Emergency Flashcards
Airway management
- Head tilt/chin lift
- Jaw thrust
- Oropharyngeal airway (guedel)
- Nasopharyngeal airway – if reject the guedel
- Intubate
- Tracheotomy
Consider patient unable to protect own airway if below GCS 8
Assessing breathing
Effort
- accessory muscles use
- noises (stridor, wheeze, grunt)
- resp rate
Effectiveness
- O2 sats
- chest expansion
- breath sounds
Effect
- other organ systems - tachycardia, cyanosis/paleness, agitation/confusion/reduced consciousness
If not breathing but have patent airway
(due to drugs, major stroke, bleed in brain, cardiac arrest)
- Bag valve mask (1 squeeze every 5 seconds)
- air can go into stomach if high pressure and too fast
- need two people ideally - Supraglottic airways (IGEL, LMA then attach to bag valve)
- Mouth to mouth
- Pocket mask
Oxygen delivery
Nasal specs (1-4L) Hudson mask (4-10L) Nebuliser mask (can be with salbutamol, adrenaline etc) - up to 6L, but can use nasal cannula underneath so total 10L delivery Non-rebreathe mask (10-15L)
Causes of acute SOB
Chest infection
Exacerbation of COPD
Asthma
+ PE, airway obstruction, anaphylaxis, pneumothorax, HF, metabolic acidosis, panic attack, drugs, malignancy (pleural effusion)
Management of asthma
OSHIT! (safest to overtreat)
Oxygen
Salbutamol - nebuliser every 20 mins or back to back, effective in 5 mins
Hydrocortisone - 20 mins to work if nebulised
Ipratropium bromide - 30 mins to work
Theophylline (aminophylline) - many side effects, only if life-threatening
! magnesium
Severity of asthma
Not always appropriate to do a PEFR - if very sick then won’t be able to do it anyway
Mild - well, normal obs, normal peak flow, just mildly symptomatic (eg normal after sport) - need own inhaler
Moderate - normal obs, but may feel breathless, elevated respiratory rate, reduced peak flow (50-100% of normal) - need inhaler and maybe some steroid and go home
Severe - if PEFR 33-50% of normal, abnormal obs (resp rate >25, heart rate >110)
Life threatening - if PEFR <33% of normal, abnormal obs and any hypoxia (<94% O2)
- CHEST
- CO2 normal or raised (should be low if breathing fast - it is abnormal even if CO2 looks at normal levels. If raised, then pre-terminal sign, represents how tired) - measure via ABG
- Heart rate > 110 (accounts for salbutamol will increase)
- Exhausted
- Silent chest
- Tachypnoea
Investigations for SOB
- CXR (pneumonia, HF, pneumothorax)
- Auscultation (crackles - infection/HF, wheeze - asthma, absent breath sounds unilat - pneumothorax)
- Percussion
- O2 sats
- Blood gas (all have low CO2 as increased respiration, but high pH if respiratory alkalosis from panic attack, low pH if metabolic acidosis)
- Specific tests eg CTPA for pulmonary embolism
- Rule out tests eg D-dimer, CRP
Needle thoracostomy
Indications
- to decompress chest in tension pneumothorax
- to drain fluid/pus from pleural cavity
- to collect pleural fluid sample
Needle into second intercostal space in midclavicular line
Chest drain
Indications
- unresolved large pneumothorax after two aspiration attempts
- secondary large pneumothorax
- unilateral pleural effusion causing SOB/bilateral medically unresponsive pleural effusions
- empyema
- tension pneumothorax after needle decompression
- pallation of breathlessness in malignant pleural effusions
Use USS to guide if pleural effusion
In space between base of axilla, lateral edge of latissimus dorsi, 5th IC space, pec major
Signs of shock
Low BP (systolic <90mmHg or MAP <65mmHg (CO x SVR)) \+ signs of tissue hypoperfusion – mottled skin, low urine output, raised serum lactate
- Reduced GCS or agitation
- Pallor
- Cool peripheries
- Tachycardia
- Slow cap refill
- Oliguria
- Tachypnoea
Causes of shock
PROVED?
