Clin Assess Flashcards
What is more common, LE or UE injuries?
LE
What are the 2 most commonly injured blood vessels?
femoral and popliteal
Which is more damaging, GSW or stabbing?
GSW
What are signs of vascular trauma (6)
- absent/diminshed pulses
- obvious arterial bleeding
- large expanding hematoma
- audible bruit
- palpable thrill
- distal ischemia
What should you do if there definitely is a vascular injury to an extremity?
Vascular consult ASAP!
What should you do if you are highly suspicious of a vascular injury?
CT angiography
What should you if there are no signs of a vascular injury but you want to r/o?
ABI
What are some additional tests you can order when concerned for vascular bleeding?
- creatinine (before CT with contrast)
- CBC (if significant blood loss)
- xray (if concerned about fx)
What is a complete disruption of joint?
dislocation
What is a partial dislocation of a joint?
subluxation
What is a tearing injury of muscle fibers called?
strain
What is a tearing injury of ligament called?
sprain
Patient presents with unilateral swelling in leg, pain out of proportion, discoloration, decreased pulses and coolness?
compartment syndrome
What is the first step in an orthopedic PE?
Inspection!
What is the second step in an orthpedic PE?
Palpation (check for bony step-off, extend palpation area beyond location of pain– pain may be referred)
What nerve controls the pinky and half of ring finger?
ulnar nerve
what nerve controls half the ring finger to the thumb
median
What nerve controls the base of the thumb?
radial
What nerve controls most of the top of the foot?
superficial fibular
Which nerve has the lateral side of the foot?
dorsilateral cutaneous nerve
Which nerve only has half the big toe and half the next toe?
deep fibular
Which nerve has the medial malleolus and above?
saphenous
What are different ways of describing a fracture? (6)
- open v closed
- location (midshaft, distal, proximal, intra-auricular)
- orientation of fracture line (transverse, oblique, spiral)
- displacement and separation
- shortening
- angulation
What are steps you should take in the ER for someone with a fx?
- control pain and swelling
- withhold oral intake (if surgery)
- reduce fx deformity
- reduce dislocation
Why should you redice fx deformity?
- alleviates pain
- relieve tension on nerves/vessels
- minimize possibility of inadvertently closed changing to open
- restore circulation to pulseless distal extremity
What should you always do when reducing a joint?
get pre and post xrays
When should you use a shoulder immobilizer? (4)
- clavicle fx
- AC separation
- shoulder dislocation
- humeral head fx
When should you use an arm sling? (2)
-non-displaced radial head fx
When should you use a long-arm gutter? (2)
- elbow fx
- elbow dislocation
When should you use a sugar tong? (1)
-wrist/forearm fx
When should you use a short-arm gutter? (1)
metacarpal/proximal phalanx fx
When should you use a thumb spica splint?
scaphoid, thumb, metacarpal
When should you use a knee immobilizer? (4)
- patellor fx/subluxation
- knee dislocation
- tibial plateau fx
- knee ligament/meniscus injury
When should you use a posterior ankle mold? (4)
- ankle dislocation
- unstable fx
- widened medial mortise
- metatarsal fx
When should you use an ankle stirrup? (2)
- simple ankle sprain
- stable lateral malleolus fx
When should you use a hard-soled shoe? (1)
toe fx
When should you use a short-leg walking boot?
toe/foot fx with wt-bearing allowed
What are discharge instructions you should give someone with an orthopedic injury?
- rest
- elevate (above heart)
- ICE (keep splint dry)
- no weight-bearing until ortho
- pain meds prn
when should a patient call/return immediately? (3)
- pain severe/worsening
- numbness is new/worsening
- skin discoloration (dusky toes)
What are delayed complications of an orthopedic injury?
- fat embolus
- non-union/malunion
- joint stiffness
- traumatic arthritis
- avasculuar necrosis
- osteomyelitis
What does a BMP give you info on?
- kidneys
- electrolyte balance
- acid/base balance
- blood glucose
- Ca levels
What does an elevated Ca concern you for?
- Malignancy
- hyperparathyroid
What does a low CO2 concern you for?
- Acidosis
- possible ketoacidosis (esp of low K and high glucose)
What does a low glucose concern you for?
