Emergency & acute medicine 1 Flashcards
Three reasons why people deteriorate?
Airway obstruction
breathing problems
circulation problems
Causes of airway obstruction? 6
- CNS depression
- foreign body (blood vomit, secretions, food)
- blocked tracheostomy
- trauma
- swelling (infections, oedema)
- laryngospasm, bronchospasm
Ways in which airway obstruction kills you? 5
- cerebral oedema
- hypoxic brain injury
- pulmonary oedema
- secondary apnoeas
- exhaustion
Three groups of causes of breathing problems (in critically unwell pt)?
1) CNS depression causing decreased / abolished respiratory drive
2) Poor / diminished respiratory effort (from muscle weakness or pain or restrictive abnormalities)
3) Disorders of lung function (eg pneumonia, pneumothorax, haemothorax, asthma, COPD, PE, ARDS, oedema)
Ways in which breathing problems kill you? 5
- hypercapnia and apnoeas
- pulmonary oedema
- exhaustion
- hypoxic brain injury
- secondary cardiac ischaemia
Causes of circulation problems (in critically unwell pt):
- two main types? (with 8 egs each - though don’t obsess!!)
Primary cardiac
- MI
- ischaemia
- arrhythmia
- cardiac failure
- tamponade
- rupture
- myocarditis
- HOCM
secondary heart problems
- asphyxia
- tension pneumothorax
- blood loss
- hypoxia
- hypothermia
- septic shock
- hyperthermia
- rhabdomyolysis
How do circulatory problems kill? 1
cardiac arrest
What is the most useful NEWS observation to identify a critically unwell / deteriorating pt?
resp rate!
anything above 20 should worry you!
Assessment (& management) of critically unwell patient: AIRWAY (3 things)
1) look for signs of airway obstruction
2) treat the obstruction as an emergency
3) give 15L oxygen in non-rebreath mask to EVERYONE with obstruction (regardless of other stuff)
Assessment (& management) of critically unwell patient: BREATHING (8 things)
1) look, listen & feel forRESP DISTRESS (learn signs**)
2) Count the RR (15secs)
3) assess QUALITY of breathing
4) note any DEFORMITY
5) Record O2 SATS (& if/what oxygen they’re on!!!)
6) Listen near the face then Palpate, Percuss & Auscultate chest
7) TRACHEA position?
8) Initiate TREATMENT (eg nebulisers, needle decompression etc)
Assessment (and management) of critically unwell patient: CIRCULATION (10 things)
1) Look and feel HANDS
2) peripheral and central (sternum) CAP REFILL
3) assess VENOUS filling
4) count PULSE (and look on cardiac monitoring - nb don’t need 12 lead ecg)
5) Palpate central and peripheral PULSE
6) measure BP
7) AUSCULTATE heart
8) Look for SIGNS of poor cardiac output (brain, kidneys etc)
9) Look for HAEMORRHAGE (orifices and bruising)
10) TREAT cause of cardiovascular collapse
Assessment (& management) of critically unwell patient: DISABILITY (7 things)
1) Review & treat ABC’s, check no hypoxia & hypotension
2) Check drug chart for REVERSIBLE drug-induced low GCS
3) examine PUPILS
4) Assess GCS or AVPU
5) Check lateralising signs**
6) Check capillary GLUCOSE
7) Ensure AIRWAY protection
Assessment (& management) of critically unwell patient: EXPOSURE (2 things)
1) EXAMINATION
2) TEMPERATURE
7 things to do once patient is stabilised post A-E assessment?
1) take a HISTORY
2) review NOTES
3) review RESULTS
4) which LEVEL of care is required?
5) REASSESS response
6) DOCUMENT everything
7) decide upon definitive TREATMENT
Three definitions of hypotension:
1) Systolic BP <90mmhg
2) decrease in systolic >40mmhg or 30% from patient’s BASELINE
3) mean arterial pressure** (MAP) <60mmhg
nb beware of ‘normal’ BP in pt with chronic hypertension
TYPES of causes of hypotension? 4
also in order that you look for them
1) HEART RATE
- Can be a response to BP or cause of low BP (work it out)
2) VOLUME STATUS
- Are they dry? (vomiting, diarrhoea, GI bleed etc)
- if low, give fluids
3) CARDIAC PERFORMANCE
- Is this cardiogenic shock? secondary cardiac cause?
