Emergency Medicine Flashcards
What is shock?
Definition – circulatory failure resulting in inadequate organ perfusion.
What are the clinical features of shock?
Hypotension < 90 SBP or MAP < 65 with evidence of tissue hypoperfusion e.g. mottled skin, urine output < 0.5ml/kg/hr or serum lactate > 2mmol/l Reduced GCS Agitation Pallor Cool peripheries Tachycardia Slow CAP refill Tachypnoea Oliguria
What are the 4 main classes of shock?
Hypovolaemic – Blood loss or fluid loss
Cardiogenic – pump failure such as ACS, arrhythmias, valvular disorders etc.
Distributive – poor distribution of blood to the tissues such as in spinal, septic and anaphylactic
Obstructive – obstruction to the cardiovascular system such as in massive PE, pneumothorax or cardiac tamponade
What are the parameters for class 1 shock?
Heart rate <100
Systolic BP Normal
Pulse Pressure Normal
Cap Refill Normal
Respiratory rate 14-20
Urine output >30ml/h
Cerebral perfusion
Normal and/or anxious
Blood loss <750ml (15%)
What are the parameters for class 2 shock?
Heart rate >100
Systolic BP Normal
Pulse Pressure Normal
Cap Refill >2s
Respiratory rate 20-30
Urine output 20-30ml/h
Cerebral perfusion
Anxious and/or hostile
Blood loss <1500ml (30%)
What are the parameters for class 3 shock?
Heart rate 120-140
Systolic BP Low
Pulse Pressure Narrow
Cap Refill >2s
Respiratory rate >30
Urine output 5-20ml/h
Cerebral perfusion
Anxious and/or confused
Blood loss <2000ml (40%)
What are the parameters for class 4 shock?
Heart rate >140
Systolic BP Unrecordable
Pulse Pressure
V.Narrow/absent
Cap Refill Absent
Respiratory rate >35
Urine output Negligible
Cerebral perfusion
Confused and/or unresponsive
Blood loss >2000ml (40%)
How should you assess someone in shock?
ABCDE – 2 large bore cannula and ECG very important
Cold and clammy suggest cardiogenic or fluid loss
Assess JVP – if raised suggestive of cardiogenic shock
Assess abdomen for trauma or internal bleeding
When replacing fluids in shock how should this be done?
Replace like for like and treat cause
What is the definition of sepsis?
Life-threatening organ dysfunction caused by dysregulated host response to infection.
What is the definition of septic shock?
Septic shock = lactate > 2mmol/l despite adequate fluid resuscitation or requirement for vasopressors to maintain MAP >65mmHg.
What are the red flag features of sepsis?
Responds only to voice or pain/unresponsive
Acute confusion state
Systolic BP < 90 (or drop >40 from normal)
Heart Rate > 130
Respiratory rate > 25
Oxygen requirement to maintain sats > 92%
Non-blanching rash, mottled/ashen/cyanotic
Oliguria in past 18 hours
Lactate > 2mmol/l
Recent chemotherapy
What are the amber flag features of sepsis?
Relatives concerned about mental status
Acute deterioration in functional ability
Immunosuppressed
Trauma/surgery/procedure in last 6 weeks
Respiratory rate 21-24
Systolic BP 91-100
Heart rate 91-130 or new dysrhythmia
Oliguria in last 12-18 hours
Temperature < 36
Clinical sign of wound, device or skin infection
How is sepsis managed?
- Take blood cultures
- Monitor urine output
- Check lactate levels
- Give high flow oxygen 15L via non-rebreathe mask
- Give IV broad spectrum antibiotics
- Give fluid resuscitation
What is anaphylactic shock?
Definition – Type IgE mediated hypersensitivity reaction causing release of histamine and other immune agents that cause capillary leakage, oedema of the larynx, lips and tongue and urticaria.
What are the clinical features of Anaphylactic shock?
Itching Sweating Erythema Urticaria Oedema Wheeze Laryngeal obstruction Cyanosis Tachycardia Hypotension Diarrhoea and vomiting
What investigations should you consider after stabilising an anaphylactic patient?
Tryptases 1-6 hours after suspected anaphylaxis
What is the management process for anaphylaxis?
