Emergency Ix Mx Flashcards
Acute respiratory distress syndrome (rapid onset inflammation of the lungs)
Ix = chest x-ray and arterial blood gases
Criteria:
acute onset (within 1 week of a known risk factor)
pulmonary oedema: bilateral infiltrates on chest x-ray
non-cardiogenic (pulmonary artery wedge pressure needed if doubt)
pO2/FiO2 < 40kPa (300 mmHg)
Mx: ITU
Oxygenation/ventilation to treat the hypoxaemia
General organ support e.g. vasopressors as needed
Treatment of the underlying cause e.g. antibiotics for sepsis
Certain strategies such as prone positioning and muscle relaxation have been shown to improve outcome in ARDS
Alcohol withdrawal
(Chronic alcohol consumption enhances GABA mediated inhibition in the CNS and inhibits NMDA-type glutamate receptors
Alcohol withdrawal is thought to due to decreased inhibitory GABA and increased NMDA glutamate transmission)
Features;
6-12 hours = tremor, sweating, tachycardia, anxiety
36 hours = seizures
48-72 hours = DT’s - coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
Mx: 1st = long-acting benzodiazepines e.g. chlordiazepoxide or diazepam.
2nd = carbamazepine
Lorazepam may be preferable in pts with hepatic failure.
Typically given as part of a reducing dose protocol
Pts with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) = admitted until stabilised
Anaphylaxis
Ix = serum tryptase (remians high 12hrs post reaction)
Airway problems may include:
swelling of the throat and tongue →hoarse voice and stridor
Breathing problems may include:
respiratory wheeze
dyspnoea
Circulation problems may include:
hypotension
tachycardia
Mx = IM adrenaline (>12yo = 500mcg) + fluids
Adrenaline can be repeated every 5 minutes if necessary.
The best site for IM injection is the anterolateral aspect of the middle third of the thigh.
Refractory anaphylaxis = Respiratory and/or cardiovascular problems persist despite 2 doses of IM adrenaline
Mx following stabilisation = (Non-sedating oral antihistamines) + (2 adrenaline auto-injectors)
Urticaria and/or angioedema = Chlorphenamine
All patients with a new diagnosis of anaphylaxis should be referred to a specialist allergy clinic
Risk-stratified approach to discharge:
(as biphasic reactions can occur in up to 20% of patients)
fast-track discharge (after 2 hours of symptom resolution):
good response to a single dose of adrenaline
complete resolution of symptoms
has been given an adrenaline auto-injector and trained how to use it
adequate supervision following discharge
Minimum of 6 hours after symptom resolution
2 doses of IM adrenaline needed, or
previous biphasic reaction
minimum of 12 hours after symptom resolution
severe reaction requiring > 2 doses of IM adrenaline
patient has severe asthma
possibility of an ongoing reaction (e.g. slow-release medication)
patient presents late at night
patient in areas where access to emergency access care may be difficult
observation for at 12 hours following symptom resolution
Ankle and Foot: Achilles tendon injury (tendinosis, rupture)
- Achilles tendinopathy (tendinitis) = gradual onset of posterior heel pain that is worse after activity
Morning pain and stiffness are common
mx = supportive, simple analgesia
reduction in precipitating activities
calf muscle eccentric exercises - self-directed/w a physio
- Achilles tendon rupture = audible ‘pop’ in the ankle, sudden onset significant pain in the calf or ankle or the inability to walk or continue the sport
Ix = Examination using Simmonds triad + USS
Mx = An acute referral to an orthopaedic specialist following a suspected rupture
Simmonds triad = angle of declination, palpation for a gap, and calf squeeze
Pt lies prone with their feet over the edge of the bed.
Abnormal angle of declination - increased foot drop. Achilles tendon rupture may lead to greater dorsiflexion of the injured foot compared to the uninjured limb
They should also feel for a gap in the tendon
and gently squeeze the calf muscles - if there is an acute rupture of the Achilles tendon the injured foot will stay in the neutral position when the calf is squeezed.