4) SYSTEMIC VASCULAR RESISTANCE
- sepsis or anaphylaxis? (neurogenic shock is rare)
What is the modified A-E approach in major trauma patients?
What is this also known as?
A: Airway maintenance WITH cervical spine protection
B: Breathing AND ventilation
C: Circulation WITH haemorrhage control
D: Disability AND neurologic status
E: Exposure AND environmental control
The primary survey
What are some possible signs of obstruction or airway injury? 7
- absent breath sounds
- snoring / stridor / gurgling
- hoarse voice
- obtundation (drowsiness)
- cyanosis
- paradoxical movements / retractions / accessory muscles
- tracheal deviation / laryngeal crepitus
What is the cause of most trauma deaths?
major haemorrhage (ie blood loss)
Which injuries (/things that happen to trauma pts) could compromise the airway? 7
- facial fractures
- facial burns
- inhalation of hot smoke
- neck wounds
- epistaxis
- vomiting
- head injury w low GCS
What are the two movements you can do to improve airway?
which one DO you do if worried about c-spine?
- chin lift
- jaw thrust
DO jaw thrust if worried about c-spine
(don’t do chin lift)
What are the two types of airway adjuncts?
Which do you tend to do in trauma? why?
- oropharyngeal
- nasopharyngeal
do oropharyngeal if worried about head injury, especially basal skull fracture - also oro is used more commonly in trauma generally anyway
How do you measure for a oropharyngeal airway?
“squish to squish”
ie earlobe to corner of mouth
what are the two types of definitive airways?
Endotracheal intubation
Surgical airways
How do you fully immobilise a c-spine?
what is this called?
3 aspects
- hard collar
- blocks
- tape
three point fixation
(nb also manual stabilisation - ie someone holding head - is also effective & considered ‘full immobilisation’)
How do you size a cervical collar?
using fingers measuring from the top of
the patient’s trapezius to the point of the chin
This measurement is
then used against the sizing posts on the cervical collar which is then
adjusted to the correct size (measure from the hard plastic at the
bottom to the hole)
should be secured tightly but should still be able to open mouth
What are the signs of ventilatory collapse? 3
- inadequate or asymmetrical chest rise & fall
- laboured breathing
- decreased or absent air entry
(nb low o2 sats is NOT a measure of adequacy of ventilation)
What are the 6 thoracic injuries which can compromise ventilation & be fatal?
(incl mneumonic)
ATOM FC
- Airway obstruction
- Tension pneumothorax
- Open chest wound
- Massive haemothorax
- Flail chest
- Cardiac tamponade
What are 8 potentially less life-threatening thorax injuries? (but still need emergency care)
- simple pneumothorax
- haemothorax
- pulmonary contusion
- blunt cardiac injury
- oesophageal rupture
- diaphragmatic injury
- traumatic aortic disruption
- tracheobronchial tree injury
signs of thoracic injury?
- inspect? 5
- palpate? 1
- percuss? 1
- auscultate? 1
- on xray / ct? 1
inspect
- abnormal RR
- abnormal O2 sats
- abnormal chest movement
- chest wall bruising or wounds
- surgical emphysema
palpate
- tracheal deviation
percuss
- abnormal percussion note
auscultate
- abnormal air entry
xray / ct
- rib, clavicular, scapular or sternal fractures
immediate management options for inadequate ventilation in the context of trauma? 5
- 15L O2 non-rebreath mask (if not already done)
- consider the need for intubation
- needle decompression (if tension)
- chest drain (thoracocentesis) (ALWAYS PUT CANNULAS IN FIRST & HAVE FLUIDS)
- resuscitative thoracotomy
nb also can do pericardiocentecis if tamponade, but normally just do thoracotomy)
What is the definition of shock?
“Clinical syndrome caused by inadequate tissue perfusion and oxygenation leading to abnormal metabolic function”
Main cause of shock in major trauma patients? 1
other causes? 3
unlikely causes in trauma? 2
HAEMORRHAGIC (hypovolaemic)
other
- obstructive (eg pressure on great vessels)
- cardiogenic
- neurogenic
unlikely in trauma
- septic
- anaphylactic
(though can still happen)
What is the mneumonic when assessing circulatory signs? 4
ie assessing if someone is in/going into hypovolaemic shock
HEP B
- Hands
- End organ perfusion
- Pulse
- Blood pressure
(nb low BP is a late sign!)
when you assess for signs of shock, take account of ABSOLUTES AND TRENDS in signs
(be aware of the ‘normal’ bp in someone who is normally hypertensive)
What circulatory signs do you assess on the hands of a trauma pt? 3
H of HEP B
- temperature
- sweating
- CAPILLARY REFILL TIME
How do you assess ‘end organ perfusion’ in trauma pts? 2
E of HEP B
- conscious level (use GCS)
- urine output (may be less easy to measure)
What 3 things are you assessing when you feel pulse?
