emergency medicine Flashcards
Burns treatment
- Best initial step: Assess ABCs.
- thermal or inhalation injury to the upper airway, intubate ( non breather mask high flow O2).
- Evaluate the percentage of body surface area (% BSA)
- In patients exposed to smoke, suspect inhalation injury, CO poisoning, and cyanide poisoning. Obtain a CXR, carboxyhemoglobin level, and lactate.
- Assess for circumferential eschar formation, which can obstruct venous and lymphatic drainage, leading to vascular compromise and compart- ment syndrome.
BSA formula
Parkland formula: Fluids for the first 24 hours (in mL) = 4 × patient’s weight in kg × % BSA. Give 50% of fluids over the first 8 hours and the remaining 50% over the following 16 hours.
BSA %
head 4.5 +4.5 arm 4.5+4.5 upper chest 9+9 lower abdomen 9+9 legs 9+9
inhalation injury/ thermal injury upper air way
- singing eyebrows
- burn to face
- oropharyngeal inflammation, blistering carbon deposits
- carbonaceous sputum
- stridor - epiglottis injured in burns subepglottis spared
- carbon HB >10 %
- confinement in burining building
- textile and carpet burning
- deep burns not superficially visible
- superinfection burns common bugs
- cyanide poisoning
- electrical burns
- psueudomonas >week 1, staph areus < 1 week
electrical burns complications 3.
- deep muscle injury –> rhabdomyolysis –> compartment syndrome
- thrombosis of vessels - limb ishemia
- electrolyte abnormalities - arrythmia
electrical burns special managements 3
- Early prophylactic fasciotomies and débridement can prevent compartment syndrome and rhabdomyolysis
- Closely observe pulses and kidney function Amputation may be necessary
- Monitor electrolytes (especially potassium); obtain ECG
chemical burns complication + mngt
abnormal PH irrigate for 20 30 min before taking to hospital
n- acetylcystein
- acetaminophen induced liver injury
- mucolytic agent cystic fibrosis
- radiocontrast prevention of renal damage with renal insufficient patient s
- rebound tenderness, guarding, decreased bowel sounds
- pain out of portion to physical findings, periumbilical , N/V, fecal blood currant jelly SMA
- constant epigastric pain radiates to back, N/V,
- intermittent epigastric pan radiate to right sided shoulder, N/V, after fatty meal, no fever, resolves, no leukocytosis
- constant epigastric pain, radiate right shoulder, fever, N/V, fever, leukocytosis
- peritonitis
- acute mesenteric ischemia
- fat necrosis
- distended gallbladder contrasts against obstructs cystic duct. biliary colic
- inflammation of gallbladder - acute cholecystitis
acute abdomen mandatory exams 3.
- rectal exam
- pelvic exam
- β-hCG
- Sudden onset of diffuse, excruciating pain. Patients will lie still to minimize pain. Peritoneal signs are prominent.
- Sudden onset of severe, colicky, intermittent pain. Patients cannot sit still. Peritoneal signs are usually absent.
- Gradual onset (over 10–12 h) of constant, poorly localized pain that later localizes to problem area. Patients lie still to minimize pain. Peritoneal signs are prominent
- variable depends on location
- rupture/ perforation
- obstruction
- inflammation
- ischemia
esophageal rupture signs/symptoms
air mediastinum, sever retrosternal pain
bronchial rupture signs/symptoms
1.deceleration shearing forces.
2. respiratory distress, hemoptysis, sternal tender-ness, and subcutaneous emphysema., crepitus audible on CV exam
3. large pneumothorax ( CXR can cause JV distension) or pneumomediastinum
(see Figure 2.17-4).
4. Air may persistently pour into chest tube when hooked to wall suction
aortic rupture signs and symptoms
pseudocoartication
pulmonary contusion
CXR- alveolar opacities
tachypnea, tachycardia hypoxia, chest bruising decrease breath sounds on side of injury
hypoxia from damage capillaries –> interstitial edema so - it worsens with IV fluid
common kids
cardiac tamponade S/S
equalization of pressure all chambers
tachycardia, JV distension, hypotension, despite aggressive fluid
CXR- normal cardia silhouette, no tension pneumonia
cariogenic shock
cardiogenic shock treatment
inotropic support with vasopressors
- dopamine (if hypo- tensive) or
- dobutamine (if not hypotensive). Intra-aortic balloon pump may help
cardiogenic shock causes ?