Ankle and Foot: Fracture (ankle, metatarsal stress, Lisfranc)
Epidemiology:
Most common fractured metatarsal = The proximal 5th metatarsal
Least = The 1st metatarsal
5th metatarsal fractures:
Proximal avulsion fractures (pseudo-Jones fractures): most common type. Occurs at the proximal tuberosity.
Usually associated with a lateral ankle sprain and often follow inversion injuries of the ankle.
Jones fractures: much less common. This is a transverse fracture at the metaphyseal-diaphyseal junction.
Metatarsal stress fractures
Occurs in otherwise healthy athletes, e.g. runners
The most common site of metatarsal stress fractures is the 2nd metatarsal shaft
Features:
Pain and bony tenderness
Swelling
Antalgic gait
Ix: X-Ray + isotope scan/MRI
X-rays: distinguishes between displaced and non-displaced fractures. This differentiation guides subsequent management options. Although stress fractures may appear normal on X-ray, sometimes there is a periosteal reaction seen on 2-3 weeks later
Isotope scan or MRI: in the case of stress fractures, X-rays are often normal and may remain normal in up to half of all cases. An isotope bone scan or MRI may help to establish the presence of a stress fracture
Ottawa rules for getting an X-Ray;
An ankle x-ray is required only if there is any PAIN in the malleolar zone and any one of the following findings:
- bony tenderness at the lateral/medial malleolar zone (from the tip of the lateral/medial malleolus to the lower 6 cm of posterior border of the fibular)
- Inability to walk four weight bearing steps immediately after the injury and in the emergency department
Aspirin overdose (and indications for haemodialysis)
Features
Hyperventilation (re-spirin-g)
tinnitus (aspi-ringing)
sweating, pyrexia* (per-spirin-g)
lethargy
nausea/vomiting
hyperglycaemia and hypoglycaemia
seizures
coma
Mx = bruh (as-bruh-in)
Bicarb, Resus, Urinary alkalinization, Haemodialysis
Resus (ABC - fluids!!!, charcoal)
urinary alkalinization with intravenous sodium bicarbonate - enhances elimination of aspirin in the urine
haemodialysis
Indications for haemodialysis in salicylate overdose;
serum concentration > 700mg/L
metabolic acidosis resistant to treatment
acute renal failure
pulmonary oedema
seizures
coma
Asthma
Ix = spirometry + BDR + FeNO
Pt should be asked if their symptoms are better on days away from work/during holidays. If so, patients should be referred to a specialist as possible occupational asthma
FeNO
>= 40 parts per billion (ppb) = positive
in children its >=35
Spirometry
FEV1/FVC < 70% = obstructive
Reversibility testing
An improvement in FEV1 of >12% + increase in volume of >200 ml = Positive
In children, its just an improvement in FEV1 of 12% or more
A chest x-ray is not routinely recommended, unless:
life-threatening asthma
suspected pneumothorax
failure to respond to treatment
Mx:
Target SpO2 < 92%
Mx:
1. O2 (target: 94-98%)
2. Salb + Ipratropium bromide
3. PO pred(40-50mg) + IV hydrocortisone
- Senior support
- IV mag sulph
- IV aminophyline
- ITU intubation
Admit Pt’s who; are pregnant or FUN (fatal, unresponding, night)
- Have had a previous near fatal attack
- or are PREGNANT
- Have have life-threatening asthma
- severe asthma that hasn’t responded to treatment
- an attack occurring despite already using oral corticosteroid
- and presentation at night
if patients are acutely unwell they should be started on 15L of supplemental via a non-rebreathe mask, which can then be titrated down to a flow rate where they are able to maintain a SpO₂ 94-98%
bronchodilation with short-acting beta₂-agonists (SABA)
high-dose inhaled SABA e.g. salbutamol, terbutaline
in patients without features of life-threatening or near-fatal asthma, this can be given by a standard pressurised metered-dose inhaler (pMDI) or by an oxygen-driven nebulizer
below-life-threatening = standard pressurised metered-dose inhaler (pMDI) or by an oxygen-driven nebulizer
Life threatening = neb
corticosteroid
all patients should be given 40-50mg of prednisolone orally (PO) daily, which should be continued for at least five days or until the patient recovers from the attack
during this time, patients should continue their normal medication routine including inhaled corticosteroids.
