Critical and Emergency Care Flashcards
In blunt trauma, what causes paradoxical moving of the chest wall and what is the treatment?
Flail Chest - rib fractures in at least 4 adjacent ribs and at least 2 places.
Tx:
- pain control - morphine
- OOB, IS, pulm toilet
If any signs of respiratory distress (problems with oxygenation/ventilation), we intubate and use PPV.
If you are acidotic and hypercapnic on mechanical vent with an air leak what do you do?
CLOSE THE LEAK. Aka reintubate with larger tube.
Ex: ARDS permissive hypercapnia as long as pH > 7.25. If it’s not and you are acidotic with air leak, then you need to reintubate with larger tube
Formula for size of ETT tube
4 + age/4
Malignant Hyperthermia Causes and Tx
Autosomal Dominant mutation in ryanodine receptor in the myocyte -> when given a specific agent during anesthesia -> leads to prolonged opening of the receptor -> increased myocyte cytosolic Ca -> persistent muscle contraction -> using up O2 leading to hypercarbia, hypoxia, lactic acidosis
Drugs associated with it:
- inhaled anesthetics - halothane, isoflurane, and desflurane
- depolarizing neuromuscular blocking agent succinylcholine.
Tx: dantrolene to close the ryanodine receptor
How to declare someone Brain Dead
- Exam
Brainstem reflexes must be absent, including pupillary, bulbar response, cough, gag, suck, corneal, and oculovestibular. There must be flaccid tone and the absence of spontaneous or induced movement other than spinal reflexes. - Apnea Test
The diagnosis of brain death requires 2 clinical examinations, 12 (30 days - 18 yrs) or 24 hours apart (37 wker to 30 days)
PECARN rules for CT >/= 2 yo
CT only if AMS or Skull Fracture
Based on the findings of the PECARN study, the risk of clinically important traumatic brain injury is estimated at more than 4% for children with a Glasgow coma scale score of 14, other signs of altered mental status, palpable skull fracture, or signs of basilar skull fracture.
Otherwise observe for 4-6 hours
What injury do you suspect in pt with LUQ pain after blunt abdominal trauma? What is best diagnostic study?
Splenic injury - can also have L shoulder pain due to presence of subphrenic blood (Kehr sign)
CT abdomen
What causes Nursemaid’s Elbow?
Annular ligament displacement - radial head subluxes from the annular ligament and it gets traps btwn radial head and capitellum
Mech: traction mostly. but can also be caused by a fall like foosh
Red Flag: The presence of swelling, bruising, or point tenderness around the elbow should prompt evaluation for upper extremity fracture.
What is a chance fracture?
Chance fractures: transverse fractures through the vertebral body from MVAs in which the affected individual was restrained by only a lap belt.
Any localizing symptom to neck or back must be suspected spine injury: pain, tenderness, decreased range of motion, deformity
Symptoms of AC acromioclavicular joint dislocation?
Tenderness at AC joint + pain with adduction
XRs are normal
Mech: blow to the AC joint or a fall onto the lateral aspect of the shoulder.
Tetantus Guidelines
Clean minor wound
- If received at least 3 tetanus containing vaccine doses, only give Tetanus vaccine if < 10 years since last one
- If received less than 3, then definitely give Tetanus vaccine
All other wounds (PUNCTURE, dirt, fecal matter, or saliva)
- If received at least 3, give Tetanus if < 5 years since last one
- If received less than 3, give Tetanus and tetanus immune globulin
ALL PUNCTURE WOUNDS from cat, dog, human needs Augmentin to prevent infection
Bee, Wasp, Ant Bites Treatment
- minor localized redness and swelling
- remove stinger, cool compresses, tylenol, antihistamine for itching
- resolve within hours to days - more severe local reactions - pain, swelling, redness. can be mistaken for cellulitis, but usually uncommon in first 48 hours
- anaphylaxis. if real and treated then you need to observe for 4-6 hours in ED.
Treatment of jellyfish sting
Hot water soak
Topical lidocaine
Management of Spider Bites
Only 2 spider species in the United States, black widow and brown recluse spiders, are dangerous.
