Emergency Medicine Flashcards
What is involved in a rapid primary survey
Airway maintenance with C spine control
Breathing and ventilation
Circulation (pulses, hemorrhage control)
Disability (neurological status)
Exposure (complete) and Environment (temperature control)
- Continually reassessed during secondary survey
- Changes in hemodynamic and/or neurological status necessitates a return to the primary survey beginning with airway assessment
Approach to cardiac arrest (hint: letters)
CAB
Chest compressions
Airway
Breathing
Approach to the critically ill patient
- Rapid Primary Survey (RPS)
- Resuscitation (often concurrent with RPS)
- Detailed Secondary Survey
- Definitive Care
Signs of airway obstruction
- Agitation, confusion, “universal choking sign”
- Respiratory distress
- Failure to speak, dysphonia, stridor
- Cyanosis
Who should have a cervical collar applied
assume a cervical injury in every trauma patient and immobilize with collar
What are conditions that you should think of impending airway collapse
Facial fractures
Edema
Burns
When should you not conduct a head-tilt
suspected c spine injury
temporizing airway measures
- nasopharyngeal airway (if gag reflex present i.e conscious)
- oropharyngeal airway (if gag reflex absent ie. unconscious)
- “rescue” airway devices (e.g. laryngeal mask airway, Combitube®)
- transtracheal jet ventilation through cricothyroid membrane (last resort)
What are definitive airway management strategies
• ETT intubation with in-line stabilization of C-spine
■ orotracheal ± RSI preferred
■ nasotracheal may be better tolerated in conscious patient
◆ relatively contraindicated with basal skull fracture
■ does not provide 100% protection against aspiration
- surgical airway (if unable to intubate using oral/nasal route and unable to ventilate)
- cricothyroidotomy
Contraindications to intubation
• supraglottic/glottic pathology that would preclude successful intubation
Medications that can be delivered via ETT
NAVEL Naloxone (Narcan) Atropine Ventolin (salbutamol) Epinephrine Lidocaine
Indications for intubation
- Unable to protect airway (e.g. GCS <8; airway trauma)
- Inadequate oxygenation with spontaneous respiration (O2 saturation <90% with 100% O2, or rising pCO2)
- Impending airway obstruction: trauma overdose, CHF, asthma, COPD, anaphylaxis, angioedema, airway burns, expanding hematoma
- Anticipated transfer of critically ill patients
In patients with a C-spine xray that is positive and that require intubation, what type of intubation should be used
Fibreoptic ETT
or nasal ETT
or RSI
Rescue techniques in intubation
- Bougie (used like a guidewire)
- Glidescope®
- Lighted stylet (uses light through skin to determine if ETT in correct place)
- Fiberoptic intubation – (uses fiber optic cable for indirect visualization)
What does noisy breathing mean
Noisy breathing is obstructed breathing until proven otherwise
How to evaluate breathing
• Look
■ mental status (anxiety, agitation, decreased LOC), colour, chest movement (bilateral vs. asymmetrical), respiratory rate/effort, nasal flaring
• Listen
■ auscultate for signs of obstruction (e.g. stridor), breath sounds, symmetry of air entry, air escaping
• Feel
■ tracheal shift, chest wall for crepitus, flail segments, sucking chest wounds, subcutaneous emphysema
Breathing interventions in order of increasing FiO2
nasal prongs → simple face mask → non-rebreather mask → CPAP/BiPAP
What breathing interventions supplement inadequate ventilation
Bag-Valve mask
CPAP
Definition of shock
• inadequate organ and tissue perfusion with oxygenated blood (brain, kidney, extremities)
What type of shock do you assume in a trauma patient until proven otherwise
hemorrhagic
Types of shock
Hypovolemic
- hemorrhage (external and internal)
- Severe burns
- High output fistulas
- Dehydration (diarrhea, DKA)
Cardiogenic
- Myocardial ischemia
- Dysrhthmias
- CHF
- Cardiomyopthies
- Cardiac valve problems
Distributive (vasodilation)
- Septic
- Anaphylactic
- Neurogenic (spinal cord injury)
Obstructive
- Cardiac tamponade
- Tension pneumothorax
- PE
- Aortic stenosis
- Constrictive pericarditis
Acronym for causes of shock
SHOCKED
Septic, spinal/neurogenic
Hemorrhagic
Obstructive (e.g. tension pneumothorax, cardiac tamponade, PE)
Cardiogenic (e.g. blunt myocardial injury, dysrhythmia, MI)
