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 your diffferential?
Pneumothorax
- Anaphylaxis
- Asthma
- Pneumonia
- Cardiac failure
- ARDS
- Pleural effusion
24 year old male • Acutely short of breath • HR 120 • BP 129/87 • RR 35 • SpO2 98% on 15LO2 • GCS 15
Initial assessment •
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 it?
Asthma
How do you differentiate between acute severe asthma and life threatening Asthma
Acute Severe Asthma •
(PEF) 33-50% of best
Can’t complete sentences
Respiration ≥25/min
ƒPulse ≥110 beats/min
Life-threatening Asthma
- PEF <33% of best
- SpO2 <92%
Silent chest, cyanosis, or feeble respiratory effort
Arrhythmia/hypotension
Exhaustion, altered consciousness
Essentially:
Decompensation
Unable to maintain adequate PO2 and PCO2
Drowsy due to rising PCO2, hypotension or exhaustion
Need intubation
how does an Asthmatic present?
Wheeze
breathless
tachycardic
How do you treat an acute asthma attack?
Nebulised salbutamol • IV salbutamol • Nebulised adrenaline • Nebulised magnesium • Oral steroids • IV steroids
What is the pathophysiology of asthma
Reversible airway disease
Hyper reactivity
Airflow limitation
A patient with an acute attack get#s worse
RR drops to 10/minute • SpO2 91% on 15L • HR 90 • Drowsy
What do you do?
Call for specialist
is the carbo dioxide high low or normal in asthmatics
low
hyperventilating
34 year old female • Suddenly felt unwell • Widespread urticarial rash • HR 130 • BP 75/40 • Collapsed • Wheezy
What are differentials
- Ectopic pregnancy
- Acute severe asthma
- Sepsis
4. Anaphylaxis
- Pneumonia
What are causes for collapse
drugs
- alcohol
- likely intracranial pathology
- low BP
- bleeding
What does this person have
ANAPHYLAXIS
What is the pathophysiology of anaphylaxis
34 year old female • Suddenly felt unwell • Widespread urticarial rash • HR 130 • BP 75/40 • Collapsed • Wheezy
No known allergies • Ate a chicken korma • Lips and mouth felt tingly • 1 episode of diarrhoea • Then was complaining of feeling itchy • Collapsed • Ambulance report she developed wheeze en route to hospital
what does she have?
anaphylaxis
How do you treat anaphylaxis
Adrenaline • 500mcg • 0.5ml 1;1000 IM
- Lie her flat and put legs in the air – Why? get blood to the brain
- Piriton • Hydrocortisone • Fluids
how does adrenaline work
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
Central chest pain to left arm • Pale and sweaty • Smokes 30/day • Hypertension • Diabetes • As his ECG is performed he collapses and becomes unconscious
MI anteriorlateral
What are your priorities in someone with an MI?
What do you initiallly
- Call for help
- Open his airway and start rescue breaths
- Get IV access
- Get a 12 lead ECG
Check for signs of life? • Open airway • Check pulse • no pulse , not breathing = cardiorespiratory arrest
do CPR
What are reversible causes of cardiac arrrest
hypoxia
hypovolaemia
hypothermia
hypokalaemia
Tension pneumothorax
Tamponade
Toxins
Thromboembolic
What does this ECHO show
cardiac tamponade
what are shockable rhythms
pulseless VT and VF
Which are non shockable rhythms
Pulseless activity
asystole
What do you do if someone has a cardiac tamponade
Emergency pericardial centesis
What is a life threatnening feature of Asthma?
A can’t complete a sentence
resp rate >25
PEF <33%
Pulse >110
PEF <33%
Which is the correct dose of adrenaline in anaphylaxis
A 0.5ml of 1:10
B: 0.5ml to 1:100
C. 0.5 of 1:1000
D. 0.5 of 10000
C. 0.5 of 1:1000
38 year old male • Motorcycle vs car • Bullseye windscreen • LOC initially then GCS 15/15 • HR 100 BP 145/78 • GCS 9/15
What does he have?
how do you approach it
extradural haematoma
Structured approach to the injured patient • Catastrophic Haemorrhage?
- Airway with c spine control
- Breathing
- Circulation
- Disability
- Exposure
- ‘C-ABC’
A- Noisy •
B - Good air entry, no obvious injury – Normal breath sounds, Percussion resonant
- C- HR 100 BP 145/78
- D- E 2 V 2 M 5 = 9/15 – Dilated left pupil
- E- large scalp wound, blood from ear
What does he have?
- Subarachnoid haemorrhage
- Subdural haemorrhage
- Extradural haematoma
- Tumour
Why do you get a dilated pupil in head trauma
herniation of the brain through the foramen magnum - at first one pupil and then the other
How do you know how bad an extradural haematoma is?
midline shift
How do you manage an extradural haematoma?
- 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 could you when looking for an airway in ABCD
IF there is a problem what would you do?
Are they breathing?
• Is it normal or noisy?
– Noisy = obstructed
– Obstructed = do something!
• Do they need a ‘definitive airway’
- LMA
- intubation
How do you assess breathing in a trauma patient?
– Look: chest rising
– Palpate: surgical emphysema, lacerations
– Percuss: look for pleural effusion
– Auscultate
What does this guy have
pneumothorax
What does this guy have
broken ribs
haemothorax
surgical emphysema
How do you treat a tension pneumothorax
large bore canula in th e 2nd intercostal space
How do asses circulation
Assessment
– Pulse, BP, capillary refill time
– General appearance
if someone is really hypotensive and you suspect bleeding
Where would you look?
Source of haemorrhage – ‘ on the floor & 4 more’ – Chest/Abdo/Pelvis/Long bones
How do you deal with haemorrage
What is this?
open book fracture
close the hip with a pelvic binder
if someone is hypotensive due to haemorrhage or blood loss, how do you get their BP up
transfusion of packed red cell and plasma
Turn off the tap
- Fluids
- Warfarin •
Coagulopathy to correct
• TXA
Damage control surgery
how quickly do you need to give TXA
wihtin an hour
HOw do you look at dissability out of ABCD
GCS
- Glasgow Coma Score – level of consciousness •
Pupils
- Blood sugar
- Limb movements
A 17-year-old male is stabbed in the left side of his chest just medial to the nipple. • His blood pressure is 90/60 and his pulse is 130. • On inspiration his JVP increases and his peripheral pulses and blood pressure decrease.
*Diagnosis?*
- Tension pneumothorax
2. Cardiac tamponade
- Pneumonia
- Thoracic heamorrhage
If someone has a caridac tampopnade due to trauma how would you treat it
thoracotomy
need to close off the site of bleeding
Pericardiocentesis - would just refill
what are injuries you want to look out for in people that were in a fire?
Direct Burns
- Inhalation Injury
- Smoke Inhalation
- Carbon Monoxide Poisoning
- Cyanide Poisoning
- Trauma
how does a full thickness burn look like
turn white
According to ATLS principles what should you treat first?
A. cardiac tamponade
B. splenic rupture
C. traumatic haemothorax
D. fractured pelvis
E.bladder rupture
C. traumatic haemothorax
if a patient had a history of a lucid period which traumatic brain injury would you be most concerned about
subarachnoid
subdural
extradural
diffuse axonal injury
extradural