- rate
- rhythm
- character / quality
What’s the rhyme to remember where to look for blood loss / haemorrhages in trauma pts? 5
“on the floor & four more”
- external wounds
- chest cavity
- abdo cavity (incl retroperitoneal)
- pelvic cavity
- long bone fractures (esp femur)
What should you do immediately if you think there may be any pelvic injuries or bleeding?
put a pelvic binder on
don’t put pelvis under any kind of pressure as could cause more bleeding
What 2 questions should you ask yourself when assessing the circulation of a trauma pt?
- are there signs of shock?
- are there injuries which could or will cause shock?
immediate management options for inadequate circulation in the context of trauma? 6
(which 3 should do if actively haemorrhaging)
- optimise oxygenation (if not done already)
- 2x large bore cannulas in antecubital fossa (take some bloods from)
- fluid resuscitation
- splints / tourniquet / direct pressure for active haemorrhage
- IV tranexamic acid if haemorrhaging
- consider activation of the massive transfusion protocol
NEED DEFINITIVE HAEMOSTASIS (ie stabilise & get to surgery)
What are the colours and sizes of the 6 main cannulas used?
which are considered ‘large bore’
- orange 14 (biggest)
- grey 16
- green 18
- pink 20 (normal wards)
- blue 22 (elderly or tricky veins)
- yellow 24 (norm just paeds)
(orange, gray, green are large bore)
nb green mainly used for CT scans
Which two fluids do you mainly used for resus in trauma?
- packed red cells
- WARMED crystalloid (ie saline)
don’t give hartmanns in major trauma
do you get crossmatch or group & save in trauma pts? why?
crossmatch - as need blood now
also give O neg until have results back
(nb never order both - if chance need blood but unlikely - eg routine op then do group & save)
Glasgow coma scale:
- three components?
- each out of how many?
- max score?
- min score?
- how do you record?
eye opening (E) - out of 4 verbal response (V) - out of 5 best motor response (M) - out of 6
max = 15 min = 3
by section, eg E4,V5,M6
(can also say total too)
Glasgow coma scale:
- classification of minor, moderate & severe brain injury
- at what point do you call an anaesthetist?
- definition of a coma?
- minor = 13-15
- moderate = 9-12
- severe = 3-8
call anaesthetist if 8 or lower
lower than 8 is a coma
KEEP REASSESSING as can change quickly
Glasgow coma scale:
- eye opening (what each number means)
eye opening (E)
4 = open spontaneously 3 = open to verbal 2 = open to pain 1 = no eye opening
what 2 ways can you inflict pain to assess response?
- supraorbital pressure
- trapezius squeeze
Glasgow coma scale:
- verbal response (what each number means)
5 = orientated 4 = confused 3 = inappropriate words 2 = incomprehensible words 1 = no verbal response
What three things should a person be oriented to?
- time
- place
- person
nb person is know who they are (ask their name) - is the last thing that goes
Glasgow coma scale:
- motor response (what each number means)
6 = obeys commands 5 = localises to pain 4 = normal flexion to withdraw from pain 3 = abnormal flexion 2 = abnormal extension 1 = no motor response
What to assess for in ‘disability’?
1) signs of a head injury?
- bruises (head or neck)
- lacerations (head or neck)
2) pupil size & reaction to light
3) capillary glucose
4) GCS score
immediate management options for head injury in the context of trauma? 5
- optimise oxygenation
- maintain cerebral perfusion (BP >90mmHg)
- avoid hypoglycaemia
- avoid pyrexia
- definitive imaging & treatment
What are the two main signs / groups of signs of spinal injury? 2
What two things mean that you can’t trust these sisngs? 2
- neurological deficit
- pain or tenderness along the spine (when palpated)
- patient is intoxicated
- patient has a distracting injury
nb in reality in trauma most people are likely to have a distracting injury so often er on side of caution and immobilise c-spine etc
Log rolls
- how many people do you need?
