Emergency Medicine Flashcards

Question

What are the NICE guideline for CT requirement within 8 hours?

Answer 1

Requirements for a CT head within 8 hours • All patients on anticoagulants with head injuries Any loss of consciousness or amnesia and: • Age > 65 • Coagulopathy • High impact injury • Fall > 1m or more than 5 stairs • Retrograde amnesia > 30mins (events immediately before the event)

Answer 2

Requirements for a CT cervical spine • GCS< 13 on initial assessment • Patient has been intubated • Definitive diagnosis of cervical spine injury is needed urgently • Patient is having other body areas scanned i.e. multi-region trauma • Clinical suspicion of cervical spine trauma and any of: • Age > 65 • High impact injury • Focal neurological deficit paraesthesia in either limbs

Answer 3

If CT cervical spine criteria not met but any of the following are then this allows clinical examination of the neck • Simple rear-ended motor vehicle collision • Comfortable in a sitting position • Ambulatory since injury • No midline cervical tenderness • Delayed onset of neck pain Neck movement assessment – If unable to actively rotate their neck 45 degrees or no above features present then obtain simple plain radiograph of neck within 1 hour

Answer 4

``` Peptic ulcer disease 35-50% Gastroduodenal erosions 8-15% Oesophagitis 5-15% Mallory Weiss Tear 15% Varices 5-10% Other – malignancy, vascular malformations, facial trauma, epistaxis, haemoptysis ```

Answer 5

``` The Blatchford Score • Urea • Haemoglobin • Systolic BP • Pulse • Malaena • Syncope • Hepatic disease • Cardiac failure ``` If score is 0 then patient can be considered for early discharge.

Answer 6

ABCDE including all usual A-E investigations (ECG, CXR, ABG etc.) Make NBM and inert two large bore cannulas Rapid IV 1L crystalloid infusion Replace blood with blood if shock class III or IV Correct clotting abnormalities including platelets Consider CVP line and referral to ICU Catheterise and monitor urine output Notify surgeons Urgent endoscopy for diagnosis within 24 hours

Answer 7

In non-Variceal bleeding there is need for PPI before endoscopy Variceal bleeding – terlipressin or octreotide and prophylactic antibiotics prior to endoscopy. Band ligation should be considered and injections of N-butyl-2-cyanoacrylate in those with gastric varices. Sengstaken-Blakemore tube if uncontrolled haemorrhage. Transjugular intrahepatic portosystemic shunts should be offered to those where bleeding from varices is not controlled by the above.

Answer 8

Lund and Browder charts – most accurate Rules of 9 (arm = 9%, front of trunk = 18%, head and neck = 9%, leg = 18% back of trunk = 18% and perineum = 1%) Palmer surface of someone’s hand is roughly equal to 1% of total body surface area

Answer 9

1. First degrees – Superficial epidermal – red and painful 2. Second degree – Partial thickness (superficial dermal) – painful, pale pink and blistered 3. Second degree – Partial thickness (deep dermal) – reduced sensation, white and non-blanching erythema 4. Third degree – Full thickness – painless, grey-white, brown, black, no blisters

Answer 10

All Deep dermal and full thickness burns Superficial dermal > 3% in adults or 2% in children Superficial dermal burns of special sites i.e. genitals, perineum, face, hands, feet, flexures and circumferential burns of the limbs, torso or neck. Chemical and electrical burns Burns with inhalational injury Suspicion of NAI

Answer 11

1. ABCDE 2. Irrigate with cool (note iced) water as soon as possible for 10-30 minutes. If chemical, brush off any left over chemicals before irrigation 3. Cover using clingfilm, layered rather that wrapped Cool the burn but warm the patient to avoid potentiating any shock IV morphine for analgesia Ensure tetanus immunity

Answer 12

Superficial epidermal – analgesia and emollients Superficial dermal – cleanse wounds, leave blister intact, non-adherent dressing, avoid topical cream and review in 24 hours

