ED/Trauma Flashcards
What is flail chest
Fracture of two or more consecutive ribs in two or more places
S/S of flail chest
Paradoxical chest wall movement- "Inspiration=in" Dyspnea Chest pain Hypoxia Cyanosis SubQ emphysema
Flail chest interventions
Assist with ventilation (positive pressure) supplemental oxygen Volume replacement Think about underlying injuries Pain managment (intercostal blocks) Avoid barotrauma Chest tubes as required Aggressive pulmonary toilet Surgery
What is tension pneumothorax
When air enters the pleural space on inspiration but it can’t escape on expiration
Increased pressure collapses the lung on the side of the injury followed by mediastinal shift
S/S of tension pneumothorax
Severe dyspnea Chest pain Distended neck veins Percussion findings (hyper resonance) Decreased breath sounds hypotension tracheal deviation expanded chest
Intervention for tension pneumothorax
Immediate needle thoracotomy in the 2nd intercostal space miclavicular line (advance needle until there is a gush of air)
Prepare for chest tube
-4-5 ICS at the MAL
-Should not be used lightly, can have complication
Open/sucking chest wounds
Allows free passage of air into the pleural space which is sucked back out
Can lead to tension pneumo
Can result in respiratory insufficiency
Be careful with occlusive dressing
s/s of open sucking chest wound
Dyspnea
Sucking sound on inspiration
Penetrating chest wound
Decreased or absent BS
Interventions for open chest wound
Administer oxygen
Seal the defect on three sides only
Remove dressing if s/s of tension pneumonia after application
Prepare for CT
Pneumothorax
Accumulation of air in pleural space
S/S of Pneumothorax
Sudden onset of pain with radiation to shoulders
Hyperressonance
Tactile and vocal fremitus decreased on effected side
Decreased BS
Interventions for pneumothorax
If small, monitor respiratory status
If larger or respiratory compromise than place chest tube
Hemothorax
Results from the accumulation of blood in the pleural space
s/s of hemothorax
If major, signs of shock
Dullness to percussion
Decreased BS
Tracheal shift is possible if large amount of blood
Interventions for hemothorax
Prepare for CT insertion
Monitor amount and rate of drainage (may need surgery)
Large bore chest tube
Pericardial tamponade
Life threatening
Accumulation of blood in the pericardium
Obstructive shock
s/s of pericardial tamponade
Signs of shock
Penetrating trauma 3-5th rib
Becks Triad (Decreased BP, JVD, Muffled heart sounds)
Pulsus paradoxus (decreased in SBP by 10 during inspiration)
ST segment changes
Cyanosis
Interventions for pericardial tamponade
Pericardiocentesis
Emergent pericardial window
Surgery to stop bleeding
Imaging for pericardial tamponade
Echocardiography is the diagnostic test of choice
Aortic rupture
Usually fatal at scene
Transverse tear with exsanguination or a partial tear with tamponade
Usually damage to proximal descending aorta
s/s of aortic rupture
Signs of hypovolemic shock
Chest wall ecchymosis
Marked variation of BP from right to left
Decreased or absent femoral and pedal pulses
Loud murmur in parascapular region
Widened mediastinum
Interventions for aortic rupture
CPR
Administer IVF and Blood products
Prepare for emergency thoracotomy/surgical repair
CT surgery consult
Blunt injuries are the most common cause of…
Abdominal trauma
Injuries to liver, spleen and kidneys
Seat belt sign shows there could be…
GI injury
Abdominal and Pelvic injuries are more likely associated with…
side-on collisions
Intra abdominal hypertension is pressures greater than…
12 mmHG
Intraabdominal compartment syndrome is pressure greater than…
20 mmHG
Surgery is required for abdominal pressures greater than
25 mmHG
How do you calculate BSA for burns
Rule of nines arms-9% each Legs-18% for whole leg each Trunk- 18% on each side Perineum, hand-1%
Parkland formula of resuscitation for burns
