Emergency Flashcards
What is the risk of CT scan in pregnancy?
?doubled risk of child cancer from 1-2/1,000
about 10mSv dosage for CTAP
What are the common causes of colonic pseudo-obstruction?
Orthopaedic trauma/surgery
Pneumonia/sepsis
ARF
Medications (opiates)
Electrolyte abnormalities
What pathogens most frequently cause cholecystitis?
E.coli > Enterococcus > Bacteroides
What factors are vital to obtain informed consent ?
-Understand information relevant to decision
-Retain information
-Use or weigh up that information
-Communicate decision
What legal principle underlies capacity?
Mental Capacity Act 2005
Assumption of capacity until proved otherwise
Decision specific
What risk factors are there for C.Diff infection?
Host -immune status, comorbidity, age >65, IBD, malnutrition
Exposure - hospitalisation, community sources, care facilities
Disruption - antibiotics, surgery
What factors suggest Severe C.diff infection?
WCC >15
AKI stage 1+
T>38.5
Albumin<25
Fulminant 1-3%
What type of organism is C.Diff?
Gram +ve anaerobic spore-forming bacillus
Produces enterotoxin (A) and cytotoxin (B)
How can ERCP perforations be Graded?
STAPFER classification
1 - GI tract wall (traction)
2 - peri-ampullary (sphinctertomy)
3 - bile ducts (guide wire/basket)
4 - retroperitoneal
What are the risk factors for ERCP perforation?
Periampullary diverticulum
Ampullectomy
Small calibre CBD
Longer duration of procedure
Sphincterotomy
What adrenaline is used in UGIB?
1:10,000 in quadrants
NICE recommends this + something else
What are the NICE indications for CT scan after head injury?
GCS <13 any time
GCS <15 at 2 hours
Suspected open/depressed/basal skull fracture
Seizure
Neurological deficit
>1 episode of vomiting
Amnesia >30minutes
Also any LoC with age >65 or coagulopathy, dangerous mechanism
What are the causes of ischaemic colitis?
Occlusive (small vessel disease inc radiation/vasculitis)
Non-occlusive (flow)
What is the role of nuclear red cell scanning in LGIB?
Technetium-99m labeled RBC scan can detect as low as 0.1-0.5ml/min bleeding (>1 for CT)
What factors increase the likelihood of mesenteric venous thrombosis?
Portal hypertension (Liver Cirrhosis)
Inflammatory (Sepsis, IBD, pancreatitis)
Hypercoagulable states (Malignancy, Dehydration, thrombophilia, thromboyctosis, COCP)
What are the zones of the neck?
Zone 1 - Sternal notch to cricoid (Subclavian, inomminate, common carotid, vertebral, jugular)
Zone 2 - Cricoid to angle of mandible (common carotid, bifurcation, veterbral arteries and jugular veins)
Zone 3 - Angle of mandible to base of skull (branches of ECA, ICA, vertebral, internal jugular)
What are hard and soft signs of vascular injury?
Hard - absent pulses, bruit/thrill, active haemorrhage, expanding haematoma, distal ischaemia
Soft - haematoma, past haemorrhage, hypotension, peripheral nerve injury
What scoring system is helpful for Nec Fasc?
LRINEC scoring system
Biochemical markers
What is the definition of an infant, toddler, pre-school, school-age and adolescent?
Infant - 0-1
Toddler - 1-3
Pre-school 3-5
School age - 6-12
Adolescent >12
How can a Childs weight be estimated?
2 x (age + 4)
What size ET tube should be selected for children?
Cuffed - 3.5 + (age/4)
What abdominal injuries are more common in children than adults?
Duodenal haematoma
Pancreatic injury
Bladder rupture
Small bowel rupture at ligament of Trietz
What is acceptable SBP in children?
70 + (age x 2)
UO 1.5-2ml/kg
What fluid resuscitation should be given to children?
10-20ml/kg warmed crystalloid
What size chest drain would use in a trauma setting?