Answer 13

``` Fluid resuscitation (always required in adults > 15% partial thickness and children > 10% • Parkland formula – 4 x weight x SA of burn – mL of Hartman’s solution over 24h with half in the first 8 hours. Insert catheter to monitor output aiming for 0.5ml/kg/h urine output (1ml/kg/h in children) ```

Answer 14

Consider Escharotomy if full circumference burns restricting breathing

Answer 15

Be wary and manage compartment syndromes – fluids may exacerbate or accelerate

Answer 16

Initially laryngospasm leads to hypoxia and straining which result in petechiae then hypoxia cord relaxation leads to true inhalation injury. Free radicals, cyanide compounds and carbon monoxide will accompany thermal injury. These all stop oxidative phosphorylation causing dizziness, headaches, and seizures. Tachycardia and dyspnoea will eventually evolve into bradycardia and apnoea.

Answer 17

COHb levels do not directly correlate to level of poisoning as this includes baseline from smoking and environment. Use Nomograms to extrapolate peak levels.

Answer 18

Manage with 100 oxygen to displace CO and cyanide Involve ITU and anaesthetists early Enlist expert help in cyanide poisoning

Answer 19

Hypothermia implies a core (rectal) temperature < 35 degrees Celsius. This results in regional vasoconstriction, and the hypothalamus releases TSH and ACTH. Shivering is initiated to stimulate heat.

Answer 20

Elderly – usually do not realise or complain about cold and do not attempt to warm up Younger – exposure related such as near drowning or reduced GCS and alcohol

Answer 21

Shivering – mild hypothermia (usually 32-35 degrees) | Non shivering despite core temp < 35 – severe hypothermia (usually < 32 degrees)

Answer 22

Confusion and slurred speech Cold and pale Agitation Reduced GCS Coma Tachypnoea, tachycardia, and hypertension if mild Respiratory depression and bradycardia if moderate-severe Hypotension Arrhythmias Hypokalaemia due to a shift of K+ into the intracellular space Hb and haematocrit may be high due to haemoconcentration whilst platelets, WBCs are low due to sequestration in the spleen

Answer 23

Use a low reading thermometer, preferably rectally Routine bloods, particularly U&Es, plasma glucose, coagulation, and amylase TFTs Blood cultures ABG ECG – J waves (small peak between S and T) and first-degree heart block

Answer 24

ABCD (In E don’t expose to cold) Warm humidified oxygen Remove wet clothing and SLOWLY rewarm aiming for 0.5 degree rise per hour To warm use active external warming or warm fluids Must be on a cardiac monitor Consider antibiotic prophylaxis and urinary catheterisation Rapid warming causes peripheral vasodilation and shock indicated by falling BP

Answer 25

Must question the patient, or gain collateral to determine: • What • How much • How long ago • Over what period of time • Alcohol/other drugs involved • With what intention and how they feel about that now Use Toxbase – this provides all the information you need for any potential poison and 24-hour advice if required.

Answer 26

Fast or irregular pulse – salbutamol, antimuscarinics and tricyclics

Answer 27

Respiratory depression – opiate or benzodiazepines

Answer 28

Hypothermia – phenothiazines and barbiturates

Answer 29

Hyperthermia – Amphetamines, MAOIs, cocaine, or ecstasy

Answer 30

Coma – benzodiazepines, alcohol, opiates, tricyclics, phenothiazines or theophylline

Answer 31

Constricted pupils – opiates or insecticides (organophosphates)

Answer 32

Dilated pupils – amphetamines, cocaine, or tricyclics

Answer 33

Hyperglycaemia – organophosphates, theophylline or MAOI

Answer 34

Hypoglycaemia – insulin, oral hypoglycaemics, alcohol or salicylates

Answer 35

Renal impairment – Salicylate, paracetamol, or ethylene glycol

Answer 36

Metabolic acidosis – alcohol, ethylene glycol, methanol, paracetamol and carbon monoxide

Answer 37

Routine bloods – FBC, U&Es and bone profile, LFTs, Glucose, coagulation, ABG, paracetamol and salicylate levels Specific observations according to toxbase recommendations

Answer 38

ABCDE Empty stomach if appropriate Monitor for set period of time and frequency according to Toxbase recommendations Psychiatric assessment once medically stable

Answer 39

``` Benzodiazepines – Flumazenil Digoxin – Digibind Iron – Desferrioxamine Opiates – Naloxone TCAs – IV bicarbonate Warfarin – Vitamin K Heparin – protamine sulphate Organophosphate poisoning – atropine ```

Answer 40

Aspirin is a weak acid and in overdose causing uncoupling of oxidative phosphorylation leading to anaerobic metabolism and the production of lactate and heat.

