hour until their morbidity and mortality declines.
Life saving interventions should be implemented within 10 minutes of admission.
What are the steps of the primary survey of major trauma?
CABCDE Control catastrophic haemorrhage Airways and C-spine protection Breathing with ventilation Circulation with haemorrhage control Disability - neurological status (eyes, GCS/AVPU), glucose Exposure/ environment
What are possible mechanisms of injury in major trauma?
RTC Fall from standing height (elderly) Fall from height (>2 stories = bad) Assault - head injury, stamping Penetrating - knife, gun shot Crush injury - industrial/ building falling Blast injury - explosion
What are the ways that a blast injury can injure you?
Primary - blast wave disrupts gas filled structure
Secondary - impact of airborne debris
Tertiary - transmission of body
Quaternary - All other forces
What is the paramedic trauma handover?
ATMIST Age Time of injury Mechanism of injury Injuries Signs Treatments given already
What tool can you use to decide if a person needs a specialist major trauma centre?
Yorkshire major trauma triage tool
What to do in each of the CABCDE approach
C. 1) Direct, focussed pressure, keep pushing harder
2) Indirect pressure proximally
3) Torniquet - 3 inches above, another above if not sufficient
4) Haemostatic agents (ceelox)
A. Secure the airway - Immobilise the C-spine
Look listen feel for breathing
Suction, chin lift/jaw thrust, Guedel airway
Proceed to RSI/intubation if indicated
B. Give oxygen
Depends on causative issue:
- Tension pneumothorax - thoracocentesis/ thoracotomy + chest drain
- Massive haemothorax - Requires IV access + fluids before draining
- Cardiac tamponade - thoracotomy and drain
C. Stop catastrophic bleeding Pelvic binder Splint long bone fractures Permissive hypotension with fluid replacement (RBC, PLTs, FFP) Transexamic acid 1g over 10 mins the 1g infusion Emergent damage control surgery Interventional radiology Limit crystalloid
D. Prevent secondary brain injury
Secure airway in GCS less than 8 or control ventilation
Maintain normal - ICP, Glucose, Oxygen, CO2
E. Ensure patient is warm
Pain management
What is the time frame for securing an airway in major trauma upon arrival?
45 minutes
Absolute indications for intubation
Inability to maintain airway Inability to maintain adequate oxygenation upon less invasive manoeuvres Inability to maintain normocapnia Deteriorating conscious level Significant facial injuries Seizures
What are the indications for intubation with burns?
Deep facial burns, hypoxia or hypercapnia, full thickness neck burns.
Early intubation before swelling and fluid builds up
Relative indications for intubation
Haemorrhagic shock
Agitated patient
Multiple painful injuries
Transfer to another area of hospital/ expected clinical course
Indications for c-spine immobilisation?
High force mechanism of injury with a reduced consciousness level
Life threatening injuries on primary survey
ATOM FC Airway obstruction Tension pneumothorax Open pneumothorax Massive haemothorax Flail chest Cardiac tamponade
Textbook signs of tension pneumothorax
In reality
1.Diminished breath sounds Hyperesonance Distended neck veins Deviated trachea Hypoxia Tachycardia Hypotension
- Air hunger/agitation
Hypoxia
Hypotension
Immediate management of tension pneumothorax
Thoracocentesis in 2nd intercostal space mid-clavicular line
Thoracotomy with large bore chest drain
Define massive haemothorax
Signs
Management
- Over 1.5L blood into the chest cavity
- Reduced air sounds, hyporesonance (contrasts tension)
- Obtain IV access because when you drain it they can bleed more into the space causing hypotension
Thoracotomy (indications >1.5L blood loss or >200ml/hr)
What is an open pneumothorax?
Wound to chest wall communicating with the pleural cavity. Needs to be 2/3 aperture of trachea. Air moves inwards but wound closes on way out creating a 1 way valve
Define flail chest
Fracture of 2 or more ribs in 2 or more places.
This creates a floating rib section that move paradoxically. This severely impairs ventilation.
Signs of a cardiac tamponade
Pathophysiology
Investigation?
Treatment?
Beck’s triad:
1) Hypotension
2) Diminished heart sounds
3) Distended neck veins
Penetrative trauma into the pericardium (cardiac box) which blood collects and compresses the heart causing the triad
USS
Thoracotomy and incision of the pericardium (removing fluid)
Life changing injuries on secondary survey
Simple pneumothorax Aortic injuries Diaphragmatic injuries Fractured ribs Lung contusion Cardiac contusion
Most accurate signs to show a bleeding patient in hypovolaemic shock
Others?
