Acute Medical and Surgical Emergencies Flashcards
What is the initial approach to an acutely unwell patient?
Ask the patient “How are you?” A normal verbal response means that the patient has an intact airway, is breathing and his brain is adequately perfused. If patient can speak only a few words or phrases sentences then there is likelihood of severe respiratory distress.
Get Help: Pulse oximetry, Blood pressure measurement, ECG monitor
If there is no response or reduced response: this indicates serious illness and you should fully assess in seconds.
Use ABCDE Approach: Airway, Breathing, Circulation, Disability, Exposure
How do you assess the airway in the A-E approach?
LOOK FOR:
Obstruction: blood, vomit, secretions, tongue, foreign body, dentures, neck constriction (collar, rope)
Symmetrical movement of both sides of chest? chest deformity
paradoxical see-saw abdomen/chest movement (normally chest/abdomen move outwards in expiration and vice versa, in complete airway obstruction chest/abdomen moves in on inspiration and outwards on expiration
Use of accessory muscles of respiration. (Sternocleidomastoid and muscles of the neck back and shoulder girdle).
Sweating and central cyanosis.
Depth of respiration
How do you assess the airway in the A-E approach?
FEEL FOR:
Presence of air movement at the mouth by placing your face or hand immediately in front of the patient’s mouth.
Position of the trachea in the suprasternal notch as deviation to one side may be due to tension pneumothorax, lung fibrosis or pleural fluid.
Surgical emphysema or crepitus (assume that this is pneumothorax until proved otherwise).
Percuss the chest as hyper resonance indicates pneumothorax, dull percussion note may be due to pleural fluid.
How do you assess the airway in the A-E approach?
Listen at mouth and Nose:
In complete upper airway obstruction, there are no breath sounds at the mouth or nose
In partial airway obstruction, air entry is diminished and often noisy
How do you manage the airway in an emergency?
Call for expert help immediately.
Clear Airway: simple methods of airway clearance usually suffice e.g. Head tilt and chin lift or jaw thrust if cervical injury suspected. Airway suction and insertion of an oropharyngeal (Guedel) or nasopharyngeal airway will suffice.
Clear Obstruction: suction to help clear blood, vomit, secretions, tongue, and foreign body. Retrieve dentures if obstructing otherwise leave in.
Surgical cricothyroidotomy: rarely indicated, by a trained individual.
Oxygen at high concentration: use a face mask with an oxygen reservoir. Ensure that the oxygen flow rate is sufficient (usually 10- 15 liters per minute) to prevent collapse of the oxygen reservoir during inspiration. This system will deliver approximately 85% Oxygen.
How does the position of the trachea change with pneumothorax, effusion and collapse? What will you find on percussion? How will you be assessing the chest in a respiratory examination?
Compare expansion right and left, depth of breathing, tracheal position, paradoxical breathing?
Tension Pneumothorax: tracheal away from side of pneumothorax, hyper resonant, suitable history or injury
Effusion: dullness to percussion, trachea away from effected side
Collapse: dullness to percussion, trachea towards the side of collapse
How do you manage a pneumothorax?
If pneumothorax diagnosed then consider treatment with wide-bore venous cannula in second intercostal space mid-clavicular line. Expert help will be needed in most cases.
What are you assessing in circulation?
Blood Pressure (absolute value and any change from recent more stable state)
Pulse: tachycardia > 100, bradycardia < 60
Capillary return: ? Cool, cyanosed, mottled-centrally and peripherally suggesting poor perfusion. Capillary refill (less than 2-3 seconds)
Peripheral temperature and peripheral pulse
Major Pulses: Assessment of both radials/ brachials /carotids pulses and aorta
Urine output in the last 4 hours.
(Abnormal OLIGURIA if Urine volume <0.5ml/kg/hour)
How do you assess disability in A-E?
Disability Assessment is basically a global assess from a neurological standpoint with the usual addition of a glucose assessment at the bed-side and lab value
AVPU
GCS
How do you assess E in the A-E assessment?
Urgent Observations:
BP, Pulse, Respiratory rate, temperature, oxygen saturations, (MEWS)
Urine output:
“output” from body: bleeding, discharge,
secretion
History: Full history is essential from health care professionals, clinical notes and family. Drug chart must be reviewed together with charts on IV fluid infusion or blood transfusion. Usually a quick physical examination will need to be undertaken to diagnose or exclude the main causes of acute illness listed in the
Examination:
Full general and systems examination: ABCD and pupils as above but specifically look for signs of meningitis or meningococcal septicaemia: purpuric rash, neck stiffness
Look at wounds and all drains and any intervention sites e.g. venous cannulae, urinary catheter, CVP line, central line, arterial line etc.