Answer 41

Early on patient have vomiting, dehydration, hyperventilation, tinnitus, vertigo and sweating Presentation initially is respiratory alkalosis due to direct stimulation of respiratory centres, later on a metabolic acidosis occurs due to the production of lactate and renal failure Glucose derangements in either direction

Answer 42

Correct dehydration ECG monitoring Activated charcoal if presenting within a hour Check paracetamol and salicylate levels If plasma salicylate > 500mg/L or severe acidosis consider alkalinisation of the urine with 1.5L of 1.26% sodium bicarbonate over 3h aiming for urine pH of 7.4-8 Monitor for Hypokalaemia

Answer 43

``` Serum concentration > 700mg/L Metabolic acidosis resistant to treatment Acute renal failure Pulmonary oedema Seizures Coma ```

Answer 44

In distress – maintaining afloat but struggling | Drowning – onset of suffocation

Answer 45

Do not attempt CPR in water Maintain C spine immobilisation if possible Place prone once out of water as the pressure from water maintains venous return and cardiac output Cardiac arrest occurs secondary to hypoxia, give 100 oxygen and intubation with high PEEP to reverse hypoxia Be wary of hypothermia Be wary of aspiration pneumonia with atypical organisms – follow up CXR in 2 weeks’ time

Answer 46

1. Current – AC more dangerous than DC. AC causes muscle spasm preventing victim from releasing the source and VF whilst DC causes one large contraction and asystole 2. Energy delivered – higher the energy the greater the thermal damage caused 3. Current pathway – the path taken by the current, any passage through the head or chest is associated with worse outcomes 4. Resistance encountered – bone = resistant, fluid and electrolyte rich tissues = least resistance. Low resistance structures, especially those designed to carry current such as heart and nerves do badly 5. Contact duration – the briefer the better

Answer 47

Those that appear dead should be resuscitated first in electric injuries as long and aggressive resuscitation is often successful Treat burns in specialist unit –aggressive fluid replacement as burns penetrate deeper Check for rhabdomyolysis and compartment syndrome Treat arrhythmias as normal

Answer 48

Patients are safe to touch following strikes and should be assessed via trauma pathway Assess visual impairment – electrical cataract formation Tympanic membranes almost always ruptured Generalised muscle aches and neurological deficit tend to resolve within 24 hours Asystole is common but will only lead to death if lasts long enough to induce hypoxia

Answer 49

* Lots and lots of irrigation to get clean with 0.9% saline or clean tap water * Infiltrate with Lidocaine 3mg/kg plain or 7mg/kg with adrenaline, lidocaine vasodilates, adrenaline vasoconstricts so only use in places where stopping the bleeding is important and not in hands or feet * Remove debris, necrotic tissue and foreign bodies * Use absorbable SC sutures to bring skin edges together, if no absorbable then remove within 5 days from the face, 7-10 days from upper limb/body and 14 days from lower limbs. Suture alternatives: Steri-strips and Glues * Antibiotics – only required in animal or human bites * Tetanus – very important, check immunity and vaccinate where appropriate

Answer 50

``` Percentage (%) Concentration (mg/ml) Approximate allowable volume (ml/kg) 0.25%, 2.5mg/ml, 1.12ml/kg 0.5%, 5mg/ml, 0.56ml/kg 1%, 10mg/ml, 0.28ml/kg 2%, 20mg/ml, 0.14ml/kg ```

Answer 51

Catastrophic Haemorrhage | • Before proceeding, check for any catastrophic bleeding that may impair other resuscitation efforts

