Emergency Medicine (2) Flashcards
Definitive management of AAA?
Aortic cross clamping + dacron graft insertion
EVAR (elective) if not ruptured
Triad in appendicitis?
Raised WCC
Neutrophils >75%
Raised CRP
Small bowel obstruction on AXR?
Central, valvulae coniventes, gas
Large bowel obstruction on AXR?
Big
Haustra
Volvulus on AXR?
Coffee bean sign
Differentiate by where ‘line’ of coffee bean points
Sigmoid = right Caecal = left
Immediate management of bowel obstruction?
Drip and suck (decompresses bowel)
Causes of acute pancreatitis?
I GET SMASHHHED
Idiopathic Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion bites Hyperlipidaemia Hypercalcaemia Hypothermia ERCP Drugs (thiazides)
Diagnosis of acute pancreatitis?
really high amylase (or lipase)
ABG for glasgow score
Prognostic score for acute pancreatitis?
Glasgow score - PANCREAS
PaO2 Age Neutrophils Ca2+ Raised urea Enzymes Albumin Sugars
> 3 = HDU
Presentation of renal colic?
Unilateral colicky pain - loin to groin
Frequent painful passage of small volumes of urine with sensation of incomplete emptying.
Analgesia for renal colic?
NSAIDs - diclofenac
6 Ps of ischaemia?
Pain Paraesthesia Pallor Pulselessness Paralysis Perishingly cold
Risk factors for gout?
Age Male sex Thiazides Red meat Alcohol
Management of gout (acute)
NSAIDs (diclofenac)
or
Steroids (pred)
Management of gout (long term)
Allopurinol
Lose weight, avoid starvation, avoid fatty foods, avoid XS alcohol
What do S3 and S4 heart sounds mean?
S3 = kentucky (sloshing in)
S4 = tennessee (a stiff wall)
Management of acute pulmonary oedema?
PODMAN
Position (sit up) Oxygen Diuretic (furosemide) + fluid resuscitation Morphine Antiemetic Nitrates
SIgns of basal skull fracture?
Panda eyes
Battle’s sign
Haemotympanum
Indications for CT within 1 hour in head injury?
GCS < 13 on initial assessment in ED GCS < 15 2 hours after injury Suspected open or depressed skull fracture Post traumatic seizure Any sign of basal skull fracture Focal neurological deficit >1 episode of vomiting
Indications for CT within 8 hours in head injury?
Current warfarin treatment = AUTOMATIC
IF LOC or AMNESIA as well…
>65 years old
>30 mins retrograde amnesia of events immediately before injury
Any history of bleeding/clotting disorders
Dangerous mechanism of injury
Diagnostic criteria for HHS?
Raised plasma osmolarity (>320 mOsmol/kg)
High glucose (>33.3 mmol/L)
No ketones in blood or urine
Signs of amphetamine overdose?
Thirst Confusion Agitation Tremor Dilated pupils High HR/BP/Temp Ataxia, tachyarrhythmias, hyperthermia, water intoxiciation, DIC, hyperkalaemia, hepatocellular/muscle necrosis, cardiovascular collapse, ARDS
Supportive management in amphetamine overdose?
Anxiety/seizures - diazepam
Tachyarrhythmias - metoprolol
Hypertension - nifedipine/nitrates
Hyperthermia - active cooling, dantrolene if rectal temp >39
Causes of hypocalcaemia?
Vitamin D deficiency Hypoparathyroid Acute pancreatitis Alkalosis Low Mg Alcoholism
Signs of hypocalcaemia?
Hyperreflexia
Tetany
Low BP/Low HR
Arrhythmias
Trousseau’s sign = spasm of hand from inflated BP cuff
Chvostek’s sign = unilateral twitching of face from tapping facial nerve 2cm anterior to auditory meatus
What is the Cushing response?
Hypertension
Bradycardia
Irregular breathing
Sign of impending coning
Investigations in temporal arteritis?
Bloods - ESR raised, CRP raised
Biopsy
Management of temporal arteritis?
IV steroids
Strong analgeisa
Biopsy
Ophthalmology to exclude visual complications
Complications of temporal arteritis?
Blindness (10-50%)
TIA/Stroke
Red flag symptoms for acute back pain? (PAIN 6, NEUROLOGY 4, PMH/SYMPTOMS 5, AGE 2)
AGE
Age <20 or >55
Acute onset in elderly
PAIN Constant or progressive pain Nocturnal pain Worse pain on being supine Thoracic pain Morning stiffness Bilateral or alternating leg pain
NEUROLOGY
Bladder/bowel changes
Neurological disturbance
Perianal anaesthesia/sphincter disturbance
Leg claudication or exercise related weakness/numbness
PMH/SYMPTOMS Fever, weight loss, night sweats History of malignancy Pulsatile abdominal mass Current or recent infection Immunosuppression (steroids/HIV)
Causes of acute back pain?
Serious = cord compression, cauda equina, metastases, myeloma, infection, fracture, aortic aneurysm
Common = mechanical back pain, renal colic
Management of mechanical back pain?
