Emergency medicine Flashcards
AAA
signs?
size monitoring
treatment
cullens sign above and below umbilicus grey turners on both flanks <3 is not normal <5.5 cm watch and wait - 5.5 = surgery >5.5 cm / rupture - IV morphine, surgery clamping
Treatment: If ruptered = prophylactic abx metronidzole and cefuroxime
APPENDICITIS
diagnosis + signs
treatment
- bloods WCC up and CRP up
- urinalysis to exclude UTI + pregnancy test
- rigid abdomen + rebound tenderness
- rosvigs sign = pain in RIF when pressing LIF
- TX = IV fluids, analgesia,
IV ABX = Co-amoxiclav/ cerfuroxime /metronidazole
laparoscopic appendectomy
CHOLECYSTITIS = inflammation of gall bladder often due to stone
CHOLANGITIS = INFECTION of billiary tract due to obstruction
–> pain RUQ, colicky, radiated to shoulder, worse eating fatty foods,
–> CHARCOTS TRIAD
- RUQ pain
- jaundice (obstructive post hepatic
- FEVER - septic
TX = IV abs co-amoxiclav or cephalosporin
bowel obstruction treatment
Vomiting early indicates high level obstruction
- DRIP + SUCK
- NG tube
- IV FLUIDS
- antiemetric cyclizine
- surgical resection
diverticulitis
syx
TREATMENT
infection and inflammation of pouches in descending or sigmoid colon
RF: low fibre diet, obesity
syx –> localised abdo pain in LEFT LOWER q relieved by opening bowels
fever, malaise, anorexia, nausea, achy,,
TREATMENT
- IV abx = cerfuroxime + metronidazole
- IV analgesics - avoid opiates as constipation
- IV fluids NBM
ectopic pregnancy
syx
ivx
treatement
severe lower abdo pain + shoulder tip if perforated as diaphragm irritation
MISSED PERIOD, cervical motion tenderness on bimanul
hx of ammenorhea and vaginal bleeding
IVX - pregnancy test
bloods BHCG , cross match, FBC, rh status
Transvaginal ultrasound is DIAGNOSTIC
BHCG lower than expected
treatment: A-E, iv access, fluid resuscitations
methotrexate then refer to gynaecologist!!
surgery = salpingectomy
miscarriage
- syx
- ivx
- treatment
foetus is <24 weeks gestation (peak 12 weeks)
affects > 20% pregnancies
- pelvic pain
- vaginal bleeding
- offensive vaginal discharge (septic abortion)
IVX - bloods BCHG, crossmatch, usss, speculum
TREATMENT: IM OXYTOCIN or ERGOMETRINE if continued vaginal bleeding
- Anti D Rhesus prophylaxis
- Vaginal Misoprostol for incomplete/missed miscarriage
- Antiemetic and analgesia
ovarian cyst
syx
ivx
tx
- lower abdo /pelvic pain
- may be worse in sex
- Bloating
- torsion can cause severe intermittent pain
- urinary symptoms if pressing on bladder
(usually underlying endometriosis) - ivx- bloods fbc for infection,
CA125
urinalysis and uss abdoment to confirm diagnosis
tx -> most resolve but if persisent >5cm then laporoscopic cystectomy
URGENT RESUS IF TORSION
pancreatits
syx
ivx
tx
- severe constant epigastric pain raidiates to back
- worse with alchohol + relieved by sitting forwards
anorexia, N+V, guarding, janice
cullens + grey turner may develop
ivx- INCREASED amylase, Lipase, uWCC, CRP, + UREA, Decreased Calcium.
USS detect gallstones
cxr to exclude small bowel perf
treatment: oxygen 15 NRB, BP. IV ACCSS, fluids, abx, catheter
iv analgesic = pethidine
iv antiemetic
Cause = igetsmashed = ethanol + gallstones + steroids
pelvic inflammatory disease
- syx
- ivx
- treatment
sexual active women hx of STI and many sexual partners
- painful sex
- bilateral lower abdo tenderness
- painful and irregular periods
- vaginal discharge, dysuria
- fever!!!