Criteria for discharge;
been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours
inhaler technique checked and recorded
PEF >75% of best or predicted
Burns injury
Assessing the extent of the burn
Wallace’s Rule of Nines:
head + neck = 9%,
each arm = 9%,
each anterior part of leg = 9%,
each posterior part of leg = 9%,
anterior chest = 9%,
posterior chest = 9%,
anterior abdomen = 9%,
posterior abdomen = 9%
The palmar surface = 1% of total body surface area (TBSA). Not accurate for burns > 15% TBSA
Referral to secondary care;
- all deep dermal and full-thickness burns.
- superficial dermal burns of more than 3% TBSA in adults (2% TBSA in children)
- superficial dermal burns involving the face, hands, feet, perineum, genitalia, or any flexure, or circumferential burns of the limbs, torso, or neck
- any inhalation injury
- any electrical or chemical burn injury
- suspicion of non-accidental injury
Initial mx = first aid, analgesia then depends if its epi/dermal
first aid
review referral criteria to ensure can be managed in primary care
superficial epidermal: symptomatic relief - analgesia, emollients etc
superficial dermal: cleanse wound, leave blister intact, non-adherent dressing, avoid topical creams, review in 24 hours
Mx of severe burns = intubate, fluids, catheter, escharotomy
The initial aim is to stop the burning process and resuscitate the patient.
The airway should be assessed first as with any emergency - smoke inhalation can result in airway oedema
early intubation should be considered e.g. if deep burns to the face or neck, blisters or oedema of the oropharynx, stridor etc
Intravenous fluids will be required for adults>15% and children>10% TBSA. Half of the fluid is administered in the first 8 hours.
Parkland formulae:
Volume of fluid= total body surface area of the burn % x weight (Kg) x4.
A urinary catheter should be inserted. Analgesia should be given.
Complex burns, burns involving the hand perineum and face and burns >10% in adults and >5% in children should be transferred to a burns unit.
Circumferential burns affecting a limb or severe torso burns impeding respiration may require escharotomy to divide the burnt tissue.
Conservative management is appropriate for superficial burns and mixed superficial burns that will heal in 2 weeks. More complex burns may require excision and skin grafting. Excision and primary closure is not generally practised as there is a high risk of infection.
There is no evidence to support the use of anti microbial prophylaxis or topical antibiotics in burn patients.
Escharotomy = An emergency surgical procedure involving incising through areas of burnt skin to release the eschar and its constrictive effects, restore distal circulation, and allow adequate ventilation.
It will potentially improve ventilation (if the burn involves the torso), or relieve compartment syndrome and oedema (where a limb is involved)
Carbon monoxide poisoning (Questions may hint at badly maintained housing ie. no smoke alarm)
Features of carbon monoxide toxicity
headache: 90% of cases!
nausea and vomiting: 50%
vertigo: 50%
confusion: 30%
subjective weakness: 20%
severe toxicity = ‘pink’ skin and mucosae, hyperpyrexia, arrhythmias, extrapyramidal features, coma, death
Ix = pulse oximetry, VBG + ABG + ECG (cardiac ischaemia)
pulse oximetry may be FALSELY HIGH due to similarities between oxyhaemoglobin and carboxyhaemoglobin
VBG/ABG for carboxyhaemoglobin levels;
< 3% non-smokers
< 10% smokers
10 - 30% symptomatic: headache, vomiting
> 30% severe toxicity
Mx = 100% high-flow oxygen for 6hours! via a non-rebreather mask
(target spO2 = 100% until sx resolve)
from a physiological perspective, this decreases the half-life of carboxyhemoglobin (COHb)
After this refer to specialist for hyperbaric oxygen
Cardiac arrest (badycardia - periarrest)
Haemodynamic compromise indicates the need for mx:
- shock: hypotension (systolic blood pressure < 90 mmHg), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness
- syncope
- myocardial ischaemia
- heart failure
Mx = Atropine (500mcg IV)
If there is an unsatisfactory response the following interventions may be used:
atropine, up to a maximum of 3mg
transcutaneous pacing
isoprenaline/adrenaline infusion titrated to response
Elbow: Fracture - Epicondilitis, radial tunnel syndrome, cubital tunnel syndrome, olecranon bursitis
- Radial tunnel syndrome = Most commonly due to compression of the posterior interosseous branch of the radial nerve. It is thought to be a result of overuse.