Answer 52

Airways and C-spine • Is the patient speaking? • Look listen and feel for breathing • Check the airway is clear – use jaw thrust in suspected c-spine injury • If C-spine injury suspected or likely immobile with 3 points of support (head blocks, spinal collar, and straps) preferably patient should be on a trauma board and maintain MILS (manual inline stabilisation)

Answer 53

``` Breathing • Measure sats • Count RR • Consider blood gas • Check tracheal position • Look - depth, expansion and equal movement • Listen using stethoscope • Feel – percuss and feel or surgical emphysema • Look for obvious trauma and bruising • Chest X-ray if indicated ```

Answer 54

Circulation • Pulse • CAP refill • Temperature • BP • Get 2 wide boar IV access and take bloods including Clotting, GS+CM • Auscultate heart • 3 lead ECG monitoring + 12 lead ECG • Fluid balance – check hydration status and urine output with a catheter • Asses for abdominal, limb and pelvis trauma (apply pelvic binder if appropriate)

Answer 55

``` Disability • AVPU/GCS • Temperature (if not already checked • Pupils • Blood glucose • Pain • Head injury and CNS trauma e.g. spine or brain ```

Answer 56

Exposure • Expose the patient completely looking for trauma, rashes, or excess losses • Logroll to assess back and spine • Check medical notes Repeat survey as appropriate

Answer 57

* Quick US assessment for fluid in the peritoneum and pericardium * Fluid is visualised as black * FAST will detect any collection over 200ml * 5 views – pericardial, R and L upper quadrant and pelvis * Extended FAST (eFAST) can detect haemo- and pneumothoraces

Answer 58

Trauma CT (head, spine, chest, abdomen, and pelvis) should be completed within 30minutes of arriving in hospital

Answer 59

* GCS < 9 * Sustained seizure activity * Facial or airway trauma * High aspiration risk * Flail segment or respiratory failure

Answer 60

Consider TXA within 3 hours of injury and continue over 4 hours Involve surgeons early in large haemorrhage Avoid crystalloids as they dilute clotting factors and worsen hypothermia Permissive hypotension to balance tissue hypoxia and clot disruption – maintains to 70-80 in penetrating trauma, 90 in blunt trauma and cerebration in conscious patient Replace fluids like for like

Answer 61

On the floor and 4 more These helps remember the 5 places to look for occult haemorrhage Chest – haemothorax, treat with chest drain Abdomen – surgical intervention Long bones – splinting makes a massive difference Pelvis – fractures Floor – from external bleeding

Answer 62

Cat bites – be wary of infection by Pasteurella Multiocida Management – cleanse wound, do not close punctures wounds unless cosmesis is at risk, give Co-amoxiclav or doxycycline and metronidazole if penicillin allergic.

Answer 63

Humans bites – commonly cause multimicrobial infection including both aerobic and anaerobic bacteria. Management – cleanse wound, do not close punctures wounds unless cosmesis is at risk, give Co-amoxiclav or doxycycline and metronidazole if penicillin allergic. Risk of viral BBI should be considered.

Answer 64

Caused by tetanospasmin exotoxin released from clostridium tetani, spores from the organism are usually found in soil.

Answer 65

Prodrome of fever, lethargy and headache Trismus - painful restriction of opening mouth Risus sardonicus – spasm of the facial muscles causing a teethy grin Opisthotonus – arched back and hyperextended neck Spasms e.g. dysphagia

Answer 66

Tetanus vaccine currently give at 2m, 3m, 4m, 3-5 years and 13-18 years. After 5 doses you are considered to have adequate long-term protection.

Answer 67

Clean wounds – any wound less than 6 hours old, non-penetrating with neglibile tissue damage Tetanus prone wound – puncture type injuries in contaminated environments such as gardening, wounds containing foreign bodies, compound fractures, wounds or burns with systemic sepsis and certain animal bites and scratches. High-risk tetanus prone wound – heavy contamination with material such as soil and manure, wound or burns that show extensive devitalised tissues and wounds or burns that require surgical intervention.