DDx head
Stroke: cerebral, brainstem, Cerebral bleed esp. Subarachnoid Meningitis, encephalitis Epileptic seizure Alcohol or illicit drugs Poisoning: carbon monoxide, overdose e.g. paracetamol, tricyclics, opioids
DDx thorax
Respiratory Tract Infection
Pneumothorax
Pulmonary Embolus
DDx cardiac
Acute Coronary Syndrome Cardiac Failure DVT or PE Severe Hypotension or severe hypertension with encephalopathy Arterial Insufficiency or occlusion:
DDx Infections, Inflammation, Injury
Infections: Sepsis (e.g. UTI, cellulitis, cholecystitis), malaria
Abscess
Meningitis
Trauma: fracture, tissue injury, burns, hypothermia, heat stroke
Anaphylaxis or allergic reaction
DDx Na, K, Glucose, Ca, Cortisol, Thyroid
Acidosis or Alkalosis Hypoglycaemia or Hyper Hyponatraemia or hyper (metabolic encephalopathy) Addison’s Hypocalcaemia or hyper Thyrotoxic crisis
DDx Kidney and Abdomen
Acute Abdomen
Acute Renal failure
Acute Liver Failure
Bleed: GI tract, Aortic aneurysm
What are the 8 causes of reversible cardiac arrest?
4 Hs and 4 Ts Hypoxia Hypothermia Hypovolaemia Hyperkalaemia: hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia, and other metabolic disorders.
Tension pneumothorax Tamponade Toxins Thrombosis: pulmonary embolism or coronary thrombosis
Causes of upper abdominal pain
Liver: Any condition stretching Glisson’s capsule, e.g. Hepatitis, CCF, Liver metastases.
Biliary system: Acute Cholecystitis, Biliary Colic and Cholangitis.
Oesophagus: Spontaneous rupture (Boerhaave’s Syndrome).
Stomach and duodenum: Peptic ulcer perforation or bleed, acute gastritis, Gastric volvulus, Hiatus hernia, gastric cancer (rare).
Spleen: Injury, Rupture, Torsion (rare), Infarction.
Causes of lower abdominal and pelvic pain
Small Bowel: Obstruction, Perforation, Ischemia, Meckels’ diverticulitis, Crohn’s disease.
Large Bowel: Colitis (Ulcerative Colitis, Crohn’s colitis, Pseudo-membranous colitis), Diverticulitis, Ischemia, Perforation, Pelvic abscess, volvulus
Appendix: Acute appendicitis and Perforation.
Omentum: Torsion and Ischaemia.
Reproductive organs: Mid-cycle pain (Mittelschmerz), Ovarian torsion, ruptured ectopic pregnancy or ovarian cysts, Pelvic inflammatory disease, Fibroids in uterus, salpingitis, tubo- ovarian abscess and Testicular tortion.
Hernias: Strangulation (Epigastric, Paraumbilical, Spigelian, inguinal and femoral.
Systemic causes of abdominal pain
Diabetic ketoacidosis, Mesenteric adenitis (Yersinia pseudotuberculosis infection), Mesenteric thrombosis, Porphyria, Familial Mediterranean fever (autosomal recessive condition), Sickle cell crisis, Phaeochromocytoma
What are the three phases of management?
Phase 1 initial management: 1st hour
Phase 2: 2-6 hours
Phase 3 on-going management
Acute abdominal pain phase one management
Clinically: History, Examination focus on Respiratory rate, temp, BP, pulse, oxygen sats, Glasgow Coma Score, MEWS.
Investigations: ECG, erect chest x-ray and abdominal x-ray, urine dipstick, pregnancy test if female, bloods (FBC, U&Es, Creatinine, LFTs, CRP, ESR) and blood group.
Oxygen via mask and non-rebreathing bag (100%) if sats <92%.
Analgesia: Morphine 10mg IV or IM.
Start IV fluids (if dehydrated) or colloids (if hypotensive).
NG tube with Metoclopramide 10mg IV if patient is vomiting
More intensive monitoring: catheter (hourly input/output chart).
Nil by mouth and hourly observations/MEWS.
Acute abdominal pain phase two management
Continue to monitor patient and give analgesia and fluids as above.
Start antibiotics if indicated from test results.
Suspected pancreatitis: ABG and assess GCS (score >2 urgent ITU review).
Suspected renal colic: CT KUB or IVU. Monitor for complications
(obstruction). Continue fluids and analgesia.
If surgery indicated, cross match for 2-4 units blood.
Suspected AA: urgent referral to on-call vascular.
Suspicious ECG: urgent medical advice.
Unknown cause: further imaging (CT, USS).
Acute abdominal pain phase three management
Most respond to conservative approach.
Definitive management:
Laparotomy (where all other possibilities failed to improve patient).
Laparoscopy (reduce need for laparotomy) to diagnose pathologies: to view appendix, uterus, ovaries, fallopian tubes etc.
Laparoscopy for cholecystectomy, appendectomy, closure duodenal ulcer perforation etc.
Drainage of localised abscess or abdominal/pelvic collections – send sample for culture and biopsy.
What is the phase one management of an Upper GI bleed?
Clinical History: previous UGIB, dyspepsia, known peptic ulcers, liver disease, weight loss, drugs (NSAIDs, Aspirin, Corticosteroids, COX - 2 inhibitors, bisphosphonates) and co-morbidities.
