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Emergency Medicine > Emergency Medicine > Flashcards

Emergency Medicine Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

What is involved in a rapid primary survey

A

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
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2
Q

Approach to cardiac arrest (hint: letters)

A

CAB

Chest compressions

Airway

Breathing

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3
Q

Approach to the critically ill patient

A
  1. Rapid Primary Survey (RPS)
  2. Resuscitation (often concurrent with RPS)
  3. Detailed Secondary Survey
  4. Definitive Care
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4
Q

Signs of airway obstruction

A
  • Agitation, confusion, “universal choking sign”
  • Respiratory distress
  • Failure to speak, dysphonia, stridor
  • Cyanosis
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5
Q

Who should have a cervical collar applied

A

assume a cervical injury in every trauma patient and immobilize with collar

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6
Q

What are conditions that you should think of impending airway collapse

A

Facial fractures

Edema

Burns

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7
Q

When should you not conduct a head-tilt

A

suspected c spine injury

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8
Q

temporizing airway measures

A
  • 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)
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9
Q

What are definitive airway management strategies

A

• 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
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10
Q

Contraindications to intubation

A

• supraglottic/glottic pathology that would preclude successful intubation

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11
Q

Medications that can be delivered via ETT

A 
NAVEL 
Naloxone (Narcan) 
Atropine 
Ventolin (salbutamol) 
Epinephrine 
Lidocaine
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12
Q

Indications for intubation

A
  • 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
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13
Q

In patients with a C-spine xray that is positive and that require intubation, what type of intubation should be used

A

Fibreoptic ETT
or nasal ETT
or RSI

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14
Q

Rescue techniques in intubation

A
  • 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)
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15
Q

What does noisy breathing mean

A

Noisy breathing is obstructed breathing until proven otherwise

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16
Q

How to evaluate breathing

A

• 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

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17
Q

Breathing interventions in order of increasing FiO2

A

nasal prongs → simple face mask → non-rebreather mask → CPAP/BiPAP

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18
Q

What breathing interventions supplement inadequate ventilation

A

Bag-Valve mask

CPAP

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19
Q

Definition of shock

A

• inadequate organ and tissue perfusion with oxygenated blood (brain, kidney, extremities)

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20
Q

What type of shock do you assume in a trauma patient until proven otherwise

A

hemorrhagic

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21
Q

Types of shock

A

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

22
Q

Shock clinical evaluation

A

Early - tachypnea, tachycardia, narrow pulse pressure, reduced capillary refill, cool extremities and reduced central venous pressure

late - hypotension, altered mental status, reduced urine output

23
Q

Estimation of degree of hemorrhagic shock

A 
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
24
Q

Estimated systolic blood pressure based on position of most distal palpable pulse

A

Radial >80 mm Hg
Femoral >70 mm Hg
Carotid > 60 mm Hg

25
Q

Management of hemorrhagic shock

A
  • 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
26
Q

3:1 rule

A

Since only 30% of infused isotonic crystalloids remains in intravascular space, you must give 3x estimated blood loss

27
Q

How to assess LOC

A

GCS

28
Q

What do inequal/sluggish pupils suggest

A

local eye problem or lateralizing CNS lesion

29
Q

What does a relative afferent pupillary defect (swinging light test) indicate

A

optic nerve damage

30
Q

What etiologies of decreased LOC should be considered if pupils are reactive

A

metabolic or structural

31
Q

What etiologies of decreased LOC should be considered if pupils are not reactive

A

structural cause (especially if asymmetric)

32
Q

GCS use and components

A
  • 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)
33
Q

GCS scoring

A 
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

34
Q

Fluid resuscitation method and rate in shock

A

• 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)

35
Q

exposure/environment component of primary survey

A
  • 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)

36
Q

Unilateral, dilated, non-reactive pupil differential

A
  • Focal mass lesion
  • Epidural hematoma
  • Subdural hematoma
37
Q

resuscitation components

A
  • 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
38
Q

contraindications to foley insertion

A
  • Blood at urethral meatus
  • Scrotal hematoma
  • High-riding prostate on DRE
39
Q

NG tube contraindications

A
  • Significant mid-face trauma

* Basal skull fracture

40
Q

Secondary survey timing, purpose and components

A
  • 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)
41
Q

Type of history to take in secondary survey

A

“SAMPLE”: Signs and symptoms, Allergies, Medications, Past medical history, Last meal, Events related to injury

42
Q

Four areas of a FAST

A
  1. Subxiphoid pericardial window
  2. Perisplenic
  3. Hepatorenal (Morrison’s Pouch)
  4. Pelvic/retrovesical (pouch of Douglas)
43
Q

Physical exam in secondary survey

A

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

44
Q

Secondary survey initial imaging

A
  • 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
45
Q

Signs of increased ICP

A
  • 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
46
Q

What is the best imaging modality for intracranial injury

A

Non-contrast head CT

47
Q

Ethical emergency rule

A

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

48
Q

Exceptions to the emergency rule

A

• 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
49
Q

Consent to treatment for children

A
  • 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
50
Q

Other issues of consent - HIV testing, administration of blood products

A
  • 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
51
Q

Duty to report

A

• 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

Emergency Medicine (6 decks)

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