Features;
symptoms are similar to lateral epicondylitis making it difficult to diagnose
Differentiator = the pain tends to be around 4-5 cm distal to the lateral epicondyle
symptoms may be worsened by extending the elbow and pronating the forearm
Cubital tunnel syndrome = Due to the compression of the ulnar nerve -> intermittent tingling in the 4th and 5th finger
May be worse when the elbow is resting on a firm surface or flexed for extended periods
later numbness in the 4th and 5th finger with associated weakness
Olecranon bursitis = Swelling over the posterior aspect of the elbow. There may be associated pain, warmth and erythema. It typically affects middle-aged male patients.
Head injury
Who’s safe to discharge, who gets immediate CT head and who can wait 8hrs?
Ix =
CT head within 1 hour;
GCS < 13 on initial assessment
GCS < 15 at 2 hours post-injury
suspected open or depressed skull fracture
any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
post-traumatic seizure
focal neurological deficit
more than 1 episode of vomiting
CT head scan within 8 hours of the head injury;
for adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury:
- > 65yo
- Any history of bleeding or clotting disorders including anticogulants
- Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)
- > 30 minutes’ retrograde amnesia of events immediately before the head injury
- Pt is on warfarin with no other indications for a CT head
Mx:
Life-threatening/rising ICP = IV mannitol/ frusemide
Diffuse cerebral oedema = decompressive craniotomy
Exploratory Burr Holes have little management in modern practice except where scanning may be unavailable and to thus facilitate creation of formal craniotomy flap
Depressed skull fractures that are open require formal surgical reduction and debridement, closed injuries may be managed nonoperatively if there is minimal displacement
GCS 3-8 and normal/abnormal CT scan = ICP monitoring
Hip: Fracture (neck of femur, pelvic, pubic ramus)
Features = pain + shortened and externally rotated leg
Patients with non-displaced or incomplete neck of femur fractures may be able to weight bear
The Garden system is one classification system in common use
Type I: Stable fracture with impaction in valgus
Type II: Complete fracture but undisplaced
Type III: Displaced fracture, usually rotated and angulated, but still has boney contact
Type IV: Complete boney disruption
Blood supply disruption is most common following Types III and IV.
Intracapsular hip fracture = un/displaced fracture
Undisplaced Fracture mx = internal fixation, or hemiarthroplasty if unfit.
Displaced Fracture = Replacement arthroplasty (total hip replacement or hemiarthroplasty)
Total hip replacement is favoured to hemiarthroplasty if patients:
- were able to walk independently out of doors with no more than the use of a stick and
- are not cognitively impaired and
- are medically fit for anaesthesia and the procedure.
