EM and Surgery Flashcards
Choking
Clinical features:
stridor, coughing, gagging, wheezing
CXR: location of FB
Bronchoscopy - definitive dx and removal
Management:
Monitor pulse ox symmetry - supplemental O2
Encourage actively coughing patients to keep coughing
Heimlich maneuver or emergency tracheotomy - can’t breathe
IV glucocorticoids - reduce bronchial inflammation, aid extraction
Complications: lung abscess, pneumonia
Drowning
High risk groups: under 5, Males 15 to 25
Pathophysiology:
Submersion water -> hypoxemia
Reflex laryngospasm -> hypoxemia
Wash out of pulmonary surfactant -> alveolar collapse and ARDS
Hypoxemia -> cerebral ischemia and edema -> elevated ICP
No significant difference between fresh water and saltwater
Features: Unresponsive or obtunded Cyanosis and respiratory arrest Arrhythmias or cardiac arrest Hypothermia common
Tx:
CPR, intubate, O2
warm
Persistent hypoxia following successful resuscitation suggest underlying lung injury
Cat and dog bites
Consequences:
Deep puncture wounds damage nerves and tendons
High risk for abscess:
-Pasturella multocida (cat > dog)
-S. aureus (esp MRSA) - from skin surface
Tx:
Clean surface with iodine, Copious pressure irrigation with NS
-use soft IV catheter to get deep into wound
Suturing:
- do not close puncture bites and dog bites to hand
- suture facial wounds - low rate of infection
Ppx abx: Amoxicillin-clavulanate "dog-mentin" Doxy + metronidazole or clindamycin Rabies ppx if can't observe animal for 10 d or suspected to be rabid Td if not within 5 yr
F/u psych assessment for PTSD - occurs in more than 50% of children
Human bites
Contaminated by S. aureus or Group A strep
Tx:
Irrigate with saline
Debridement as needed
Abx ppx: Amox-clav Doxy + metronidazole or clindamycin Td Document thoroughly
Black widow spider bite
Latrotoxin - neurotoxin that causes ACh release -> muscle pain/spasm, diaphoresis, autonomic stimulation
Tx:
Mild rxn resolve in less than 12 hrs without complications
-wash with soap and water
-ice to reduce inflammation
-Td ppx
-analgesia as needed
-pressure and immobilization to slow the systemic spread of venom
-24 hrs of observation for signs of systemic involvement
Systemic systoms - aka latrodectism
-benzo’s for muscle spasm
Analgesia with acetaminophen +/- opioids
Antivenin within 30 min
Brown recluse spider bite
Venom causes LOCAL ulceration, skin necrosis -> full thickness
Usually 1 bite
April - October
Pale center, flat/sunken
Systemic sxs: Fever Nausea/vomiting Malaise Hemolytic anemia Rhabdomyolysis
Tx:
If ulceration: wound care with dressing changes and debridement
S/S of infection, cellulitis, abscess - erythromycin or clindamycin or doxycycline or TMP-SMX
Td ppx
consider Dapsone to reduce the extent of local necrosis d/t leukocyte inhibitory properties (r/o G6PD prior)
Ruling out brown recluse spider bite
NOT RECLUSE
Numberous Occurance - not in secluded area Timing - November to March Red center Elevated Chronic Large Ulcerates in less than 7 days Swollen Exudative
Indications for tetanus booster in adult
Td q10 yr
Tdap at least once between 19-64
Injuries:
If clean, minor, low risk of tetanus - give if more than 10 yrs or if uncertain of last dose or has had less than 3 lifetime doses
Dirty, contaminated, puncture or crush injury that is tetanus prone - give Td if more than 5 yrs since last dose, if unknown last dose or less than 3 life time doses, give Td + tetanus immune globulin at site other than the Td
For those with less than 3 life time doses - complete series
Rule of nines for Burns
Each are 9% Full head Chest Upper back Abdomen Lower back and buttock Full arm Front of leg Back of leg
Genitalia - 1%
Treatment of severe burns
3rd degree >2-3 %, 2nd degree >10%
Admit
Fluid resuscitation
Escharotomy - decreased risk of ischemia or restricted breathing
