ED Flashcards
GCS scoring & intubation criteria
Eyes: 4 points possibleVerbal: 5 points possibleMotor: 6 points possible GCS < 8 = intubate (…it rhymes)
Tension pneumo presentation, dx, tx*
Absent breath sounds
hypotension
JVD
hypoxia
Clinical dx!
CXR: hyperlucent, midline shift (away), flattened diaphragm
Tx: STAT needle decompression* w/ 14 gauge @ midclavicular line 2nd intercostal space ==> thoracostomy (chest) tube
Systolic BP estimation
Carotid pulse = 60
Femoral = 70
Radial = 80
ED thoracotomy indications
Chest trauma w/ cardiac arrest in hospital or just before arriving
Warning signs for not placing foley in trauma patient, management, sequelae:
High riding prostate Non palpable prostate Ballotable prostate Pelvic fx Urethral blood Perineal echymoses Blood in scrotum
Dx: retrograde urethrogram BEFORE foley ==> *always do one before surgical penile intervention
Foley could cause abscess and/or worsen tear
ICP elevation signs, tx
Cushing: Bradycardia + hypertension + respiratory depression Fixed, dilated pupil Respiratory depression Vomiting Papilledema Oculomotor nerve is first compressed
*Tx: mannitol, hyperventilation, surgery
Epidural hematoma path, hx, PE, dx
Arterial bleed
Loss of consciousness ==> lucid interval
Ipsilateral pupil dilation, contralateral hemiparesis
CT: biconvex, lens shaped bleed
Diffuse axonal injury hx, dx*
Rapid deceleration injury
CT: blurring & punctate hemorrhage at grey-white junction
Subdural hematoma path, dx
Vein bleed
Crescent shaped bleed that CAN cross suture lines
Aortic dissection/disruption presentation, dx, tx
Rapid deceleration injury
Hoarse or quiet voice 2/2 laryngeal nerve injury
HYPERtension 2/2 vasoconstriction in non-damaged upper extremities
CXR: >8cm mediastinum, loss of aortic knob, deviated trachea
Angiography +/- TEE
Surgery
Flail chest definition, PE, tx
3+ adjacent ribs fractured in 2+ places==> inward motion with inspiration
Hyperventilation 2/2 shallow breathing
Progresses to respiratory failure
Pain control
O2
Intubation with PEEP if severe
Pulseless electrical activity (pea) ddx
5H5T Hypotension Hyper/hypo K+ Hydrogen (acidosis) Hypothermia Hypoxia Tablets (drugs) Tension pneumo Tamponade Thrombosis: cardiac Thrombosis: pulmonary
Kehr’s sign*
Referred shoulder pain 2/2 diaphragm injury
Pelvic fx presentation, tx
Hypotension with negative FASTX-ray
FLUIDS!
External binder
Embolization and/or surgery
Fat embolism hx, PE
Trauma w/ fracture Fever Tachypnea Tachycardia Petechia
Positive beta-HCG plus abdominal pain =
Ruptured ectopic until proven otherwise
Female abdominal pain diagnostic not to miss
Pelvic exam and beta-HCG
Burn BSA estimation
Arm: 9% Head: 9% Leg: 18% Back: 18% Chest: 18%
Burn degrees w/ associated PE findings, workup, tx
1- epidermis only: red, +capillary refill, no blisters
2- partial dermis: blistered
3- full dermis and into fat: white, painless(!)
BSA assessment
Carboxyhemoglobin levels
Cyanide levels
Parkland formula for 24 hr fluids: 4x Kg x%BSA ==> 50% given in first 8 hours
Tetanus ppx
Stress ulcer ppx
Appendicitis presentation, dx (normal vs abscess)*, tx (normal & abscess)
Mcburneys: RLQ pain 1/3 toward ASIS
Rosving: LLQ palpation creates RLQ pain
Psoas: RLQ pain with passive hip extension
Obturator: RLQ pain with hip internal rotation when flexed Hamburger: anorexia
Usually rebound or guarding
Dx: clinical but CT (PO and IV contrast) if equivocal or u/s if child or pregnant
Abscess: delayed presentation, inconclusive McBurney’s point, +Psoas sign (aggravates posteriorly)
ALWAYS: broad spectrum abx
Surgery unless abscess (wait 6 weeks)
When to transfer burn patient to critical burn unit
> 10% BSA if child or old
>20% BSA if healthy
Vital sign changes in shock
HR increases first
BP doesn’t fall until 30% volume loss
Post-op fever ddx w/ timing*
Transfusion rxn (immediately post-op)NMS/malignant (immediately post-op)>24hrs post-op: 6WsWind: [1-2 days] atalectasis, pneumonia, PE Water: [3-5] UTIWalking: [4-6] DVTWound: [5-7] infection (clostridium, beta hemolytic strep)Wonder drugs: [7+] many drugs, especially TMP/SMX, anticonvulsant*Womb: endometritis
Types of shock w/ CO & when to use pressors
Hypovolemic: CO decreases ==> no pressors! Cardiogenic: CO decreases ==> pressors Obstructive: CO decreases Septic: CO increases ==> pressors Anaphylactic: CO increases ==> epi!