anaphylactiK
Endocrine (e.g. Addison’s, myxedema, coma)
Drugs
Shock clinical evaluation
Early - tachypnea, tachycardia, narrow pulse pressure, reduced capillary refill, cool extremities and reduced central venous pressure
late - hypotension, altered mental status, reduced urine output
Estimation of degree of hemorrhagic shock
Class I <750 cc <15% blood volume pulse <100 BP normal resp rate 20 cap refill normal urinary output 30 cc/h fluid replacement crystalloid
Class II 750-1500 cc 15-30% blood volume pulse >100 *** BP normal resp rate 30 cap refill decreased *** urinary output 20 cc/h fluid replacement crystalloid
Class III 1500-2000 cc 30-40% blood volume pulse >120 *** BP decreased *** resp rate 35 cap refill decreased urinary output 10 cc/h fluid replacement crystalloid + blood
Class IV >2000 cc >40% blood volume pulse >140*** BP decreased *** resp rate >45 cap refill decreased urinary output none *** fluid replacement crystalloid + blood
Estimated systolic blood pressure based on position of most distal palpable pulse
Radial >80 mm Hg
Femoral >70 mm Hg
Carotid > 60 mm Hg
Management of hemorrhagic shock
- clear airway and breathing either first or simultaneously
- apply direct pressure on external wounds while elevating ex remities. Do not remove impaled objects in the emergency room setting as they may tamponade bleeds
- start TWO LARGE BORE (14-16G) IVs in the brachial/cephalic vein of each arm
- run 1-2 L bolus of IV Normal Saline/Ringer’s Lactate (warmed, if possible)
- if continual bleeding or no response to crystalloids, consider pRBC transfusion, ideally crossmatched. If crossmatched blood is unavailable, consider O- for women of childbearing age and O+ for men. Use FFP, platelets or tranexamic acid in early bleeding
- consider common sites of internal bleeding (abdomen, chest, pelvis, long bones) where surgical intervention may be necessary
3:1 rule
Since only 30% of infused isotonic crystalloids remains in intravascular space, you must give 3x estimated blood loss
How to assess LOC
GCS
What do inequal/sluggish pupils suggest
local eye problem or lateralizing CNS lesion
What does a relative afferent pupillary defect (swinging light test) indicate
optic nerve damage
What etiologies of decreased LOC should be considered if pupils are reactive
metabolic or structural
What etiologies of decreased LOC should be considered if pupils are not reactive
structural cause (especially if asymmetric)
GCS use and components
- for use in trauma patients with decreased LOC; good indicator of severity of injury and neurosurgical prognosis
- most useful if repeated; change in GCS with time is more relevant than the absolute number
- less meaningful for metabolic coma
- patient with deteriorating GCS needs immediate attention
- prognosis based on best post-resuscitation GCS
- reported as a 3 part score: Eyes + Verbal + Motor = Total
- if patient intubated, GCS score reported out of 10 + T (T = tubed, i.e. no verbal component)
GCS scoring
Eyes open - 4 spontaneously 3 to voice 2 to pain 1 no response
best verbal response 5 answers questions appropriately 4 confused disoriented 3 inappropriate words 2 incomprehensible sounds 1 no verbal response
best motor response 6 obeys commands 5 localizes to pain 4 withdraws from pain 3 decorticate (flexion) 2 decerebrate (extension) 1 no response
13-15 mild injury
9-12 moderate
0-8 severe
Fluid resuscitation method and rate in shock
• Give bolus until HR decreases, urine output increases, and patient stabilizes
- Maintenance: 4:2:1 rule • 0-10 kg: 4 cc/kg/h
- 10-20 kg: 2 cc/kg/h
- Remaining weight: 1 cc/kg/h
• Replace ongoing losses and deficits (assume 10% of body weight)
exposure/environment component of primary survey
- expose patient completely and assess entire body for injury; log roll to examine back
- DRE
- keep patient warm with a blanket ± radiant heaters; avoid hypothermia
- warm IV fluids/blood
• keep providers safe (contamination, combative patient)
Unilateral, dilated, non-reactive pupil differential
- Focal mass lesion
- Epidural hematoma
- Subdural hematoma
resuscitation components
- done concurrently with primary survey
- attend to ABCs
- manage life-threatening problems as they are identified
- vital signs q5-15 min
- ECG, BP, and O2 monitors
- Foley catheter and NG tube if indicated