Clinical Examination: assess for signs of shock, evidence of chronic liver disease and other co- morbidities such as heart and renal failure. ? telangiectasia due to Hereditary Haemorrhagic Telangiectasia
Resuscitation: 2 large bore IV cannulas are inserted. IV fluids (colloids or crystalloids), avoid crystalloids in patients with cirrhotic ascites. Blood transfusion if Hb <10g/dl and patient in shock or active heavy bleeding, otherwise wait for FBC results.
Investigations: full blood count, blood group and save, LFTs, U & Es, coagulation screen, AXR and CXR if suspected ruptured peptic ulcer. Consider ECG if patient has history of IHD or heart failure.
Monitoring: patients with significant bleeding need continuous cardiac monitoring, and those with shock might need CVP and renal function monitoring.
What investigation should you consider in an Upper GI bleed, pertaining to phase 2 management?
Consider Oesophageal-gastro-duodenooscopy (OGD): Use Rockall Score (pre- OGD); score of 0, consider no admission or early discharge. If the score is > 0, endoscopy required in most cases after resuscitation. Or use Glasgow Blatchford Score: greater than 3 consider OGD.
What are the pharmacological therapies used in the phase two management of an Upper GI bleed?
Start a proton pump inhibitor: there is only minimal evidence that pre- endoscopic PPI improves the clinical outcome. Most clinical protocols include their use at this stage. IV PPI eg omeprazole 80mg bolus followed by 8mg/hr infusion for 72 hrs in patients with high risk ulcers on OGD i.e. active bleeding, non-bleeding visible vessel or adherent clot.
Intravenous Terlipressin or similar agent: prior to endoscopy in acute variceal bleeding. 2mg then repeated at 4 hour intervals up to 72 hrs.
Start antibiotics: preferably iv ceftriaxone or oral norfloxacin, in patients with chronic liver disease presenting with acute UGIB.
Describe V/Q mismatching in respiratory failure
Low V/Q – despite adequate perfusion some areas of lung are poorly ventilated, therefore some blood leaves the pulmonary circulation without being adequately oxygenated (physiological shunt).
High V/Q – despite adequate ventilation some areas of lung are poorly perfused.
How many types of respiratory failure are there? Describe these.
Type 1 respiratory failure: Is defined as hypoxia (PaO2 < 8 KPa) with normal or low PaCO2. It is primarily caused by ventilation/perfusion (V/Q) mismatch.
Type 2 respiratory failure: Is defined as hypoxia (PaO2 < 8 KPa) with hypercapnia (PaCO2 >6 KPa). This is caused by alveolar hypoventilation, with or without V/Q mismatch.
What are the symptoms of respiratory failure?
shortness of breath, cough, haemoptysis, chest pain or tightness, wheeze, stridor,
What are the signs of respiratory failure?
cyanosis, tachycardia, tachypnoea, hypotension, reduced respiratory rate (?opioid overdose, check pupil size), unable to speak in full sentences, agitation.
What is paradoxical respiration?
all or part of a lung is deflated during inhalation and inflated during exhalation, such as in flail chest or paralysis of the diaphragm.
What is kussmaul’s breathing?
deep rapid breathing as seen in respiratory acidosis.
what accessory muscles are used to aid breathing?
Use of accessory muscles of respiration – including intercostal muscles, neck
muscles and abdominal wall muscles.
What is Cheynes Stokes breathing?
breathing with rhythmic waxing and waning of
depth of breaths and regularly recurring apnoeic periods.
What is flail chest?
chest wall moves paradoxically with respiration, owing to
multiple fractures of the ribs post-trauma.
What are the causes of T1RF?
Parenchymal disease (V/Q mismatch) – Pulmonary Embolism Pneumothorax Pulmonary oedema Arrhythmia Congestive heart failure Acute lung injury
Interstitial lung disease Acute Respiratory Distress Syndrome Pneumonia Fibrotic lung disease Bronchiectasis
What are some causes of T2RF?
Reduced breathing effort
Fatigue, drug intoxication
Neurological disease, head injury
Inability to overcome increased resistance to breathing Asthma or COPD Cardiac Failure Foreign body Tumour
Decrease in area of lung available for gas exchange: COPD, emphysema Chest wall deformity Primary muscle disorders A combination of these factors
How is pneumonia diagnosed?
Systemic features: at least one (fever >38°C, rigors, malaise, sweating, aches & pains, confusion, diarrhea).
Tachypnoea: especially if the respiratory rate is greater than 30.
Cough: dry or productive with purulent sputum / haemoptysis. Other
features include pleuritic pain.
New focal chest signs on examination: such as bronchial breathing, coarse
crackles, increased vocal fremitus/resonance, pleural rub and pleural
effusion.
New radiographic shadowing: for which there is no other explanation such
as pulmonary oedema or infarction.
What is pneumonia?
Pneumonia is defined as an inflammation of the lung parenchyma. It is characterized by the presence of exudate, inflammatory cells and fibrin in the alveolar air spaces with consolidation of the affected part usually caused by infection with bacteria, viruses, fungi and parasites.