Early mobilisation, avoid lifting, maintain good posture
Analgesia (consider tricyclic or strong opioids if PCM, NSAIDs and weak opioids ineffective)
Diazepam for muscular spasm
Safety net - if bilateral symptoms or incontinence
Ottawa ankle rules?
DONT APPLY TO CHILDREN UNDER 6
- Unable to walk 4 steps in ED or immediately after injury
- Bony tenderness at any of the points described
- Pain in midfoot (foot x-ray) or malleolar zone (ankle x-ray)
Posterior edge or tip of lateral/medial malleolus - 6cm
Base of 5th metatarsal
Navicular
Management of ankle injury?
For 72 hours - PRICE
Protection - from further injury
Rest - for 48/72 hours. Use of crutches + controlled weight bearing
Ice - as soon as possible after injury for 10-30 mins
Compression - with bandage will limit swelling
Elevation - limits and reduces swelling
Two types of distal radius fracture?
Colle’s fracture - dorsal displacement of fracture fragments - results from fall onto outstretched hand –> forced dorsiflexion of wrist
DINNER FORK
Smith’s fracture = reverse colle’s - anterior displacement of fracture fragments. Falling backwards with arm pronating as body falls.
GARDEN SPADE
Presentation of hip fracture?
Shortened, adducted and externally rotated
Exacerbation of pain on palpation of greater trochanter and by rotation of the hip
What is garden classification?
Femur fracture classification
I - IV
III and IV is bad because avascular necrosis of femoral head
Most common type of shoulder dislocation?
Anterior (98%)
Presentation of anterior shoulder dislocation?
Arm at side of body in external rotation
Shoulder loses its usual roundness
Humeral head palpable anteriorly
Neurovascular things in anterior shoulder dislocation?
Radial pulse
Radial nerve function - extension and sensation
Axillary nerve - regimental badge area
Presentation or posterior shoulder dislocation?
Abducted and internally rotated
Nerve/vascular injury not common
X-ray in anterior shoulder dislocation?
AP - humeral head lies under coracoid process
Axillary - shows head of humerus (golf ball) anterior to glenoid (tee)
Transscapular ‘Y’ view - humeral head seen lying anterior to ‘Y’ with glenoid at centre of ‘Y’
X-ray in posterior shoulder dislocation?
AP - lightbulb sign (due to rotation) and widened GH joint
Y-view - humeral head posteriorly positioned in relation to glenoid
Adverse features in dysrhythmias?
Shock
Syncope
(usually brady)
HF
MI
(usually tachy)
Tachyarrhythmias - what to do if adverse features?
Synchronised DC shock (up to 3 attempts)
Seek expert help
Amiodarone 300 mg IV over 10-20 minutes
Repeat shock
Amiodarone 900 mg over 24h (in ICU - thrombophlebitis)
Regular narrow complex tachycardia?
SVT
Vagal menoeuvres Adenosine 6mg rapid IV bolus If no effect give 12mg If no effect give further 12mg Monitor ECG continuously
If sinus rhythm achieved, probable re-entry paroxysmal SVT.
If sinus rhythm not achieved - possible atrial flutter - control rate with beta blocker and SEEK EXPERT HELP
Irregular narrow complex tachycardia?
Probable AF
Control rate with beta blocker or diltiazem
In HF consider digoxin or amiodarone
Assess thromboembolic risk and consider anticoagulation
Regular broad complex tachycardia?
VT or SVT + BBB
If VT (or uncertain) - amiodarone 300mg IV over 20-60 mins then 900 mg over 24h
If known to be SVT w/BBB - treat as regular narrow complex tachycardia
Irregular broad complex tachycardia?
AF + BBB or Pre-excited AF
SEEK EXPERT HELP
If AF + BBB - treat as for narrow complex
If pre-excited AF - consider amiodarone
Examples of vagal manoeuvres?
10s of carotid sinus massage
Straining down as if passing a stool
Blowing plunger out of clean syringe
Immersing face in icy water
Bradycardias - what to do if adverse features?
Atropine 500 mcg IV
What to do if adverse features in bradycardia but no response to atropine?
Consider interim measures:
Atropine 500mcg IV repeat to maximum 3 mg OR Transcutaneous pacing OR Isoprenaline 5 mcg/min IV Adrenaline 2-10 mcg/min IV Alternative drugs
SEEK EXPERT HELP + ARRANGE TRANSCUTANEOUS PACING
Alternative drugs in bradycardia?
Aminophylline
Dopamine
Glucagon (if brady caused by B blocker or CCB)
Glycopyrrolate (anti muscarinic)
What are the conditions that cause risk of asystole in bradycardia?
Recent asystole
Mobitz II AV block
Complete heart block with broad QRS
Ventricular pause >3 s
What are the different types of heart block?
1st degree = lengthened PR interval
2nd degree (Wenkebach/Mobitz I) = progressive PR prolongation until dropped beat - beats dropped in regular pattern
2nd degree (Mobitz II) = intermittent non-conducted P waves. PR interval constant. Fixed no. of non-conducted P waves for every QRS (2:1/3:1)
3rd degree = no relationship between QRS and P waves
Management of testicular torsion?
Emergency surgical exploration
USS can confirm diagnosis but should not delay management