- tests and investigations: CBC, electrolytes, BUN, Cr, glucose, amylase, INR/PTT, β-hCG, toxicology screen, cross and type
contraindications to foley insertion
- Blood at urethral meatus
- Scrotal hematoma
- High-riding prostate on DRE
NG tube contraindications
- Significant mid-face trauma
* Basal skull fracture
Secondary survey timing, purpose and components
- done after primary survey once patient is hemodynamically and neurologically stabilized
- identifies major injuries or areas of concern
- full physical exam and x-rays (C-spine, chest, and pelvis – required in blunt trauma, consider T-spine and L-spine f indicated)
Type of history to take in secondary survey
“SAMPLE”: Signs and symptoms, Allergies, Medications, Past medical history, Last meal, Events related to injury
Four areas of a FAST
- Subxiphoid pericardial window
- Perisplenic
- Hepatorenal (Morrison’s Pouch)
- Pelvic/retrovesical (pouch of Douglas)
Physical exam in secondary survey
Head and Neck
• palpation of facial bones, scalp
Chest
• inspect for: 1. midline trachea and 2. flail segment: ≥2 rib fractures in ≥2 places; if present look for associated hemothorax, pneumothorax, and contusions
• auscultate lung fields
• palpate for subcutaneous emphysema
Abdomen
• assess for peritonitis, abdominal distention, and evidence of intra-abdominal bleeding • DRE for GI bleed, high riding prostate, and anal tone
Musculoskeletal
• examine all extremities for swelling, deformity, contusions, tenderness, ROM
• check for pulses (using Doppler probe) and sensation in all injured limbs
• log roll and palpate thoracic and lumbar spines
• palpate iliac crests and pubic symphysis and assess pelvic stability (lateral, AP, vertical)
Neurological
• GCS
• full cranial nerve exam
• alterations of rate and rhythm of breathing are signs of structural or metabolic abnormalities with progressive deterioration in breathing indicating a failing CNS
• assess spinal cord integrity
• conscious patient: assess distal sensation and motor function
• unconscious patient: response to painful or noxious stimulus applied to extremities
Secondary survey initial imaging
- non-contrast CT head/face/C-spine (rule out fractures and bleeds)
- chest x-ray
- FAST (see Figure 2) or CT abdomen/pelvis (if stable)
- pelvis x-ray
Signs of increased ICP
- Deteriorating LOC (hallmark)
- Deteriorating respiratory pattern
- Cushing reflex (high BP, low heart rate, irregular respirations)
- Lateralizing CNS signs (e.g. cranial nerve palsies, hemiparesis) Seizures
- Papilledema (occurs late)
- N/V and headache
What is the best imaging modality for intracranial injury
Non-contrast head CT
Ethical emergency rule
consent is not needed when a patient is at imminent risk from a serious injury AND obtaining consent is either: a) not possible, OR b) would increase risk to the patient
■ assumes that most people would want to be saved in an emergency
• any capable and informed patient can refuse treatment or part of treatment, even if it is life-saving
Exceptions to the emergency rule
• exceptions to the Emergency Rule – treatment cannot be initiated if
■ a competent patient has previously refused the same or similar treatment and there is no evidence to suggest the patient’s wishes have changed
■ an advanced directive is available (e.g. do not resuscitate order)
■ NOTE: refusal of help in a suicide situation is NOT an exception; care must be given
- if in doubt, initiate treatment
- care can be withdrawn if necessary at a later time or if wishes are clarified by family
Consent to treatment for children
- treat immediately if patient is at imminent risk
- parents/guardians have the right to make treatment decisions
- if parents refuse treatment that is life-saving or wll potentially alter the child’s quality of life, CAS must be contacted – consent of CAS is needed to treat
Other issues of consent - HIV testing, administration of blood products
- need consent for HIV testing, as well as for administration of blood products
- however, if delay in substitute consent for blood transfusions puts patient at risk, transfusions can be given
Duty to report
• law may vary depending on province and/or state • examples: gunshot wounds, suspected child abuse, various communicable diseases, medical unsuitability to drive, risk of substantial harm to others