- what does each do?
- who’s in charge?
five people - one to stabilise the neck - 3 to roll the patient (height order) - one person to examine the back/spine and perform a
DRE
person at neck is in charge
What are the signs of a spinal injury? 7
- breathing difficulties
- evidence of neurogenic shock
- spinal tenderness, bruising or swelling on log roll
- responds to pain only above the clavicle
- patient complains of loss of sensation or function
- priapism
- flexed posture of upper limbs or flaccid areflexia
Immediate management of spinal or suspected spinal injury? 8
nb may not do all but would do majority
- optimise oxygenation
- ensure adequate VENTILATION
- maintain spinal cord perfusion (avoid hypotension)
- maintain immobilisation
- document thorough spinal cord examination
- urinary catheter
- NG tube
- definitive imaging & specialist advice
Why do you want to avoid hypothermia in trauma?
because it stops you clotting (coagulopathy) - making any bleeding worse!!
possible signs of MSK trauma (ie pelvis or limbs) 6
- limb deformity (or amputation)
- soft tissue injury / bruising
- patient localising pain to a limb / body part
- any splinting applied pre-hospital
- pelvic instability (palpate very gently!!)
- neurovascular compromise distal to injury
immediate management options for MSK injury in the context of trauma? 6
do not get fixated on MSK injuries until ABCD sorted (unless pelvic haemorrhage - pick up inC)
- maintain oxygenation
- maintain tissue perfusion (avoid hypotension)
- apply splints
- analgesia
- IV antibiotics (if open wound)
- monitor for complications
Why do we apply splints to limb injuries? 3
- reduces blood loss
- lessens pain
- improves alignment
What are the three major immediate complications you monitor for in MSK injuries?
- compartment syndrome
- skin necrosis
- nerve compression (or any neurovascular compromise)
What happens to majority of major trauma patients when they come into resus?
- primary survey (w immediate management)
- trauma CT series once stabilised (ideally within 30 mins)
- secondary survey / definitive management / surgery
What is an ‘LMA’ (in trauma context)?
laryngeal mask airway
When is RR useless as clinical sign?
When you are ventilating them - as you are giving them a respiratory rate
Why are burns patient at high risk of compromised airway?
inhaled smoke -> oedema in pharynx / larynx
What three things are you looking at when you look at pupils?
- equal?
- size (in mm)
- reactive?
What are all of the possible airway management techniques:
- manoeuvres? 2
- temporary airways? 3
- definitive airways? 2
- chin lift
- jaw thrust
- oropharyngeal airway (aka guedel)
- nasopharyngeal airway
- laryngeal mask airway
definitive:
- endotracheal intubation
- surgical airways
nb use suction as well
(also boogie if intubating)
also always plan for vomiting
How do you measure a nasopharyngeal airway?
match diameter to diameter of pinky finger
What are examples of traumatic primary brain injuries?
- skull fracture
- concussion
- contusion
- intracranial haematoma
- diffuse axonal injury
- penetrating injury
what’s the difference between concussion and contusion?
concussion
- microscopic damage (so can’t see on CT)
- widespread damage
contusion
- is a bruise on the brain
- is macroscopic, can see localised ‘bruises’ on ct
- damage is more focal
what is cerebral perfusion pressure?
what are the two things that affect it?
what’s the equation?
a measure of how perfused, and thus how oxygenated, the brain is
1) intra cranial pressure (ICP)
2) blood pressure, measured using mean arterial pressure (MAP)
CPP = MAP - ICP
basically you always want the blood pressure to be higher than the ICP so that there’s enough pressure to pump blood into the brain
how do you calculate mean arterial pressure?
((2x diastolic) + systolic) / 3
What will happen to the cerebral perfusion pressure if the blood pressure drops?
it will decrease
so when loosing blood, be aware that this will cause secondary brain injury even if original trauma is nowhere near brain
treat this with fluids (warmed saline & blood) and stop the bleeding etc
what will happen to the cerebral perfusion pressure if there is raised ICP?
it will decrease
therefore brain will become hypoxic quickly, must ensure BP is kept high so that don’t decrease CPP further then may have to do emergency craniotomy etc to relieve pressure
What is the monro-kellie doctrine and what is it relevant for?
brain is fixed volume so when there is an intra-cranial mass increasing in size the body compensates by getting rid of other fluid in the brain (ie CSF and venous blood)
once it can no longer compensate then start getting brain herniation etc
How do you prevent secondary brain injury secondary to major head trauma?