Antivenin for black widow spider given for
- if you have severe pain and muscle rigidity after a spider bite
- child < 40 kg
Brown recluse bites can display a spectrum of manifestations at the bite site, from minor local reactions (pain, erythema, and a blister at the bite site) to development of extensive tissue necrosis and ulceration. There’s no antivenin for this.
Ethylene glycol
Antifreeze
Anion gap met acidosis
Ca oxalate crystals in urine (leading to hypoCa)
renal failure
CNS effects
Tx:
Fomepizole
Na hco3
Toddler’s Fracture
Non-displaced spiral fracture of distal tibia
Due to twisting while walking in a toddler.
Tx: Long leg cast
Mechanism of Injury for different fractures
Compression - Buckle fracture Blunt force - greenstick Twisting - toddler's Traction - metaphyseal or nursemaid's Sudden Deceleration - intracranial hemorrhage or aortic injury
Symptoms of organophosphate poisoning
Organophosphates = Cholinergics = Insecticides
DUMBBELS
defecation, urination, miosis, bradycardia/bronchospasm, emesis, lacrimation, salivation
Tx:
Atropine - antagonist of acetylcholine-R
Pralidoxime - displaces the organophosphate from acetylcholinesterase
Kerosene ingestion leads to
Chemical pneumonitis - leads to resp distress. CNS changes only occur with very large amounts of ingestion, and occur later.
Opiate Toxidrome and Treatment
Coma, Resp Depression, Miosis
Also bradycardia, hypotension, pulm edema,
Tx: Naloxone
Brown Recluse Spiders vs. Black Widow Spiders
Brown Recluse
- southeast, southwest, midwest US
- blister -> necrotic ulceration
- rarely has systemic symptoms and hemolysis
- local wound care
Black Widow Spiders
- has antivenin
- local pain, muscle rigidity (can result in acute severe muscular pain and cramping in abd or chest, rhabdomyolysis)
- also can get vomiting, malaise, hypertension
- supportive care (oral analesgics), tetanus ppx
- benzos or opioids to control pain or muscle spasm
Dystonic reactions associated with what meds?
Dystonic reactions
- Torticollis, Choreiform movements, etc
CNS Dopamine blockade from
Chlorpromazine (anti-psychotic)
Promethazine (anti-histamine)
Salicylate Poisoning
fever, tachycardia, increased RR, n/v, pulm edema, AKI
metabolic acidosis with increased anion gap
AMS, seizure, coma
TX:
fluids
activated charcoal
Blood and urine alkalization to promote excretion
What electrolyte abnormality makes it hard to alkalinize urine in salicylate poisoning?
HypoK
Because of K/H pump reabsorbs K and secretes H into urine
If pulse ox is 85% but paO2 is 97, what would you expect?
Methemoglobin. Can happen with benzocaine
Changes hemoglobin to methemoglobin (fe2 to fe3 which cannot bind oxygen).
Other sx: cyanosis, chocolate blood
Tx: methylene blue rescues it back to hemoglobin. Reduces ferric iron back to ferrous state
Treatment of serotonin syndrome
Benzos for control of agitation, hyperreflexia, tremor, and clonus.
If supportive measures fail,
Cyproheptadine is used (serotonin receptor antagonist)
Activated charcoal for what drugs?
Carbamazepine (has enterohepatic recirculation)
Salicylate Toxicity
Respiratory Alkalosis
- causes stimulation of resp center resulting in tachypnea and hyperpnea
Metabolic Acidosis
- compensation for resp will excrete bicarb
- then uncoupling of oxidative phosphorylation
- blocking steps in krebs cycle
TCA toxicity (amitriptyline)
Cardiac: Hypotension, arrhythmias, prolonged QT, conduction delays, widened QRS
CNS: seizures, AMS, lethargy,coma
Anticholinergic symptoms
Tx:
QRS > 100 ms = Na HCO3
Seizures = Benzos
Physostigmine is contraindicated! Decreases seizure threshold.