4 cc/kg x % BSA that was burned over 24 hours
1/2 in the first 8 hours
Mechanisms of burn injuries
Inhalation
Thermal
Electrical
Chemical
Concerns with inhalation burn
Edema, Obstruction, Hypoxia
Electrical injury
Entrance and Exit wound
Do not look bad but do have a lot of nerve, vessel and muscle damage
Unable to calculate surface area burned
Chemical injury
Length of contact and concentration is needs to be taken into account
Burn patients are at risk for…
hypovolemic shock
Burn patients should be assessed for what electrolyte imbalance
Hypernatremia
Hypokalemia
1st degree burn
Superficial partial thickness
Redness, no blisters
Blanches/tender
2nd degree burn
Deep partial thickness
Appears moist, may blister
Painful-nerve endings exposed
3rd degree burn
Full thickness burns
Pale yellow to brown
Dry leathery
No pain-superficial nerve endings destroyed
Somatic pain from inflammation and ischemia
Emergency management for burns
Airway- TOP PRIORITY Remove clothing Cool, moist NS compresses 2 large bore IVs IVF replacement- LR fluid of choice
Burn management
Monitor for dysrhythmias- hypokalemia Monitor NGT output- can get ileus Monitor UO- can go into rhabdo Prepare for escharotomies Topical antimicrobial agents
Chlamydia symptoms
Copious amounts of purulent discharge
Mild discomfort
Chlamydia Treatment
gram stain, Giemsa stain and culture
Tetracycline
erythromycin
single dose azithromycin
Allergic conjunctivitis symptoms
Bilateral tearing and stringy discharge
Allergic conjunctivitis treatment
Topical antihistamines and/or steroids
Naphazoline
H1 receptor antagonist (Ketotifen (gtts), loratadine (PO), fexofenadine (PO), cetirizine (PO)
NSAIDS (Ketorolac)
Bacterial conjunctivitis Symptoms
Purulent discharge
Mild discomfort
Bacterial conjunctivitis treatment
Usually self-limiting Topical antibiotic solutions and ointments Gentamicin Neomycin Polymyxin Sulfacetamide Ofloxacin
Acute conjunctivitis symptoms
Redness
Discharge
Irritation
Possible photophobia
Acute conjunctivitis treatment
Most are benign, with a self-limited process
Emergency care of corneal abrasion
Tetanus prophylaxis- indicated for foreign objects with dirt
Eye patch- no longer indicated
Antimicrobial therapy
Opthalmologic consultation is warranted for…
suspected retained foreign body
suspected corneal ulcerations
How do corneal abrasions present?
Eye pain (occasionally described as severe) Tearing Sensation that a foreign body is present Inability to open effected eye Photophobia Pain with movement Blurred vision
How does acute angle-closure glaucoma present?
At least two of these: Unilateral Ocular pain Nausea and Vomiting History of intermittent blurring or vision with halos At least three of these: IOP > 21 mmHG Conjunctival injection (bloodshot eye) Corneal epithelial edema mid-dilated nonreactive pupil shallower chamber in the presence of occlusion
Treatment for acute angle-closure glaucoma
Acetazolamide (Diamox)- Diuretic- reduce the amount of aqueous fluid (can use mannitol or glycerol as well)
Topical beta blocker
Topical alpha blocker
Topical steroid
Emergent opthamologic consultation (once pressure is down, laser peripheral iridectomy is the permanent cure)
Corneal ulceration presentation
*
Corneal ulceration treatment
Topical antibiotics- fluoroquinolones
Topical steroid- once you have confirmed its bacterial
Hordeolum is…
Staphylococcal abscess on the upper and lower eyelid
Hordeolum s/s are.
localized edema
acutely tender
pain is proportional to the amount of edema
Hordeolum is diagnosed…
based on physical findings alone, no tests need to be run
Hordeolum treatment
Warm compress
Bacitracin or erythromycin
I/D
Chalazion is…
A granulomatous inflammation of a meibomian gland
May follow a hordeolum
Chalazion s/s…
May not be any Visual distortion if large enough Itching Hard, non-tender cyst red conjunctiva
Chalazion treatment…
Incision and curettage
Blepharitis is..
