Emerg Flashcards
Which of the following can primary care paramedics NOT perform:\n12 leak EKG\nIV starts\nSymptom relief meds\nAdvanced first aid\nSemi–automatic defibrillator\nPneumothorax decompression
Pneumothorax decompression – must be performed by advanced care paramedic
Paramedics are not regulated health care professionals. How do they perform regulated health acts?
Offline medical control – treatment algorithms\nOnline medical control – physician on call to provide advice or direction (for decompression of pneumothorax, etc.)
What valuable information can you gain from a paramedic?
Is the house safe to go home to, is there food in the fridge? any concerns about how the person is being cared for?\nIn the case of a car crash – how bad was the crash?
List the four types of shocks, and provide an example for each.
Hypovolemic (hemorrhage)\nCardiogenic (MI)\nObstructive (PE, cardiac tamponade)\nDistributive (sepsis, liver failure)
SIRS Criteria (4)
Temperature below 36 or over 38\nHR over 90\nRR over 20\nWBC under 4 or over 12
Define sepsis, and severe sepsis
Sepsis: 2 sirs criteria, and infection source\nSevere sepsis: sepsis with signs of end organ damage, hypotension, or elevated lactate (lactate suggests hypoperfusion)
Define septic shock
Severe sepsis with persistent signs of end organ damage (i.e., hypotension despite fluid challenge)
How would a patient in septic shock present?
Hypotension\nTachycardia (>90)\n\nPeripheral hypo–perfusion\nSigns of end organ dysfunction: encephalopathy, ARDS, ARF/ATN, DIC, cardiovascular dysfunction
How is qSOFA used in the emerg?
Prognostication – determine if this person can go home\nNot used to identify sepsis
What are the indications to intubate? Think of the mnemonic ABCDEF
Airway (failure to protect)\nBreathing (failure to oxygenate/ventilate)\nCirculation (unload resp muscles)\nDisability (LOC, Sz, weakness, CNS catastrophe such as cerebral hemorrhage)\nExpected course (anticipated decline)\nFeral (need aggressive sedation to protect patient/staff)
What is the purpose of delayed sequence intubation?
Stabilize agitated patient with pre–oxygenation before intubating (use Ketamine to help patient tolerate preoxygenation)
Management of Sepsis (3 components)
Supplemental O2, Intubate once more stable if needed\n40–60cc/kg fluid, then vasopressors if not stabilized\nTreat infection: Abx and source control
In which patients should you limit supplemental O2
MI patients\nCOPDers
Alpha 1 adrenergic receptors – what do they do?
Vascular constriction (general constriction throughout body)
Beta 1 adrenergic receptors – what do they act on and what do they do?
Heart: increased chronotropy, inotropy
Beta 2 adrenergic receptors – what do they act on and what do they do?
Lungs: bronchodilation, vasodilation
When would you use phenylephrine?
Have it ready to push during intubation in case BP drops
When would you use Levophed?
Levophed is the “go to” vasopressor. It increases SVR (and as a result BP). It also increases chronotropy and inotropy
When would you use epinephrine?
Vasopressor used in pediatrics. It increases SVR, chronotropy, inotropy.
Which line should be used for for vasopressors
IV can be used in the short run, but in the long run (days), a central line is needed
What are the 6 steps in a general approach to a trauma patient.
preparation\nprimary survey resuscitation\nadjuncts to primary survey\nsecondary survey\nadjuncts to secondary survey\ndefinitive care
Who do you call for a trauma patient
The trauma team!
When the black “patch” phone in the emerg is ringing, who is calling?
Paramedics
When the “bat” phone is ringing, who is calling?
911 dispatch
What information should you request when dispatch/paramedic calls to let you know a trauma patient is coming?
mechanism of injury\nscene details\ntime to transfer patient to hospital\nnumber of patients\nvital signs\nobvious injuries\nwhat has been done in field
What are the components of the primary survey (ABCDE)
airway\nbreathing\ncirculation\ndisability\nexposure (perform this survey while resuscitating)
How do you treat a tension pneumothorax? How do you treat an open pneumothorax?
