Emergency medicine Flashcards
What is a pneumothorax?
a collection of air between the visceral and parietal pleura
What is a primary pneumothorax?
a pneumothorax that occurs without any underlying disease causing it
What is a secondary pneumothorax?
a pneumothorax that occurs due to an underlying disease eg. asthma or COPD
What is a tension pneumothorax?
a life-threatening event where air is trapped in the pneumothorax under positive pressure so the intrathoracic pressure rises, reducing venous return to the heart and potentially cardiac arrest
What are symptoms of a pneumothorax?
sudden onset chest pain
acute SOB
a feeling of not being able to take a deep breath
What are the signs of a pneumothorax?
tachypnoea tachycardia hypoxia reduced breath sounds on affected side hyperresonance on affected side tracheal deviation away from affected side in tension
What are the target oxygen sats for a
a) normal patient?
b) COPD patient?
a) 94-98
b) 88-92 only if CO2 retaining as shown in ABG
Why do COPD patients have lower target o2 sats?
they are CO2 retainers so if given too much oxygen you can reduce their hypoxic drive
What is seen on CXR for pneumothorax?
Air in the pleural space
Decreased lung markings around the outer edge of the lung field
Lung collapse
How is a simple pneumothorax managed?
high flow O2
sit up if conscious
aspirate with 16-18G cannula if large primary, symptomatic or small secondary
How is tension pneumothorax managed?
peri-arrest call on 2222
needle decompression into 2nd intercostal space, mid-clavicular line
chest drain insertion
What IV access is needed for an acutely unwell patient?
2 large bore cannulas (grey or orange)
Which fluid is used for fluid resuscitation?
NaCl 0.9% or Hartmann’s solution
Name some signs of airway compromise
see-saw breathing
use of accessory muscles
diminished breath sounds
added sounds
What clinical findings might suggest respiratory compromise?
tachypnoea
reduced air entry
What does a hypoxic patient with a falling respiratory rate indicate?
impending respiratory failure
How is an acute asthma attack managed?
O SHIT ME
oxygen salbutamol 2.5-5mg nebs hydrocortisone 100mg IV ipratropium 500mcg NEB theophylline
magnesium sulphate 2g IV over 20 mins
escalate care
What does diaphoretic mean?
extreme sweating
Where is a chest drain inserted?
4th or 5th intercostal space in triangle of safety
just anterior to the mid axillary line and posterior to the lateral border of the pectoral muscle.
In trauma, what is a shocked patient assumed to be suffering?
blood loss/ haemorrhagic shock
Which areas can have significant blood loss?
on the floor and 4 more
external haemorrhage chest abdo pelvis long bones
What is the mainstay treatment of a shocked patient?
IV crystalloid fluid
0.9% saline or Hartmann’s
250-500ml boluses of warmed NaCL
What are the 3 components of the GCS?
eyes /4
verbal /5
move /6
How is the patients eye response for GCS scored?
4 spontaneous
3 voice
2 pain
1 no response
How is the patients verbal response for GCS scored?
5 orientated 4 confused 3 inappropriate words 2 noises 1 no response
How is the patients movement response for GCS scored?
6 obeys command 5 localises to pain 4 normal flexion 3 abnormal flexion 2 extension 1 no response
How is hyperkalaemia treated?
calcium chloride then an infusion of insulin dextrose
How would you investigate a ? abdominal aortic aneurysm?
US if trained
definitive is CT
How would you investigate ischaemic gut or DKA?
ABG
How would you investigate shocked patient?
FBC U+E LFT lactate ABG
Which medication is good for crampy abdominal pain?
buscopan
What medication is good for renal colic?
diclofenac
Differentials of chest pain
CV eg. acute MI, angina, aortic dissection, PE, pericarditis
resp: pneumothorax, pleurisy, pneumonia
costochondritis
GI: oesophageal rupture, cholecystitis, GORD, biliary colic
What are atypical presentations of MI? Who presents like this?
burping
reflux
more common in diabetics
What is the typical presentation of acute MI?
central chest pain sudden onset heavy, achy, dull radiates to left shoulder assoc N+V
What is the typical presentation of PE?
sudden onset sharp, pleuritic pain
assoc SOB
When would a patient with chest pain get a CT?
? massive PE
aortic dissection
oesophageal rupture
major trauma
What is a PERC score? what forms it?
rules out PE
criteria to rule in:
- age >50
- HR >100
- O2 sats <95 on room air
- unilateral leg swelling
- haemoptysis
- recent surgery or trauma
- previous PE/DVT
- on hormonal contraceptive
What is a Wells score? what forms it?
work out risk of PE: low risk or high risk
- clinical signs +symptoms present
- immobilisation > 3 days or surgery in past 4 weeks
- HR >100
- previous DVT/PE
- haemoptysis
- malignancy
How is someone with a
a) low-risk
b) high risk
Wells score managed?
a) needs d-dimer
b) CTA
What are the differential diagnoses for shortness of breath?
resp: airway obstruction, anaphylaxis, PE, pneumothorax, asthma, COPD, pneumonia, pleural effusion, rib #
Abdo: ascites, obesity, pregnancy
metabolic: acidosis, poisoning, renal failure
anaemia, anxiety
What type of breathing can be seen in DKA?
kussmaul’s breathing
fast, sighing breath trying to blow off CO2
What can cause respiratory acidosis?
severe asthma
pneumonia
hypoventilation
What can cause respiratory alkalosis?
hyperventilation
panic attack
salicylate poisoning
What can cause metabolic acidosis?