- bedside? 5
- definitive? 2
- ensure good airway
- give high flow oxygen
- maintain BP (control bleeds, give fluids)
- repeat observations
- prevent hypoglycaemia
(ie do good A-E)
- early CT
- liaise with neurosurgery
What are the indications for a definitive airway? 3
- failure of airway maintenance / protection
- failure of oxygenation / ventilation
- anticipated clinical course (ie going straight to surgery)
what are the four types of hypoxia?
1) Hypoxic hypoxia - ↓ O2 supply
2) Anaemic hypoxia - ↓ haemoglobin function
3) Stagnant hypoxia – inadequate circulation
4) Histotoxic hypoxia – impaired cellular O2 metabolism
How do you assess breathing (B) in a trauma A-E?
- inspect 4
- palpate 3
- percuss 1
- auscultate 1
- main treatment? 1
inspect
- signs of respiratory distress
- thorax injury / asymmetry / deformity / raised JVP
- COUNT RR
- O2 sats (on 15L)
palpate
- tenderness
- surgical emphysema
- trachea position
percuss
- both sides of chest
auscultate
- both sides of chest
15L high flow O2 in non-rebreath mask
Signs of a tension pneumothorax?
- severe respiratory distress
- unilaterally hyper-expanded chest with reduced movement
- hyper-resonant & decreased air entry on affected sign
- tracheal deviation (this is a late sign!!
How do you treat a tension pneumothorax? (incl landmarks)
1) needle decompression (stick a cannula in)
- 2nd intercostal space mid-clavicular line
2) chest drain (trauma-sized)
- 5th intercostal space, mid-axillary line (safe triangle from bottom of the hair line in blokes)
nb 5th intercostal space is known as nipple line but only true in fit young men
What is an open pneumothorax?
How do you treat?
open wound in chest wall (only has to be >60% size of trachea to cause a problem)
- when chest expands air goes in defect rather than trachea -> no gas exchange in pleural space
treat with an occlusive dressing which lets air out but not in!
nb multiple small wounds can cause this, doesn’t just have to be one large wound - need to cover all!
When is it hard to spot a haemothorax?
how do you overcome this?
when patient is supine
ie all major trauma
FAST ultrasound scan
AND percuss laterally as far as you can go
What is the gelly LMA called?
I gel
What is the first line airway management for an in-hospital cardiac arrest?
I gel (the jelly Laryngeal mask)
Massive haemothorax
- definition (by volume)?
- norm caused by?
- How do you manage? (& what to be careful of)
> 1500ml blood in the thorax
significant injury to major vessels in chest
put two large bore cannulas in, cross match & other bloods then give warm saline & blood FIRST
THEN insert a chest drain
(this is because draining all that blood will probably make them less haemodynamically stable so you need to have venous access before you do it)
also nb they will probs already be haemodynamically unstable as a lot of blood is in chest instead of not circulating (so approach in a full A-E)
Flail chest
- what is it?
- what does it look like?
- what norm caused by?
- what deeper injury is normally present?
Mobile segment of chest wall- two or more ribs broken in two or more places
an area of the chest goes in during inspiration & out during expiration (ie opposite to the rest of the normal chest)
indicator of high force injury
lung often crushed underneath = pulmonary contusions
Flail chest findings:
- inspection? 3
- palpation? 1
- auscultation? 1
- other obs finding? 1
- CXR? 2
- respiratory distress
- visible injury
- classic flail chest movement (may not see!)
- tenderness to palpate
- reduced air entry
- hypoxaemia
CXR
- rib fractures
- lung contusions (this may occur hours later!!)
Flail chest management:
- to do immediately? 2
- to assess for / anticipate? 2
- early intubation and / or intubation
- ANALGESIA (as need them to be able to breath well!!)
assess for haemothorax and shock (likely to coexist)
anticipate worsening hypoxia
Cardiac tamponade - what is it? & what happens as a result? - what norm caused by? - how does it present? 3 how is it normally picked up?
injury to myocardium -> blood leaks out into pericardial sac -> heart unable to fill properly which often -> shock
norm sharp, penetrating injury to myocardium, but can be blunt
