Emergency Medicine Flashcards by Roshni Timms

Airway

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Upper Airway Anatomy

Label this image bro

Extra info:
Pharynx
- Pharynx is a half tube shaped passage connecting oral + nasal cavities in the head to larynx/oesophagus in neck
- Nasopharynx - from choanae to lower margin of soft palate
- Oropharynx - from soft palate to epiglottis
- Laryngopharynx - from epiglottis to oesophagus - passes posteriorly to larynx
Larynx (voice box)
- in anterior neck. functions = phonation, cough reflex, protection of lower airway
- superiorly connected w/ laryngopharynx + inferiorly w/ trachea
- posterior to larynx = oesophagus
  - can apply pressure to cricoid cartilage (of larynx) to occlude oesophagus if emergency intubation needed (prevents gastric contents regurg)
    - cricoid pressure

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Label this image of the vocal cords

Describe how recurrent laryngeal nerve damage might present

Extra info:
- Parts of the internal cavity of larynx:
  - supraglottis- from inf. epiglottis to vestibular folds (false vocal cords)
  - glottis - contains vocal cords + 1cm below them
    - rima glottis = opening between the vocal cords
  - subglottis - from inf. glottis to inf. border of cricoid cartilage
Recurrent laryngeal nerve damage:
- causes:
  - apical lung Ca, thyroid Ca, aortic aneurysm, cervical lymphadenopathy, iatrogenic
- Presentation:
  - unilateral: hoarse voice
  - bilateral: cords paralysed between abduction + adduction - impaired breathing + also phonation cannot occur
  - if nerves only partly damaged, vocal folds paralysed in fully adducted position - if bilateral rima glottis is completely closed –> emergency intervention is needed

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How might you identify a comrpomised airway?

Compromised/obstructed airway:
- Complete obstruction = absence of airway sounds
- Partial obstruction:
  - added sounds/laboured breathing
  - accessory muscle use:
    - tracheal tug
    - paradoxical chest + abdo movement = see-sawing
    - supraclavicular + intercostal indrawing
    - tripoding (moving patient to supine may precipitate complete airway loss)
  - Inspiratory stridor - indicates laryngeal obstruction
    - children more susceptible to stridor due to smaller airways
- Other:
  - tachycardia + tachypnoea (resp distress)
  - irritability, agitation, reduced consciousness
    - can reflect hypoxaemia + hypercapnia
  - cyanosis = late sign = pre-terminal
  - low O2 sats
  - resp acidosis on ABG
  - high pCO2 (due to alveolar hypoventilation)
- be esp wary if patient has RFs for airway compromise:
  - reduced consciousness (unable to clear secretions or protect airway)
    - if GCS = 8/15 or below = intubate
  - burns Hx - esp carbon in sputum, soot around face/mouth, singed hair
  - bleeding/foreign body in the airway
Management - early help from anaesthetics

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What are possible causes of compromised airway?

Intraluminal obstruction:
- blood, vomit, foreign body, secretions, intraluminal tumours, tongue (in obtunded patient- blocks pharynx), oedema (eg. anaphylaxis), laryngotracheobronchitis (croup), epiglottitis
Decreased central drive (obtunded)
- head injury w/ reduced LOC
- drugs: BDZs, opiates, alcohol
- raised ICP
External compression:
- haematoma, tumour, goitre, lymphadenopathy
Direct trauma
- blunt trauma to maxilla, larynx or mandible
- burns or smoke inhalation
Artificial airways:
- blockage/displacement of tracheostomy
Excessive granulation tissue:
- prolonged mechanical ventilation, tracheal stenosis, supraglottic stenosis
Neurocognitive + neuromuscular disorders:
- risk of aspiration eg. PD, post-stroke, myasthenia gravis

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Describe methods of maintaining a compromised airway and also ways of securing an airway