DKA, lactic acidosis, alcohol, salicylate
What can cause metabolic alkalosis?
vomiting
potassium loss
What are the differentials for abdominal pain ?
GI:oesophagitis, gastritis, PUD, pancreatitis, bowel obstruction, appendicitis, diverticular disease, IBD, ischaemic bowel, gastroenteritis, acute liver failure, constipation
gynae: ectopic, PID, ovarian cyst
urology: renal colic, pyelonephritis, UTI, testicular torsion
vascular: AAA
other: DKA, hypercalcaemia, mesenteric adenitis
What must be done for
a) male patients
b) female patients
presenting with abdo pain?
a) testicular exam
b) pregnancy test
What is Rovsig’s sign? what diagnosis does it indicate?
palpation of LIF illicits RIF pain
appendicitis
What is Mcburney’s point?
2/3rd way from umbilicus to right ASIS
painful to palpate in appendicitis
What is Murphy’s sign?
when palpating under right ribs, ask patient to take a deep breath
this will cause pain and a sharp inspiration when hand comes into contact with inflamed gallbladder
indicating acute cholecystitis
What dose is used for morphine?
0.1-0.2 mg/kg
so adult needs 7-14 mg
How should suspected STEMI be managed?
Phone CCU give 5000 units heparin IV 600 mg clopidogrel orally 300 mg aspirin orally transfer to cath lab for PCI
If PCI cannot be done, how is STEMI managed?
thrombolysis with alteplase
How does appendicitis present?
abdo pain: general then to RIF anorexia N + V tender RIF fever rebound tenderness
What can be used to confirm ACS if clinical signs but no ECG changes?
cardiac biomarkers eg. troponin
Which features of history are important when someone presents with a head injury?
mechanism LOC vomiting seizure visual problems amnesia bleeding risk
Who is at risk for bleeding with a head injury?
on anti-coagulation
haemophiliacs
low platelets (alcoholic)
What forms a head injury exam?
GCS/ AVPU pupil response examine ears look for wounds, depression, haematoma neuro exam cervical spine
What GCS would a a) mild b) moderate c) severe head injury have?
a) 13-15
b) 9-12
c) 3-8
An AVPU response to pain is equal to a GCS of?
<8
Which GCS score would indicate that a patient should be intubated?
<8
What is a fixed, dilated pupil a sign of?
late sign of raised ICP caused by 3rd nerve palsy
What are the signs of a base of skull fracture?
haemotympanum
battle’s sign
panda/racoon eyes
CSF leak
What is Cushing’s triad in head injury and why does it occur?
triad of hypertension, bradycardia and irregular breathing
occurs when there is an intracranial bleed increasing the ICP so that cranial blood flow is reduced, then the body tries to increase blood pressure to increase this
irregular breathing occurs due to decreased brain stem perfusion
What does an extradural haemorrhage look like on CT?
a hyperdense convex shape between the skull and dura that is limited by the suture lines
What does a subdural haemorrhage look like on CT?
a hypodense crescent between the dura and arachnoid that can cause midline shift
Where is the bleed usually in an
a) extradural haemorrhage?
b) subdural haemorrhage?
a) middle meningeal artery
b) bridging veins
How does an extradural haemorrhage present?
younger people with brief LOC then lucid then dec. GCS
How does a subdural haemorrhage present?
insidiously in the elderly after low-impact trauma
How can poison absorption be prevented?
give activated charcoal within 1 hour of ingestion
How can poison metabolism be altered?
give antidote
How can poison elimination be increased?
haemofiltration or dialysis
What is the antidote for paracetamol?
N-acetylcysteine
What is the antidote for TCAs?
sodium bicarbonate
What is the antidote for beta blockers?
glucagon
What is the antidote for ethylene glycol?
ethanol, fomepizol
What is the antidote for opiods?
naloxone
What dose of paracetamol overdose justifies referral to hospital?
> 75mg/kg
If paracetamol is taken in its therapeutic dose how is it metabolised?
5% converted by cytochrome P450 to NAPQI which is detoxified in the liver by conjugation with glutathione
If paracetamol is overdosed, how is it metabolised?
excess paracetamol causes increased NAPQI and depleted glutathione supplies in the hepatocytes so NAPQI reacts with cellular membranes causing hepatocyte damage and death which can lead to acute liver necrosis
What are the features of paracetamol overdose?
N + V
abdominal pain
hepatic necrosis, jaundice, right subcostal pain, hepatic encephalopathy
How should paracetamol overdose be managed?
give activated charcoal within 1 hour
check blood paracetamol level at 4hrs
treat with n acetylcysteine if above line
How should response to nacetylcysteine be monitored?
after treatment check LFTs, U+Es and INR
if deranged continue treatment
What is INR the most accurate indicator of?
synthetic function of the liver
How is a c-spine protected?
collar, blocks and tape
How long does naloxone work for?
works in around 15seconds and lasts 20-30 min
How should naloxone be dosed?
slowly titrate by giving doses of 100-200 mcg until no resp depression but not until patient alert
How should hypoglycaemia with a blood glucose <4mmol/L be managed?
give 75ml of IV 20% dextrose
