EM AND TRAUMA MANAGEMENT

Question 1

PT WITH HEADACHE VOMITING AND LOC

Answer 1

PRIMARY INTRACEREBRAL HAEMORRHAGE

Question 2

TOTAL ANT CIRCULATION INFARCT CAUSES

Answer 2

BOTH ACA (lower limb ) AND MCA ( face and upper limb )
3 H’s
. hemisensory loss ( hemiparesis )
. homonymous hemianopia
. higher cognitive dysfunction ( dysphasia )

Question 3

lacunar infarcts causes

Answer 3

HEMI PARESIS HEMISENSORY LOSS OR WITH LIMB ATAXIA
( ARTERIES AROUNF INTERNAL CAPSULE THLAMUS AND BASAL GANGLIA

Question 4

POST CIRCULATION INFARCTS CAUSES ?

Answer 4

VERTEBROBASILAR ARTERIES
BRAIN STEM DANAGE

ATAXIA
VISION AND GATE DISORDERS
CN LESIONS

Question 5

head injury assesment

Answer 5

with in 15 min of arrival for all pts

Question 6

first thing to do with gcs < or = to 8

Answer 6

intubate and stabilize airway

Question 7

full spine immobilization ? when after head injury ?

Answer 7

gcs <15
parasthesia in extremities
neck pain or tenderness
focal neurological deficit
suspected c spine injury ( 3 view c spine xray )

Question 8

when to go for c spine CT after head injury ?

Answer 8

if intubated
gcs <13
normal x ray and still suspicion of c spine injury
ct head is performed
initial plain films are abn
focal neurology

Question 9

when to go for immediate CT post head injury ( in an hour)

Answer 9

gcs <12 on adm
gcs <15 in 2 hrs after adm
suspected open or depressed skull fracture
suspected skull base fracture ( panda eyes / battles’s sign / CSF leak from nose or ear / bleeding ear)
vomiting >1 episode
focal neurology
post traumatic seizure
if pt is on anticoagulants ( MUST)

Question 10

when to contact neurosurgeon after head injury ?

Answer 10

GCS <8 or = 8
unexplained confusion >4 hrs
reduced GCS after adm
incomplete recovery after seizure
penetrating injury
CSF leak
progressive neuro signs

Question 11

observations post head injury

Answer 11

half hourly until GCs 15

Question 12

splenectomy after trauma ? when ?

Answer 12

if HILAR INJURIES ( GRADE 4 ) OTHERWISE CONSERVATIVE MANAGMENT

Question 13

AORTIC DISSECTION SYMPTOMS and FACTORS

Answer 13

SYMPTOMS :
tearing chest pain
syncope ( LOC)
early diastolic murmur ( like AR)
right coronary artery involvement ( inf MI)

PREDISPOSING FACTORS :
hypertensive pregnancy
CT disorders ( ehler danlos / marfans )
congenital heart disease

scenario : A 28 year old woman, who is 30 weeks pregnant, presents with sudden onset chest pain associated with loss of consciousness. Her blood pressure is 170/90 mmHg, saturations on 15L oxygen 93%, heart rate 120 bpm and she is apyrexial. On examination, there is an early diastolic murmur, occasional bibasal creptitations and mild pedal oedema. An ECG shows ST elevation in leads II, III and aVF. What is the most likely diagnosis?

SURGICAL REPAIR :
<28 weeks = repair with fetus in utero
28-32 = depends on fetus condition
>32 weeks = C/Section followed by aortic repair

Question 14

treatment of PE in pregnancy ?

Answer 14

LMWH throughout preg and 4-6 wks after
warfarin CI in preg except in women with mech heart valves due to risk of TE

ecg changes : No changes
S1, Q3, T3
Tall R waves: V1
P pulmonale (peaked P waves): inferior leads
Right axis deviation, RBBB
Atrial arrhythmias
T wave inversion: V1, V2, V3
Right ventricular strain: if identified is associated with adverse short-term outcome and adds prognostic value to echocardiographic evidence of right ventricular dysfunction in patients with acute pulmonary embolism and normal blood pressure.

Question 15

mitral stenosis association ?

Answer 15

Rheumatic heart disease

commonest cardiac condition in preg

tx : valve surg / balloon valvoplasty

Question 16

torsades de pointes tx ?

Answer 16

iv mgso4 ( 2g over 10 min)

rare arrhythmia associated with a long QT interval may progress to VF and then death

Question 17

causes of long QT interval ?

Answer 17

congenital: Jervell-Lange-Nielsen syndrome, Romano-Ward syndrome
antiarrhythmics: amiodarone, sotalol, class 1a antiarrhythmic drugs
tricyclic antidepressants
antipsychotics
chloroquine
terfenadine
erythromycin
electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia
myocarditis
hypothermia
subarachnoid haemorrhage

Question 18

62 year old woman presents with acute bowel obstruction. She has been vomiting up to 15 times a day and is taking erythromycin. She suddenly complains of dizziness. Her ECG shows torsades de pointes. What is the management of choice?

Answer 18

iv mgso4 2g over 10 min

excessive vomiting = hypokalemia / hypomagnesemia

erythro contributes to torsades

Question 19

j waves on ecg ?

Answer 19

hypothermia

Question 20

compartment syndrome ?

Answer 20

characterised by raised pressure within a closed anatomical space. complication that may occur following fractures (or following ischaemia re-perfusion injury in vascular patients

symptoms ( 6 P’s )
pain / pressure / paralysis / paresthesia / pallor / pulsation of artery may felt as necrosis is due to microvascular compromise

dx : intracompartmental pressure measurement (>20mmHg =abn > 40mmHg = diagnostic)

tx : fasciatomy

muscle groups are frankly necrotic at fasciotomy they should be debrided and amputation may have to be considered

Death of muscle groups may occur within 4-6 hours

complications :
lower limb the deep muscles may be inadequately decompressed by the inexperienced operator when smaller incisions are performed
Myoglobinuria may occur following fasciotomy and result in renal failure and for this reason these patients require aggressive IV fluids