A chronic, bilateral inflammation of the lid margins
Blepharitis causes…
Staphylococcus, Seborrhea, Meibomian gland dysfunction
Blepharitis s/s…
Irritation Burning Itching Erythema Crusting of lid margins Red rimmed eyes
Blepharitis treatment…
Clean scalp and eyebrows removal of scales antibiotic ointment expression of meibomian gland systemic antibiotics topical steroids
Conjunctivitis is..
inflammation over the posterior surface of the lids and up over the sclera to the cornea
Viral conjunctivitis symptoms…
Watery discharge
Viral conjunctivitis treatment…
Symptomatic treatment only
Cataracts are…
an abnormal progressive opacity of the eye causing visual blurring and decrease in acuity
(occurs in 46% of people age 75-85)
Causes of cataracts
Age Congenital Systemic disease (diabetes) Systemic corticosteroid use Substance abuse (tobacco, alcohol)
Cataract symptoms
Enhanced glare decrease in vision painless Loss of red reflex Opacity
Cataract management
Lens replacement- only definitive treatment
(Contact lenses
magnifying glasses- in interim while waiting for surgery)
Otitis Externa is caused by…
Bacterial infection (gram negative bacteria) Recent water exposure (swimmers ear) Mechanical trauma (Qtip use) Fungal infection (will look like tiny poppy seeds in the external canal
Otitis externa symptoms…
Otalgia
Pruritis
Purulent discharge
Otitis externa managment
Remove exudate (warm water lavage)
Topical otic drops
Protect from moisture
Otic drop medication options for otitis externa…
Cortisporin
Aminoglycoside and anti-inflammatory
Cipro
Otitis media symptoms…
Decreased hearing Otalgia Fever Pressure Vertigo Nausea/vomiting
Acute Otitis media is…
A bacterial infection of the mucosally lined air contained spaces of the temporal bone
The causes of Acute Otitis media…
Streptococcus
H. Flu
M. Catarrhalis
Often follows a viral Upper respiratory infection
Otitis media PE findings…
Erythematous tympanic membrane (TM)
Bulging or retration
Occasional bull
Decreased TM movement
Otitis media management..
Amoxicillin Cephalexin Septra (for beta lactase producing bug) Ceclor Cipro Nasal decongestant
Serous Otitis media is due to…
a blocked eustachian tube and an inability to equalize the pressure.
May be precipitated by allergy, barotrauma, neoplasm or subacute infection
Serous otitis media symptoms..
Hearing loss Ear fullness Popping sounds with pressure changes Air bubble posterior to the TM Decreased membrane mobility Changes in Rinne, Weber (conductive hearing loss)
Serous otitis media management…
Oral decongestants
Cholesteatoma is…
chronic otitis media from prolonged auditory tube dysfunction, chronic middle ear pressure which creates a a sec which causes chronic infection and can eventually erode into the bone.
Cholesteatoma symptoms…
Hearing loss
Dependent on the degree of bone erosion
Tympanic membrane retraction or perforation
Cholesteatoma management…
Surgical- removal of the sec
Vertigo causes…
Medication
Middle ear infection
CNS disorder
Labyrinthitis
Vertigo symptoms…
Room spinning Sensation of falling Nausea/vomiting Tinnitus Hearing loss
Vertigo lab workup should include…
Serum B12
Medication levels to check for toxicity (digoxin)
CT/MRI of the head
Syphillis testing
Vertigo management…
Diazepam- for acute symptom management
Antihistamines
Anticholinergics
Antiemetics
Conductive hearing loss causes..
Due to something blocking the conduction of sound Cerumen impaction Foreign body Otitis media Otosclerosis Cholesteatoma
Conductive hearing loss management…
Correct the source of blockage
Causes of sensorineural hearing loss…
Neuro problem, can get overlap with vertigo
Acoustic neuroma Meniere's disease (if hearing loss and vertigo think) Presbycusis Syphilis CNS disease Medication toxicity
Sensorineural hearing loss management…
Refer to ENT
Common cold has an official name of…
“Viral Rhinitis”
Caused by Rhinovirus and adenovirus
Infectious mononucleosis symptoms
sore throat fever malaise anorexia myalgia
Mono is caused by…
Epstein-barr virus
Mono PE findings..
