EM + CC Flashcards
What are the indications for a tracheostomy?
- weaning from prolonged mechanical ventilation (reduced dead space and the work of breathing compared to ET tube)
- emergency airway compromise
- in preparation for major head and neck surgery
- neuromuscular disorders (to manage excess trachea-bronchial secretions)
A-E management in a patient with a tracheostomy in urgent resp distress
- call for help (anaesthetist, ENT surgeon) plus have difficult airway trolley nearby
- A-E
- apply humidified oxygen 15L/min via a non-rebreathe mask and over the tracheostomy site.
- remove speaking valve and suction any secretions
remove cuff so patient can breathe around it - change inner cannula
- monitor
What are the 2 different types of nutrition and their key subtypes?
Enteral
- oral
- NG tube
- NJ tube
- PEG
- PEJ
Parenteral (intravenous)
What does PEG/PEJ stand for?
percutaneous endoscopic gastrostomy / jejunostomy
reasons to use an NJ tube rather than NG and vice versa?
NJ: in acute pancreatitis as they bypass the duodenum and pancreatic duct and therefore reduce pancreatic enzyme release that would have exacerbated pancreatic inflammation; good if pt is at risk of lung aspiration as they bypass the stomach.
NG: larger diameter and less likely to block
Considerations when starting parenteral nutrition
- build up gradually
- slow down feed if experiencing diarrhoea or distension
- daily bloods to check for re-feeding syndrome (low K+, phosphate and Mg)
indications for total parenteral nutrition (TPN)
- insufficient intestinal absorption e.g. short bowel syndrome
- bowel rest (e.g. bowel obstruction, intestinal fistula)
complications of TPN
contributes to gut atrophy if prolonged
exacerbates acute phase response
IV line infection
re-feeding syndrome
acalculous cholecystitis
fatty liver
electrolyte and glucose imbalance
What is the electrolyte disturbance that you get in re-feeding syndrome?
hypokalaemia
hypophosphateamia
hypomagnesaemia
Where on the chest do you perform CPR to get maximal output?
- middle of the sternum
- 1/3 depth or 4-5 cm (check tidal volume and pulses)
VF on ECG
- broad
- irregular
VF on ECG next step
1) continue CPR as defibrillator is charging
2) defibrillate
3) restart CPR for 2 minutes
4) second shock
5) CPR for 3 minutes
6)
what type of defibrillation in cardiac arrest / VF?
unsynchronised
VT features
- broad complex
- fast rate
- constant QRS morphology
can be monomorphic or polymorphic (torsades de pointes)
summarise cycle of CPR
1st shock -> CPR
2nd shock -> CPR
3 shock -> adrenaline 1mg IV (1 in ????), amiodarone (300mg) -> continue CPR
Mx of asystole on ECG (pulseless)
- CPR
- adrenaline
(make sure that the pads are on, especially if completely flat)
6Hs and 4 Ts
Hypothermia
Hypovolaemia
H
H
Hypoglycaemia
Heroin OD
Thrombosis
loin to groin pain in elderely
AAA - do not miss
be careful of diagnosing renal colic
can often be a ruptured AAA!!
causes of commonly missed life threatening causes of epigastric pain?
- ruptured AAA
- inferior MI
(peptic ulcer, pancreatitis, gallstones - commonly considered)
causes of life threatening abdo pain with soft abdomen
- mesenteric ischaemia (pain out of proportion to examination findings)
Pain out of proportion - diagnoses
-> usually vascular
PE
mesenteric ischaemia
necrotising fasciitis
What to consider if a pt with asthma is not responding to treatment
In pts with acute asthma make sure that you did not miss a pneumothorax (CXR)
call anaesthetist
IVDU + back pain
dx?
discitis until proven otherwise
-> MRI
define shock
inadequate tissue perfusion and oxygenation
Where might the blood be in a trauma patient?
intra abdominal
chest
pelvis
long bones
+ at the scene (ask the paramedics)
are adults hypotensive from head injury?
no
(children are more likely to be, but also rare)
can you get neurogenic shock from head trauma?
yes
can get it from head and high C-spine injuries
Spinal shock vs neurogenic shock
What % of rib fractures are missed on CXR
50%
What MAP is needed to sustain good organ perfusion?
60 mmHg
What is Prehn’s sign?
When is it +ve and -ve?
What doe +ve and -ve mean here?
- useful in acute testicular pain
Positive = pain improves upon elevating testicle -> suggests orchitis/epidydimorchitis
Negative = pain still present when elevating testicle -> Testicular torsion
What are the indications to start NAC in paracetamol OD?
- staggered OD
- above treatment line on nomogram
- pts who present 8-24h after ingestion of an acute overdose of more than 150 mg/kg of paracetamol even if the plasma-paracetamol concentration is not yet available
- present > 24h if they are clearly jaundiced or have hepatic tenderness, their ALT is >ULN
What does “staggered” OD mean?
drug taken in >1h