28-30fr
What are the indications for thoracotomy in blunt chest trauma?
> 1500ml initial blood
200ml/hr for 4 hours
Consider - exsanguinating abdominal vascular injuries, unresponsive hypotension (<70), with witnessed signs of life
What are the indications for thoracotomy in penetrating chest trauma?
Witnessed cardiac arrest with <10minutes loss of CO
What is Beck’s triad?
Muffled heart sounds
Low blood pressure
Distended neck veins
- Tamponade
How should perforated peptic ulcer be closed?
WSES
<2cm primary repair +/- omental patch
>2cm consider resection
nb biopsy gastric
in septic shock adopt a damage control approach
What are the principles of non operative management of splenic trauma?
1) Fasted patient
2) Admission to critical care setting
3) Bed rest with analgesia for 5-7 days
4) Regular reassessment of patients clinical condition
5) Consider repeat CT scan at 10 days for evidence of splenic artery pseudo-aneurysm (peak rupture at 7-10days)
What are Truelove and Witts criteria?
For severe UC
Severe if:
Bowel motions >5
T >37.5
HR >90
ESR>30/CRP>45
Hb<10
What are the causes of mesenteric ischaemia?
Arterial embolism (50%)
Arterial thrombosis (20%)
Mesenteric venous thrombosis (10% - ProteinC/S/AT-III/FVL or secondary)
NOMI (20%)
How might you assess intestinal viability at cut edges?
Clinical - colour, pulsation, peristalsis, bleeding
Physiological - doppler probe, flourescence, IcG
Temporary abdominal closure
What are the 6 ps of acute limb ischaemia?
Pale
Pulseless
Paralysed
Paraesthesia
Painful
Perishingly cold
What is the risk of abnormality in a macroscopically normal appendix?
25-35%
What is a hydatid of morgagni?
Embryological remnant of cranial end of Mullerian duct attached to tunica vaginalis
What clinical signs are suggestive of torsion?
swollen, high-riding testicle
difficult to palpate cord
horizontal lie
absent cremasteric reflex
What are the causes of anastomotic leak?
Local factors
- Technique (tension, vascularity)
- Infection
- Radiation
- Missed proximal obstructing lesion
- Low anastomosis
- >500ml Blood loss
General factors
- BMI>30
- Crohns disease
- Malnutrition
- Anaemia
- Steroids
- Diabetes
- Age
- Smoking
How is cellulitis classified?
1 - No systemic toxicity
2 - Significant comorbidity
3 - Significant systemic upset
4 - Necrotising fasciitis
What is the purpose of damage control surgery?
Arrest haemorrhage
Minimise contamination
Which patients are most likely to need a damage control laparotomy?
pH<7.2, T <34, coagulopathy
Lactate >5, BD >6
At what B-HCG level would you expect a visible intra-uterine gestation to be visualised on USS?
> 1500
How are entero-cutaneous fistulae classified?
High (>500ml),
Moderate (200-500ml),
Low (<200ml) output
Location
- Type 1 (OGD)
- Type 2 (Small bowel)
- Type 3 (Colonic)
- Type 4 (Entero-atmospheric)
What are the common causes of enterocutaneous fistula
Iatrogenic 75-85% (Trauma, inter-operative, leak)
Spontaneous 15-25% (IBD, Malignancy, infection e.g. TB/actinomycosis, radiation, ischaemia)
How should patients with entero-cutaneous fistula be managed?
SNAP
Procedure - >6 weeks
What is the differential diagnosis of a painful groin lump?
Skin (Cyst, abscess)
Fat (lipoma)
Muscle (hernias)
Vein (Varix)
Artery (aneurysm)
Nerve (Schwannoma)
Lymph node
Psoas bursa
How do bullets cause injury?
Laceration and cutting (higher with Low velocity)
Cavitation (negative pressure due to temporary expansion entraining air, higher with HV)
Direct energy transfer
Fragementation
What are the causes of a raised ICP?
