Acute medicine Flashcards
What are the types of injuryies seen in major trauma (4)
Blunt force - falling off motorcycle
Penetrative - e.g gunshot/knife
Sports injuries - open fractures/ splenic/ renal injuries
Blast injuries (explosive force)
Types of blast injury (4)
Primary - blast disrupts gas filled structures
Secondary - impact airborne debris
Tertiary - transmission of body e.g thrown against wall
Quaternary - all other forces e.g injured by fire
What does the ATMIST handover for emergency medicine stand for?
A - age
T - time
M - mechanism
I - injuries found/suspected
S - vital signs
T - treatment
How to manage Catastrophic haemorrhage
- Clear any clots obscuring bleeding source
- Direct pressure
- More direct pressure
- Indirect pressure (proximal source of bleeding)
- Torniquet
- Haemostatic agents (i.e. ceelox)
When is intubation absolutely indicated?
- Inability to maintain and protect own airway regardless of conscious level
- Inability to maintain adequate oxygenation with less invasive manouvres
- Inability to maintain normocapnia
- Deteriorating consciousness level
- Significant facial injuries
- Seizures
Timeframe for securing an airway
45 minutes
When is intubation relatively indicated?
- Haemorrhagic shock - presence of evolving metabolic acidosis
- agitated patient
- multiple painful injuries
- transfer to another area of hospital
When is a person high risk for C spine injury?
At least one of the following…
- Age 65 or older
- Dangerous mechanism of injury
- Paraesthesia in upper or lower limbs
When is a person low risk for C spine injury?
At least one of the following…
- Involved in minor rear-end motor vehicle collision
- Comfortable in sitting position
- Ambulatory at any time since injury
- No midline cervical spine tenderness
- Delayed onset of neck pain
- Unable to actively rotate their neck 45 degrees to left and right
Signs of tension pneumothorax
- Diminished breath sounds
- Hyperesonance
- Distended neck veins
- Deviated trachea
- Hypoxia
- Tachycardia
- Hypotension
Airway and c spine management (4)
-Immobilise the C-Spine*
-Provide oxygen
-Assess airway - Look, listen, feel
-Proceed to RSI if indicated
Open pneumothorax
- Wound to chest wall communicating with pleural cavity
- More than 2/3 aperture of trachea
- Air moves down pressure gradient into pleural space
- Wound seals on expiration
Tx for tension pneumothorax
Thoracostomy followed by large bore chest drain (if chest wall is too thick)
Needle thoracocentesis - 2nd IC space mid clavicular line
What is a massive haemothorax
Defined as over 1500ml blood in the lung space
Massive haemothorax what do you do if there is >1500ml blood or >200ml/hr
consideration urgent thoracotomy
What is the triad of cardiac tamponade?
Beck’s triad
* Hypotension
* Diminished heart sounds
* Distended neck veins
What is flail chest
Fracture of 2 or more ribs in 2 or more places causing ventilators failure
Treatment of flail chest
Intubation to help ventilation
What is the treatment of cardiac tamponade?
Pericardiocentesis
Secondary survey injuries - (ones that wont kill you immediately)
Simple pneumothorax
Aortic injuries
Diaphragmatic injuries
Fractured ribs
Lung contusion
Cardiac contusion
Signs of a bleeding patient
- Sweaty/diaphroetic
- Anxious/confused
- Pallor/periopherally cold
- Tachycardia
- Tachypnoea
- > CRT
- Narrow pulse pressure
- Hypotension
- Bradycardia
- Arrest
Places you can bleed to death from: (‘Blood on the floor and 4 more’)
- External haemorrhage
- Chest
- Abdomen
- Pelvis
- Long bones
Indications for emergency laparotomy
- Peritonism
- Radiological evidence of free air
- GI haemorrhage
- Persistent/resistant haemodynamic instability
What are the long bones in the body?
- Humerus
- Femur
- Tibia
- Metacarpals
- Fibula
- Radius
Bold ones = clinically important (vascular so can bleed more from these)
Blood product administration in trauma: what do you give?
- Blood for blood
- Clotting factor
- Tranexamic acid
What is a pelvic binder
Aim to reduce and stabilise pelvic fractures and stop bleeding e.g sheet and cable ties
Triangle of death in acute medicine
Coagulopathy
Acidosis
Hypothermia
Indications for blood product administration in trauma
- Systolic blood pressure < 90
- HR > 130mmHg
- Reduced consciousness level
- Obvious massive ongoing blood loss
Indications for blood product administration in trauma (4)
Systolic blood pressure <90*
HR >130mmhg
Reduced conscious level
Obvious massive ongoing blood loss
How to stop bleeding in trauma
Pelvic binder
Splint long bone fractures
Permissive hypotension
Tranexamic Acid 1g 10min then 1g infusion
Emergent damage control surgery
Interventional radiology
Limit crystalloid
Categories of head injuries
Primary injury:
* the incident
Secondary injury:
* hypoxic injury
* hypoperfusion
* hypoglycaemia
Assessment of neurology in primary survey injury (4)
-AVPU
-Pupillary size and response
-Motor score of GCS most predictive outcome
-Sensory level if able
What is Cushing’s triad?