CHF, arrhythmia, structural heart disease (severe mitral regurgitation, ventricular septal defect), MI (> 40% of left ventricular function)
hypovolemic shock signs/symptoms and treatment
decrease PCWP, and CO increase SVR
- Replete with isotonic solution (eg, LR or NS) or blood.
- Initiate blood transfusion in the setting of blood loss if blood pressure does not correct after 2 L isotonic crystalloid
hypovolemic shock causes
Trauma, blood loss, dehydra- tion with inadequate fluid repletion, third spacing, burns
septic shock management
1.Administer broad-spectrum antibiotics
2.Measure central venous pressure (CVP), and give fluid
until CVP = 8
3.Vasopressors (norepinephrine or dopamine) may be
needed
4.Obtain cultures before administration of antibiotics
anaphylactic shock management
1:1000 epinephrine
Consider adjuncts H1/H2 antagonists and steroids
SIRS (systemic inflamma- tory response syndrome)
- causes, treatment
Pancreatitis, burns, trauma
manage underlying cause
neurogenic shock management
Maintain pressures with fluid and pressor support
arterial thrombosis vs arterial embolism
- arterial thrombosis slow onset, pulses diminished bilaterally
- embolism - sudden onset sever, pain, bilateral diminished pulses, hx atrial fibrillation or MI originate form heart
arterial occlusion
5 p’s
pallor pulselessnes, paresthesias, paralysis painlessnes
venous occlusion
dull aching pain, pain with dorsiflexion
warm, red, tender
ischemia reperfusion syndrome
mechanism and out come
arterial occlusion
extremities with 4-6 hours of ischemia –> interstitial and intracellular edema upon reperfusion –> edema cause pressure in fasciae > 30mmhg- causes compartment syndrome
compartment syndrome
causes, S/S
earliest sign,
- ischemia reperfusion syndrome, fractures, trauma
- ” SEVER “ extremity pain, POOP, 6’ps
- pain earliest symptoms, increase pain with movement o of toes/ fingers/stretch of muscle
- burning, tingling, parasesthia
- pallor
- pluslessness, paresis/paralysis - late findings do not rule out
compartment dx, MNGT
Diagnosis
Based on history, exam, and elevated compartment pressures (although not necessary). delta pressure
trEatmEnt
Immediate fasciotomy to ↓ pressures and ↑ tissue perfusion.
calculate delta pressure- when and how
Calculate delta pressures (diastolic pressure – compartment pres- sure); ⊕ if delta pressure ≤ 30 mm Hg).
DVT management
- Anticoagulate with subcutaneous low-molecular-weight heparin (LMWH) or IV unfractionated heparin followed by PO warfarin or NOACs for a total of 3(1st time )–6 months. ( INR- 2-3)
- In patients with contraindications for anticoagulation, inferior vena cava filters should be placed.
- Hospitalized patients should receive DVT prophylaxis consisting of exercise as tolerated, antithromboembolic stockings, and subcutaneous LMWH or unfractionated heparin.
sepsis
2/4 criteria means--> SIRS 1. fever or hypothermia <36 degrees 2. tachycardia 3. leukocytosis, bandana or leukopenia 4. tachypnea SIRS due to infection --> sepsis
sever sepsis S/S
- end organ dysfunction- hypotension , oliguria, metabolic acidosis, hypoxema thrombocytopenia < 80, 000, hypotension systolic < 90mmhg
septic shock S/S
infection relation to SIRS hypotension unresponsive to fluid resuscitation and vasopressor req to keep blood pressure > 90 mmhm
burn complication
burn wound infection or bronchopneumonia lead to sepsis or septic shock
tension pneumothorax
S/S, mangament
clinical diagnosis - tachypnea tachycardia, JV distension, trachea deviation,
emergency needle decompression (2nd intercostal space at the midclavicular line) followed by chest tube placement.
pneumothorax S/S
Hyperresonant ↑
Tactile fremitus ↓
Breath sounds ↓ /Absent
Voice transmission- Bronchophony Egophony ↓
- acute onset of unilateral pleuritic chest pain and dyspnea. tachypnea, JVD 2° to compression of the SVC. See
pneumothorax
- Small pneumothorax (≤ 2 cm): Observation ± supplemental O2. It may resorb spontaneously.