Posterior cervical chain lymphadenopathy
Exudative tonsillitis
Splenomegaly
Rash
Mono management…
Supportive care
Corticosteroids
Lab work for Mono…
Monospot will be positive
Lymphocytic leukocytosis
Early rise in IgM
Permanent rise in IgG
Sinusitis symptoms…
Pain and pressure over the maxillary sinuses, worse with dependent head positions Headache Toothache Discolored nasal discharge Postnasal drip and cough
Sinusitis diagnostics…
X-ray may show thickening of the sinus mucosa with or without air/fluid levels
Head CT is more sensitive but more expensive
You can culture the nasal discharge
Sinusitis management…
Amoxicillin Bactrim DS Ceclor Afrin nasal spray Guaifenesin Sudafed
Normal IOP
10-21 mmHG
Open angle glaucoma
Initially asymptomatic Cupping of the disc Constriction of visual fields Central vision is good until late IOP > 21 (30-50)
Open angle glaucoma management
Beta blockers Carbonic anhydrase inhibitors (Trust, adopt) Prostaglandin analogs (Xalatin) Adrenergic agonists (Alphagan, iodine, propine) Cholinergic agonists (Pilocar, isopto carbachol)
Narcotic overdose treatment…
Respiratory support
Gastric lavage
Nalaxone 5 ug/kg IV then 2-20 mg if unresponsive
Acetaminophen presentation…
Nausea/vomiting
RUQ pain at 24-48 hr
Hepatotoxicity- jaundice prolonged bleeding time, hepatic encephalopathy
Acetaminophen treatment…
Blood levels 4 hours after ingestion Induce emesis/gastric lavage Activated charcoal N-acetylcysteine Blood levels every 4 hours
Benzo/GHB toxicity presentation…
Drowsiness Ataxia Confusion Slurred speech Unsteady gait Respiratory depression Hypoactive reflexes
Benzo/ GHB treatment…
Monitor BP and support respirations
Gastric lavage
Flumazenil
Stimulant overdose presentation…
Insomnia Irritability Dry mouth Anorexia Arrhythmias Chest pain heart block HTN Seizures
Stimulant OD treatment…
Induce emesis (Ipecac) NS lavage Activated charcoal Reduce stimuli Administer Chlorpormazine or diazepam Beta blockers
Alcohol toxicity presentation..
Respiratory depression Nystagmus Mydriasis Diplopia Coma Seizure Tachycardia Hypotension Hypoglycemia
Alcohol toxicity management…
ABCs
HD for severe toxicity
IV glucose
Thiamine, multivitamin, folic acid
Class I antiarrhythmics presentation…
Nausea Vomiting Diarrhea Dizziness Blurred Vision Bradycardia Hypotension Cardiovascular collapse Tinnitus Hearing loss Confusion Delirium Psychosis Seizures
Class I antiarrhythmic management
12 lead and tele
Charcoal
Atropine, overdrive pacing, Isuprel
Barbiturate Presentation
CNS depression Drowsiness Confusion Coma Hypothermia Respiratory depression Respiratory acidosis Absent DTR, gag, corneal Miosis
Barbiturate OD managment
Maintain airway
charcoal within 1 hour of OD
Insert NGT
hemodynamic support
Beta blocker presentation…
Bradycardia Hypotension CNS depression Coma Bronchospasm Myocardial depression Cardiogenic shock Heart failure
Beta blocker OD managment
ABCs Glucagon Charcoal or whole bowel irrigation Calcium IV Monitor K and glucose Treat hypotension Temporary pacing
Calcium channel blocker presentation
Bradycardia Conduction disturbances hypotension cyanosis seizure coma death
Calcium channel blocker managment
IV calcium Glucagon Atropine, Isuprel Aggressive GI decontamination Activated charcoal Insulin with glucose Tele monitoring
Carbon monoxide presentation…
Dysrhythmias Cardiac arrest Heart failure Respiratory depression hypoxia
