Emergency Medicine Flashcards
Etiology, presentation, and tx of croup
inflammation of larynx, trachea, and bronchi
3 mo - 3 yrs
complication of viral infxn
difficulty breathing (often while asleep)
crowing on inspiration (stridor)
seal like barking cough - NOT SPECIFIC TO JUST CROUP!!
“steeple sign” in radiographs
tx: breath cool moist air 5 min. no improvement > cont to monitor for fever, tonsils, worsening breathing. worsens > hospital
A parent calls and says their child has a seal like barking cough. What do you reccomend they do, why?
barking cough = stridor
could be croup but can also be other situations that are on their way to becoming airway compromise (obstruction to foreign object, epiglotttitis, asthma, etc)
assume the worst if no other info!
epiglottitis etiology, presentation, and tx
3-10
h flu (or BH strep)
high fever, toxic child
diff breathing
inspiratory stridor
drooling, head tipped
“thumbprint sign”
NEEDS ABX AND AIRWAY MGMT! DO NOT MOVE NECK OR OPEN MOTH > ER BY EMS WITH AIRWAY MGMT!
At what RR should emergency oxygen be considered in adults, children, and infants?
adults: < 12, > 20
child: < 15, > 30
infant: < 25, > 50
Flow rates, %, and uses for O2 devices
nasal cannula: 1-6 LPM, 24-44%, breathing victims
non-rebreather: 10-15 LPM, 90+%, breathing victims (can be used as a blow-by with children; inflate reservoir bag 2/3 full and cover valve with thumb)
resuscitation: 6-15 LPM, 35-55%, breathing and nonbreathing
BVM: 15+ LPM, 90+%, breathing and non-breathing (squeeze as victim inhales)
signs of upper airway obstruction
inspiratory and/or expiratory stridor
possible retractions of thorax (intercostal, suprasternal, supraclavicular)
cyanosis
drooling (esp in peds)
LOC with full obstruction
upper airway obstruction tx
determine if mechanical or infectious
mechanical: heimlich procedure
infectious (fever, pneumonia sx): consider epiglottitis
Reasons for choking
tongue in unconscious victim (head tilt, chin lift)
vomit
foreign body
swelling (anaphylaxis, irritants)
spasm (water inhaled suddenly)
tx for conscious choking/foreign body airway obstruction in adults
heimlich
- fist above umbilicus
- 5 upward and inward thrusts (if pregnant or obese, chest thrusts with fists on sternum or support chest and give back blows)
cont until successful or victim becomes unconscious
if victim becomes unconscious > call 911, support with knees while lowering them, assess, CPR > check for object before giving breaths
tx for choking conscious infants
position w head downward
5 back blows (check for expelled object)
5 chest thrusts (check for object)
repeat
tx choking: unconscious infants
when first breaths dont go in, check for object in throat then try 2 more breaths
if neither set goes in, suspect choking
30 compressions, check for object in throat (no blind finger sweep)
give 2 breaths
compensated vs decompensated shock
early (compensated); reversible
- tachy, anxiety, restlessness, delayed cap refill, diaphoresis, widened PP
- tx are preventative in nature w/ ABC interventions
late (decompensated): diff to reverse
- hypotension, confusion, LOC, oliguria, acidemia
- tx are aggressive and rapid volume resuscitation, meds, and invasive procedures
types of shock
hypovolemic
cardiogenic (pump failure, MI)
obstructive (fall in CO, CHF)
distributive (loss of IV and dec vascular vol; neurogenic, septic, infectious)
if you are giving an IV and the pt goes into anaphylaxis, what do you do?
STOP infusion but do NOT discontue line; change bag and line to NS infusion and run it
how to differentiate allergic rxn and anaphylaxis? how would you tx each?
shock sx; inc HR, low BP
if NO RR/cardio shock signs: allergic, tx with H1 blocker and maybe steroids
if R compromise and/or CV shock: anaphylaxis; epi, H1 blocker, and steroids
anaphylaxis tx
pt in recumbant position
ABCs
patent airway - oral berman or intubate (if not breathing > rescue breaths)
BP, or if in a hurry > peripheral/emergency BP (with palpation, not cuff)
- if you can feel a radial pulse = AT LEAST 80 systolic
- femoral = AT LEAST 70
- carotid = AT LEAST 60
epinephrine dosages / forms for emergency medicine
- 1:1000 (stronger) for IM/SQ and Intratrachial
- IM: 0.5-1 mg/mL, subQ: 0.3-0.5 ml
- can take 2-10+ min to show response
- 1:10,000 (more diluted) is IV form ONLY
- push 0.1-0.2 mg (1-2 mL)
- can repeat q 3-5 min
diphenhydramine dosing in emergency medicine
50 mg (1 ml) IV stat AFTER epi (even without seeing response if not IV)
in allergy may start with 12.5-25 mg
oxygen rate by mask in emergency medicine; how does it change with COPD?