ICP rise
- Hypertension
- Bradycardia
- Irregular breathing
How to manage head injury
- Prevent secondary brain injury
- Secure airway (GCS < 8 or need to control ventilation)
- Maintain normal ICP/Glucose/O2/CO2
What is done in an Exposure of A-E
-Look for limb threatening injuries
-Ensure patient is kept WARM
-consider bedside test e.g x rays
-pain relief
Reversible causes of cardiac arrest (4)
HOTT
-hypovolemia
-hypoxia
-tension pneumothorax
-cardiac tamponade
What is a FAST scan
Focused assessment with sonography in trauma
-where quick assessment of patients condition is necessary/ when CT scan is delayed
What is flail chest associations
Marker for chest trauma:
Pulmonary contusion/ laceration
Pneumothorax
Haemothorax
Complications of pelvic fracture
-retroperitoneal haemorrhage
-bladder/uretheral rupture
-perforation
What are the 3 types of pelvic fracture?
- AP compression - ‘open book’ fracture
- Vertical shear - unilateral pubic rami fracture
- Lateral compression
What is a pelvic open book fracture
Pelvis is opened up due to disruption to the pelvic ring spreading the pubic symphysis and/or fractures pubic rami
How does open book pelvic fracture usually occur
Anteroposterior compression force
What is pelvic vertical shearing injury
-vertical, unilateral fractures of the pubic rami
-vertical fracture of the sacral foramina on the same side
What is a malgaigne fracture
A vertical shear fracture involving one side of the pelvic ring
-usually caused by high energy vertical shear force e.g motor vehicle accident
What is bucket handle fracture
A pelvic ring injury characterized by fractures or disruptions on opposite sides of the pelvis.
-usually caused by lateral compression force such as side impact motor vehicle collision
What is a Jefferson fracture
Fracture to C1 (atlas)
-a burst fracture due to C1 ring is disrupted in multiple places
Cause of Jefferson fracture
Axial compression
-e.g diving head first into shallow water
What is hangmans fracture
The fracture involves the pedicles of C2 and often results in anterior displacement of the body and peg of C2.
-caused by hyperextension and axial loading
What is a flexion teardrop fracture
-Fracture of the cervical spine caused by sudden pull of the anterior longitudinal ligament on the anterior.
inferior aspect of the vertebral body
-due to extreme hyperextension of the neck
What is a Burst fracture
Axial loading most often due to motor vehicle accidents - cause severe compression.
-leads to bin fragments being displaces into the spinal canal - lead to nerve damage
When do you use body CT
Common visceral inJuries e.g spleen, liver , kidney
Gold standard imaging for trauma
CT
Indications for a CT in trauma
1.Haemodynamic instability
2.Mechanism of injury — more than one system/body part
3.Findings on plain film/FAST scan are inconclusive or suggestive of injury.
4.Obvious severe injury
What age counts as an ‘older patient’
over 65
What is the difference in mechanism of injury between younger and older patients?
- Younger: usually road traffic collisions, blows, shooting/stabbing
- Older: usually falls (< 2m = falling from standing)
What is physiologically different regarding respiratory system in older patients?
- Increased chronic resp illnesses (COPD, emphysema, lung cancer)
- Lower chest wall compliance (makes ventilation more difficult)
- Higher rates of kyphosis (reduces space for lung expansion = reduces ventilation)
- All of above = higher risk of hypoxia & hypercapnia
What is physiologically different regarding cardaic system in older patients?
- HTN & orthostatic BP changes
- Reduced cardiac output
- Increased vascular resistance (due to ‘stiff’ vessels/ atherosclerosis)
- Heart failure
What is physiologically different regarding neurological system in older patients?
- Dementia - makes Hx taking difficult, pt doesn’t remember falling
- Brain atrophy = more space for bleeding without mass effect (worsened by alcohol use)
How can frailty lead to trauma?
- Fragile skin = significant tearing with even minor mechanisms
- Brittle bones = osteoporosis
- Prone to infection = can cause falls
- Polypharmacy = increased falls risk
- Reduced mobility = increased risk of rhabdomyolysis, pressure damage & hypothermia
What is shock?
Circulatory failure
* tissue hypoperfusion
* energy deficit
* accumulation of metabolites
What is the pathophysiology of shock?
Inadequate perfusion -> cullular hypoxia -> energy deficit -> lactate build up -> metabolic acidosis -> cell memb dysfunction -> intracellular lysosome release -> toxic substances enter circulation -> capillary endothelial damage -> further destruction/dysfunction/cell death
Causes of shock?
Think of plumbing: fluid, pump, pipes…
Fluid:
* Hypovolaemic
* Haemorrhagic
Pump:
* Cardiogenic - ischaemic, arrhythmia
* Obstructive - tension PTX, PE, tamponade
Pipes:
* Distributive - neurogenic, endocrine
* Septic
* Anyphylactic
How do you treat hypovolaemic shock?