Clonidine Toxicity
Sympatholytic
hypotension, bradycardia, lethargy, pinpoint pupils, resp depression
Methanol Toxicity
Windshield wiper fluid
Metabolized to form formaldehyde and then formic acid. Tiny amount leads to toxicity and takes time to metabolize so clinical effects may not be apparent until 8-12 hours later
Anion gap met acidosis
Visual: color changes, photophobia, blurry
CNS: drowsiness and disinhibition -> seizures, coma, etc
GI sx
TX: Fomepizole
What does fomepizole treat?
Ethylene glycol toxicity
Methanol toxicity
Competitive inhibitor of Alcohol dehydrogenase to prevent metabolism.
What causes methemoglobinemia?
Nitrates from well water.
Amyl nitrate “poppers” at party (also causes vasodilation and hypotension)
Converted to nitrites -> oxidizes iron to to ferric state -> forming methemoglobinemia that can’t bind O2 well.
Sx: cyanosis
Tx: methylene blue reduces iron back to ferrous state so it can bind O2
CO poisoning
Flu-like, non specific symptoms.
Multiple ppl in same environment
Pulse ox is normal (can’t distinguish oxy vs carboxyhemoglobin)
Tx: 100% O2 to decrease half life of CO
Tx of anticholinergic toxicity
Anticholinergic: Mad as a hatter Blind as a bat (dilation of pupils) Hot as a hare Dry as a bone Red as a beet
Physostigmine: cholinesterase inhibitor
Sedation with benzos
Caustic Ingestions
Alkaline substances are the worst.
Cause liquifaction necrosis. and serious penetrating injuries/perforation.
= toilet bowl cleaners, etc
NOT household bleach - that is relatively benign…
Acidic substances
cause coagulation necrosis
Iron toxicity
5 phases:
GI -> latent -> shock (cards, coags, resp, renal) and met cidosis -> hepatotoxicity -> bowel obstruction
Tx: for severe cases or > 500 in blood = IV deferoxamine chelating agent
Toxicity of bath salt
Amphetamine toxicity
Long term consequence of hallucinogen use
Hallucinogen persisting perception disorder
recurrence of perceptual distortions that were previously experienced when the individual was under the effects of the substance
Ankle injury in a prepubertal child is most likely what?
Occult salter Harris 1 or 5 fractures (not seen on XR)
Splint
RICE
Ortho eval
Bc prepubertal childs ligaments are stronger than the growth plate - so young children get fractures more than sprains
What drug causes rhabdo?
PCP
Findings of basilar skull fracture
Hemotympanium
Rhinorrhea - clear aka CSF
Post-auricular ecchymosis
Rule of 9’s for Burns
3 mL/kg for every 1% of body surface area with partial- or full-thickness burn.
3 mL × 30 kg × 27% = 2430 mL. Half of this fluid (1,215 mL) should be given over the first 8 hours, with the other half given over the subsequent 16 hours.
The Rule of 9s => for those < 14 and greater than 10 kg
Head and neck: 9% => 18% Each upper limb: 9% Thorax and abdomen, front: 18% Thorax and abdomen, back: 18% Perineum: 1% Each lower limb: 18% => 13.5%
Serotonin Syndrome Tx
Confusion, hallucinations, and/or agitation, profuse diaphoresis associated with shivering, hypertension, tachycardia, hyperthermia, nausea, and diarrhea. Hyperreflexia and myoclonus.
Tx: cyproheptadine - serotonin antagonist
2 types of poisoning from fires
- CO
- flu like symptoms -> seizures, loss of consciousness, respiratory failure, and cardiac arrest. - Cyanide
- lactic and metabolic acidosis, hemodynamic instability
TCA toxicity
TCAs include impramine, amitriptyline, nortriptyline, desipramine, clomipramine, and doxepin
CNS + CV + anticholinergic sx!
Sodium bicarbonate is used to alkalinize the serum pH to 7.45–7.55 and treats TCA-induced dysrhythmias.
Seizures are treated with benzodiazepines.
IV fluids and vasopressors treat significant hypotension.
What causes cyanosis unresponsive to O2?
The nitrite (such as poppers at a party) induces methemoglobinemia, which causes cyanosis unresponsive to oxygen administration.
