Emergency Medicine Flashcards by Jessie Puchalski

circulation: give what kind of fluids first?

2-3 L of crystalloids (normal saline or lactated ringers) then after then add blood

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primary survey

A-airway with c-spine stabilization
B-breathing
C-circulation with hemorrhage control
D-disability
E-exposure

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which injuries do you treat first?

the most lethal ones

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how do you assess patience of airway?

c-spine injury? Stridor, signs of obstruction
Blood, loose tissue, avulsed teeth,
Fx’s: facial, mandibular, tracheal

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when to intubate?

Altered mental status

Unable to maintain airway

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when to do cricothyroidotomy?

If inability to intubate due to airway edema, hemorrhage, laryngeal fx.

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airway interventions

Chin lift/jaw thrust
Suctioning
Oral or nasal airway
Intubation
Altered mental status
Unable to maintain airway
Cricothyroidotomy

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what do you assess for circulation?

Vital signs: hypotension, tachycardia
Pulse: strong vs. rapid/thready
Level of consciousness:
Impaired cerebral perfusion?
Skin color: pink vs. pale/ashen
Bleeding
External: identify and control
Internal: intra-abdominal, intra-thoracic, femur/pelvis fx.
Need for emergent surgery?

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how do you assess disability?

brief neuro exam: mental status ,pupil size, see if can move all 4 extremities

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what doees AVPU stand for?

Alert
Responds to Verbal StimulI
Responds to Painful Stimuli
Unresponsive

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3 std initial trauma x rays

lateral c-spine, CXR, pelvis

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initial labs in trauma

Type and crossmatch in severely injured pt
CBC, chem-7, amylase
UA
UPT in females
ETOH, drug screen

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secondary survey of head

Head
Scalp bleeding
Control with direct pressure
Skull
Signs of fx: creptius or stepoff
Pupils
Ears
Hemotympanum? (basilar skull fx)
Facial fractures

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secondary survey of neck

C-spine tenderness
Laryngeal injury, tracheal deviation (tension pneumo)
Keep immobilized until injury definitely ruled out

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secondary survey of cheset

Bruising, deformity, tenderness, crepitus
Review CXR
Injuries
Sternal fx, rib fx
Flail chest
Tension pneumothorax
Hemothorax
Sucking chest wound
Cardiac tamponade
Aortic rupture

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secondary survey of abdomen/pelvis

Distention (internal bleeding)
Ecchymosis
Penetrating wound
Tenderness
Pelvic instability (press on anterior superior iliac spine)
Place nasogastric or orogastric tube
Frequent reassessment to look for change

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“High-riding” prostate suggests ?

pelvic fracture/urethral disruption

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secondary survey of genitourinary

External inspection
Bruises, hematomas, lacerations
Rectal exam
Blood?
“High-riding” prostate suggests pelvic fracture/urethral disruption
Bimanual vaginal exam
Lacerations, blood
Pregnancy test on females
Place Foley catheter

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secondary survey of m/S system

Musculoskeletal
Back
Log-roll patient while stabilizing C-spine
Inspection
Percussion for tenderness of thoracic or lumbar spine
CVA tenderness
Extremities
Soft tissue injury
Lacerations
Fractures

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secondary survey of neuro

Neuro
More thorough neuro exam
Level of consciousness
Glascow Coma Score is the standard
Re-eval of LOC and pupils
Look for signs of deterioration
Motor/Sensory of extremities

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3 components of glasgow coma scale

eye opening, verbal response, motor response

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lowest and highest scores of glasgow coma scale

3, 15

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T or F: always assume hypotension is due to brain injury

F: always look for other source of hemorrhage head injuries usu cause hypertension

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assessment of head trauma

Neurologic Exam
Level of consciousness
Glascow Coma Score
Pupil size/reactivity/equality
Motor exam
Unilateral deficit suggests intracranial mass lesion
If flaccidity, suspect spinal cord injury
Brainstem function
Corneal, gag reflexes
Repeated exams essential to detect deterioration

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standard imaging for suspected head trauma

CT: head X-rays are worthless b/c don't give you info on brain

tx of linear non depresses skull fx

none! if no depression, no problem with brain no tx needed

tx of depressed skull fx

feel for crepitus, surgery to elevate fragment, abx (if open)

basilar skull fx signs

Hemotypanum Raccoon’s Eyes Battle’s sign: mastoid ecchymosis CSF rhinorrhea/otorrhea

tx of basilar skull fx

none! close observation

causes of airway obstruction

* Loss of muscle tone in obtunded pt: tongue obstructs oropharynx * Foreign body aspiration * Epiglottitis • Angioedema * Oral-facial trauma * Signs: stridor, inability to speak, breathe, cough

opening maneuvers of airway

* Head tilt/chin lift, jaw thrust (lift tongue away) * If foreign body: finger sweep, back blows, Heimlich, direct visualization/removal with forceps * If complete obstruction, consider cricothyroidotomy

life threatening causes of chest pain

* Unstable angina/acute MI * Aortic dissection * Pulmonary embolus • CHF * Pneumothorax * Pneumonia

generally benign causes of chest pain

* Costochondritis * Pleurisy • Pericarditis * GERD/esophageal spasm

who can have atypical presentations of chest pain/MI

women, elderly, diabetic pts

what does reversible ischemia look like on EKG?