Extensive burns and facial burns require intubation to protect the airway
Smoke inhalation -> CO poisoning -> treat 100% O2, Monitor for respiratory failure
Td booster
Life threatening complications in burn patients
Hypovolemia -> shock Inhalation injury Sepsis - pneumonia or Pseudomonas wound infections Renal failure Arrhythmias
Parkland burn formula
4ml X kg X % burned
Fluid resuscitation volume for mod-severe burns - not maintenance needs
LR - give half within 8 hrs, 1/2 following 16 hrs
electrical burns
Presentation: Internal damage worse than external Arrhythmias Compartment syndrome Bony injuries myoglobinuria Acidosis Rhabdomyolysis Renal failure Neurologic disturbances
Tx:
Aggressive IVF to prevent myoglobinuria, renal failure, acidosis in face of muscle necrosis
High index of suspicion for compartment syndrome
Obtain an ECG and monitor for arrhythmias
Heat exhaustion
Features: Tachycardia Hypotension Weakness/collapsed Headache Muscle cramps G.I. upset Profuse sweating Temperature slightly elevated - 102-104
Tx:
Cool the patient
Hydration - oral or IV
Close monitoring
Heat stroke
Features:
Temperature over 104
Brain dysfunction - disorientation, coma, seizures
Features of heat exhaustion
Tx:
Cool patient rapidly - immersion in ice water, spray with water and fan, gastric lavage the cold saline, Cold IV fluids
IV fluids
Monitor labs - ensure not progressing to organ failure
Treat seizures with benzo’s
Mild hypothermia
90-95 F
Features: Tachycardia Tachypnea Ataxia dysarthria Impaired judgment
ECG: J waves V2-V5
Tx:
External heating - out of wet clothes, underline gets
Possible forced air warming systems
Moderate hypothermia
82-90 F
Features:
Bradycardia
CNS depression
ECG: J waves V2-V5
Tx:
Start with the external heating
Internal:
-warm saline 42C or warm humidified O2
Severe hypothermia
below 82F
Features: Hypotension CV collapse Unstable arrhythmias - V tach, V fib Areflexia coma like state
Tx: External heating Warm saline, warm humidified O2 pleural and peritoneal irrigation with warm saline Extracorporeal heating
Make it parodoxical drop in temperature as cold blood returns to core -> worse condition
Acetaminophen overdose
Stage I: 30 min - 24 hr
Nausea, vomiting, diaphoresis, pallor, lethargy, and malaise
Stage II: 24-72 hr
Elevated LFTs, PT, and total bilirubin
RUQ pain and tenderness
Stage III: 72-96 hrs
Peak LFT elevation
Jaundice, hepatic encephalopathy, bleeding, +/- acute renal failure
Possible multisystem organ failure -> death
Stage IV: 4 d-2w
Recovery
Dx: check acetaminophen level
Tx:
Activated charcoal within 4 hours
N-acetylcysteine within 8 hrs - restores hepatic glutathione stores
Theophylline overdose
Narrow therapeutic index - 10-20 mg/L
Mild toxicity - hypokalemia, hyperglycemia, vomiting
Severe toxicity: seizures, hypotension, cardiac tachyarrhythmias
Tx: Supportive - IV hydration, potassium ACLS protocol for SVT Benzodiazepines for seizure - no phenytoin G.I. decontamination Hemodialysis
Beta blockers and calcium channel blocker overdose
Bradycardia
Hypotension
Pulmonary edema
Hypoglycemia
Tx: IVF Atropine GLUCAGON - 1st line antidote for b-blocker toxicity (activates adenylyl cyclase -> elevated Ca2+ level) Calcium Insulin and glucose
Anticholinergic overdose (atropine, benadryl)
Hot as a hare - hyperpyrexia Dry as a bone Red is a beet Blind as a bat - cycloplegia, mydriasis Mad is a hatter - disoriented Bloated as a toad - constipation and urinary retention Tachycardia Decreased or absent bowel sounds
Antidote: physostigmine
Digoxin toxicity
Yellow vision Fatigue Blurred vision Anorexia Nausea/vomiting Diarrhea Abdominal pain Headache Dizziness Confusion Delirium
ECG changes:
- prolonged PR interval, “scooping” ST segments - at therapeutic levels
- bradycardia