- risk of abscess formation
ivx- bloods up WCC, chlamydia + gonnorhea test endocervical/vulvogainal swab,
urinalysis exclude UTI
PREGNANCY TEST
treatment: fluids if shocked
- PO abx 14 days
Low risk gonorrhoea = ofloxacin + metronidazole
High risk gonnorrhea = ceftiroxime IM and doxyclcline and metronidazole.
peptic ulcer risk syx ivx treattment
elderly male smoker
- severe epigastric pain may radiate to shoulder/ abdomen
- worse on movement/ coughing
- GASTRIC worse on eating
- duodenal relieved by eating + 4X commoner
- hx of indigestion anorexia and bloating
if severe + perf –> haematemesis, fatigue, sob, Anaemia
IVX- h.pyloria- breath or stool, upper gi endoscopy repeat at 6 weeks and bloods, check FBC for anaemia
treatment: acute if perf a-e triple therapy: BD 7 DAYS- PPI 4 weeks clarithromyic + amoxicillin or metronidazole alc + smoking sessation
Renal colic
SYX
ivx
treatment
elder male
SYX- pain dull ache in loin = stone in renal pelvis
severe clicky worse pain ever felt = ureteric stone
N+V, sweating and restlessness
urinary symptoms: dribbling, anuria, macroscopic haematruia
syx of hypercalcamiea, palpable kidney
ivx- increased urea, creatinine + ca. kidney xr and contrast ct kidney urethrea bladder
treatment- analgesic, NSAIDS 1st line! DICLOFENAC PR abx for any infection - metoclopramide - tamsulosin a blocker relaxes smooth muscle of bladder and ureter - high freq US to break up stones surgery for 1/5 - larger stones
UTI
syx
upper + lower
ivx
tx
E.COLI
lower - cystitis
- dysura, freq, urgency, suprapubic pain and smelly wee
upper- pyleonephritis - loin/back pain - fever, nausea, vomiting shock/sepsis hx preceeding cystitis
ivx- urinalysis, MSU, dipstick, bloods, sepsis screen
treatment: LOWER
trimethoprim, nitrofurantoin for 3-6 days
catheterised = ciprofloxacin
UPPER -
A-E and cefuroxime 10 days
analgesia
acute ischamic leg
6ps
causes
treatment
pallor pulselessness pain paraesthesia paralysis perishingly cold cause: thrombus, embolus, dm, SMOKING, alcohol, obesity, HTN
treatment: urgent angioplasty within 6hrs
emboli may be thrombolysed with TISSUE PLASMINOGEN ACTIVATOR - most effective when given via local arterial catheter.
- anticoagulate with heparin after thrombolysis and angioplasty
cellulitis
syx
treatment
- painful swollen red warm unilateral leg + systemic fever sometimes
treatment: ABX 7 days
- flucloxacillin (if prep give pen V)
- Clarithromycin in pen allergic
DVT
syx
ivx
treatment
pain and tenderness in calf / limb
red warm swollen
distension of superficial veins
pitting oedema
ivx - well score more than 2 = do USS and give LMWH if positive
less than 2- d dimer and if positive USS if negative discharge
screen for thrombophilia / cancer
tx- LMWH - tinziparin / enoxaparin
Warfarin for 3 months
MOa: heparin bind to antithrombin
compression stockings
GOUT
syx
KNEE OR MTP 1st toe
rapid onset warm swollen
shiny skin - deposition of urate crystals
ivx- serum urate up and wcc up
joint aspiration = exclude septic arthritis
treatment: NSAIDs, Colchine = acute
Allopurinol = Chronic
Septic arthritis
- syx
- causes
- ivx
- treatment
one joint- normally knee
IVDU more unusual joints affected
painful tender joint with hot red swollen
systemic fever and rigours
70% causes by staph areas
- ivx joint aspiration = yellow, purulent wcc up
treatment= joint aspirate until DRY - ABX- BENZYLPENICILLIN AND FLUCLOX iv for 2 weeks po for 4 weeks nsaid analgesia
ASTHMA
severe
severe= 33, 92 sats CHEST Cyanosis Hypotension Exhaustion Silent chest Tachycardia