- Large (> 3 cm), symptomatic pneumothorax: Needle aspiration.
- Unstable patients or recurrent pneumothorax: Chest tube placement.
submandibular salivary gland damage
winged scapula
- hypoglossal nerve
2. long thoracic nerve
non malignant features of SPN
Age < 35 years Nonsmoker No change from old films Central, uniform, or popcorn calcification Smooth margins Size < 2 cm
malignant feat SPN
> 45–50 years of age Smoker New or enlarging lesions Absent or irregular calcification Irregular margins (scalloped, spiculated) Size > 2 cm
SPN test to run depending on malignancy
Low risk: Serial CT scans.
Intermediate risk: Further investigation required with biopsy or PET.
High risk: Surgical resection.
SPN :
- nodule has fat or calcifications characteristic of a benign lesion
- nodule does not have characteristics of a benign lesion,
- If nodule is old and size is stable (> 2 years)
- If nodule is new, increasing in size, or no prior CT scans
- (eg, hamartoma, granuloma), then no further evaluation.
- then next step is to review medical record for a previous CT (if available).
- then no further evaluation.
- then determine risk for malignancy
SPN best initial test?
Chest CT. Obtain noncontrast chest CT if nodule was discovered on another modality.
High risk vs low risk SPN
low risk
<0.8 low risk -
<45
smooth margins
never smoked or > 15 years since smoking
3 months then 6 months then every 2 years monitoring
HIGH >2 > 60 < 5 yrs since smoking smoker corona radiate or speculated
kidney stoney
non contrast - spiral abdominal CT
- no peritoneal inflammation so movement does not worsen pain
- afebrile, pain radiating to groin, N/V can’t sit still, soft abdomen
Parotitis s/s, Treatment, prevention bug
Painful swelling of parotid gland caused by S aureus in states of dehydration, especially in the elderly and after surgery.
Prevented with adequate fluid intake and oral hygiene. Treated with IV antibiotics.
- prevention post op patient w CAD - MI
- prevention post op - pneumonia
- abdominal surgery prophylaxis
- perioperative BB metoprolol
- incentive spirometry
- all patients having abdominal surgery have prophylactic antibiotics
bowel obstruction - strangulation signs and symptoms
complete loss of blood supply to bowel wall,
rigid abdomen, shock, increase WBC, fever, tachycardia
- bowel obstruction proximal
- mid or distal obstruction
- most common cause of SBO
- abnormal filling on x ray
- dilate loops of bowel x ray
- adhesions - surgery or lad bands kids
pilonidal sinus cyst
define, management
foreign body reaction to entrapped hairs in chronic sinus tract causes abscess superior gluteal cleft,
complication - perianal fistula
Treat with incision and drainage of the abscess followed by sterile packing of the wound.
Good local hygiene and shaving of the sacrococcygeal skin can help pre- vent recurrence.
antibiotics only if cellulitis present then areobic and aerobic
suppurative hidradenitis
underarm infection folliculitis
variocele
- pathophysio
- signs and symptoms
- tortuous dilation pampiniform plexuses - incompetent veins no drainage
- more common left because drains into renal vein at right angle
- dull aching pain , dragging while standing, bag of worms
- Does not transluminate , enlarged valsva maneuver
communicating hydrocele
fluid in tunica vaginalis
transluminates, reducible, increase in valsva
spermatocele
- cystic dilations of efferent painless fluid filled cysts that contain sperm
- masses distinct form testis transluminate
oliguria, azotemia BUN >20:1 postop patient
dx, next step, management
pre renal failure due to hypovolemia
- change urinary catheter rule out clog
- IV fluid challenge
postop complication lungs first 2 hours
atelectasis, most common respiratory complication 24 hours - can lead to pneumonia
chest physio, incentive spirometry, early mobilization, head elevation, coughing all increase FRC
supine to sitting reduces intrabdominal pressure
whispering noise with respiration following rhinoplasty dx
and other causes
nasal septal , perforation resulting in septal hematoma
Werner granulomatis, intranasal cocaines, syphilis tb sarcodidis