- PVCs
- atrial tachycardia with AV block (4:1 or 6:1)
Labs: hyperkalemia - indicates severity
Elevated serum digoxin levels
Tx: Digoxin antibody fragments for: -V tach, V fib, asystole, complete heart block Mobitz II, symptomatic bradycardia -Hyperkalemia -end organ dysfunction
Activated charcoal
Atropine is bradycardia present
Aspirin overdose
Tinnitus
Hyperthermia - uncouples mitochondrial oxidative phosphorylation
Alkalosis (hyperventilation) -> mixed respiratory alkalosis and metabolic acidosis with elevated anion gap
-tachypnea - stimulated medullary respiratory center
-acidosis
N/V, dehydration, AMS
Tx:
Charcoal
Dialysis
Sodium bicarb
Heparin toxicity sxs
Easy bruising/bleeding
Gross hematuria
isoniazid toxicity sxs
peripheral neuropathy
hepatotoxicity
TCA toxicity sxs
Tachycardia Dry mouth Anti-cholinergic affects Urinary retention Seizures ECG: QRS widening >100
Warfarin toxicity
Excessive bleeding - nose bleed, hematuria, intracranial bleed
INR less than 5: decrease dose
INR > 5 - oral vit K, adjust dose
INR >20 or serious bleeding - IV vit K, FFP
Alternatives: prothrombin complex concentrate, recombinant human factor VIIa isntead of FFP
Methanol and ethylene glycol
Methanol - antifreeze - smells like ethanol, -> blindness
Ethylene glycol - antifreeze - sweet -> vomiting, hyperventilation, slurred speech, metabolic acidosis, kidney failure
Dx: hx and elevated anion gap
Tx:
Sodium bicarb - correct acidosis, limit penetration of toxic metabolites into tissues (retina)
Fomepizole or ethanol
Dialysis for severe metabolic acidosis or organ damage
caustics (acid and alkali) ingestion
Sxs: Oropharyngeal and gastric irritation or burns Drooling odynophagia Abdominal pain Gastric perforation
DO NOT give emetics, a neutralizing agent, or attempt to place NG tube
Supportive care in ICU
Endoscopy in first 24 hrs
Complications: esophageal strictures, 1000 fold increase in esophageal squamous cell carcinoma (lye ingestion)
organophosphate poisoning
Insecticides and fertilizers
DUMBBELSS: Diarrhea Urination Miosis Bronchospasm Bradycardia Emesis and excitation of skeletal muscles Lacrimation Sweating Salivation - drooling
Tx:
Atropine (anticholinergic)
Pralidoxime (reactivates acetylcholinesterase)
Iron toxicity
GI phase: 30min - 6 hrs
-abdominal pain, vomiting, diarrhea (often bloody), hematemesis, melena, lethargy -> shock
latent/stable phase: 6-24 hrs
Shock and metabolic acidosis: 6-72 hr
- widespread cellular destruction
- Multi systems organ failure, G.I. bleeding and or perforation, pulmonary dysfunction, coagulopathy, renal dysfunction, neurologic dysfunction
- Core outcome
hepatotoxicity/hepatic necrosis 12-96 hr
Bowel obstruction 2-8 wks
-G.I. scarring, gastric outlet
XR - radioopaque pills
Tx: deferoxamine, gastric lavage
Lead toxicity
paint chips, house older than 1950s
Presentation: asx vomiting cognitive impairment language delay hearing loss behavior problems at low levels abdominal pain anemia seizures renal insufficiency encephalopathy
Pediatric mod tox: 45-69 - succimer
Ped severe tox over 70 - dimercaprol AND calcium disodium edetate
Adults - succimer
Cyanide poisoning
domestic fires, mining, plastic manufacturing, nitroprusside
inhibits cytochrome c oxidase
Rapidly lethal
Presentation: tachycardia and hypertension - early bradycarida and hypotension - late headache confusion seizures coma flushing almond-scented breath
Tx:
sodium thiosulfate - converts to thiocynate - renally excreted
Hydroxocobalamin (B12 precursor) - forms cyanocobalamin - excreted in urine
-causes reddish discoloration to skin, mucous membranes, urine
Amyl nitrite and sodium nitrite
-induce methemoglobin -> cyanomethemoglobin
-don’t give methylene blue - releases free cyanide
Carbon monoxide poisoning
car fumes, smoke, paint thinner, house fire
