Emergency medicine Flashcards
1
Q
ATLS
def?
when is it useful?
4 stages?
A
- 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
2
Q
Members of a trauma team?
A
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
3
Q
6 Things to ask ambulance crew when they’re bringing the patients in?
A
- 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)
4
Q
Airway
- Assessment
- 5 Managements if not patent?
A
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
5
Q
Breathing
- What is included
- Assessment
- Mx 5
A
- 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
6
Q
Emergency treatment for pneumothorax?
What kind of shock does it cause?
A
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
7
Q
Flail chest
def?
paradoxical chest movement?
complication?
A
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.
8
Q
Observations normal range
- Respiratory Rate
- Oxygen saturations
- Heart rate
- Blood pressure
- Temperature
- glucose
A
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)
9
Q
Arterial Blood Gas (ABG) normal range
- pH
- PaO2
- PaCO2
- HCO3
- BE
A
- 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
10
Q
2 types of respiratory failure?
A
Type I:
- Low pO2 (hypoxia)
- Normal pCO2
Type II:
- Low pO2 (hypoxia)
- High pCO2 (hypercapnia)
11
Q
Use of venturi masks?
A
- 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.
12
Q
Def shocks
- Hypovolaemic
- Vasodilatory
- Cardiogenic
- Obstructive
- Neurogenic
A
- 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
13
Q
Circulation
- assessment
- Mx
A
- 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.
14
Q
Disability assessment
A
- Conscious level (GCS/AVPU)
- Pupils
- Blood glucose
15
Q
Glasgow coma score
A
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
16
Q
AVPU
A
A = Alert
V = responds to Voice
P = responds to Pain
U = Unconsciou
17
Q
Pupil test interpretation
Size, respond to light
- Unilaterally dilated, Sluggish or fixed
- Bilaterally dilated, Sluggish or fixed
3 .Bilaterally constricted, May be difficult to determine
- Unilaterally constricted, Preserved
A
1 .IIIrd nerve compression due to tentorial herniation
- Inadequate brain perfusion or bilateral IIIrd nerve palsy.
- Drugs (opiates)
- Metabolic encephalopathy
- Pontine lesion
- Injured sympathetic pathway
18
Q
Exposure assessment?
A
- Removing remaining clothing (some clothing will have already been removed to complete earlier stages)
- Cover with blankets to keep warm.
- Ensure IV fluids have been warmed.
19
Q
What Else Should You Do Before the Secondary Survey?
A
- ECG monitoring.
- Urinary catheter - to monitor urine output.
- Consider gastric catheter - reduces stomach distension and the risk of aspiration,
- Arterial Blood Gases
- X-rays: Chest film, Pelvic Film,
Lateral Cervical Spine Film
20
Q
Secondary Survey
When to start?
What is involved?
A
The secondary survey does not begin until
- the primary survey is completed,
- resuscitative efforts are well established
- and the patient is demonstrating normalisation of vital signs.
- The secondary survey is a complete history and physical head to toe examination (including a complete neurological examination)
- plus a reassessment of vital signs.
21
Q
AMPLE history
A
Allergies Medication currently used Past illness and pregnancy Last meal time Events and the environment of the injury e.g. blunt trauma (falls, car crashes etc.), penetrating trauma, burns, cold, chemicals, toxins and radiation?
22
Q
Questions to ask in addition to ample post-head injury?
A
- Loss of consciousness immediately after the injury and their level of alertness between now and then.
- Amnesia - both antegrade and retrograde.
- Headache
- Seizures
23
Q
Appropriate cervical immobilisation?
A
- A semi rigid collar
- Head blocks
- Tape or straps.
24
Q
How to Recognise Haemorrhage as a Result of Pelvic Injury
A
Is there…
- Unexplained hypotension?
- Progressive swelling or bruising in the flanks, scrotal or perianal areas?*
- A failure to respond to initial fluid resuscitation?
- Blood at the urethral meatus?*
- A high-riding prostate on digital rectal examination.*
- Mechanical instability of the bony pelvis?
25
Signs of shock?
- hyperventilation
- hypotension
- tachycardia
- confusion
- sweating
- pale
26
Canulae sizes? small to big
Blue --> pink --> red--> grey --> orange
27
3 lead ecg lead placement?
Red: Right up
Yellow: Left
Green (rhymes with spleen): left low
28
Anaphylactic treatment?
- swollen airways
:
1. adrenaline IM 1:1000
2. Antihistamine (chlorophenamine)
3. Steroids (hydrocortisone)
29
Crash team bleep?
2222
30
Acute management of acute coronary syndrome?
```
MONA
Morphine + metocloprimide (anti-emetic)
O2
Nitrates (GTN spray under the tongue)
Aspirin (300 mg, chewable)
```
31
3 CVS causes of acute chest pain?
Acute coronary syndrome
Pericarditis (eases off on leaning forward)
Aortic dissection
32
Wounds
1. 4 types
2. Hx 1
3. O/E
4. Ix?
1.
- incised (sharp surgical)
- lacceration (blunt force)
- abraision (removed upper skin layer)
- puncture (needle: width
33
Wound management
I. Stop bleeding
Stop the bleeding using direct pressure or tourniquets
II. Analgesia
- L.A. +/- adrenaline
III. Clean
- Irrigate with saline
- Remove non-viable tissue & grit
- If near a fracture : cover with clean, saline-soaked dressing, and give abx
IV. Close
a. If safe to close, options:
- Primary closure – close it immediately
- Delayed primary closure – clean, give antibiotics for 48 hrs then close
- Secondary healing – allow to heal on its own
b. if it's complex and dirty:
- refer for exploration & closure in theatre
34
Methods of wound closure?
1. Sutures
A. Non-absorbable: eg nylon
B. Absorbable: eg vicryl; used inside the mouth such as lips/tongue
2. Others:
A. Glue:
- useful in children and superficial wounds or scalp wounds
- Not to be used in areas under tension or over joints
B. Adhesive strips
- Pretibial skin: thin skin where sutures may skin disintegrate
- not over the joints
C. Staples
- Effective for simple wounds
- Staples fast way of closing linear wounds that do not need perfect cosmetic result
D. Dressings
35
When to opt for a surgical airway?
Difference between cricothyrodotimy and tracheostomy?
when cant intubate/cant ventilate
Tracheostomy is better for long term, but has more complications
36
When to use D-dimer/troponin I?
D-dimer:
- indicates clotting
- not very specific, but good to exclude DVT
Troponin I:
- ischaemic condition: heart attack
37
When would you ask for a CT of head in A&E?
- post-trauma seizure
- GCS<13 straight after
- GCS<15 2 hours post-trauma
- signs of base of skull fracture
- >1 episode of vomiting
38
Signs of coning?
- ipsilateral dilation of pupils
| - bradycardia, hypertension, altered respiration
39
Management of paracetamol overdose?
1. Within 1 hour
- activated charcoal
- gastric lavage
2. After 4 hours
- measure plasma level of paracetamol
3. If time is not known:
give anticysteine
40
Opioid overdose management
1. ventilation
2. IV nalaxone
3. Naltrexone longer term management
4. Methadone (to wean off heroin)