15L/min by mask / highest conc
3 or less L/min in COPD
what is the next step in anaphylaxis after epi and diphenhydramine?
steroids to stabilize cytokine storm
dexamethasone 10-20mg (2.5-5mL)
hydrocortisone 100-500 mg
prenisone 30-60 mg
infxn control with unknown powders
unknown powder, assume to be anthrax
get away, put on PPE
by the time one has sn/sx of anthrax it is often too late to tx so presumptively tx - doxycycline, minocycline, OR ciprofloxacin
basics of mass casualty triage
hemorrhage > ABCs (my ABCs dont mean shit if im bleeding out of my missing leg…)
the dead stay dead (open skull fractures, pulseless, under water 20 min..)
scene survey > don’t respond if it is not safe!!!!
considerations for seizures (tonic-clonic) in emergency setting
most common are febrile
toxin ingestion
treat as any seizure and get follow up med care
- protect pt during seizure to degree possible - move stuff away, but DONT intervene, put hands/anything near mouth
approach to head injuries in emergency medicine
all pts with head injuries and trauma should be treated as if they are pos for cervical spine injury
-c spine immobilization (cerv collar, head blocks, long board)
-ABCs, glasgow coma scoring, neuro exam techniques
-100% o2 therapy (conscious with non-rebreather, unconscious or impaired breathing with bag valve mask)
head injury associations sx/considerations
seizures
combativeness (assess for hypoxia, hypoglycemia, hypotension, and pain)
pain control: sedatives-analgesics (narcotics, benzos)
sys HTN, signs of IC HTN (bradycardia & HTN)
approach to penetrating wounds of the neck and spine
leave sharp objects in
test canial nerves
approach to whiplash injuries/cervical strain
hyperextension most common
no associated fx
xray is dx
12-24 hrs for manifestation of sx
wound assessment
time of occurance
- <6 hours, reduced bacteria (closure)
- inc blood supply inc exposure time
- facial wounds up to 24 hours
environmental contaminants
mech of injury
risks / tx for tetanus exposure in wounds
usually deep puncture with soil exposure
wash wound w antibacterial soap immediately
immunisation hx q 10 yrs, shots if exposure is high risk
rabies exposure tx
consider rabies immune globulin USP
how to assess the severity of a burn?
adults, rule of 9’s (each arm, head/neck = 9, each side of torsio, each leg = 18, genitals and perineum =1)
peds, rule of 5’s (10 each arm and infant leg, 15 head/neck of child and each child leg, 20 each infant head/neck, child side of torso)
burn tx
100% 15L/m O2 in non-rebreather (or bag valve if impeded R); intubate if inhalation injury
IV access with pts with 15% + body surface area burns, 16+ gauge or central venous access
process of inserting a urinary catheter
supplies:
- foley catheter or straight french catheter
- urine drain bag
- sterile lubricant
- sterile syringe (5-10ml NS)
cleanse area
lubricate catheter and insert til urine visualized in tube
advance another 4-5 cm past for full baloon placement
inflate balloon with sterile h2o and attach bag tape tube to medial thigh
in what scenario would catheterization be cautioned? what would you do instead?
if significant uriary retention (no urination >12 hrs/volume >500ml) - be careful of rapid bladder drainage; in bladder distention, rapid decompression can cause shock
drain 300-400 ml and let bladder relax for 30-60 mins, then drain the balance
considerations in eye trauma
leave foreign body, use gauze to stabilize
cover other eye (diminishes movement)
getting hit in eye with closed globe trauma > biggest concern is damage to the optic nerve (may be okay initially) > go to ER with inc pain, dec vision
what is hyphema and what is a complication of this?
bleeding in the ant chamber of eye; indicates significant trauma; can cause acute glaucoma attack
subconjunvtival hemorrhage
bleeding on sides of globes
potentially significant trauma to globe but typically more cosmetic like a bruise
chemical burn to eye tx
irrigation!!!!!! > emergency referral
ointment prior to transport (lacrilube/vit A oil) if no water available;keeps eye from sticking to itself
flash burn tx
common with welding
shredded raw potato poultice
vit a oil eye application
direct cold hydro x 10 min
CPR/BLS steps
scene survey
R - responsiveness “YOU GUD???”