Surgical
- Extradural haematoma
- Subdural haematoma (tearing of dural bridging veins)
- SAH
- Contusions
- Diffuse axonal injury
Medical (Electrolyte, ischaemia, infection)
How does CO2 embolus present?
Pressure differential between abdomen and thorax forces gas through
Sudden cardiovascular collapse by interfering with RV function
Machinery-type murmur, hypotension and hypoxia
How should CO2 embolus be treated?
Vent abdomen
Place in left lateral position with head down
Insert central line into RV and aspirate air bubbles
What is the risk of seroconversion after needle-stick?
0.3% needle stick HIV+
0.1% Mucocutaneous contamination HIV+
0.5-1.8% needle stick HCV+
30% Hbe Ag+ non-immune
What would make you abandon a resuscitative thoracotomy?
Visible air in coronary vessels
Aortic disruption
Unable to fill heart after 5 minutes
No spontaneous rhythm after 10 minutes
Unable to maintain SBP >70 or carotid pulse after 15 minutes
What are the potential sources of bleeding in pelvic trauma?
Venous plexus (90%)
Bony surfaces
Arterial
Intra-pelvic organs
Extra-pelvic injuries
How can pelvic fractures be classified?
WSES Minor (Grade 1) Haemodynamically/mechanically stable
WSES Intermediate (Grade 2/3) Haemodynamically stable /mechanically unstable
WSES Major (Grade 4) Haemodynamically unstable
Also Young-Burgess and Tile classifications.
If more than 1 breakpoint then unstable
Vertical shear or open book
What are the common causes of postoperative fever?
Seven Cs - Cut, Chest, Cannula, Catheter, Central Line, Collection, Clot
Immediate - endocrine
Day 0-2 - Atelectasis, reaction to implanted graft
Days 3-5 - UTI/Pneumonia
Days 5-7 - Wound infection, abscess, leak
Days 7-10 - DVT
Any time - Line sepsis, transfusion reaction, drug reaction
What are the components of the GCS?
Eyes 1-4 None, Pain, Voice, Spontaneous
Motor 1-6 None, Extension, Flexion, Withdraws from pain, Purposeful to painful stimulus, Commands
Voice 1-5 None, Incomprehensivble, Inappropriate with discernible words, Confused, Oriented
Which organ is most often damaged by penetrating stab wounds?
Liver (40%)
Small bowel (30%)
Diaphragm (20%)
Colon (15%)
Which organ is most often damaged by gunshot?
Small bowel (50%)
Colon (30%)
Liver (20%)
What proportion of abdominal stab wounds do not penetrate the peritoneum
1/3
How should a colonic laceration be repaired?
In general with a primary closure
Which organ is most frequently injured by blunt trauma?
Spleen
Which organisms are involved in Post splenectomy sepsis?
Encapsulated organisms - Neisseria meningitides, Haemophilis Influenzae and Streptococcus Pneumoniae
In major perineal wounds (E.g. devolving), what abdominal procedure is often required
End colostomy
Which artery is the classical cause of a traumatic extradural haemorrhage?
Middle meningeal
What is the Cushings reflex?
Hypertension and Bradycardia caused by raised ICP (Munroe Kellie doctrine)
What is an appropriate cerebral perfusion pressure (MAP-ICP) in adults and children?
70 in adults, 40-70 in children
What cranial nerve is most frequently involved after head injury and raised ICP?
3rd nerve - occulomotor - caused dilated pupils with poor light response
Often associated with 4,5 and 6th nerve palsies
What is the major mechanism of pancreatic injury?
Deceleration injury
What is the most reliable imaging where pancreatic injury is suspected?
MRCP >CT for ductal injuries
What are the indications for clamshell thoracotomy?
Penetrating trauma with cardiocirculatory arrest, <15min of CPR
What blood products should be given in a major haemorrhage situation?
PRC, FFP and Platelets in a 1:1:1 ratio
Remember TXA (CRASH study)
What is the most common cause of diaphragmatic injury?