* ST depression, T-wave flattening or inversion | * Changes resolve after episode is over

what does acute mI look like on EKG?

* ST elevation * Reciprocal changes * New LBBB * Q-wave develops later

which cardiac enzyme is best to look for MI? how long do you follow?

troponin about 3-6 hours is detectable, follow for one day?

management of mI: mONAH

* Oxygen * Aspirin (+/- clopidogrel) • Heparin/enoxaparin * Nitrates • Beta-blockers * If acute MI: emergent cardiac cath (vs. t-PA)

RFs for aortic dissection

age, HTN, atherosclerosis, Marfan’s syndrome

what is the typical and atypical presentation of aortic dissection?

typical: ripping or tearing pain in chest or BACK atypical: if Dissection may occludes major vessels − Carotids: stroke symptoms − Coronaries: acute MI − Brachial, iliac: arm/leg ischemia- common presentation

tx of aortic dissection

* Emergent cardiovascular surgery consult * Lower BP, decrease shearing forces: propranolol, nitroprusside * Proximal dissections require surgery- type II may not

what do contusions look like on brain?

white blood, surrounded by dark edema

Tearing/shearing of nerve fibers at time of impact CT may be normal despite profound neurological deficit Results in prolonged, possibly permanent coma Mortality 33%, usually due to cerebral edema

diffuse axonal injury

Focal hemorrhagic area on brain, often surrounded by edema

cerebral contusion

how is intracerebral hemorrhage different from cerebral contusion/

more blood, possibility of expanding more d/t torn blood vesels

artery torn in epidural hematoma

middle meningeal

signs of impending brain herniation

ipsilateral dilated pupil and contralateral weakness

Bleeding between dura and arachnoid/brain Appears “sickle-shaped” on CT Due to tears of bridging veins between cerebral cortex and dura Often with severe underlying brain injury

subdural hematoma

Bleeding between inner skull table and dura Appears “lenticular” on CT Usually due to skull fx. which tears middle meningeal artery Often, little or no injury to underlying brain May rapidly expand, causing herniation/death If rapid surgical intervention, prognosis is often excellent

epidural hematoma

assume ___ in all pts with significant trauma

spinal injury

neuro assessment of spine

``` Entire spine: cervical, thoracic, lumbar Tenderness, deformity Log-roll pt to examine back One person maintains inline neck immobilization Neuro assessment Motor: corticospinal tract Pain: spinothalamic tract Position/vibration: posterior columns Rectal tone/perianal sensation ```

assessment of chest trauma

``` ABC’s,Vital signs Tachycardic? Hypotensive? Neck veins Distended? Expose chest completely Equal respiratory movement? Chest wall trauma? Crepitus? Bruising? Deformity? Quality of respiration Shallow? Rapid? Breath sounds Equal? Diminished? ```

signs of a tension pneumo

``` Resp distress Tachycardia Hypotension Tracheal deviation JVD Unilateral absent breath sounds A clinical diagnosis ```

these things make you think of which condition? what is the triad called? Hypotension Distended neck veins Muffled heart tones

becks triad of pericardial tamponade

EKG pattern of electrical alternans signifies what?

of cardiac tamponade

tx of pericardial tamponade

IV fluids to

internal organs most commonly injured in trauma

spleen and liver

what sign will alert you to the fact that stomach or intestines have been punctured?

peritonitis and pertioneal findings; guarding, rebound tenderness, etc

organs in retroperitoneum

Duodenum, pancreas, kidneys, ureters

advantages and disadvantages of FAST exam (focused abdominal sonography for trauma)

Accurate, fast, noninvasive, portable (done at bedside) Looks for free intraperitoneal fluid suggesting organ injury/bleed Disadvantage: doesn’t show etiology of fluid

advantages and disadvtanges of abdominal CT for trauma

advantages: shows precise lesion, sensitive and specific disadvatanges: takes extra time

signs of positive diagnostic peritoneal lavage (DPL)

>100,000 RBC >500 WBC presence of bile or vegetable matter

signs or sx of compartment syndrome

Pain, paresthesia, pallor, pulselessness, paralysis of involved muscles Measure compartment pressures > 35-45

tests for near drowning

CXR, ABG, CBC, lytes

treatment of near drownign

``` Airway, ventilation, oxygenation C-spine stabilization and eval Cardiac monitor, O2 sat monitor, IV If persisten hypoxia: ntubation and mechanical ventilation Warming measures No role for steroids or antibx ```