Emergency Medicine Flashcards
Aspects of A-E assessment
Identify a problem and deal with it as going along…
- Airway - patent? look, listen and feel –> head tilt + chin lift, jaw thrust, airway adjunct
- Breathing - RR, O2 Sats (>94% - scale 1, 88-92% - scale 2 if COPD), resp exam, ABG –> Oxygen (15L/min O2 non-rebreather mask)
- Circulation - HR, BP, CRT, cardio exam –> IV fluids
- Disability - BM, pupils (PEARL - pupils equal and reactive to light), GCS/AVPU, abdo/neuro exam
- Exposure - assess everything but not all at the same time –> calf tenderness, bleeding, bruising, rashes etc.
NOTE: if put in intervention say to examiner I would reassess previous steps e.g. A&B if gave IV fluids are there any changes
Alcohol withdrawal management?
- Chlordiazepoxide (decreasing regimen + PRN) - prevent alcohol withdrawal Sx (anxiety, shakes etc.) + CIWA scoring (dose increased inf CIWA score increases)
- Pabrinex (thiamine, B1) - prevent Wernicke’s encephalopathy (ophthalmoplegia, ataxia, confusion)
- Bloods - coagulation (injury, bleeds), LFTs
Major hemorrhage GI Mx?
High risk of variceal bleed:
- MASSIVE –> balloon tamponade
- Assess - A-E approach:
- Circulation –> blood transfusion (Hb <70) but if haemodynamically unstable and waiting give IV fluids
- Drugs
- IV Terlipressin(/Somatostatin) - blanked vascoconstriction
- Ceftriaxone/Norfloxacin (apparently helps outcomes)
- Intervention - endoscopic band ligation
F1 essentials: 2x large bore cannula, VBG, G&S + X-Match, bleep the bleed registrar (arrange endoscopy)
Delirium definition? Common causes?
Delirium screen breakdown? Mx?
Def: Acute confusional state caused by a physical condition
Causes: U PINCHES ME
- Urinary retention
- Pain
- Infections
- Nutrition
- Constipation
- Hydration
- Endo & electrolytes
- Stroke
- Medications & alcohol
- Environmental
Delirium screen:
- FBC, U&E, LFT, glucose, BC, Ca, TFTs, B12/folate
- Urine dip + MC&S
- CXR, possibly CT-head
Management: Tx cause
- Conservative: lighting, clocks, 1:1 nursing, adequate hydration, laxatives, involve family/carers
- SOS (risk to themselves/others):
- Lorazepam (PO/IM/IV)
- Haloperidol (PO/IM) - be careful if Parkinson’s –> worsens Sx
Anaphylaxis Mx (acute & chronic)
ABCDE
- Stop suspected cause
- Secure airway, give 100% oxygen, +/- intubate if respiratory obstruction imminent
- IM 0.5mg adrenaline (1:1000)
- IV 10mg chlorpheniramine
- IV 100mg hydrocortisone
- Treat bronchospasm – salbutamol +/- ipratropium
Going forward:
- Maintain fluids + monitor pulse oximetry, ECG and BP
- If still hypotensive, may need transfer to ICU and an IVI of adrenaline +/- aminophylline (bronchodilator) and nebulised salbutamol
After acute episode:
- Admit to ward and monitor ECG, monitor for 6hrs for biphasic reaction
- Measure mast cell tryptase 1-6 hours after = confirm anaphylaxis
- Continue chlorpheniramine
- Suggest MedicAlert bracelet with name of culprit allergen
- Teach about self-injected adrenaline & give auto-injector
- Skin prick tests showing specific IgE to help identify allergens to avoid
Sepsis definition? Septic shock def?
Life-threatening organ dysfunction caused by dysreg host response to infection
Septic shock = persistent hypotension (<90/MAP <65) or lactate >2 despite fluid resus (30ml/kg)
What is qSOFA score?
qSOFA = risk of ITU admission/death at the point of presentation with sepsis
- Hypotensive, altered mental status, tachypnoea (>22)
What is sepsis 6?
3 in, 3 out
All within 1hr
Status epilepticus - def? Triggers in epilepsy? Mx?
Tonic-clonic seizure ≥ 5 mins or ≥ 2 seizures without complete neurological recovery between
- Refractory = continued despite using ≥2 antiepileptic drugs (AEDs) incl benzo.
Triggers in epilepsy:
- drug withdrawal, dose change, non-compliance
- Intercurrent illness, metabolic derangement
- Drugs lowering seizure threshold:
- abx (penicillin, cephalosporins, metro, isoniazid, imipenem)
- TCA, Aminophyline
- Cyclosporin, Tramadol
What is the lethal triad of trauma? Mx?
- Hypothermia (reduced circulating volume)
- Acidosis (LA)
- Coagulopathy (coag factor consumption and reduced operation from hypothermia)
NOTE: normally happens in severe trauma with sign. blood loss
Mx: trauma laparotomy
Drugs for cardiac arrest?
DC shock (150J biphasic)
Adrenaline 1mg IV (10ml 1:10,000)
Amiodarone 300mg IV (if shockable rhythm)
Trauma patient initial Mx?
Airway and cervical spine
Next - CT-head & neck + CXR
Emergency focused Hx?
A – Allergies
M – Medications
P – Past Pertinent medical history
L – Last Oral Intake
E – Events Leading Up To Present Illness / Injury
Post-op process? Peri-operative RFs? Post-op complications?