Hypothermia dx, tx*
T < 95
ECG: bradycardia + AF + J-wave [hump after QRS]
Systemic: rapid infusion of warm liquid
Frostbite: RAPID rewarming with warm water
Hyperthermia dx, tx
T > 104
Dantrolene: NMS or malignant hyperthermia 2/2 halothane
Benzo: to prevent shivering
Anything cool!
Rabies animals, tx
Bats, dogs, cats, ferrets, skunks, raccoons
Monitor domestic animal for 10 days; immediately kill rodents for testing
If unvaccinated: 1 dose Rabies Ig and 4 doses rabies vaccine
If vaccinated: 2 doses vaccine
CO poisoning presentation, dx, tx
Smoke exposure…
Headache, confusion, myalgia
Cherry red skin (rare)
NORMAL pO2 (O2 just isn’t unloading)
ABG:
serum carboxyhemoglobin >5 (or >10 if smoker)
O2, hyperbaric if severe
Intubate: low threshold
Abdominal trauma laparotomy indications**
If penetrating trauma:
> 5th intercostal, unstable or peritonitis
If blunt trauma: Unstable ==> FAST or DPL ==> OR if positive ==> CT if negative If stable, CT for anatomical help
Pulmonary contusion* vs ARDS*
CXR: patchy alveolar infiltrate in both
Contusion: hypoxic respiratory alkalosis within 24 hours post-trauma; chest pain & SOB; worsens with fluids!
ARDS: 24-48 hours post-trauma; necessarily bilateral
Burn intubation criteria*
Very liberal: anything from singed eyebrows to stridor…be more careful than not
AAA presentation, dx, tx
Abdominal and/or back pain
Syncope
Hematuria*
Hypotension
If suspicious ==> OR
CT if not unstable
Rib fx presentation, dx, tx*
Localized tenderness 2/2 trauma
CXR: MAY NOT show fracture
Pain meds ==> nerve block to PREVENT ATALECTASIS & PNEUMONIA 2/2 hypoventilation
Acute mediastinitis presentation, dx, tx, complication*
Recent sternotomy
Chest pain
Septic-looking
Leukocytosis
CXR: MEDIASTINAL WIDENING*
Tx: immediate debridement & abx
*A-fib can occur, but don’t anticoagulate/cardiovert until after surgery
Myocardial contusion presentation, dx*
[Cardiogenic shock]
Hypotension
Tachycardia
Elevated PCWP (>14) increasing w/ fluid \+Cardiac markers EKG changes
Trauma fluid resuscitation challenge dx, tx
If IVF doesn’t increase >100 systolic ==> exlap without need for FAST CXR etc.
Leriche syndrome path, presentation*
Thrombosis @ iliac branch point
Triad: bilateral hip/thigh/butt claudication + LE atrophy + impotence
Often overlooked management of spinal cord trauma*
Bladder catheterization ==> assess for retention to prevent distention damage
Parotitis path, presentation*
Post-op parotid infection, often S. aureus
2/2 poor oral hygiene & fluids
Jaw pain, swelling, purulence
Post-op atalectasis path, dx**, tx
Impaired cough & shallow breathing
NO FEVER
Hypoxic (pO2 < 35; pH > 7.4)
Spirometry
Mechanisms to lower ICP (with path*)
Hyperventilation: decrease CO2 ==> cerebral vasoconstriction (dilation increases ICP…opposite of BP)
Sedation: reduce metabolic demand ==> vasoconstriction
Head elevation: increase venous outflow
Mannitol
INR reversal values & options*
INR > 1.5-ish
Immediate: FFP
Longer-term: vitamin K
pRBC transfusion threshold*
Hgb <7
Malignancy arising from non-healing wound*
SCC
Anterior, posterior, and central cord syndrome findings**
Anterior:
bilateral motor paresis
pain/temperature loss
Posterior: [“P”roprioception]
bilateral proprioception/vibration loss
Central:
UE weakness with preserved LE function
Brown sequard syndrome path, presentation*
Cord hemisection
Ipsilateral motor loss
Contralateral pain/temperature loss
Respiratory quotient (RQ) meaning & associated values
CO2 produced / O2 consumed
normally = 0.8
Carb > 0.8
Protein or fat < 0.8
Escharotomy vs fasciotomy
Fasciotomy goes deeper and should be performed only if escharotomy does not relieve symptoms
Imaging/discharge rules for TBI*
- No CT
“minor” trauma [GCS 15, no neuro abnormalities, no skull fracture evidence]
“mild” TBI [GCS 13-15] without headache, vomiting, LOC - CT & discharge if normal
“mild-moderate” TBI [GCS 9-15] or headache, vomiting, LOC - CT & admit:
“severe” TBI [GCS <8] or prolonged LOC, skull fx, focal neurologic deficit, seizure
Clavical fx presentation, dx*, tx
Holding arm with opposite hand
XR ==> if broken ==> REQUIRES bruit exam, angiography & neuro exam to r/o subclavian and brachial plexus injury
middle third fx: closed reduction
distal third fx: ORIF
Ludwig angina path*, presentation, tx
Infected molar ==> bilateral submandibular/sublingual gland infection 2/2 strep or anaerobe
Pain, induration, swelling, fever, drooling
Abx
Remove tooth
Intubate if necessary ==> asphyxiation risk!
