Emergency Medicine Flashcards
- •24 year old male
- •Acutely short of breath
- •HR 120
- •BP 129/87
- •RR 35
- •SpO2 98% on 15LO2
- •GCS 15
What are the differentials?
- •Pneumothorax
- •Anaphylaxis
- •Asthma
- •Pneumonia
- •Cardiac failure
- •ARDS
- •Pleural effusion
History:
- Known asthmatic
- •Acute SOB today
- •No chest pain
- •SPO2 92% on arrival- 98% with O2
- •Chest- bilateral wheeze
- •No other PMH
- •Able to say a few words
What is the diagnosis?
Likely asthma attack
What is the examination in an effusion?
Stony dullness to percussion
Absent or reduced breath sounds
What should you ask an asthmatic having an acute asthma attack?
- Previous ITU - Must ask if they have ever been intubated; If yes then will most likely need admission.
- Other medical conditiosn
- Allergies
- Any infective symptoms
What is the pathophysiology of acute asthma?
- •Reversible airway disease
- •Hyper reactivity
- •Airflow limitation
What are the treatments?
- •Nebulised salbutamol
- •IV salbutamol
- •Nebulised adrenaline
- •Nebulised magnesium
- •Oral steroids
- •IV steroids
If acute asthmatic is getting worse what must you do?
Give IV medication
Call for specialist help
What is the difference between severe vs life threatening asthma?
- Decompensating - unable to maintain adequate PO2 and PCO2
- Drowsy due to rising PCO2, hypotension or exhaustion
- Need intubation
What is a non-blanching rash characteristic of in someone who is acutely unwell?
Meningitis
What is an uricarial rash characteristic of?
Anaphylaxis - it is raised, itchy and blanching.
What are the differentials?
- •34 year old female
- •Suddenly felt unwell
- •Widespread urticarial rash
- •HR 130
- •BP 75/40
- •Collapsed
- •Wheezy
- Ectopic pregnancy
- Acute severe asthma
- Sepsis
- Anaphylaxis
- Pneumonia
Pathophysiology of anaphylaxis.
Capillaries become leaky and fluid goes everywhere
Body learns to react quickler next time you are exposed to the antigen.
What does and medication is given in anaphylaxis?
Adrenaline 500mcg
0.5ml 1:1000 IM (slowly goes into cells and doesn’t have massive effects on the heart)
Why do we put legs in the air in anaphylaxis?
To increase blood flow to heart
What are the effects of adrenaline on receptors around the body.
- α1 – vasoconstriction and relaxation of GI tract
- α2 – platelet aggregation and reduction in noradrenaline release from nerve terminals
- β1 – inotropic and chronotropic cardiac effects and relaxation of GI tract
- β2 – bronchodilatation, increase in noradrenaline release from nerve terminals, increase in intracellular cyclic adenosine monophosphate (cAMP) production in mast cells and basophils, reduction in the release of cellular mediators
Tombstoning ECG
Mostly anterior but all around
Which pulse would you measure?
With low BP you can lose all your peripheral pulses si it is always better to measure the central BP
What are the two types of cardiac arrect rhythm
Shockable:
- VT
- VF
- pulseless VT
Non-shockable rhythms
- Asystole
- PEA (pulseless electrical activity)
What are the reversible causes of H?
- Hypoxia
- Hypovolaemia - measure NA by doing ABG
- Hyper/hypokalaemia (& other electrolyte disturbance)
- Hypothermia
What are the reversible causes of T?
- Tension pneumothorax
- Cardiac tamponade/pericardial effusion (ECHO - fluid around the heart)
- Toxins
- Thromboembolic
How do you treat cardiac tamponade in an emergency?
Pericardiocentesis
Assess:
- •38 year old male
- •Motorcycle vs car
- •Bullseye windscreen
- •LOC initially then GCS 15/15
- •HR 100 BP 145/78
- •GCS 9/15
Bullseye winscreen - head hits windscreen
LOC initially then GCS15/15 and then 9/15 so head injury
What should you check for in any peripheral injuries e.g. inverted foot?
Pulse
Sensation
Which drug is used for sedation when readjusting a displaced ankle/wrist?
Penthrox
What does the primary survey consist of?
Structure approach:
- Airway with c spine control
- Breathing
- Circulation
- Disability
- Exposure
C-ABCDE
What is the cause of a dilated pupil in trauma?
- So much blood/swelling that pons is going through forament magnum and then you lose function (usually in one eye to begin with)
- Can give mannitol (hypoosmolar saline)
What does an extradural look like on CT?
Concave
Like a banana
Sulci lost
Midline shift
- 1.Subarachnoid haemorrhage
- 2.Subdural haemorrhage
- 3.Extradural haematoma
- 4.Tumour
How do you manage a head injury in ED?
Optimise oxygenation
- –A, B, C
Keep CO2 normal
- –A,B
Maintain cerebral perfusion
- –(CPP= MAP-ICP)
Make sure nothing more life threatening takes priority
- –Primary survey
Neurosurgical input & theatre
What is the strongest predictor of injury from a history?
Mechanism of injury
- –Applies to all trauma- minor and major
- –Create a mental picture of events in your head
How do you assess GCS?
What are the different types of airways?
- oropharyngeal.
- nasopharyngeal.
- endotracheal.
- laryngeal mask airway.
- cricothyroidotomy.
- tracheostomy.
What is a definitive airway?
Breathing is protected
Cuffed tube (with balloon at end) and able to provide oxygen
Nasopharyngeal is not a definitive airway.
What might you feel in relation to breathing on palpation of the chest?
Surgical emphysema - feels like bubble wrap.
How do you manage a tension pneumothorax?
In non trauma cases put a cannula to release pressure in the second intercostal space lateral to the sternum. Eventually a chest drain will be required.
In trauma –> thoracostomy - scalpel making hole. In the same position as a chest drain.
Multiple rib fractures
Haemothorax
Surgical emphysema
How do you assess circulation?
•Assessment
- –Pulse, BP, capillary refill time
- –General appearance
•Source of haemorrhage
- –‘ on the floor & 4 more’
- –Chest/Abdo/Pelvis/Long bones
•Treatments
What is the mnemonic for sources of haemorrhage?
- External sites and scalp
- Occult Traumatic Hemorrhage sites
- Chest
- Pelvis
- Abdomen (and Retroperitoneum)
- Thigh and long bones
What should you give when someone in hypotensive in trauma?
- Blood
- Platelets and FFP
- TXA
- Warfarin
- Correct caogulopathy with clotting factors
- Damage control surgery
How do you assess disability?
•GCS- Glasgow Coma Score
- –level of consciousness
- Pupils
- Blood sugar
- Limb movements
Would you be worried if a 17 year old had a BP of 90/60 in trauma case?
Yes, usually young people can hold their blood pressure well