Process:
- A-E
- Focused Hx
- Input (fluid, food) –> Output (urine, drain, stool)
- Review prev admission Hx + operation note
- Review Ix e.g. blood, scan, histology
- Escalation plan (ITU, ward-based care), DNAR status
RFs:
- Patient - obesity, IS, malnutrition, steroids, DM
- Operation - contamination/soiling, foreign body, prosthesis, duration
Complications:
- Immediate <24hrs: haemorrhage, anaesthetic (anaphylactic, hypotension, agitation)
- Early (3-4 days):
- Pyrexia - Chest, Catheter, Cut, Cannula, Central venous line, Calf (DVT)
- Anastomotic leak, collection, paralytic ileus, prosthesis inf
- Late:
- Anaemia
- Malnutrition
- Dumping syndrome (if vagus nerve severed –> stomach dumps food into duodenum without digestion –> very tired after eating)
- Reoccurrence
- Incisional hernia
- Chronic pain
Blood transfusion reactions - Immediate? Delayed?
Immediate (<24hrs):
- Immune:
- Acute haemolytic transfusion reaction (ABO incompatibility)
- Anti-A/B abs activating complement pathway –> inflammatory cytokine release
- Features:
- Early - fever, low BP, anxiety, red urine
- Late - low BP, widespread haemorrhage secondary to DIC
- Transfusion-related acute lung injury (TRALI)
- Donor abs against recipient HLA antigens (neutrophil, leukocyte)
- Within 6hrs - sudden dyspnoea, severe hypoxemia, low BP, fever
- Resolves with supportive care within 2-4 days
- Anaphylaxis - allergic to protein components in donor transfusion
- Itchy rash, angioedema, SoB, vomiting, lightheaded, low BP
- Acute haemolytic transfusion reaction (ABO incompatibility)
- Non-immune:
- Bacterial infection
- Transfusion-associated circulatory overload (TACO)
- Acute/worsening resp compromise/pul oedema up to 12hrs post-transfusion
Delayed (>24hrs):
- Immune:
- Delayed haemolytic transfusion reaction (DHTR)
- Abs to antigens e.g. Rhesus/Kidd
- 3-13 days post-transfusion
- Sudden drop in Hb, fever, jaundice, haemoglobinuria
- Febrile non-haemolytic transfusion reaction (FNHTR)
- Abs against donor leukocytes/HLA antigens
- Fever during transfusion, no haemolysis
- Normally if received multiple transfusions/women with multiple pregnancies
- Post-transfusion purpura (PTP)
- Adverse reaction to blood/platelet transfusion when body produces allo-abs to introduced platelets’ antigens –> destroy patient’s platelets –> thrombocytopenia
- 5-12 days post-transfusion
- Graft versus host disease (GvHD)
- After receiving transplanted tissue from a genetically different person
- WBCs in donated tissue (graft) recognise recipient as foreign –> attack host cells
- Can also occur in blood transfusion if blood has not been irradiated/treated with approved pathogen reduction system
- Delayed haemolytic transfusion reaction (DHTR)
- Non-immune:
- Viral infection
- Malaria
- Prions
Types of airway management? Airway management procedure?
Artificial airway types:
- Oropharyngeal airway (OPA) - prevent tongue blocking the airway/upper airway muscle relaxation in unresponsive individual (no cough/gag reflex)
- Nasopharyngeal airway (NPA) - used in responsive individuals/jaw clenched (more risk of soft tissue damage)
- Endotracheal airway (ETA) with intubation - if can’t breath on their own (need mech ventilation)/planned surgery requiring general anaesthetic, protects the airway from aspiration
- Supraglottic airway devices - step prior to intubation (elective procedures, cardiac arrests, prehospital airway Mx)
- Laryngeal mask airway (LMA) - temporary open airway during anaesthesia or life-saving measure during difficult airway intubation (≥ 3 attempts of 10mins each)
- iGel - as above but prevent aspiration & has port for NG tube insertion
Airway management:
- Basic (non-invasive):
- Head tilt & chin lift
- Jaw thrust
- Bag-valve mask
- Advanced (invasive/specialised):
- OPA/NPA
- Laryngeal mask airway (LMA)/iGel
- ETA with intubation
- Rapid sequence induction (RSI) of anaesthesia & intubation
- Cricothyroidotomy (emergency procedure - between thyroid & cricoid cartilage)
- Tracheostomy (2nd/3rd tracheal rings - surgical procedure for temp/permanent intubation)
Management of poisoning <1hr since ingestion, conscious, protected airway?
oral activated charcoal within 1hr
Treatment of high INR? Target?
- Any bleeding: stop Warfarin AND IV vit K slowly
- If major bleed = ADD dried PCC/FFP
- INR @24hrs –> continue Tx if INR high, continue Warfarin when INR <5
- INR >8: stop Warfarin AND oral Vit K
- INR @24hrs –> continue Tx if INR high, continue Warfarin when INR <5
- INR 5-8: miss dose of Warfarin –> reduce maintenance dose
Target: 2.5 (2-3 range)
Drugs for cardiac arrest?
DC shock (150J biphasic)
Adrenaline 1mg IV (10ml 1:10,000)
Amiodarone 300mg IV (if shockable rhythm)
Drugs for anaphylaxis?
Adrenaline 0.5mg IM (0.5ml 1:1000)
Hydrocortisone 200mg IV
Chlorphenamine 10mg IV
Seizure drugs?
Lorazepam 4mg IV (diazepam 10mg PR if no IV access)
Hypoglycaemia drugs?
20% glucose 75ml IV (repeat as needed) over a time period up to 20 mins
- 2nd line - glucagon 1mg IM (if no IV access, not ideal if anticoagulated as IM + causes nausea/flushing
- NOTE: risk of aspiration of glucose gel in an unconscious patient
Torsade de Pointes (TdP) - Tx?
Broad-complex irregular tachycardia where the size and shape of the QRS varies complex to complex within any given lead (polymorphic)
- Increased QT interval increases the risk e.g. drugs (clari, amiodarone)
Magnesium sulfate IV 2g over 10 minutes