O2 - high flow 15L/min
Recovery position (if reduced consciousness)
Simple manoeuvres
- Head tilt
- Chin lift
- Jaw thrust - only one okay in C-spine injury
Suction any visible airway secretions or FB
Airway adjuncts
- simple adjuncts:
  - nasopharyngeal airway
    - tip of nose to tragus (measure size)
  - oropharyngeal airway (guedel)
    - incisors to angle of mandible
    - insert upside down + rotate 180degrees
    - conscious patients will not tolerate
- Bag-valve-mask ventilation
  - if reduced consciousness + inadequate spontaneous ventilation
- Supraglottic airways
  - I-gel (non-inflatable cuff)
  - Laryngeal mask airway (inflatable cuff) - not a secure airway tho
  - (won’t be tolerated in those w/ preserved laryngeal reflexes)
Securing an airway (secure means protected from aspiration of gastric contents by presence of cuffed ET tube)
- Endotracheal tube
- Fibreoptic intubation
- Cricothyroidotomy
- patient needs to be sedated - rapid sequence induction of anaesthesia before doing tracheal intubation

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Breathing

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Tachypnoea

Give possible causes of tachypnoea. What might be involved in the investigation of someone with tachypnoea?

Possible causes:
- Resp pathology
  - Asthma
  - COPD
  - Pneumonia
  - Pulmonary fibrosis
  - PE
  - Pneumothorax
  - Pleural effusion
  - Atelectasis
    - decreases breath sounds, crackles, wheeze, narrowed intercostal spaces
    - do deep breathing + analgesia
  - Haemothorax
- Non-resp
  - pain
  - anxiety
  - dehydration
  - acidosis
  - malignant hyperthermia
    - increased temp, tachycardia, muscle rigidity
    - ABG, check for hyperkalaemia + acidaemia
    - Dantrolene
  - Congestive cardiac failure
  - transfusion associated acute lung injury (TRALI)
    - hypoxia, hypotension, pulmonary oedema, transfusion within last 6h
    - supplemental O2, mechanical ventilation, supportive care, avoid diuresis
  - Anaemia
    - weakness, fatigue, malaise, dyspnoea, palpitations, chest pain
  - ACS
  - Sepsis
Investigations - obvs targeted on finding the cause:
- Hx + examination
- ECG
- ABG
- Blood cultures
- CXR
- Other bloods: CRP, FBC, U&Es, LFTs
- ? HF = BNP/echo
- (etc. as needed)

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Bradypnoea

Give possible causes of bradypnoea + possible investigations that you might do

N.B. hypoventilation can be due to either slow breathing (bradypnoea) or shallow breathing (e.g. due to obesity or neuromusc conditions like guillain-barre)

Causes- unlike tachypnoea less likley to be due to lung pathology + more likley due to resp drive supression due to disturbance in resp centre of CNS
- Alkalosis
  - can be partially compensated by drop in resp rate (obvs limited as still need O2)
- Exhaustion in severe airway obstruction
- raised ICP
  - Cushing’s = HTN, bradycardia, bradypnoea
- Diabetic coma
  - eg. w/ hypoglycaemia, DKA or HHS
- Excessive sedation
  - opiate OD eg. heroin or morphine
    - low doses can be toxic if renal impairment
    - signs of opioid OD:
      - confusion, delirium, vomiting, pinpoint pupils, drowsiness, slow/irregular breathing
    - management
      - 400mcg naloxone IV
      - (then 800 for up to 2 doses at 1min intervals- then 2mg for 1 dose if still no response)
      - naloxone v short acting so need to monitor patient closely
  - BDZs + alcohol can –>
    - altered mental status/unresponsive; resp depression; hypotension, bradycardia, ataxia, slurred speech
- Alcohol intoxication
  - inital: speech/memory/attention/coordination/ balance + relaxation or ? aggression
  - then: vomiting, blackouts/amnesia, impaired judgement
  - then: LOC, hypoglycaemia, bradypnoea, stupor, involuntary eye movement, coma
- Illicit drug use
- Cholinergic agents
  - SLUDGE: salivation, lacrimation, urination, defaecation, GI cramps, emesis
  - OD -> bradycardia, bronchospasm, resp failure, seizures
  - give atropine for cholinergic crisis/bradycardia
Investigations - obvs target as needed:
- Hx + examination
  - eg. opioids –> pin point pupils
  - ? papilloedema
- CT head
- ECG
- Bloods: ABG, U&Es, FBC, CRP, LFTs, clotting, glucose, BM etc.
General management
- apnoea –> mechanical ventilation
- Non-apnoeic -> if unable to maintain sats or if retaining CO2 enough to impact mental function:
  - unable to protect airways -> intubate
  - otherwise -> non-invasive ventilation

