emergency medicine Flashcards
indications for a CT scan
immediate: 1. GCS less than 13 on arrival if the GCS is less than 15 2 h post arrival if there was a seizure after trauma FNDeficiet vomiting more than 1 suspected skull fracture with 8 hour CT head injury and on warfarin LOC or amnesia plus age greater than 65, fall greater than 1 meter, fall greater than 5 steps, pedestrian vs vehicle bike vs vehicle more than 30 min amnesia of before injury events
what is likely to cause a lateral neck lump in an adult?
75% chance of malignancy
80% mets and the rest lymphomas
in absence of systemic illness a lateral neck mass is due to metastatic carcinoma until proven otherwise
lump in neck there for less than a few weeks
most likely infective or inflammatory but can be malignancy
lump in the neck for a few weeks
malignancy until proven otherwise
is the lump in the neck going bigger?
if yes rule out malignancy
B symptoms of lymphoma
fever night sweats and weight loss
what blood pressure is considered shock?
less than 90/60
what gauge is a large bore cannula
14G-16G
elevated urea can tell you
kidney functions but also can tell you if upper GI bleed
fluid resuscitation
2 L of warmed crystalloid solution (hartmanns normal saline)
pre endoscopy procedure magagement for heamatemsis
terlipressin 1-2 mg 4-6 hourly (splachnic vasoconstriction)
prophylactic abx
What is the Blatchford score?
classifies patients coming into the hospital with heamatemsis into either high risk requiring urgent intervention or low risk being able to be taken care of as a outpatient.
components: urea, HB in men, HB in women, systolic BP, and other markers: pulse (less 100) melaena or syncope, hepatic disease cardiac disease
What is the Rockwell score?
The rockwell score predicts the patient’s risk of rebleeding and mortality of patients with an upper Gi heamorrage.
The rockwell score is separated into pre endoscopic and endoscopic scoring.
Initial is age less than 60 (0) over 80 is 2
shock heart rate is over 100 bpm, (1) systolic BP less than 100 (2)
comorbities 1 point if heart disease or failure 2 points if liver or renal disease
post endo
stigmata of recent heamorrhage 2 points in the upper GI tract clot visible spurting blood vessels
diagnosis Mallory Weiss or normal(0) 1 all other ddx 2 malignancy of the upper GI tract
indications for emergency endoscopy in a patient with suspected upper GI bleed?
continuance of upper GI bleed, and also a blatchford score of greater than 6
if a patient with a known recent aortic graft comes in with heamatemsis what do you order to outrule?
contrast angiogram to rule out an aorto-enteric fistula.
management for a bleeding oesophageal varix
- band ligation
- sclerotherapy
- balloon tamponade
- TIPPS transjugular intrahepaticportosystemic shunt(catheter down jugular vein and creating a shunt from hepatic vein to portal vein)
- portcaval (portsystemic) shunt
indications for red cell blood transfusion
heamorrahage major trauma and amputations
hb less than 70 g/L with signs of compromise (tachycardia, syncope, dyspnoea)
Hb less than 80 g/L plus signs of compromise in patients greater than 65 or who have ischemic heart disease or severe respiratory distress.
risks associated with blood transfusion
immune active transfusion reaction anaphylaxis heamolytic transfusion reaction transfusion related lung injury delayed heamolytic reaction alloimmunization post transfusion purpura non immune transfusion associated circulatory overload coagulopathy transfusion related infection
what are the five things you must outrule in your history exam and investigations with a patient presenting with chest pain?
- acute coronary syndrome
- aortic dissection
- pneumothorax
- PE
- boerhaaves perforation
risk factors of CVD?
angina on exertion, previous MI
smoking hypertension hypercholesterolemia, DM family history of CVD
what is SIRS
this is the body’s response to pro inflammatory processes
two or more of the following criteria
1. temperature greater than 38 or less than 36
2. heart rate greater than 90
3. RR greater than 20 or PCO2 less than 4.3
4. white cell count grater than 12 or less than 4 or greater than 10% immature forms
what is sepsis
sepsis is SIRS *systemic inflammatory response syndrome
caused by suspected or proven infection
What is severe sepsis?
sepsis causing hypotension (systolic bp less than 90 or greater than 40
drop compared to normal for that patient
and end organ hypo-perfusion (lactic acidosis on VBG)
septic shock
severe sepsis that is refractory to fluid resus (and therefore in need of vasopressors like debutamin)
multiorgan dysfunction syndrome
evidence of two or more organs failing (confusion due to cerbral hypoperfusion, renal failure, respiratory failure, liver failure)
why is it important to ask about a aortic graft in patients who present with GI bleeding?
because if they do it is an aortenteric shunt until proven otherwise.