Tachypnoea
Pale
Sweaty
Anxious/ confused Tachycardiac Narrow pulse pressure CRT Hypotension Bradycardia - terminal sign
Sites for massive haemorrhage
Blood on the floor (external haemorrhage) and four more:
- Chest
- Abdomen
- Long bones
- Pelvis
Causes of abdominal bleeding
Signs
Investigation required
Treatment + indications
Blunt force trauma/ penetrating
Not always obvious. Peritonism is a late sign so scan
CT abdo required
Laparotomy/ interventional radiology Peritonism Radiological evidence of free air GI haemorrhage Persistant/ resistant haemodynamic instability
Treatment of pelvic fractures
Pelvic binders to push it back together
What is permissive hypotension?
Numbers?
Allow lower BP
MAP 50mmHg
Systolic 90mmHg
Why are crystalloids not used in trauma?
It doesn’t carry oxygen
High chloride content so causes hyperchloraemic acidosis
Indications for fluid administration in trauma?
Systolic pressure <90mmHG
HR >130mmHg
Reduced consciousness level
Obvious massive ongoing blood loss
How are patients volume resuscitated in trauma?
1 unit RBC
1 unit platelet
1 unit FFP
What is the sequence of management in massive haemorrhage?
Stop catastrophic bleeding Pelvic binder Splint long bone fractures Permissive hypotension Transexamic acid 1g over 10 mins the 1g infusion Emergent damage control surgery Interventional radiology Limit crystalloid
How is neurology assessed on the primary survey?
AVPU
GCS - particularly motor for outcomes
Pupillary response
Sensory level if able
What is the Cushing’s reflex?
Altered cardiac functioning from raised ICP (pre-coning and a very bad sign)
Raised ICP = Raised BP = baroreceptor stimulation = bradycardia
Management of head injuries
Prevent secondary brain injury
Secure airway in GCS less than 8 or control ventilation
Maintain normal - ICP, Glucose, Oxygen, CO2
What are the respiratory differences in the elderly?
Weak respiratory muscles Kyphotic T spine Rigid chest wall Reduced alveolar exchange surface area Impaired central response to hypoxia
What are the cardiovascular differences in the elderly?
Total body water reduces (preload)
Reduced vascular compliance and increased rigidity (afterload)
Myocardium becomes fat and collagen reducing contractility
All the above lead to reduced stroke volume
What drugs can cause falls?
Antihypertensives Opioids NSAIDs Sedatives Steroids Beta-blockers Anticoagulants (higher risk of bleeds on fall)
Diagnostic criteria for a UTI in the elderly?
New urinary symptoms or fever with:
- Change in urinary character
- or haematuria
- or loin tenderness
What are the types of pelvic fractures?
Which one is made worse by pelvic binders?
Lateral compression fracture - worse with pelvic binder
AP compression/ open book fracture
Vertical shear
What angles are required for a c-spine fracture?
How to structure interpretation
AP, lateral, odontoid peg (requires opening of mouth)
ABCS A - alignment of bony structures B - bones (any fractures) C - cartilage (any widening of spaces) S - Soft tissue
Indications for a CT head
GCS <13 at presentation
GCS<15 at 2 hours after injury
Suspected open or depressed skull fracture
Any sign of basal skull fracture
Post-traumatic seizure
Focal neurological deficit
More than one episode of vomiting since injury
What radiological method is used to rapidly assess for trauma?
What does it look at?
FAST scan (Focused assessment with Sonography in Trauma)
Cardiac region
Left upper quadrant - spleen
Suprapubic region - fluid in peritoneal cavity
What are the three core features of acute liver failure?
Epidemiology?
Jaundice, coagulopathy (INR>1.5), hepatic encephalopathy (absence of chronic disease and within 12 weeks for diagnosis)
Rare but serious
How to assess for hepatic encephalopathy
Hands outstretched and they start to flap
What are the classifications of acute liver disease?
What causes fit into each?
Worst prognosis?
Hyperacute - within 7 days:
- Paracetamol, drugs, viral hepatitis
Acute - 1 to 4 weeks:
- Viral hepatitis, ischaemic hepatitis
Sub-acute - 4-12 weeks (Worst prognosis):
- Seronegative hepatitis
- Autoimmune hepatitis