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Label this image of different breathing patterns + say when they might occur

1. Tachypnoea
1. Bradypnoea
1. Apnoea
1. Cheyne-Stokes
  * periods of apnoea alternating w/ hyperapnoea
  * seen in brainstem injuries
1. Biot’s (ataxic breathing)
  * irregular pattern + volume w/ intermittent periods of apnoea. Breaths can be shallow or deep + stop for short periods.
  * Seen in raised ICP
1. Apneustic
  * deep gasping inspiration w/ a pause at full inspiration then a brief, insufficient release
  * due to brainstem damage
1. Agonal
  * slow, shallow, irregular respiration
  * due to brain anoxia eg. stroke, cardiac arrest
  * = brainstem reflex, not true breathing
1. Shallow
1. Hyperpnoea
1. Air trapping
  * abnormal retention of air in lungs if difficult to exhale completelet eg. obstructive lung disease
1. Kussmaul’s
  * deep gasping respirations - ‘blowing off’ excess CO2 in compensation for metabolic acidosis
1. Sighing respiration
  * breathing punctuated by frequent sighs

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Hypoxia

Give possible causes of hypoxia/low O2 sats and describe investigations and general management

Causes of hypoxia can be split into:
- Normal A-a gradient (alveolar-arterial)
  - Low available inspired O2
    - high altituide, scuba diving, combusation within closed space
  - Hypoventilation
    - opiate OD, COPD, neuromusc disease, chest wall rigidity, upper airway obstruction
- High A-a gradient
  - V/Q mismatch
    - pneumonia, ARDS, PE, cardiogenic pulmonary oedema
  - Shunt
    - severe ARDS, hepatopulmonary syndrome, AV malformation, intracardia right-to-left shunt
  - Diffusion disorder
    - interstitial lung disease
Investigations
- Hx + examination
- ? CXR
- ABG, bloods etc.
Management
- want to increase sats so:
  - O2 +/- ventilate
  - treat underlying cause

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How can you clinically asess ventilation? What are the different methods of O2 delivery (don’t include ventilation) + how might you work out the FiO2 from the number of litres you are giving?

Assessment of ventilation
- O2 sats + PaO2
- signs: resp rate, cyanosis, chest wall movement, air entry, abnormal breath sounds
- capnography - detects CO2 in expired air - confirms patient is being ventilated.
  - In CPR end tidal CO2 >2 = good quality compressions
Roughly determining the FiO2 from number of litres
- FiO2 of air (21%) + (4x no. of litres of O2 patient is on)
  - e.g. 15L = 81%
Methods of O2 delivery
- Nasal cannula
  - for mild hypoxia in non-acute situations
  - delivers 24-30% O2 (max flow = 4L/min)
- Hudson mask
  - for mild hypoxia in non-acute situations
  - 30-40% (5-10L/min)
- Resevoir mask aka. non-rebreathe mask
  - for acutely unwell patients - high FiO2
  - use at 15L/min
  - must fill resevoir bag by obstructing valve temporarily before positioning on patient
- Venturi mask
  - delivers constant FiO2 regardless of resp rate + flow pattern
  - often used in COPD
  - different colours require different flow rates + give different FiO2
- Humidified O2
  - can help break down/clear resp secretions
  - O2 passed through humidifying device before passing through tubing to patient

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For metabolic acidosis you can look at the anion gap to help determine the cause

(Na + K) - (Cl + HCO3)

Normal anion gap = 8-14

What are causes of metabolic acidosis with a normal + raised anion gap?