ABCDE
Remove the cause
Raise the feet to help restore circulation
Give Adrenaline 0.5mg 1:1000 IM and repeat every 5 minutes as required
Secure IV access and administer Chlorphenamine 10mg IV and Hydrocortisone 200mg IV
Fluid resuscitation – 500ml bolus STAT, repeat as necessary
If wheeze treat as for acute asthma
If still hypotensive contact ITU – may require ventilation, IV adrenaline and IV aminophylline
What causes flash pulmonary oedema/acute heart failure?
Cardiac – Left ventricular failure, valvular failure, arrhythmias, or malignant hypertension
Adult respiratory distress syndrome from any cause e.g. trauma, malaria, drugs, etc.
Fluid overload
Neurogenic e.g. head injury
What are the clinical features of flash pulmonary oedema/acute heart failure?
Dyspnoea
Pink frothy sputum
Distressed and pale
Cardiogenic shock so shock symptoms
How should flash pulmonary oedema/acute heart failure be investigated?
CXR ECG Routine bloods and troponin and ABG Consider Echo BNP
How should flash pulmonary oedema/acute heart failure be managed?
- Sit up and give high flow oxygen
- IV access and monitor ECG – treat any arrhythmias
- Investigations as above
- Opiates pain medication, IV diamorphine
- Loop diuretics (no change in mortality) – furosemide 40-80mg IV slowly
- GTN spray unless systolic BP < 90
- If Systolic > 100 start infusion of isosorbide dinitrate
If continued deterioration, then:
- Further doses of furosemide 40-80mg
- Consider CPAP
- Increase nitrate infusion without dropping systolic < 100
- Consider alternate diagnosis
How should someone with a Head trauma be assessed and who should be involved?
ABCDE
Involve ITU if airway compromised
Involve neurosurgeons early especially in dropped GCS or raised ICP
What are the NICE guideline for CT requirement within 1 hour?
- GCS < 13 on initial assessment or GCS < 15 at 2 hours
- Focal neurological deficit
- Suspected open or depressed skull fracture or signs of basal skull fracture
- Post traumatic seizure
- Vomiting more than once
What are the NICE guideline for CT requirement within 8 hours?
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)
What are the requirement for a CT cervical spine?
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
What are the requirement for a plain radiograph of the cervical spine?
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
What causes acute upper GI bleeds?
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
How should patients presenting with acute upper GI bleeds be assessed?
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.
How should acute upper GI bleeds be managed in the acute setting?
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
After initial stabilisation how should variceal vs non variceal bleeds be managed?
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.
How can we calculate the surface area of a burn?
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
What are the 4 classifications of depth of burn?
- First degrees – Superficial epidermal – red and painful
- Second degree – Partial thickness (superficial dermal) – painful, pale pink and blistered
- Second degree – Partial thickness (deep dermal) – reduced sensation, white and non-blanching erythema
- Third degree – Full thickness – painless, grey-white, brown, black, no blisters
What are the criteria for referral to a specialist burns unit?
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
How should all burns be managed acutely?
- ABCDE
- Irrigate with cool (note iced) water as soon as possible for 10-30 minutes. If chemical, brush off any left over chemicals before irrigation
- 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
How should superficial epidermal and dermal burns be managed after the acute phase?
Superficial epidermal – analgesia and emollients
Superficial dermal – cleanse wounds, leave blister intact, non-adherent dressing, avoid topical cream and review in 24 hours
When is fluid resuscitation required for burns and how do we calculate the volume required?
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)
When is an Escharotomy required?
Consider Escharotomy if full circumference burns restricting breathing
What complication of burns should we be worried about that may be exacerbated or accelerated by fluids?
Be wary and manage compartment syndromes – fluids may exacerbate or accelerate
What happens during smoke inhalation?
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.
How do we detect the level of poisoning by CO?
COHb levels do not directly correlate to level of poisoning as this includes baseline from smoking and environment. Use Nomograms to extrapolate peak levels.
How should inhalation of smoke be managed?
Manage with 100 oxygen to displace CO and cyanide
Involve ITU and anaesthetists early
Enlist expert help in cyanide poisoning
What is hypothermia and what is the vascular and endocrine response to it?
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.
What causes hypothermia in the old vs young?
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
How can you easily tell whether someone is mildly hypothermic or severely hypothermic?
Shivering – mild hypothermia (usually 32-35 degrees)
Non shivering despite core temp < 35 – severe hypothermia (usually < 32 degrees)
