Emergency medicine Flashcards
ATLS
def?
when is it useful?
4 stages?
- advanced trauma life support
- golden hour, within 60 mins post-injury
- Preparation before the ambulance crew come
- primary survey and resuscitation
- AMPLE history and secondary survey
- Continued monitoring
Members of a trauma team?
I. 4 doctors
1 doctor team leader
1 airway doctor
2 circulation doctors
II. 5 nurses 1 nurse team leader 1 airway nurse 2 circulation nurses 1 relatives nurse
III. radiographer
6 Things to ask ambulance crew when they’re bringing the patients in?
- What type of incident? e.g. car crash, chemical spill
- How many?
- Age and sex?
- Status? e.g. ABC - airway, breathing, circulation and conscious level (GCS).
- What treatment have been given so far and what were the effects?
- Estimated time of arrival? (ETA)
Airway
- Assessment
- 5 Managements if not patent?
1. I. Can they talk? II. Look - Chest movement - Accessory muscles III. Listen - Silent - Additional sounds IV.Feel - Airflow foreign bodies in the mouth
- Perform a Jaw Thrust
- Clear foreign bodies e.g. fractures, dentures, chewing gum. (YANKAUER SUCKER)
- Insert an oropharyngeal (if GCS<8) or nasopharyngeal airway if required.
- establish a definitive airway by orotracheal or surgical cricothyroidotomy.
- keep c-spine immobilised
Breathing
- What is included
- Assessment
- Mx 5
- Include lungs, chest wall and diaphragm
2. I. Look - Respiratory rate - Flail chest II. Feel - Chest expansion - Tracheal deviation III. Percuss: - pneumothorax: hyper resonant IV. Auscultate - pneumothorax: reduced lung sounds
- Give 15l/min oxygen through a tight fitting non-rebreathing, reservoir mask
- Put on the pulse oximeter
- Immediately treat a tension pneumothorax.
- Consider the need for intubation to provide ventilatory support in a patient with , flail chest / pulmonary contusion
- Consider inserting a chest drain in a patient with a massive haemothorax
Emergency treatment for pneumothorax?
What kind of shock does it cause?
Needle thoracocentesis:
1 .Get a large bore cannula.
2. Insert it into the second intercostal space, in the midclavicular line on the affected side.
3. Remove the needle to allow the trapped air to escape with a hiss.
4. Tape the cannula in place, avoid kinking it.
5. Then depending on improving clinical status get a chest x-ray and insert a chest drain and repeat the CXR.
- obstructive
Flail chest
def?
paradoxical chest movement?
complication?
This occurs when 2 or more ribs are fractured in two or more places, allowing a segment of the chest wall to move independently from the rest.
The segment moves in on inspiration (when the rest of the chest moves out) and out on exhalation.
- At the time of injury this segment will have been rammed into the underlying lung and a pulmonary contusion is inevitable.
- In severe cases this will lead to hypoxia, which may develop several hours post injury.
Observations normal range
- Respiratory Rate
- Oxygen saturations
- Heart rate
- Blood pressure
- Temperature
- glucose
Observations:
- Respiratory Rate 11-20
- Oxygen saturations >96
- Heart rate 50-100
- Blood pressure >140/90
- Temperature 35-38 (36.5)
- 3.5 to 7 (less than 10 fasting)
Arterial Blood Gas (ABG) normal range
- pH
- PaO2
- PaCO2
- HCO3
- BE
- pH 7.35 – 7.45
- PaO2 11 – 14 kPa (80-100 mmHg)
- PaCO2 4.7 – 6.0 kPa (35-45 mmHg)
- HCO3 22 – 28 mmol/l
- BE -2 to +2
2 types of respiratory failure?
Type I:
- Low pO2 (hypoxia)
- Normal pCO2
Type II:
- Low pO2 (hypoxia)
- High pCO2 (hypercapnia)
Use of venturi masks?
- Small group of COPD patients are at risk of CO2 retention and type II respiratory failure when exposed to excess oxygen.
- Their target oxygen saturation might be between 88-92%
- Venturi mask enable to give controlled amount of oxygen to those patients
- NEVER allow a patient to become hypoxic in order to attempt to prevent rising CO2levels.
Def shocks
- Hypovolaemic
- Vasodilatory
- Cardiogenic
- Obstructive
- Neurogenic
- Hypovolaemic
- Reduced preload e.g. bleeding, dehydration, fluid loss - Vasodilatory
- Reduced afterload / SVR e.g. septic / anaphylactic - Cardiogenic
- Reduced contractility e.g. MI / Chronic cardiac failure - Obstructive
- Obstruction to cardiac output e.g. PE, cardiac tamponade - Neurogenic
- Reduced afterload
Circulation
- assessment
- Mx
- I. Look
- signs of shock
- signs of haemorrhage (into the chest, abdomen, pelvis, long bone fractures or externally)
II. Feel
What are the quality, rate and regularity of the pulse?
What is the patient’s blood pressure? - I. Reduce haemorrhage: apply direct pressure to a bleeding wound, reduce and splint long bone fractures.
II. Replace fluids:
- Fluid challenge: give 500mL first to see if the BP goes back up or not before giving more
- a minimum of 2 large calibre intravenous cannulae,
- 2l crystalloid initially.
III. Take blood samples for type and cross match and other baseline studies.
Disability assessment
- Conscious level (GCS/AVPU)
- Pupils
- Blood glucose
Glasgow coma score
Glasgow coma score:
I. Eyes opening - Spontaneous 4 - To speech 3 - To pain 2 - None 1 II. Verbal Response - Obeys commands 6 - Localizes pain 5 - Normal flexion (withdrawal from pain) 4 - Abnormal flexion (decorticate state) 3 - Extension (decerebrate state) 2 - None (flaccid) 1 III. Best motor response - Orientated 5 - Confused conversation 4 - Inappropriate words 3 - Incomprehensible sounds 2 - None 1
AVPU
A = Alert
V = responds to Voice
P = responds to Pain
U = Unconsciou