Normal anion gap (hyperchloraemic metabolic acidosis)
- GI bicarbonate loss: diarrhoea, fistula, ureterosigmoidostomy
- Renal tubular acidosis
- Drugs e.g. acetazolamide
- ammonium chloride injection
- addison’s disease
Raised anion gap
- MUDPILES
- M- methanol
- U-uraemia
- D- DKA (or alcoholic or starvation ketoacidosis)
- P-paracetamol
- I- iron, isoniazid, inborn errors of metabolism
- L-lactic acidosis
- E - ethanol
- S- salicylates/aspirin OD

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Circulation

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What are the different types of shock? and brief summary of how they might present

Hypovolaemic
- exogenous loss e.g. haemorrhage of burns
- Features:
  - skin: cold, pale, grey, slow CR, clammy
  - kidneys: oliguria, anuria
  - brain: drowsy, confusion, irritable
  - Increased sympathetic tone: tachycardia, weak pulse, sweating, BP (hypotension)
  - Lactic acidosis: compensatory tachypnoea
Cardiogenic
- inability of heart to pump enough blood to meet body’s demands
- e.g. ischaemic myocardial injury
Obstructive
- physical obstruction of the great vessels of the heart
- e.g.
  - obstruction to cardiac outflow e.g. PE
  - restricted cardiac filling e.g. tamponade, tension pneumothorax
- same as hypovolaemic shock plus:
  - elevated JVP
  - pulsus paradoxus + muffled heart sounds in tamponade
Distributive –> warm peripheries (the rest -> cold))
- defining feature = loss of peripheral resistance
- Causes:
  - Septic shock = most common
    - pyrexia, rigors, hypo-or hyperthermia, bounding pulse, rapid CR, hypotension
  - anaphylactic shock
    - -> angiooedema, bronchospasm, pulmonary oedema, hypovolaemia, n+v, abdominal cramps, diarrhoea
  - neurogenic - loss of peripheral vasomotor control due to a disruption of autonomic pathways within the spinal cord
    - due to damage to CNS e.g. spinal cord or traumatic brain injury

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How do you calculate GCS?

Eye opening
- 4 = spontaneous eye opening
- 3 = opens in response in speech
- 2 = opens in response to pain
- 1 = no eye opening
Best verbal response
- 5 =patient orientated to time, person + place
- 4 = patient confused
- 3 = inappropriate words
- 2 = incomprehensible sounds
- 1 = no verbal
Best motor response
- 6 = obeys commands
- 5 = localises to painful stimulus
- 4 = withdraws from pain
- 3 = flexion to painful stimulus
- 2 = extensor response to painful stimulus
- 1 = no motor response

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What is hypothermia? Give causes + presentation + how is it diagnosed/investigated

Hypothermia (<35)
- Mild - 32-35C
- mod - 30-32C
- severe - <30C
Causes
- young adults = normally from environmental exposure
- older= normally multifactorial - poverty, immobility, alcohol, acute confusion, hypothyroid, infection etc.
Presentation
- severe hypothermia can mimic death
- mild -> apathy, amnesia, ataxia, dysarthria
- mod -> drop in LOC, coma, hypotension, arrhythmias (esp bradycardia), resp depression, muscular rigidity
- severe - VF
Diagnosis
- tympanic or rectal temperature
Investigations
- U&Es, FBC, toxicology, clotting screens (hypothermia can aggravate coagulation disorders), BM (can be falsely low), amylase, blood cultures, ABG
- ECG: prolonged elements in the PQRST complex + J waves (osborn waves), arrhythmia (AF + bradycardia are common)
- CXR - ? pneumonia, aspiration, LV failure
- CT e.g. if ? head injury of stroke

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Describe the management of hypothermia

General
- treat in warm room + remove wet clothes/dry skin
- monitor ECG
- If IV fluids needed give warmed fluids + if O2 needed give warmed humidified O2
- correct any hypoglycaemia
- N.B. in hypothermic cardiac arrest they may be less responsive to defibrillation, pacing + drugs
  - avoid drugs till core temp >30C
  - after doing 3 shocks for shockable rhythms defer further shocks till temp >30C
Rewarming methods:
- Passive rewarming (if mild, >32C)
  - Wrap in warm blankets +/- polythene sheets
  - aim to reheat at 0.5-2C/hr
    - too quick in elderly has risk of hypotension or cerebral/pulmonary oedema
- Active rewarming
  - water bath at 41C (not if injured tho or if CPR needed)
  - Hot air blanket (more convenient) eg. Bair hugger
  - Core rewarming
    - airway - heated (40-45C) O2
    - peritoneal lavage - saline run at 45C left in for 10-20mins then replaced
    - if severe hypothermia or arrest
      - –> extracorporeal rewarming w/ cardiopulmonary bypass

Describe the adult tachycardia (w/ pulse) algorithm

Describe the adult bradycardia (w/ pulse) algorithm

ALS algorithm

Criteria for CT head adults

C-spine imaging adults

C-spine imaging children

Trauma

* Why might death occur following major trauma * Give key things to remember in trauma management * What are possible thoracic + abdo injuries that can occur?