Answer 68

* If patient has had full course with the last dose < 10 years ago then no vaccine nor tetanus Ig required regardless of wound severity. * If patient has had full course but last dose was > 10 years ago then if tetanus prone wound give reinforcing dose of tetanus vaccine, if high risk wounds then give reinforcing dose of vaccine and tetanus Ig * If vaccination history is incomplete or unavailable, then give reinforcing dose of vaccine regardless of wound severity and for tetanus prone and high-risk wounds give reinforcing dose and tetanus Ig.

Answer 69

Metronidazole is the antibiotic of choice

Answer 70

Assess the environment checking it is safe Is the patient responsive – if not proceed to ALS Send for help if needed Clean hands, introduce yourself, check patient ID and allergies Best to remember each stage by working from hands up to the head then down the body ``` Airways • Is the patient speaking? • Look listen and feel for breathing • Check the airway is clear Breathing • Measure sats • Count RR • Consider blood gas • Check tracheal position • Look - depth, expansion and equal movement • Listen using stethoscope • Percuse • Chest X-ray if indicated ``` ``` Circulation • Pulse • CAP refill • Temperature • BP • Get IV access and take blood and cultures if necessary • Auscultate heart • 12 lead ECG and 3 lead monitoring • Fluid balance – check hydration tatus and urine out put ``` ``` Disability • AVPU/GCS • Temperature (if not already checked • Pupils • Blood glucose • Pain Exposure • Expose the patient completley looking for trauma, rashes, or excess losses • Check medical notes ```

Answer 71

SBAR Handover Situation – who you are, where you are, who you are dealing with (age, sex and presentation) and why you were asked to deal with them Background – History of the patient, length of stay Assessment – what you have done and concluded Recommendations – what you would like to happen

Answer 72

1. If patient is unresponsive and not breathing start CPR – 30:2 2. Shout for help 3. Instruct first person that arrive to call double 2 double 2 and bring back the crash trolley 4. Instruct second person to arrive to take over CPR and take your position at the foot of the patient’s bed as team leader 5. Once trolley has arrived attach defibrillator and secure airway 6. As soon as ready stop CPR to assess rhythm and pulse 7. Once assessed continue CPR and follow the Cardiac arrest algorithm 8. Obtain secure airway as soon as possible including capnography and listen for air entry on both sides 9. Request and check patients notes 10. Assess rhythm every 2 minutes

Answer 73

In the time between rhythm checks through the 4 H’s and 4 T’s 1. Hypoxia – give oxygen and secure airway 2. Hypovolaemia – gain Ivor IO access and give fluid bolus or blood if bleeding 3. Hypothermia – rewarm slowing using active heating 4. Hyperkalaemia/Hypokalaemia/Metabolic – get ABG/VBG to assess 5. Thrombus – check calves and organise angiogram 6. Tamponade – request focused cardiac US assessment 7. Tension pneumothorax – listen for air entry and check tracheal position 8. Toxins – check drug chart

Answer 74

Shockable rhythms These include pulseless-Ventricular tachycardia or ventricular fibrillation. After the rhythm is assessed the team leader should hand over leadership temporarily to the person in charge of the defibrillator. Shocks should be given at trust recommended energy levels or if unsure then highest option on defibrillator. After shock continue CPR for 2minutes then re-assess rhythm. Make sure everyone (except the individual on chest compressions) stands clear of the bed and oxygen is well away (unless in a closed system) whilst the defibrillator charges. Once charged ask the person on the chest to stand clear then administer the shock. Once administered everyone should resume their positions and the person in charge of the defibrillator hands back over to the team leader. After the 3rd shock administer 1mg of 1:10’000 Adrenaline IV along with 300mg of Amiodarone. Repeat the adrenaline after every other shock. The amiodarone can be repeated at 150mg after the 5th shock is given but not again.

Answer 75

Non-Shockable Rhythm These include Asystole and any other electrical activity that does not produce a pulse, termed (PEA – pulseless electrical activity). Adrenaline 1mg 1:10’000 should eb administered as soon as available and then at every other shock and those administering ALS should continue CPR for 2 minutes then re-assess the rhythm.