Normal PaO2
SaO2 may be falsely elevated and then fall when met >30%
chocolate brown blood
Tx: Administration of methylene blue will reduce ferric iron to its ferrous state, resolving the methemoglobinemia
Ingestion of hydrocarbon compound (kerosene) Management
Can lead to pulmonary aspiration and subsequent inflammation or superinfection.
If asymptomatic - observe for 6 hours and do CXR. If nl, can discharge.
If resp sx - O2, bronchodilator, admit.
Symptoms of iron ingestion
Early on: GI mucosal injury, including abdominal pain, vomiting, diarrhea, hematemesis, and melena.
Latent phase: 6–24 hours after ingestion in which there is “improvement” with symptom resolution, but can then experience worsening metabolic acidosis, cardiovascular toxicity, and coagulopathy.
CAB and resuscitation then deferoxamine for chelation
Ovarian Torsion
Abrupt onset of severe, constant, unilateral pain in pelvis or lower abdomen. + Nausea, vomiting. + UTI sx like dysuria and frequency
VS: appendicitis - fever, migratory pain, peritoneal signs (rebound, guarding)
VS: AGE - pain should be not be localized
Oral ingestion of topical ophthalmic preparations (antihistamine-decongestant)
α-2 adrenergic agent = sympatholytic symptoms
- hypotension, bradycardia, miosis, hypothermia, hyporeflexia, resp depression
Imidazolines = found in OTC topical opthalmic and nasal decongestants = similar to those of clonidine poisoning
- same as above
If within 2 hours of ingestion = activated charcoal!
Asymptomatic = can observe at home for 24 hours, or 6 hours in ED and then at home
Symptomatic = admission and close monitoring
Bilious emesis or projectile vomiting in a newborn
Duodenal atresia
Jejunal atresia
Malrotation with midgut volvulus
Meconium ileus
GET AN UPPER GI SERIES for DIAGNOSIS
Orbital floor freactures
“Blowout fracture”
- sunken appearanc eof eye
- asymmetry in horizontal level of hte eye
- decreased sensation ot upper lip, cheek, upper gingiva (due to injury ot infraorbital nerve)
- limitation of upward gaze** due to inferior rectus muscle entrapment
Urgent OR
VS: globe rupture -dec visual acuity, “teardrop” pupil, hyphema, subconjunctival hemorrahge, “streaming” of flourescin on affected eye
Excessive tearing, Photophobia, and excessive blinking
Congenital glaucoma
- due to increased intraocular pressure which leads to corneal and globe enlargement and corneal edema
- Excessive tearing, Photophobia, and excessive blinking (from muscle spasms), Corneal clouding and enlargement of the eye
IMMEDIATE OPTHO referral
Tetanus Guidelines
A. Wound is dirty and either (1) the child has had < 3 immunizations, or (2) immunization history is unknown
Treatment: Give tetanus immune globulin + vaccine.
(Note: Immune globulin is given only if the patient has < 3 immunizations with a dirty wound or has an unknown immunization history.)
B. Wound is clean and immunizations are up-to-date (< 10 years since last)
Treatment: No Treatment. If > 10 years since last tetanus vaccine, then give vaccine only.
C. Wound is dirty and immunizations are up-to-date, with most recent < 5 years
Treatment: No Treatment. If > 5 years since last tetanus vaccine, then give vaccine only.
PREP poisoning review
2017: 1
2019: 9
EM review
2018: 4, 6
2019: 3
Crit Care review
2017: 2, 4
2019: 1, 2
Most common symptoms of lead exposure/toxicity
NONE! Most are asymptomatic.
Rabies post exposure prophylaxis
Rabies IG + 4 dose rabies vaccine at day 1, 3, 7, and 14 days (for a total of 4 doses).
Any dog, cat, or ferret that has bitten a human and is suspected of having rabies should be captured, confined, euthanized, and tested for the virus, or should be observed by a veterinarian for a period of at least 10 days.
For patients who sustain bites from dogs that appear healthy and can be observed for 10 days, rabies postexposure prophylaxis is indicated only if the dog develops signs of rabies during the observation period.