* Causes of death * immediate - brain/spinal injury, cardiac/large vessel damage * early hours - splenic rupture, subdural haematoma, haemopneumothoraces * days - sepsis or multi organ failure * Key aspects of trauma management - A-E (A includes C-spine) * ventilation --\> worsens tension pneumothorax * External haemorrhage - needs managing in A-E * packing is the preferred method of haemorrhage control * Urethral injures - be careful w/ catheter insertion, ? suprapubic needed * ?basal skull fracture - don't use nasogastric tubes or NPA * H&N trauma = assumed C-spine injury till proven otherwise * Thoracic injuries * simple pneumothorax * mediastinal traversing wound * tracheobronchial tree injury * haemothorax * blunt cardiac injury * diaphragmatic injury * aortic dissection * pulmonary contusion * Abdo trauma * deceleration injuries * splenic injury * stab wounds often damage liver * gunshot often damages small bowel * blood at urethral meatus suggest urethral tear * high riding prostate on PR = urethral disruption

Describe the presentation + management of the following chest trauma * Isolated rib fracture * multiple rib #s * flail segment

* Isolated # * localised chest wall tenderness + Hx of trauma * look for signs of pneumothorax, secondary pneumonia + multiple rib #s - if present --\> CXR * (if no signs of these then is just clinical diagnosis) * Manage w/ oral analgesia * Multiple rib fractures * observe for ? flail segment, pneumothorax + pneumonia * check: O2 sats, ABG, CXR * management * if any pre-existent resp disease --\> admit for analgesia + physio * if pneumonia obvs treat * Flail segment * # of 3 or more ribs in 2 places * = implied significant injury of underlying lung (contusion) * -\> pain + paradoxical movement + less effective respiration * Ix * pO2, ABG, CXR * management * high flow O2 * contact ITU for ?tracheal intubation/ventilation * some may need epidural anaesthetic * ?intra-arterial line for freqeunt ABG analysis

Haemothorax What is it? How does it present? How would you investigate and

* Blood in pleural cavity can --\> hypovolaemic shock (massive haemothorax) * Presentation * similar to pneumothorax but dull percusion +/- hypovolaemia * Ix * CXR - blood = increased shadowing on supine X-ray - hard to differentiate from contusions (so needs erect) * Management * O2 + 2 large cannulae * G&S + X-match * IV fluids before chest drain if hypovolaemic * Chest drain * if initial yield \>1500ml OR \>200ml/hr --\> urgent thoracic surgery referral

Pulmonary contusions How do they present? How are they investigated and managed?

* suspect in any patient w/ flail segment * Presentation * ventilation-perfusion mismatch --\> hypoxia + resp distress + risk of ARDS * X-ray * patchy opacification * becomes more evidence w/ time * Management * high flow O2 + check ABG * involve ITU early * ? intubation/ventilation + GA

What can an open chest wound lead to? How would you manage this?

* An open wound between the pleural cavity + outside can --\> resp insufficiency * basically causes a pneumothroax --\> hypoxia, resp distress, SOB + cyanosis * Management * high flow O2 * cover chest wound w. square polythene dressing + secure 3 sides to the chest wall w/ tape (leave one side free) * allows air to exit on expiration but not enter * insert a chest drain (not through the wound tho) to drain the pneumothorax * + further resus + involve thoracic surgeons

What is a FAST scan and what does it look for?