Commonly injured organs in blunt abdominal trauma w/ presentation*, dx
- Spleen
Abdominal pain / nausea
Kehr sign: L shoulder pain 2/2 diaphragmatic irritation
Ultrasound ==> if inconclusive & stable ==> CT - Pancreas
Abdominal pain / nausea
Retroperitoneal abscess: chills, fever
May be missed on initial CT
AAA screening*
Men 65+ who ever smoked
Ankle brachial index (ABI) use & values*
Use if:
symptomatic claudication of extremities
cramping with activity or at rest
0.9-1.3 = normal ankle to brachial ratio
Fat necrosis of breast presentation, dx*, tx
Trauma or surgery
Mimics breast cancer presentation
U/S, mammography mimic breast cancer calcification
*Core biopsy differentiates: foamy macrophages and fat globules
No intervention
Splenic dysfunction prophylaxis*
Vaccinate against:
N. meningitidis
H. influenzae
S. pneumo (q5)
Sringomyelia path, presentation*
Impaired CSF drainage @ cervical cord 2/2 trauma or arnold-chiari
UE weakness
Loss of pain/temperature sensation in UE and/or cape-like
Preserved vibration/proprioception
Acute vs chronic pericardial tamponade*
Acute (2/2 trauma) requires little fluid to cause tamponade, thus CXR will not show enlarged mediastinum
Both show hypotension, tachycardia, JVP
Pilonidal cyst presentation*, tx
Painful purulent swelling over coccyx, midline in gluteal cleft
I&D
Post-op oliguria tx*
FIRST: change catheter to r/o obstruction
SECOND: fluid challenge if suspecting pre-renal AKI
Intraductal carcinoma path, presentation*
Benign breast tumor
Unilateral bloody nipple discharge
No appreciable mass
Bladder rupture anatomical site and presentation*
Bladder dome
Abdominal pain with Kehr sign (referring to shoulder)
DVT treatment*
Heparin ==> warfarin ==> goal INR 2-3
Nasopharyngeal carcinoma risk factors*
EBV infection
Smoking
Eastern & Mediterranean descent
Hemothorax presentation*
Hypovolemia ==> flat neck veins
Dullness to percussion on affected side
Decreased breath sounds on affected side
Tracheal shift away from affected side (if massive)
Diaphragmatic hernia presentation, dx
2/2 blunt trauma
Respiratory distress…though sometimes asymptomatic
XR: hemidiaphragm elevation (usually L-sided bc liver protects right), mediastinal/tracheal deviation
NG tube goes into thorax
CT: required for definitive diagnosis
Inflammatory breast carcinoma presentation, dx*
Unilateral inflammatory nodule
“Peau d’ orange” appearance
Palpable axillary LN
Nipple discharge
Biopsy for histology
Torus palatinus path, presentation*, tx
Congenital bony growth
Hard, non-tender bony growth @ midline mouth palate
No surgery unless symptomatic
How to preserve amputated tissue in the field*
Wrap in saline moistened gauze ==> put on ice
Central line procedure, complications
Insert into SVC ==> CXR to confirm placement ==> heparin flush
Aortic perf
Pneumothorax
Hemothorax
Myocardial perf ==> tamponade
Anaphylaxis dx, tx
Symptoms in MORE THAN ONE organ system:
Skin: hives
GI: lip swelling, vomiting
Respiratory: wheezing
Cardio: hypotension
IM epinephrine