- insulin OD
- sepsis
What does an elevated BUN AND elevated creatinine concern you for?
renal failure
What does an elevated BUN and normal creatinine concern you for?
diureased
What does the CMP have?
Everything the BMP has PLUS:
- Albumin
- Alka phos (ALP)
- total bilirubin
- total protein
- LFT’s
What are reasons to order CMP?
- LFT’s (alcoholics)
- Nutritional status (albumin, total protein)
What does a low albumin worry you for?
malnutrition
What does an increase in alk phos worry you for?
gallstones
What does an increase in AST/ALT worry you for?
hepatitis
What does an increase in bilirubin concern you for?
cirrhosis, hepatitis
What does a low RBC, hemoglobin, hematocrit worry you for?
- blood loss
- anemia
What does a high RBC, H/H concern you for?
- hemoconcentration due to DEHYDRATION
- polycythemia
What does a CBC WITH DIFF show you?
breakdown of WBC’s into types
What is the most abundant type of WBC normally?
Neutrophils
What does a low platelet count concern you for?
- acute infection
- BLEEDING
- DIC
- HELLP (preeclampsia in PG lady)
What does an increase in neutrophils concern you for?
BACTERIAL infection
What does a decrease in neutrophils concern you for?
Widespread infection (left shift)
What does an increase in lymphocytes concern you for?
VIRAL infection (mono, mumps, measles)
What does an increase in eosinophils concern you for?
acute allergic reaction
What does a VERY elevated eosinophil level concern you for?
parasitic infection
What urine glucose level concerns you for uncontrolled DM or possible DKA?
urine glucose over 130 with ketones
What do positive nitrates and leukoesterase on UA concern you for?
UTI
What if someone has UTI sxs but negative nitrates and leukoesterase on UA?
interstitial cystitis
What does metabolic acidosis concern you for?
DKA
What does metabolic alkalosis concern you for?
vomiting
What does resp. acidosis concern you for?
hypoventilation (PE, pna, COPD, heroin)
What does resp. alkalosis concern you for?
hyperventilation (PE, anxiety, pain, febrile illness)
What is present with DKA?
serum and urine ketones
What should you measure to monitor DKA tx response?
capillary blood ketones
What does a d-dimer measure?
fibrin content
What is d-dimer a good test for?
RULING OUT PE in pt w/low risk factors
Why is BNP secreted?
In response to volume overload/myocardial stretch
What is BNP used for?
CHF detection
What are cardiac troponins?
They are essential proteins in cardiac muscle contraction
What happens to troponins during myocardial injury?
extracellular leakage of troponins
What is the biomarker of choice, troponins or CK-MB?
troponins
What is considered an early presentation of someone with chest pain?
w/n 6hrs of sxs
What test do you order to monitor warfarin effect?
PT/INR
What pathway does PT/INR evaluate?
EXTRINSIC
What is the extrinsic pathway responsible for?
Most pro-coag activity (TF, factor VII)
What does coumadin do?
Inhibits Vit K (II, VII, IX, X)
What do you order to monitor heparin?
PTT (partial thrombin time)
What does PTT evaluate?
INTRINSIC pathway
What is the role of the intrinsic pathway
Involved in procoag activity related to inflammation and innate immunity
How soon will a monospot test become positive?
2-6 weeks after onset of sxs
What can cause a false-pos monospot test?
- toxoplasmosis
- rubella
- lymphoma
- malignancies
What can cause a false-neg monospot test?
testing too early
Which pathogen does rapid strep test detect?
Group A streptococci
What influenza strains do influnza swabs detect?
Both A and B
When should influenza swabs be done?
ASAP to start of sxs
What secretes amylase? and why?
salivary glands and pancreas to digest starch
Shat secretes lipase? and why?
Pancreas to breakdown dietary fats
What is the most specific pancreatic enzyme?
lipase
What are the 2 most common ED complaints?
- chest pain
- abd pain
Where is the glottis located in normal adults?
level of FIFTH cervical vertebrae
What are pre-op airway assessments (6)
- Mallampati classification
- Neck ROM
- TMD (3 finger lengths between hyoid bone and chin)
- mouth-opening
- Teeth
- Bones
What is the usual cause of airway obstruction?
tongue
How can you get that damn tongue out of the way?