Tension pneumothorax: Needle in second intercostal space in midclavicular line, then place a chest tube\nOpen pneumothorax (i.e., sucking chest wound): Place occlusive dressing taped on three sides, then place a chest tube with an occlusive dressing
What is a code orange, and when would you call it?
Code orange represents a “disaster” external to the hospital that is going to overwhelm the hospitals current capacity.
Which five compartments can a patient bleed into? What additional compartment is a concern in infants?
thorax\nabdomen\nretroperitoneum (pelvic fracture)\nlong bones (femur)\n”the street”\nInfants: the head (baby’s have relatively large heads, and their suture lines are open)
How do you treat a bleed?
Direct pressure or tourniquet proximal to wound
How do you manage intra–abdominal bleeding (as identified with point of care ultrasound showing dark fluid between liver and kidney)
Surgery
How would you manage a retroperitoneal bleed suggested by a wide–open broken pelvis on x ray?
Bind the pelvis using ties
How would you manage bleeding from a long bone?
Splint the fracture to prevent the two ends from moving across each other and causing more bleeding
In the emerg, what are your four options for vascular access? List in order from most to least preferred
Large bore IV\nInterosseous (fast to place)\n\nCordis with sheath introducer (large central line)\nTriple lumen central line (long and thin means decreased flow rate)
Which fluid is best for trauma resuscitation?
Blood\nUse crystalloid if no immediately available blood
Why is it important to follow the massive hemorrhage control protocol?
Large blood transfusions can dilute out coagulation factors, the protocol ensures they are provided back.
What is the most common cause of shock in trauma patients?
Bleeding
Your trauma patient has a headache, back pain, is vomiting but is not feeling nauseated, also their level of consciousness is declining. Fundoscopy shows papilledema (see pic). What do you do?
https://images.cram.com/images/upload-flashcard/53/63/95/33536395_m.jpg
What two intracranial bleeds are associated with trauma?
Subdural and epidural.
How can you tell the difference between subdural and epidural bleeds?
Subdural: between the dura and the arachnoid matter –– crescent shaped on ct\n\n\nEpidural: between the dura and the skull –– lentiform shaped on ct, meaning convex on both sides
What are you worried about with epidural bleeds? How do you manage them?
Epidural bleeds are fast bleeds and can increase intracranial pressure to the point of herniation.\nTo manage: \nstat call to neurosurg\nmanitol\nhypertonic NS
What imaging would you order for a trauma patient? How would this differ for a pediatric patient?
Adult: cxr, pelvic xray, c–spine, injured extremities, head–to–toe CT\nPeds: see above, but be selective with what parts of the kid get CT’ed
What would cue you to consider inhalation injuries in a burn patient?\nWhat do you need to do for such a patient?
Presentation:\nfacial burns, singed nasal hair, carbon in sputum, hx of “trapped in confined space” \n\n\nTreatment:\nFluids (parkland formula), intubate early due to edema risk
What rule would you use to calculate the percentage of the body covered in burns?
Rule of 9s \n\nhead: 9% \nback: 18%\nfront of torso: 18% \nlegs: 18% (9% each side)\narms: 9% (4.5% each side)
1st degree burn, presentation
sunburn
Superficial second degree burn, presentation
blisters, pain, no intervention required
Deep second degree burns, presentation
yellow tissue, heals in 3 to 8 weeks, require intervention
third degree burn presentation and treatment
charred, leathery, insensate, require skin grafting
4th degree burn presentation
deep, muscle and bone affected
Criteria for referral to burn center
It exists, look it up when you need it
STEMI treatment
fluids and vasopressors for low BP\nPCI if at PCI centre, or within an hour travel of centre, otherwise thrombolysis
Management of unstable supraventricular tachycardia
Fluids\nElectrical cardioversion (ketamine for pain, then cardiovert)