Blunt trauma causing large radial tears (laceration –> smaller tears)
More common on left
Initial CXR normal in 50% of cases
Treatment with surgery
What are the defining characteristics of the 4 stages of shock?
Stage 1: <750ml/15%
Stage 2:750-1500ml 15-30%
Stage 3:1500-2000ml 30-40%
Stage4: >2000ml, >40%
Stage 1 Normal
Stage 2 Tachypnoea, HR100-120, reduced UO
Stage 3 HR120-140, BP reduced, poor UO, confused
Stage 4 HR>140, v.low UO
What antibiotic prophylaxis is required after splenectomy?
Probably 250mg BD Amox.
Consider septrin if allergic
What are the classification systems for splenic trauma?
AAST (1-5)
1 - sub capsular haematoma <10%, capsular tear <1cm depth
2 - sub capsular haematoma 10-50%, intraparenchymal <5cm, 1-3cm lac
3 - haematoma sub capsular >50%, ruptured haematoma, intraparenchymal haematoma >5cm or >3cm laceration
4 - devascularisation of >25% of spleen
5 - shattered spleen, hilar disruption
and WSES (1-4)
1- AAST 1-2, stable (NOM)
2- AAST 3 , stable (consider angio)
3 - AAST 4-5, stable (all angio)
4 - AAST 1-5, unstable - Operative managment
What are the risk factors for failure of non operative management of splenic injuries?
Age >55
High injury severity score
AAST IV-V injuries
Where will an embolus most frequently lodge in mesenteric ischaemia?
SMA distal to origin of middle colic and pancreaticoduodenal
How do you perform a four compartment fasciotomy?
Anterior incision - for anterior and lateral compartments - 2 finger breadths lateral and below tibial tuberosity to two finger breadths proximal to lateral malleolus - then 2 x fascial incisions
Posterior incision - 2 finger-breadths posterior to medial border of tibia and 2 FB distal to head to 2FB sup to medial malleolus, then sup fascia opened and deep entered by taking gastrocneumeus/soleus down
Risk - Anterior - superficial peroneal
Posterior - long saphenous vein
How would you gain access and to and control of the femoral artery?
- Longitudinal incision from midinguinal point down
- Through fascia lata to identify CFA, SFA and PFA, then sling and clamp
Which vein is most at risk when dissecting out the PFA?
Lateral femoral circumflex vein
If the CFA is inaccessible through haematoma how may proximal control be obtained?
Through dividing the inguinal ligament or posterior inguinal canal
Which vessel injury carries the highest rate of limb loss?
Popliteal
How is the popliteal artery accessed through a medial approach?
Proximal - Incision between vastus medialis and sartorius. Incise deep fascia posterior to femur and palpate artery immediately behind bone - artery is medial here
Distal - separate incision 1cm behind tibia from medial femoral condyle, through the deep fascia avoiding the vein which is medial to the artery here
What is the most superficial structure in the popliteal fossa?
The tibial nerve. Starts laterally and passes medially
The artery is deepest
Encountered first in a medial exploration proximally then after the vein distally
What is the Mattox maneuver?
Complete left medial visceral rotation to access aorta
How is the axillary artery best accessed?
Supine, arm abducted. Transverse incision inferior to clavicle through pectoralis major.
Exposure and division of clavipectoral fascia to identify axillary vein.
May need to divide thoracoacromial artery (superficial branch)
Which is the most frequently injured peripheral artery?
Brachial
How is the brachial artery accessed?
Supine, arm abducted, incision in groove between biceps and triceps
Incise deep fascia, avoiding basilic vein at lower aspect
First aspect encountered is median nerve (starts lateral and passes anteriorly)
Distally - S shaped incision across ACF, with brachial artery bifurcation immdeidately deep to biceps tendon
How do you access the suprarenal aorta?
Open the gastrohepatic ligament and palpate the aorta against the vetebrae