EM Flashcards
What should be done in every trauma patient?
Assume a cervical injury and immobilize with collar
Indications for intubation
Patent airway
Protects against aspiration ie if GCS < 8
Positive pressure ventilation
Pulomonary toilet (suction)
How to calculate GCS?
Eyes/4 Verbal/5 Motor/6
No response to most response
Severe injury if <8
Moderate injury if 9-12
Most useful if repeated and monitored for improvement or decline
What should you consider if you see unilateral, dilated, non reactive pupil?
Focal mass lesion, epidural hematoma, subdural hematoma
Contraindications to foley insertion
Blood at urethral meatus, scrotal hematoma, high riding prostate on digital rectal exam
NG tube contraindications
Significant mid face trauma or basal skull fracture
How long should you do compressions for before considering defibrillation in an unwitnessed arrest?
5 cycles or 2 minutes
What areas are examined during FAST?
Focused Assessment with Sonography for Trauma
Subxiphoid pericardial window
Perisplenic
Hepatorenal
Pelvic/retrovesical (Pouch of Douglas)
U/S protocol developed to assess for hemoperitoneum and hemopericardium
Signs of increased ICP
- Decreasing consciousness
- Decreasing respirations
- High BP, low HR, irregular respirations (Cushing reflex)
- Lateralizing CNS signs (cranial nerve palsies, hemiparesis)
- Seizure
- Papilledema (occurs later) - swelling of optic nerve
- Nausea, vomiting, headache
Imaging modailty of choice for intracranial injury
Non contrast head CT
What to do if life saving treatment of a child is refused by the parent/guardian?
Contact CAS - consent of CAS is needed to treat
How to manage hemorrhagic shock
- Clear airway & assess breathing
- While doing so apply direct pressure on external wounds while elevating extremities
- Do not remove impaled objects in ER
- Start two large bore IV
- Run 1-2L IV warmed normal saline or ringers lactate
- If no response or continuous bleeding then consider pRBC transfusion (crossmatched best but if no time give O- to females and O+ for males)
- Use FFP, platelet, or tranexamic acid in early bleeding
- Consider INTERNAL bleeding sites - may need surgical intervention
Must give 3x estimated blood loss replacement for fluids
Signs of basal skull fracture
Battle’s sign (bruised mastoid process aka behind ear), hemotympanum (blood in middle ear on exam), raccoon eyes, CSF rhinorrhea/otorrhea
Can be radiologically or clinically diagnosed
Rupture of what artery is MCC of epidural hematoma?
Middle meningeal artery
Warning signs of severe head injury
GCS < 8
Deteriorating GCS
Unequal pupils
Lateralizing signs?
Head CT is only required in patients with minor head injury with any one of the following:
High risk: GCS < 8, suspected open/depressed skull fracture, Battle sign, raccoon eyes, CSF from ears or nose, hemotympanum, vomiting more than twice, older than 65
Medium risk: Cannot recall events just before impact, dangerous mechanism (fall > 3 ft or 5 stairs)
Low risk: Witness LOC, definite amnesia, witness disorientation in a patient with 13-15 GCS
Treatment for suspected raise intracranial pressure
- Intubate
- Calm (sedate)
- Paralyze if agitated
- Hyperventilate 100% O2 to PC02 of 30-35 mmHg
- Elevate head of bed to 20 degrees
- Maintain adequate BP to ensure good cerebral perfusion
- Diurese with mannitol 1 g/kg rapid infusion (CI in shock/renal failure)
Indications for C-Spine collar
Midline tenderness
Neurological symptoms or signs
Significant distracting injuries
Head injury
Intoxication
Dangerous mechanism
History of altered LOC
What does SAMPLE history stand for?
Signs and symptoms
Allergies
Medications
Pertinent past history
Last oral intake
Events leading up to injury
What is the most important film?
Lateral C spine x-ray as 95% of radiologically visible abnormalities are found on this film
Do full C spine series for trauma (AP, lateral, odontoid)
Signs of cauda equina
Incontinence, anterior thigh pain, quadriceps weakness, abnormal sacral sensation, decreased rectal tone, variable reflexes
Can occur with any spinal injury below T10
What is important to remember in securing an airway in the setting of obstruction?
Do not wait for ABG to intubate
INTUBATE EARLY
Remove foreign body if visible with laryngoscope prior to intubation
What is a tension pneumothorax and how is it diagnosed?
One way valve causing accumulation of air in pleural space
Clinical diagnosis
Can compress the heart, lungs, blood vessels, etc
Tx: Needle decompression/thoracostomy: large bore needle in 2nd ICS mid clavicular line followed by chest tube
What is the leading cause of death in pregnancy?
Thrmboembolic disease
(Helical CT preferred over VQ during pregnancy due to radiation exposure)
What is the treatment for hepatic encephalopathy?
- Treat underlying cause
- Lactulose to prevent diffuse of ammonia from the colon into the blood and acts as laxative to remove nitrogen producing bacteria from colon
- Oral rifaximin
What causes scarlet fever and what treats it?
Delayed hypersensitivity reaction to pyrogenic exotoxin made by GAS resulting in diffuse eryhtematous eruption
Requires prior exposure to S pyogenes
Can present with strawberry tongue, 2-3 days after pharyngitis with rash in creases that fades in 3-4 days
Rx: Penicillin, amoxicillin or erythromycin
What are the most immediately life threatening complications of adrenal insufficiency?
Hypotension and hypoglycemia
Hypotension rx fluids + glucocorticoids
Hypoglycemia rx dextrose fluids
Treatment of Cryptosporidium
Self limiting watery diarrhea or diarrhea in AIDS
Supportive
In AIDS pts give highly active antiretroviral therapy and if persists then try nitazoxanide or macrolides
Treatment of acute migraines
NSAIDs (IV kerotolac), triptans like sumatriptan and dopamine receptor antagonists such as prochlorperazone, metoclopramide, or chlorpromazine
What does linezolid cover?
Vancomycin resistant organisms
What is the treatment for community acquired pneumonia?
Common causes: pneumococcus, M pneumoniae, C pneumoniae
Rx: macrolide, 2nd/3rd gen cephalosporin, fluoroquinolone, doxycycline
Doxy is cheap and has twice a day dosing and covers most causes
What electrolyte is affected by thiazides?
Increases calcium reabsorption causing HYPERCALCEMIA
Treatment of subarachnoid hemorrhage
What is it: bleeding into subarachnoid space
How: Trauma usually but sometimes can be spontaneous or due to coagulopathy
How to recognize: sudden onset thunderclap headache after exertion, N/V, stiff neck
How to test: NC CT or LP (bloody tap, high opening pressure, elevated protein) or can consider MRA or CTA
Treat: Admit to ICU, O2, NPO, elevate head 30 degrees, IV NS, nimodipine (neuroprotective)
Burning pain in hands and feet and erythema of the skin
ERYTHROMELALGIA
Pathognomonic for microvascular thrombotic complication of PV or essential thrombocythemia, associated with more platelets