displaces O2 from hemoglobin
Features: headache dizziness nausea myalgias cherry-red lips AMS hypotension
Increased carboxyhemoglobin -> normal pulse oximetry
Tx: 100% O2, hyperbaric oxygen therapy
Body packing -> OD
Tx: polyethylene glycol - Golightly
reversal agent if know substance
Initial management for femur fracture
Close reduction via manual traction then stabilize with traction brace
Initial management of open fractures
Remove any gross debris -> NS pressure wash X 5L -> cover with Kerlex
Meds: abx, analgesics, tetanus shot
Consult surg/ortho
Document, talk with family
Glasgow coma scale
Eye response 1-4 4 Open spontaneously 3 Opened to voice 2 opened pain 1 none
Verbal response 1-5 5 oriented 4 confused 3 inappropriate words 2 incomprehensible sounds 1 no verbal response
Motor response 1-6 6 obeys commands 5 localizes the pain 4 withdrawal from pain 3 abnormal flexion with pain - decorticate 2 extension to pain - decerebrate 1 no movement with pain
GCS 8 or less - intubate
Cushing triad
Hypertension
Bradycardia
bradypnea
Signs of increased ICP
Hypertension Bradycardia Bradypnea Papilledema AMS pupil asymmetry
Basilar skull fracture
Bruising around eyes - raccoon eyes
Bruising over mastoid process - Battle sign
Blood behind TMs
CSF rhinorrhea or otorrhea
Interventions to lower ICP in head injury
HOB at 30
pretreat with lidocaine before intubation (minimize ICP elevations)
IV mannitol q6h
- check serum Na and osmolarity q6
- hold mannitol if Na >152 or osmolarity >305
Intubate and hyperventilate until pCO2 25-30 on ABG
- decreasing pCO2 by 5-10 will lower ICP by 20-30
- temporary
Decompressive craniectomy
Ventriculostomy
bariturate coma
paralysis
Treatment for anterior spinal cord syndrome following traumatic injury
ABCs - keep spine stabilized
hypotension - aggressive bolus fluids, limit fluids once normotensive to avoid cord swelling
+/- high dose IV steroids 3-8 hrs of injury (controversial)
CT/MRI of spinal cord
Decompression via closed reduction (halo) or surgical intervention once stabilized
Neck zone 1
clavicle -> cricoid cartilage
Structures: Great vessels Aortic arch Trachea Esophagus lung apices Cervical spine Spinal cord Cervical nerve roots
Evaluation:
CT angio
Triple endoscopy - EGD, bronchoscopy, laryngoscopy
Neck zone 2
Cricoid cartilage -> angle of mandible
Structures: Carotid arteries Vertebral arteries Jugular veins Pharynx Larynx Trachea Esophagus Cervical spine Spinal cord
Evaulation:
Surgical exploration
Neck zone 3
Angle of the mandible -> base of skull
Structures: Salivary glands Parotid glands Esophagus Trachea Cervical spine Carotid arteries Jugular veins Major cranial nerves
Evaluation:
CT angio
CXR findings indicating ruptured thoracic aorta
Widened mediastinum
Loss of aortic knob
Pleural cap
Deviation of the trachea in esophagus to the right
Depression of the left main stem bronchus
Tension pneumothorax
Absent breath sounds and hyperresonance to percussion (hollow sound) on the affected side
Distended neck veins
Hypotension
Tx:
Immediate chest tube placement
If delayed - needle decompression
-2nd or 3rd intercostal space at midclavicular line
5th intercostal space midaxillary line - preferred site of tube thoracostomy
Intraperitoneal vs extraperitoneal bladder rupture
Intra: blunt force injury to the lower abdomen with full bladder
-> dome rupture, urine in peritoneal space
Extra: pelvic fracture, anterior or anterolateral wall of bladder
Dx: IV pyelogram retrograde urethrogram pelvic XR CT scan
Tx:
penetrating injury -> ex lap
Cystoscopy w/ repair - urethral, intraperitoneal, renal pelvis injury
Flail chest
Free-floating portion of the chest wall that moves paradoxically to the rest of the chest wall
-three or more sequential rib fractures
Presentation:
Muscle splinting due to pain - conceals motion
Direct impact or crush injury
Tx:
O2
Close monitoring for early signs of respiratory compromise
BiPAP or ET intubation with vent
Analgesia - improve breathing, prevent hypoxia
Initial management of abdominal stab wound
ABCs - hypotensive -> surgical exploration
Abd exam:
- signs of peritonitis -> ex lap
- penetrates anterior fascia -> ex lap
- no penetration or unable to asses - admit for serial 24 hr exams -> ex lap if develops peritonitis or hemodynamically unstability
NG tube - decompress stomach and rule out blood In stomach
Urinary catheter
Diagnostic peritoneal lavage
upright CXR - hemo/pneumothorax and/or intraperitoneal air
US - identify hemoperitoneum
Abd CT with con
Dx: laparoscopy
Mangement of blunt abdominal trauma with stable V/S
ABC's Establish IV access - two large bore IVs NG tube and Foley CT abd/pelvis H&H +/- type and cross
Management of blunt abdominal trauma with unstable V/S
ABCs
Assessed for and manage pelvic fracture, focused assessment with sonography for trauma (FAST)
- blood -> emergent laparotomy
- no blood in pelvis - possible retroperitoneal hemorrhage - get angiography with possible embolization
-FAST inconclusive -> diagnostic peritoneal lavage
If no blood in pelvis and angio normal -> CT abd/pelvis + observation +/- admission
R/O other causes of hypotension
Treatment for retroperitoneal hematoma
penetrating injury or exsanguination into abdomen -> ex lap and repair
Blunt trauma without blood in abd - follow H&H
-if hemodynamically unstable or falling H&H -> angiography with possible embolization
Immediate treatment for pelvic fracture
ABCs + thorough neurovascular exam
IVF +/- blood
FAST
- no fluid in pelvis + unstable -> diagnostic peritoneal lavage to detect bleeding missed by FAST
- blood -> emergent ex lap
- no blood, unstable - consider retroperitoneal hemorrhage -> angiography with possible embolization
Use a pelvic binder until external fixator placed
- assessed for bladder and urethral injury with retrograde cystourethrogram
- Extraperitoneal bladder rupture - Foley x10-14 d
- Intraperitoneal bladder rupture - urgent ex lap repair
Sites a significant blood loss of more than 1.5 L
At injury scene Pleural cavity Intra-abdominal Pelvic into thigh
Antibiotic ppx for rape vicitms
Ceftriaxone 125 mg IM (gonorrhea)
Azithromycin 1 g PO x1 or doxy 100 mg BID x7 days (chlamydia)
Metronidazole 2 g PO (trichomoniasis)
Hep B vaccine 1 of 3 if not vaccinated +/- Hep B IG
HIV ppx x 3-7 days
Antiemetics - promethazine for nausea caused by HIV meds and pregnancy ppx
Levonorestrel 0.75 mg PO, repeat 12 hrs (or both doses at same time)
Postop fever
Ws
Wind - pneumonia >3 days
Water - UTI 3-5 d
Walking - DVT and PE
Wound - infection 5-8 d
Wonder drugs - antimicrobials, heparin, SSRIs
Wein - thrombophlebitis, IV or central line infection
Other: sinusitis (NG tube), MI, stroke, transfusion reaction
Most common postop fever causes in cardiovascular surgery
Pneumonia, sternum wound infection
Most common postop fever causes in neurosurgery
Meningitis, DVT, UTI
Most common postop fever causes in abdominal surgery
Deep abdomen abscess, pancreatitis
Most common postop fever causes after C/S
endometritis
Most common postop fever causes in ortho surgeries
DVT
infected prosthesis
Malignant hyperthermia
halothane and/or succinylcholine
Within one hour of anesthesia induction
Presentation: Unexplained rise in end tidal carbon dioxide Muscle rigidity (should be limp) Hyperthermia Cyanosis Tachycardia Autonomic problems Arrhythmias DIC Acidosis
Labs:
Mixed metabolic and respiratory acidosis
Hyperkalemia, elevated urine myoglobin, elevated serum creatinine kinase - due to muscle cell breakdown
Tx: 100% O2, increase ventilation rate Stop agents - change to propofol Dantrolene Cool body