- Fluid +++
- Vasopressor ++
- Inotrope -
How do you treat septic/anaphylactic shock?
- Fluid ++
- Vasopressor ++
- Inotrope +/-
How do you treat cardiogenic shock?
- Fluid +/-
- Vasopressor -
- Inotrope ++
What are the 5 Rs of prescribing IV fluids?
- Resuscitation
- Routine maintenance
- Replacement
- Redistribution
- Reassessment
Who is exempt from receiving IV fluid therapy as per the NICE guidelines?
These people require more specialist fluid therapy
- < 16
- Pregnant
- pt receiving inotropes
- Burns
- Severe liver / renal disease
- Diabetes
What is the distribution of fluid in the body?
- Total body weight - 42L
- Intracellular fluid (2/3 of TBW) - 28L
- Extracellular fluid (1/3 of TBW) - 14L
- Interstitial fluid (2/3 of ECF) - 9L
- Intravascular fluid (1/3 of ECF) - 5L
Definition: Osmolality
osmoles per kg of solvent
Definition: Osmolarity
osmoles per L
Definition: Tonicity
Ability of a solution to cause water movement
What are the 2 types of fluid?
- Crystalloids
- Colloids
Give 3 examples of crystalloids
- 0.9% saline
- Hartmann’s solution
- Dextrose (5%,10%)
Give some artificial and organic examples of colloids?
Artificial:
* Gelofusine
* Hetastarch
Organic:
* Blood
* Albumin solutions
What does vomiting lead to?
- Loss of H+ ions and chloride along with fluid
- Leads to hypochloraemic alkalosis
Causes of resp failure
Atelectasis:
* pneumonia
* anaesthesia
* lying down
Fluid:
* oedema
Bronchoconstriction:
* asthma
* copd
What causes low O2
V/Q mismatch
What does biPAP
Device that provides both expiratory and inspiratory positive airway pressure - used in type 2 respiratory failure
When can’t you use non invasive ventilation
Asthma - because gas is already trapped
Pneumothorax
Agitation - pulling mask off constantly is a CI
Airway loss - actelasis
What are EPAP and IPAP used for
EPAP used for improved impaired oxygenation
IPAP used for improving CO2 levels
Stages of AKI
Stage 1 creatinine increase of 1.5x above baseline
OR <0.5ml/kg/hr for greater than 6 hrs
Stage 2 creatinine x2
OR <0.5ml/kg/hr for greater than 6 h
Stage 3 creatinine x3
OR <0.3/kg/hr for greater than 24hrs
OR Anuria for less than 12 hrs
OR Renal replacement therapy
What is the cause of acute interstitial nephritis (renal cause of AKI)
NSAIDS
Contrast - directly toxic to tubules
Gentmimicin - directly toxic to tubules
Causes of obstruction that lead to AKI
Masses e.g BPH
Renal Stones
Most common cause of reduced urine output post surgery
Hypovolemia
Uteric stone main modality of imaging
CT KUB (kidney, ureter, bladder)
What is sepsis?
Life threatening organ dysfunction caused by dysregulated host response to infection
In the case of any poisoning/ overdose what key pieces of info would you need ? (5)
- What was taken
- When was it taken - exact timing
- Why was it taken - accidental/intentional
- How much was taken
- Were there any co ingestants e.g alcohol
What is a staggered overdose
Overdose where doses have been taken more than an hour apart
Which organ is principal site of paracetemol toxicity
Liver
Secondary - kidneys ( acute tubular necrosis / CNS (encephalopathy)
How long does it take for paracetemol toxicity to occur
- Liver damage typically starts 12–24 hours post-ingestion
- Peaks at 72–96 hours
Which patietns are at particular risk of liver damage in paracetemol overdoses (5)
-Chronic alcohol use
- Malnourished or fasting
- On enzyme-inducing drugs (e.g., phenytoin, carbamazepine, rifampicin, St John’s Wort)
- Pre-existing liver disease
- Very young or elderly
Give some examples of enzyme inducing drugs (4)
phenytoin
carbamazepine
rifampicin
St John’s Wort
Why are paracetemol levels taken 4 hours post ingestion
The 4-hour level is when plasma paracetemol concentration peaks - so is not falsely low
What is the management for someone post 8 hours of ingestion
Start N-acetylcysteine treatment immediately
How does NAC work
- Replenishing glutathione in the liver
- This detoxifies the toxic metabolite NAPQI (which causes hepatocellular injury)
- Also improves hepatic perfusion and may limit injury even after toxicity has begun
When would you start NAC before seeing paracetamol level (4)
-More than 8 hours have passed since ingestion
-unsure of ingestion time
-staggered overdose
-levels in plasma not readily available
What is the most sensitive blood test to test for liver function
INR/ prothrombin time
Time frame for NAC to be given
Within 24 hours post ingestion
What should you do if patietn starts flushing and vomiting during NAC treatment
-initially stop
-if sysmtoms resolve start at a lower rate