Chin lift/jaw thrust
How if chin lift/jaw thrust doesn’t work and that tongue is still obstructing the shit out of the airway?
oral/nasal airway is next step
What, other than the tongue, can also cause airway obstruction?
dentures
Who are ORAL airways NOT good for?
people with gag reflexes
What can happen if an oral airway is poorly sized/improperly inserted?
can worsen obstruction
What are 2 oral airway insertion techniques?
- tongue depressor
- insert and rotate
Why are nasal airways sometimes better than oral airways?
less stimulating, better tolerated
What is the most common complication from nasal airways?
hemorrhage
What are relative contraindications to using nasal airways?
- coagulopathies
- head trauma
Who should you def not use nasal airways in?
someone taking anticoag
What are some advantages to using a laryngeal mask airway? (6)
- allows one-handed ventilation
- forms seal around larynx
- less stimulating than ETT (asthma, CAD)
- less S/T
- less risk eye/facial nerve injury
- helps w/difficult airway
What are contraindications to using LMA? (7)
- suspected gastric contents/acute abd
- gross obesity
- PG
- thoracic injury
- heavy opiate intox
- hiatal hernia
- low pulm compliance
What are insertion techniques for LMA?
- LMA held in DOMINANT HAND like pen
- confirm placement iwth BBS and ETCO2
What should ventilatory pressure not exceed with LMA? and why?
20mm (risk aspiration)
What are indications for ETT? (9)
- controlled ventilation
- compromised/inaccessible airway
- failure of other methods
- aspiration risk
- PG
- airway disease/distortion
- lack gag reflex
- surgical procedure
- various positions
What are contraindications to using ETT?
No contraindications
What is monitoring equipment?
- pulse ox
- BP gauge
- cardiac monitor
What are some oxygenation equipment?
- O2 source and tubing
- face mask
- anesthesia bag or self-inflating amby bag (HIGH FLOW)
- suction catherter w/Yankauer tip
What classifies as high flow?
10-15L
What do you call a curved laryngscope blade?
Macintosh
How does a Macintoch blade work?
top of blade rests of valecular and epiglottis and lifts INDIRECTY
What do you call a straight laryngyscope blade?
Miller/Wisconsin
How do straight blades work?
Tip instered below epiglottis and lifts DIRECTLY (long-floppy epiglottis)
What cuff pressure should ETT tubes not exceed?
25 torrs
What length should ETT tubes be for females?
7-7.5
What length should ETT tubes be for males?
7.5-9
What are some equipment for verifying tube position?
- stethoscope
- CO2 detector/end-tidal CO2 monitor
- esophageal syringe
- CXR to confirm placement (REQUIRED)
How should you always hold a layngscope?
in LEFT hand
Why are stylets helpful?
allow curvature of ETT to be customized
What is a risk with stylets?
can cause trauma (LETHAL!)
What position should a patient be in for tracheal intubation?
sniffing position
What is sniffing position?
- enables alignment of axes of patients mouth for direct visualization of larynx
- moderate head elevation (7-10cm) and extension of A/O joint accomplishes flexion of lower CS and extension of upper CS
How should you open a patients mouth?
scissor maneuver
What are some common mistakes made when intubating? (3)
- Inserting blade too far– into esophagus
- Pulling the lever- Wrist NEVER breaks (pull up and away)
- Inserting ETT too far– bronchial intubation
What are subjective ways to verify correct placement of ETT (6)?
- chest wall rise
- EQUAL breath sounds
- condensation in ETT
- right “feel’
- no gurgling noise/vomit
- pink patient
What are objective ways to verify correct placement? (2)
- Continued presence ETCO2
- interpreted CXR
What are Gllidescope applications (6)?
- potentially difficult airway
- trauma/emergency intubations
- morbidly obese
- C-spine immobilization
- reintubation in ICU
- awake intubations
What are predictors of a difficult airway? (8)
- protruding incisors
- permanent dentures/caps
- missing/mal-aligned teeth
- ornementation/tongue jewelry/braces
- macroglossia
- obese (morbidly)
- large breasts
- hoarseness/stridor
How far should normal adult be able to open their mouth?
4-5 cm (3 fingers)