Answer 76

ROSC (return of spontaneous circulation) When this occurs at a rhythm check or becomes obvious during CPR stop chest compressions. Maintain airway and breathing support as necessary, if they begin to not tolerate being tubed then remove this. ITU should be informed as well as the patient’s family as soon as possible. Continue treating the cause and someone should complete regular ABCDE assessments. Remember to thank the team, document everything that happened and the order it happened in and then and if possible, have a team de-brief.

Answer 77

This described three physiological parameters often seen in trauma – hypothermia, acidosis, and coagulopathy, all of which work to worsen each other. This occurs as a result of a cascade of inflammatory markers and neuroendocrine compensation. The combination can lead to multiple organ failure even after patients are initially stabilised.

Answer 78

Temperature < 36 degrees in trauma (normally < 35 degrees) because it is associated with such poor outcomes. Hypothermia dampens the CVS compensatory response to shock worsening tissue hypoxia and so worsening or causing acidosis. Temperature also decreases clotting and platelet function.

Answer 79

The elderly Intoxicated Burnt Exposed patients

Answer 80

This occurs because of tissue hypoperfusion and subsequent lactic acid production, further exacerbated by respiratory acidosis from hypoventilation (flail segments, opiates/alcohol, and COPD). As tissues are not able to normally respire the heat usually produced isn’t available and so encourages hypothermia.

Answer 81

This occurs in 25% of trauma patients and increases mortality by 4x. Without clotting haemorrhage can continue unchecked, worsening tissue perfusion (and so acidosis) and loss of circulating volume reduces core temperature and metabolic rate exacerbating hypothermia.

Answer 82

1. Airway obstruction – use airway adjuncts and clear airway before moving on, have suction readily available as vomiting and aspiration is likely. 2. Tension Pneumothorax – one way valve in lung or chest wall, this causes compression of the mediastinum and reduced venous return eventually leading to obstructive shock. Decompress with a wide bore cannula in 2nd intercostal space midclavicular line. 3. Open Pneumothorax – large chest wall defects, occlude with sterile dressings on 3 sides and complete seal with chest drain insertion. 4. Massive haemothorax – is the accumulation of >1500ml of blood in the hemithorax and can case shock. Treat with large bore chest drain and blood replacement. Thoracotomy may be required 5. Flail segment – multiple rip fracture causing part of the chest wall to suck inwards on inspiration reducing ventilation of the lungs. Results in serious hypoxia – treat with high flow oxygen and intubation if required. 6. Cardiac Tamponade – Beck’s triad (rising JVP, falling BP and muffled heart sounds) are difficult to assess so rely on US to rule out. Pericardial aspiration can buy time until thoracotomy can be performed.

Answer 83

Questions to answer – is the peritoneum breached, are the abdominal organs damaged and do I need a surgeon?

Answer 84

Penetrating injuries – liver most commonly affected by stab wounds, almost all penetrating abdominal injuries require urgent laparotomy/laparoscopy.

Answer 85

Blunt trauma – deceleration injuries will tear organs from their support and surrounding vasculature. Pay close attention to spleen (ruptured) and liver (torn from vena cava).

Answer 86

With the pelvis because it is a ring structure 1 fracture in the elderly is usually very stable. 2 or more fracture however can be very unstable and >25% will have internal injuries.

Answer 87

When assessing for pelvic injury one senior clinician should compress to assess.

Answer 88

``` Leg length discrepancy Abdominal distention Loin bruising Perineal or scrotal haematoma PV bleeding Palpable haematoma ```

Answer 89

* Avoid hypotension and keep systolic > 90mmHg but do not overload or use glucose fluids * Avoid hypoxia and hypercapnia – can hyperventilate patients to cause vasoconstriction and lower ICP * Opiates can be used safely * Mannitol causes osmotic diuresis and reduced ICP but avoid systemic hypotension as above * Treat seizures aggressively * Raise head above 30 degrees to improve jugular venous return * Avoid hyperglycaemia and hyperpyrexia