Treatment: Oxygen Salbutamol Hydrocortisone 100mg/Pred 40mg Ipratropium Theophyline Magnesium sulfate Escalate
COPD exacerbation
syx
COSICAARR
- acute dyspnoea chest tightness productive cough green sputum confusion/ cyanosis pursled lip breathing /- accessory muscles IVX- abg, perf, cxr, ecg
treatment COSICAARR Controlled Oxygen Salbutamol 5mg neb Ipratropium 0.5mg neb Corticosteroids pred 30mg Antibiotics Aminiphyline Radiography Resp support - BIPAP + refer
PNEUMONIA
syx
signs:
CURB-65
ivx
tx
breathlessness + cough + purulent sputum + hamoptysis
pleuritic chest pain
fevers + rigors
signs: dull percussion, decreased breath sounds, crackles
Confusion Urea >7 Resp rate >30 Blood pressure 90/60 >65 yrs score of 2 = admission in hosptial
ivx- cxr, BLOODS ^wcc, ^esr/crp, sputum culture
treatment: A-E, sepsis screen, BUFALO iv fluids abx CAP guided by curb score mild- 7 day amoxicillin mod- amoicicillin and clarityrhomycin severe- iv co-amoxiclav and clarithromycin
HAP = trust guidelines = genatamicin and cephalosporin
pneumothorax
types
syx-
ivx-
tx-
primary = young tall men
secondary = underlying disease
syx- asymptomatic or ^hr ^rr decreased chest expansion, hyperresonant, decreased breath sounds, deviated trachea if tension
ivx- abg (resp alkalosis as blowing off co2)
cxr- not if acute!!!
tx = if not tension but bigger than 2cm = CHEST DRAIN 5TH ICS MIX AXILLIARY LINE
if tension:
A-E
aspirate 16/18g cannula 2nd ICS MID CLAVICULAR LINE
continue until 2.5L aspirated
then chest drain 5TH ICS MID AXILLARY LINE
PE
syx
ivx + score
treament;
unless massive pe, has vague syx and dyspnoea
MASSIVE: sudden onset SOB
pleuritic chest pain, worse on inspiration, haemoptysis, ^Hr, ^rr, down bp. raised JVP and hypoxia.
WELLS SCORE + 4 = CTPA
wells score under 4 d dimer- if +ve do CTPa
If negative = discharge
TX: troponin, ecg, abg, echocardiography
15l nrm, iv fluids, cardiac monitor
ANTICOAGULATE: LMWH
- start warfrin until INR 2-3 then stop LMWH
- DOAC ribaroxiban
analgesia
- consider alteplase in massive pe when haemodynamically acceptable
pulmonary oedema
syx
signs
ivx:
Treatment:
Short sentences hx of orthopnoea, PND COUGH- pink frothy anxious, sweaty, cold, pale sign: fine basal inspiratory crackles callop rhythm
ivx: BNP, FBC, LFT, ecg, odoppler, abg, Cxr CXR SIGNS: Alveolar oedema B kerley lines Cardiomegaly Dialted upper lobe vessels Effusion -pleural
TX: A-E and get patient to sit up 0MFG Oxygen 15L nrbm Morphine / diamorphine Fureoeminde diuretic GTN 2 sprays / iv nitrate \+ B blocker + Ace I Catheter + CPAP if needed "pain, pee, puff pap"
ACS
syx
ivx:
- crushing central chest pain
- sudden onset
- radiates to back/ jaw/ arm
- impending doom
- dyspnoea
- N+V, sweating and palpitations
IVX: troponin raises at 12hr and peak 24hrs.
CK increased, CXR heart failure, ECG signs
STEMI = st elevation and LBBB
NSTEMI = st depressiion and t wave inversion
IMMEDIATE MANAGEMENT for confirmed STEMI or NSTEMI (MMONACH)
ECG + blood markers + Secure IV access
Morphine 2.5-10mg (treat nausea)
Metoclopramide 10mg IV
O2 high glow if sats <94%
Nitrates - GTN spray 2 sprays + BB - Bisoprolol
Aspirin 300mg PO
Clopidogrel 300mg
Heparin (if within 12hrs of Sx onset and undergoing rimary PCI) OR Fondaparinux (NSTEMI – LMWH continue for 2-5d, CI with PCI)
Bloods: FBC, U+E, glucose, lipid profile (LDL, HDL, triglycerides)
CXR
After care for all patients with recent NSTEMI or STEMI (ABC’S):
ACEi – indefinite
BB – 12 months
anti-Coagulants X 2 (Aspirin and Anti-plat = ticagrelor or clopidogrel) 12 months
Statin