A - act EMS (YOU - CALL 911)
P - position on back (don’t move head and neck into another position)
C - A - B (circ, airway, breathing)
compression to breath ratio by age/number of responders
30:2 for all ages if one rescuer
adult 2 rescuer; 30:2
child and infant two rescuer: 15:2
depth of compressions
1.5-2 inches for adults
for kids, 1/2 - 1/3 chest depth; use 1 or 2 hands (keep one hand on forehead)
stomach distension indicates what during BLS
breaths are not reaching lungs; consider mouth to nose rescue breaths
how to check for CPR effectiveness
chest rising and falling with rescue breaths
have 2nd rescuer check pulse while u give compressions
differences in CPR for infants
still 30:2 unless have a second person, then 15:2
give “puffs” vs breath
between nipple 2finger(middle/ring) compressions 1/2- 1/3 depth
if alone, resuscitate for 2 mins before calling 911 they respond better to urgent CPR
signs of imminent birth
mother feels urge to push with each contraction
contractions 2-3 min apart
crowning
preparation for emergency childbirth
get mother comfy
drape adbomen, each leg, under her
wash hands
get ready for “the catch” (something to move stool/blood out of the way if they come out)
babies are normally born in what position?
head down, nose down
after the head of a baby is birthed, what is the next step?
head and shoulders rotate naturally
at what point would you clear a baby’s airway during delivery?
after the head is out/before shoulders are delivered
first steps after emergency childbirth
lay baby NEXT to mom or ON mom
- clear airway
- towel dry and wrap in dry blanket
- if not breathing (crying), clear airway again, flick soles of feet
- if still not breathing, give 2 breaths, check pulse, CPR if needed
two most importnant concerns with emergency childbirth
airway & breathing
preventing heat loss
notes on cutting the cord with emergency childbirth
you dont have to; you dont want to cut too soon!!!
after drying and breathing has started; at least 2-3 mins
make 2 ties: 4 inch from baby and 6 inch from baby
cut between
notes on placenta delivery
deliver PASSIVELY!!! you may utilize fundal massage but you want all lobes to be intact and not retained inside uterus
cont fundal massage after for oxytocin for stopping bleeding
criteria of Apgar scoring
scale of 0-2
Appearance
Pulse
Grimace (reflex irritability)
Activity (muscle tone)
Respiration
what should you do when there is nuchal cord?
slip over babys head as soon as neck is visible/possible
DO NOT PUSH BABY BACK IN
mgmt of postpartum hemorrhage
Four T’s
- Tone (soft, boggy uterus): bimanual uterine massage, bimanual massage between vagina/fundus, empty bladder
- Trauma (genital laceration, uterine inversion)
- Tissue (retained placenta)
- Thrombin (clotting disorder, labs and replace)
uterotonic meds:
- oxytocin
- methergine
- hemabate
- misoprostol
common cause of neonatal sepsis and meningitis
GB strep
tx for neonatal eye infxns
0.5% erythromycin or 1% tetracycline hydrochloride
normal vital signs for ages:
0-1
1-5
5-10
0-1:
- 120 HR
- 80/40 BP
- 40 RR
1-5
- 100 HR
- 120/80 BP
- 30 RR
5-10
- 80 HR
- 120/80 BP
- 20 RR
length where epistaxis becomes an emergency
after 10-15 mins of firm pressure or frequent epistaxis
preferred injection site for small children <2
vastus lateralis
angle degrees for IM, SQ, and ID
IM 90
SQ 30-45
ID 5-10
common drug/nutrient IV interactions
CCB and EDTA, magnesium > Heart block
Rauwolfia/Reserpine - makes more hypotensive w mg, ca, EDTA
BB + magnesium
what IV preparations can cause hypoglycemia? how would you tx it?
high dose vit C
EDTA chelation
tx with dextrose
antidoes for speed shock
ca antidotes mg
mg antidotes ca
considerations for IV rehydration
largest catheter offered (smaller g = bigger catheter; pick 20 g over 24 g)
use itotonic solution (normal saline, ringers lactate, d5w - NEVER sterile water)
fluid replacement quantities for rehydration
1.5-2 L / day
CI to chelation therapy
organs that have to process chelation!
renal insufficiency
liver dz
anticoagulation
CHF
pregnancy