Pump - cardiogenic
Rhythm abnormalities - tachy/brady
Obstructive - tampenode, tension pneumothorax
Volume - major bleed, dehydration
— in young/healthy, can lose 1.5L before tachy, 2.5L before lowered BP
Endocrine - Addison’s crisis, DKA
Distributive - neurogenic if damage to symp chain, loss of venous tone, liver failure, sepsis, drugs
? check bp cuff etc
Signs of pericarditis
Localised pleuritic chest pain, relieved on leaning forwards
Maybe pericardial rub
Widespread saddle shaped ST elevation
Signs of aortic dissection
Tearing inter scapular pain, worst at onset
No associated symptoms usually, but maybe symptoms of stroke or maybe collapse
Unequal BPs in arms
ECG maybe normal, or similar to MI
CT chest/echo/angiogram useful
CXR shows widened mediastinum, pleural cap, pleural effusion, calcium ring sign (2% normal)
In the elderly hypertensive
Signs of pneumonia
Pleuritic chest pain Productive cough SOB Fevers Raised respiratory rate Reduced O2 sats Reduced chest expansion, dullness to percussion, coarse crackles, reduced air entry, bronchial breathing Patchy white shadowing (collapse, consolidation) on CXR
Signs of PE
Sudden onset localised pleuritic chest pain
SOB
Haemoptysis
Collapse
Normal or tachycardia on ECG (maybe signs of RV strain)
Tachycardia, raised respiratory rate, reduced O2 sats
Signs of reflux
Retrosternal burning pain Foul acid taste in mouth Worse bending forwards Triggered by eating Normal examination No investigations in ED - need to exclude other more serious diagnoses
Glasgow coma scale
Coma = unrousable unresponsiveness
GCS 3-15, give best possible score if better on one side
Eyes/4 - never open, open to pain, open to voice, spontaneously open
Verbal/5 - none, groaning, inappropriate words, confused speech, normal conversation
Motor/6 - none, decerebrate (extension), decorticate (flexion), flexion withdrawal from pain, local response to pain, obeys motor commands
- most significant to drop points in motor - ‘fighty’
AVPU
Alert, response to voice, response to pain, unresponsive
Assessment of pupils
Bilaterally contracted
- Opiate toxicity, midbrain damage, nerve agent poisoning (organophosphates)
Bilaterally dilated but responsive to light (aka not dead)
- Drugs (alcohol, MDMA, amphetamines, cannabis)
One side normal, one side dilated (asymmetrical)
- Only pathologically of interest if unconscious - some people always have unsymmetrical pupils
- Afferent - eye problems
- Efferent - oculomotor nerve compression often in pathology - due to haematoma on that side, pressure effect in brain
Causes of disability
Metabolic
- Drugs/poisoning – CO, alcohol, tricyclics
- Hypo/hyperglycaemia
- Hypoxia, CO2 narcosis
- Septicaemia
- Hypothermia
- Myxedema, Addison’s crisis
- Hepatic/uraemic encephalopathy
Neurological
- Trauma
- Infection – meningitis, encephalitis, malaria, typhoid, typhus, rabies, trypsosomiasis
- Tumour (primary or secondary)
- Vascular – stroke, subdural, subarachoid, hypertensive encephalopathy
- Epilepsy – non-convulsive status, post-ictal state
(Any of ABC problems - hypoxia, shock etc)
Wound management
Mechanism - foreign material (glass invisible on XR), tetanus (soil/manure), bites, stab/gunshot (to tell police)
Timing - if more than 8-12h old won’t close, may bring back to cut away and stitch later
Attempts to treat/clean
Patient comorbidities (steroids, bleeding/clotting disorders, diabetes, immunosuppression)
Always consider bones, arteries, nerves - X ray, check distal pulses, assess dermatomes and myotomes
Prophylactic antibiotics for wounds
DEFINITELY
- human bites
- animal bite to hand
- wound over fracture
- deep wound over joint, hand or face
MAYBE
- high risk patient (elderly, immunosuppressed)
- high risk mechanism (foreign body, dirty wound)
- prolonged length of time to treat
Methods of wound closure
Steristrips
Glue
Staple
Suture
Trauma triangle of death
Shock
Acidosis
Hypothermia (clotting factors ineffective, further blood loss)
Cushing’s triad
For evidence of coning
Raised BP
Lowered GCS
Lowered HR