* FAST = focussed assessment sonography in trauma * looks at four areas for free fluid: * hepatorenal recess (morrison's pouch) - 1st to fill when supine * Splenorenal recess * pelvis (pouch of douglas) * pericardium * a +ve FAST scan is one w/ free fluid in abdomen or pericardium * if there is visible free fluid in abdo this suggests minimum volume of 500ml

Blunt abdominal trauma What are you looking for? How are you investigating and managing? N.B. any lower chest injury may be associated w/ splenic or liver injuries

* Examination: * ? hypovolaemia or bruising (e.g. seatbelt) * ? tenderness or peritonism * check femoral pulses * log roll for ? loin tenderness or back injury * examine perineum + do DRE - check perineal sensation, anal tone, rectal integrity + position of prostate * Ix - depending on clinical assessment * Urinalysis * intra-abdo injury (not just renal tract) * pregnancy test * Fast USS * CT abdo * (AXR not that helpful acutely) * A-E + initial stabilisation then: * if haemodynamic instability * refer urgently to surgeons for laparotomy * Peritonism * IV Abx e.g. cefuroxime + refer urgently for laparotomy * Haem stable + no peritonism * refer to surgery for further investigation + observation * ? abdo injury in the multiply injured * FAST USS + diagnostic peritoneal lavage * if stable --\> CT * if unstable --\> theatre

Give brief overview of: * Renal trauma * bladder trauma * urethral trauma * testicular trauma

* Renal trauma * most = direct blunt abdo trauma (children esp prone) * Features * Hx of blow to loin/flank --\> haematuria * loing tenderness +/- bruising/abrasions * Ix * urinalysis - haematuria * bloods * abdo CT * Management * blunt injury - bed rest + analgesia * ? prophylactic Abx * penetrating or v severe blunt * urological assessment +/- emergency surgery * Bladder * can rupture into peritoneal cavity -\> low abdo pain +/- peritonism, haematuria, inability to pass urine, perineal bruising * X-ray for ? # + DRE. If no urethral injury can pass catheter for ? haematuria * Management * intra-peritoneal rupture - laparotomy + repair * extraperitoneal- catheter draiange + Abx * Urethral * eg. w/ pelvic # or blow to perineum * look for perineal bruising + blood at external meatus + do DRE * do NOT attempt to catheterise- refer urgently to urology * Testicular trauma * can -\> scrotal haematoma or testicular rupture * give analgesia * USS to help distinguish between the two * haematoma - may respond to conservative methods * teticular rupture- urgent surgical exploration + repair

Emergency Drug Doses

Anaphylaxis * Adrenaline * Hydrocortisone * Chlorphenamine

* Adrenaline * 500mcg IM (0.5ml) 1:1000 * (N.B. resus is 1g IV 1:10,000 every 3-5mins) * Chlorphenamine * 10mg IV * Hydrocortisone *

ACS * Aspirin * Clopidogrel * Morphine

* Aspirin * 300mg * Clopidogrel * 300mg * Morphine * 5mg IV every 4 hours - titrate it to pain response

Asthma * Salbutamol * Hydrocortisone

* Salbutamol * 2.5-5mg nebulised solution *

Bradycardia * Atropine

Hyperkalaemia * Calcium gluconate * Insulin/dextrose * Salbutamol

* Calcium gluconate * 10-20ml slow IV injection, calcium gluconate 10%. * titrate dose according to ECG improvement * Insulin/dextrose * 50ml 50% glucose over 15mins * with soluble insulin 10 units * Salbutamol * 10mg

Hypocalcaemia * Calcium gluconate

* 10-20 ml 10% solution initially * continuos ECG monitoring * ? repeat or followw/ continuous infusion

Hypoglycaemia * Oral glucose * Glucagon * Glucose

* Oral glucose * 10-20g glucose by mouth * can repeat after 10-15mins then give a slow release carb * can give glucogel if needed * Hypoglycaemia --\> unconsciousness * Glucagon * 1mg IM/SC * if no response within 10mins need IV glucose * IV glucose * 10g as 20% IV solution

Status epilepticus * Lorazepam * (? diazepam - or is this for sedation??)

* Lorazepam * IV 4mg for 1 dose * then IV 4mg again after 10mins again if needed * Diazepam * 10mg rectal or IV repeated as needed

Opioid OD * Naloxone

* IV naloxone * 400mcg initially * then 800mcg for up to 2 doses at 1 minute intervals * then 2mg for 1 dose * (if still no response can try 4mg + if then need to review diagnosis) * (can also give SC or IM if IV route is not feasible)