Extracapsular hip fracture mx:
Stable intertrochanteric fractures = dynamic hip screw
Reverse oblique, transverse or subtrochanteric fractures = intramedullary device
Knee: Anterior cruciate ligament (ACL) tear
Ruptured anterior cruciate ligament
Sport injury (lateral blow/skiing)
Mechanism: high twisting force applied to a bent knee
Typically presents with: loud crack/pop, pain and RAPID joint swelling (haemoarthrosis)
Poor healing
Instability, feeling that knee will give way
Ix = Lachmans > anterior draw
Mx = intense physiotherapy or surgery
anterior draw test =
the patient lies supine with the knee at 90 degrees
the examiner should place one hand behind the tibia and the other grasping the patient’s thigh. It is important that the examiner’s thumb be on the tibial tuberosity
the tibia is pulled forward to assess the amount of anterior motion of the tibia in comparison to the femur
an intact ACL should prevent forward translational movement
Lachman’s test = variant of anterior draw test, but the knee is at 20-30 degrees
evaluate the anterior translation of the tibia in relation to the femur and is considered a variant
more reliable than anterior draw test
Knee: Meniscus injuries
Menisceal tear
Rotational sporting injuries
DELAYED knee swelling
Joint locking (Patient may develop skills to ‘unlock’ the knee
Recurrent episodes of pain and effusions are common, often following minor trauma
Knee: Other ligament injuries (MCL, LCL, PCL)
MCL = leg forced into valgus via force outside the leg
PCL = hyperextension injuries
Tibia lies back on the femur
Paradoxical anterior draw test
Multi-organ dysfunction syndrome
Neuroleptic malignant syndrome
(patients are taking atypical antipsychotic medication - cloz, risp, olanz, quetia, aripiprazole or DA agonists)
The pathophysiology is unknown but one theory is that the dopamine blockade induced by antipsychotics triggers massive glutamate release and subsequent neurotoxicity and muscle damage.
It occurs within hours to days of starting an antipsychotic (antipsychotics are also known as neuroleptics, hence the name) and the typical features are:
pyrexia
muscle rigidity
autonomic lability: typical features include hypertension, tachycardia and tachypnoea
agitated delirium with confusion
A raised CK is present in most cases.
AKI (secondary to rhabdomyolysis) may develop in severe cases.
A leukocytosis may also be seen
Mx = Stop antipsychotic + IV fluids + dantrolene
(maybe bromocriptine DA agonist)
Patients should be transferred to a medical ward if they are on a psychiatric ward and often they are nursed in intensive care units
IV fluids to prevent renal failure
Opiate overdose
Overdose = Respiratory depression
Complications of opioid misuse:
- Viral infection secondary to sharing needles: HIV, hepatitis B & C
- Bacterial infection secondary to injection: infective endocarditis, septic arthritis, septicaemia, necrotising fasciitis
- VTE
Harm reduction interventions may include
needle exchange
offering testing for HIV, hepatitis B & C
Mx:
Emergency = IV/IM Naloxone
Detox = methadone or buprenorphine
Patients are usually managed by specialist drug dependence clinics although some GPs with a specialist interest offer similar services
Compliance is monitored using urinalysis
Detoxification should normally last up to 4 weeks in an inpatient/residential setting and up to 12 weeks in the community
Paracetamol overdose
Ix = ALT/AST in the 1000’s
Mx:
- Activated charcoal if ingested < 1 hour ago
- N-acetylcysteine (NAC)
- Liver transplantation
Acetylcysteine should be given if:
the plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity
there is a staggered overdose* or there is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol concentration; or
patients who present 8-24 hours after ingestion of an acute overdose of more than 150 mg/kg of paracetamol even if the plasma-paracetamol concentration is not yet available
patients who present > 24 hours if they are clearly jaundiced or have hepatic tenderness, their ALT is above the upper limit of normal
Acetylcysteine should be continued if the paracetamol concentration or ALT remains elevated whilst seeking specialist advice
Acetylcysteine is now infused over 1 hour (rather than the previous 15 minutes) to reduce the number of adverse effects.
Acetylcysteine commonly causes an anaphylactoid reaction (non-IgE mediated mast cell release).
Anaphylactoid reactions to IV acetylcysteine are generally treated by stopping the infusion, then restarting at a slower rate.
Liver transplant criteria;
Arterial pH < 7.3, 24 hours after ingestion
or all of the following:
(PT > 100 seconds) + (creatinine > 300 µmol/l) + (grade III or IV encephalopathy)
