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