indications for emergency dialysis
refractory severe acidosis less than 7.1
hyperkalemia 6.5
fluid overload- pulmonary oedema
uremic signs *encephalopathy, pericarditis
urea greater than 30 creatinine greater than 1000
What are the five symptoms of TTP
TTP (thrombotic thrombocytopenia purpura)
- fever
- microangiopathic haemolytic anemia
- thrombocytopenia
- neurological symptoms
- renal failure
three things to remember in hyperkalemia
10ml of 10% calcium gluconate over 2 minutes
10 units of actrapid insulin in 250 ml of 50% glucose solution over 30 minutes
salbutamol 5 mg nebs
So for seizures what are the four important time intervals
0-5 minutes
5-20 minutes
20-40 minutes
greater than 40 minutes
what do you need to do in a patient who is convulsing at 0-5 minutes
start the timer, make sure the scene around the patient is safe, put the patient into recovery positions monitor the HR, O2 sats, BP cardiac trace and temp
establish venous abcess
check the blood glucose if less than 3.5 mmol/l give 100,l of 20% glucose stat
what to do when the patient is continuing to seize at 5-20 minutes
important to stop the seizure
call for senior help
consider airway adjunct
if IV abcess established lorazepam 4 mg IV over 2 minutes repeat 10 minutes
no IV abcess PR diazepam 10 mg
If history of alcohol abuse than pabrinex
If the seizure is laying more than 20-40 minutes
call the anaesthetic and senior help
start the phenytoin 20 mg/kg IV at less than 50 mg per min
If greater than 40 minutes the seizure is lasting
thiopentol or propofol on the ICU
transfer to the ICU for GA EEG monitoring
So what are the medications to give in the 5-20 minutes of a seizure
lorazepam 4 mg IV/ 2 minutes peat at 10 minutes
PR diazepam 10mg
what are he important medications to remember in a patient seizing for over 20 minutes
phenytoin 20 mg/kg IV at less than 50 mg per minute
What are three things that are important to give in anaphylaxis
- adrenaline 1:100 solution 0.5 ml IM repeat in 5 minutes if no improvement
IV fluids 1 L of 0.9% normal saline
consider salbutamol 5 mg for bronchospasm
reassess
What do you give if your top three therapies in anaphylaxis are given?
adjuncts
antihistamine chlorphenamine 10 mg slow IV
hydrocortisone 200mg slow IV
Medication given in a bradyarrhythmia
atropine IV 500 micrograms repeat every 2-3 minutes (max 3 mg)
if this not working consider transcutaneous pacing
What four features on the ECG have an increased risk of asystole?
recent asystole
Mobitz 2 AV block
complete heart block with broad QRS
ventricular pause greater than 3 sec
what are the life threats presenting with SOB
asthma COPD pulmonary oedema tension pneumothorax Mi or arrthmia pneumonia pulmonary embolism pleural effusion anaphylaxis airway obstruction
What test should you do whenever a patient is acutely unwell
ABG
What are the life threats of chest pain
MI tension pneumothorax ACS pericardial effusion or cardiac tamponade aortic dissection pulmonary embolism sickle cell crisis
when do the troponin levels rise in an acute MI
sharpest rise over 1-2 days
troponin can rise in other states as well?
renal AKI and CKD
cardiac acute MI HF arrthymia myocarditis
respiratory hypoxia pulmonary embolism
haematological anaemia
neurological ischemia stroke haemorrhage
trauma cardiac contusion electrical cardioversion
what should you make sure your patient gets as soon as they are ecg shows signs of stemi
Pci if can be done within 2 hours
thrombolysis if cannot
complications of an mi
dysrrhythmia LVF dresslers septal rupture ventricular aneurysm pericarditis pain
Diabetic ketoacidosis
Take the BP if less than 90 give 500 ml blous of normal saline STAT reassess and give another bonus if still low
SBP greater than 90 1 L over hour
fixed rate dose of insulin .1 unit per kg/hr
VBG if less than 7.1 call the ICU
glu and ketones hourly
venous HCO3 and K at 60 minutes and then 2 hourly thereafter
ECG, CXR, MSU to determine the cause
HHS stands for
hyperosmolar hyperglycemic state
key management point for HHS
1 L of 0.9% NACL over 60 minutes
start IV insulin 0.05 units/kg/h ONLY if the plasma ketones are greater than 1 mmol/L or 2 plus ketones in the urine
What are the life threatening cause of DKA or HHS
sepsis
MI
trauma or surgery
acute illness
How can you diagnosis HHS
serum osmolality greater than 340 mOsm/kg
with a high glucose typically greater than 30
What are the sick day rules?
drink plenty of fluids
try to drink milk soup or fruit juice if can’t hold down solids
increase glucose monitoring to at least four times a day
go to hospital if you can’t keep fluids down BG is less than 4 or greater than 20
continue to take the insulin
What are the antibodies to look for in DM
positive islet cell antibodies
glutamic acid decarboxylase antibodies
Hypoglycemia
quick acting carbohydrate (lucozade) or one glucose gel (can give up to three)
monitor the finger prick glucose 1-2 hours until stable aim for greater than 5 mmol/L
if it continues to be below 4 than IM glucagon or IV glucose *this is started right away if low GCS * 1L of 10% glucose 4-6 hourly
What are the causes of hypoglycemia?
insulin overdose medication fasting or starvation sepsis renal failure alcohol excess acute liver failure insulinoma glucocorticoid deficiency neoplasm
What is the management of an upper GI bleed?
ATLS guidelines insert an Iv line take FBC, Coag, U and E LFT
CALL FOR SENIOR HELP
CALL GI REG for urgent endoscopy
correct coagulopathy if present- platelets
APPT= FRESH FROZEN PLASMA
PT = as above (1.5 x ULN)
INR or WARFARIN- prothrombin complex
IF hx of liver failure or disease- give terlipressin and abx
band ligation or injection of sclerant
TIPS procedure is definitive
What are the markers for HHS?
hyperglycaemic hyperosmolar
syndrome
high glucose levels (greater than 30) high osmolarity (greater than 320)
hypovolemia
complications cardiovascular (hypotension and tachycardia) and haematological (increased viscosity of blood)
How do you treat HHS?
- normalise the osmolarity gradually
- fluid replacement and electrolyte correction
- normalise the glucose gradually
fluid resus comes before insulin infusion
How do you treat a thyrotoxic storm with?
beta blockers
propylthiouracil (anti-thyroid treatment)
hydrocortisone
What are the clinical features of a thyrotoxic storm?
fever tachycardia confusion and agitation nausea and vomiting HTN heart failure abnormal LFT
Why do you give dexamthasone in a thyrotoxic storm?
blocks the seroconversion of T4 to the active form T3