Carbon monoxide management
100% oxygen
Hyperbaric oxygen for carboxyhemoglobin level greater than 25%
Digoxin presentation…
N/V/D Blurred vision Green halos Anorexia Abdominal pain Fatigue Dizzy Hallucinations
Digoxin OD managment
Maintain high normal K levels
Lidocaine for dysrhythmias
Activated charcoal
Digibind
Lithium OD presentation…
N/V/D Muscle weakness tremor rigidity ataxia dementia delirium
Lithium OD managment
Saline bolus No charcoal Gastric lavage Supportive care Diuretics for levels > 2-3 HD for levels > 4 Benzos for seizures
Salicylate presentation findings
Tachypnea cyanosis metabolic acidosis respiratory alkalosis dehydration hyperthermia
Salicylate managment
Monitor serum concentrations and electrolytes volume replacement activated charcoal Sodium bicarb HD
Narcotic OD presentation
Shallow respirations
Respiratory depression
Pinpoint pupils
Coma
Organophosphates (insecticides) Presentation…
Miosis Seizures paralysis coma bradycardia conduction defect respiratory depression/paralysis
Organophosphates management…
Maintain airway
Wash skin thoroughly
Activated charcoal if ingested
Atropine 2 mg IV every 15 min (up to 40 mg/day not uncommon) until atropinization (flushing, dry mouth, dilated pupils, tachycardia)
Pralidoxime (reverse nicotinic signs such as muscle weakness and respiratory depression- not for asymptomatic patients)
Urinary catheter
Antipsychotic OD presentation…
Dystonia Extrapyramidal symptoms (rigidity, stiff neck, hyperreflexia) Deep sleep Neuroleptic malignant syndrome urinary retention Hypotension AV block widened QRS prolonged QT
Antipsychotic OD treatment…
Activated charcoal
Benzotriptine mesylate (cogent)- for EP signs
Dantrolene for Neurleptic malignant syndrome
Supportive care
Vasopressors
Antidepressant OD presentation…
Hallucination Confusion Blurred vision AMS Urinary retention tachycardia hypotension seizures arrhythmias
Antidepressant OD treatment…
activated charcoal sodium bicarb to target pH 7.5-7.55 Benzos for seizures Ativan for rigors Cyproheptadine for delirium, skeletal muscle tone Montior for hypotension
Theophylline OD presentation…
Vomiting Hematemesis Restlessness Agitation Irritability Tachycardia PVCs Atrial arrhythmias Seizures
Theophylline OD management..
Airway Treat arrhythmias Activated charcoal until level less than 20 Consider whole bowel irrigation Ativan for seizures
Anticoagulant OD presentation…
severe hemorrhage
Anticoagulant OD management…
For heparin- given protamine
For coumadin- give Vitamin K for FFP
No antidote for other anticoagulants
Methanol OD presentation…
drowsiness Ataxia metabolic acidosis pupillary dilation hypotension rapid pulse
Methanol OD management…
Correct acidosis
Administer folic acid
HD for severe cases
Ethylene glycol OD presentation…
Euphoria Nausea Seizures CNS depression Progressive metabolic acidosis Flank pain Tubular necrosis Renal failure
Ethylene glycol OD management…
Maintain ABCs
Fomepizole every 12 hours until methanol levels below 20
Bicarb infusion
To facilitate metabolism (Pyridoxine, thiamine, magnesium)
In severe cases- HD
Retinal detachment presentation
Painless visual changes
Floaters
Light flashes
Blurred vision
Retinal detachment management
Immediate Ophthalmologist referral
Gonorrhea conjunctivitis Treatment
Gram stain
Giemsa stain
Culture
Single dose ceftriaxone
Corneal abrasion treatment
Gentamicin
Sulfacetamide
