Emergency Medicine Flashcards
Define anaphylaxis
Airway, breathing and circulation problems with associated skin changes
Give 3 signs of anaphylaxis
Anxiety Lightheadedness LOC Confusion Headache Hypotension Tachycardia Skin flushing Hives Itching Runny nose Angioedema Cough Hoarseness Odynophagia SOB Wheeze Vomiting Diarrhoea Cramping
How is anaphylaxis managed?
A-E assessment Call for help Lie patient flat and raise legs Give adrenaline (0.5ml of 1:1000 IM) Establish airway Give high flow oxygen, IV fluid challenge, chlorphenamine (10mg IM/IV), hydrocortisone (200mg IM/IV)
How are acute asthma attacks classified by severity? Give a feature of each
Moderate - PEFR 50-75% best/predicted
Severe - PEFR 33-50%, cannot complete sentences
Life threatening - PEFR <33%, SpO2 <92%, silent chest, normal PCO2
Near fatal - raised PCO2, mechanical ventilation
Give 2 indications for NIV
COPD - pH <7.35, pCO2 >6.5, RR >23, persistent
Neuromuscular disease
Obesity
Give an absolute and relative contraindication to NIV
Absolute - severe facial deformity, facial burns, fixed upper airway obstruction
Relative - pH <7.15, GCS <8, confusion/agitation, cognitive impairment
Define trauma
Bodily harm resulting from exposure to an external force or substance (mechanical, thermal, electrical, chemical or radiant) or a submersion
This bodily harm can be unintentional or violence-related
How can trauma be classified by mechanism?
Blunt Penetrating Acceleration/deceleration Burn Crush Fall Immersion/submersion
What approach should be used for a trauma patient?
Catastrophic haemorrhage Airway C-spine Breathing Circulation Disability Everything else
How can the risk of c-spine injury be assessed to determine whether a patient requires imaging?
C-spine XR needed if any of the following are present:
High risk factors - age >=65, dangerous mechanism, paraesthesia
Other factors - not ambulatory/sitting in ED, immediate neck pain, midline tenderness, unable to rotate neck
What options are available for c-spine immobilisation?
Collar
Blocks and tape
How are c-spine x-rays interpreted?
Lateral view - adequacy, alignment, bones, cartilage and corticated ring, prevertebral soft tissues (AABCCP)
AP - adequacy, alignment, bone, spaced spinous processes, soft tissue (AABSS)
How is the adequacy of a c-spine XR determined?
Check if C1-T1 can be seen (8 vertebrae)
What lines are used to check alignment on a c-spine XR?
Anterior vertebral line
Posterior vertebral line
Spinolaminar line
Posterior spinous line
What does a crack in the corticated ring mean?
Hangman fracture
How are prevertebral soft tissues assessed on c-spine XR?
Above C4 they can be 1/3rd of the width of a vertebral body
Below C4 they can be the whole width
What are the 3 views taken on c-spine XR?
Lateral
AP
Open mouth
Give 3 signs of a base of skull fracture
Battle’s sign
Raccoon eyes
CSF/blood leakage from ear/nose (haemotympanum, rhinorrhoea, otorrhoea)
Loss of function of what tracts are responsible for decorticate and decerebrate posturing?
DeCortiCate - Corticospinal
DeceRebRate - Rubrospinal
What are the indications for CT in head injury?
High risk - GCS <15 at 2 hours after injury, suspected open/depressed skull fracture, vomiting >=2 times, age >=65
Medium risk - amnesia >=30 mins before impact, dangerous mechanism
What causes a ‘blown pupil’?
Herniation of uncus through tentorium
What are the 4 types of rewarming in trauma?
Passive (blankets)
Active external (bair hugger)
Active internal (warm fluids, cavity lavage)
Extracorporeal
How should a secondary survey be structured in trauma?
Head to toe examination
Complete neurological examination
AMPLE history - allergies, medications, PMH, last eaten/drank, events related to injury
How should wounds be assessed?
A-E assessment
What information should be obtained in the history for a wound?
Mechanism of injury
Time of injury
PMH
Occupation and hand dominance
Give 2 things to consider on assessing a wound
Damage to regional structures Need for XR Need for anaesthetic for proper examination Control of bleeding Need for washout/debridement
Name 3 types of wounds
Incisional Laceration Abrasion Puncture Penetration Contusion Haematoma
What options are available for wound closure?
None Glue Steristrips Sutures Staples Skin graft
What type of wounds are fit for primary closure?
Clean
Minimal contamination
Recent
Well opposed
What type of wounds are fit for secondary closure?
Puncture Abrasion Late presentation Bites Abscesses
What type of wounds should never be closed?
Bites
What should be considered for bite wounds?
Do not close Always XR Antibiotics Tetanus status BBV Follow-up
What is the maximum dose of lignocaine? What can be used to increase this?
3mg/kg
+ adrenaline = 7mg/kg
Name 3 types of suture and their use
Simple interrupted - shallow, no tension
Continuous - scalp, long
Locking continuous - moderate tension, haemostasis
Subcuticular - cosmetic
Vertical mattress - eversion, reduce dead space, decrease tension
Horizontal mattress - fragile skin, high tension
Percutaneous/deep - reduce dead space, decrease tension
What information should be given to the patient with a wound you have managed before they leave?
Dressing information Keep it dry and clean Warn about infection and signs to look out for Timeline for suture removal (7-10 days) Healing/scarring
What is the difference between a burn and a scald?
Burn - dry thermal damage to the skin and underlying tissues (e.g. flame, electrical)
Scald - wet thermal damage to the skin and underlying tissues (e.g. boiling water)
How is the degree of a burn classified?
Superficial - erythema, mild pain, 7-14 days to heal
Superficial partial - wet pink blisters, moderate pain, 2-4 weeks to heal
Deep partial - drier red may have blisters, sluggish/absent CRT, pain may not be present, 3-8 weeks to heal with severe scarring, needs grafting
Full thickness - dry white, absent CRT and pain, needs grafting
How is the area of a burn calculated?
Lund and Browder method
Rule of 9s
How is fluid replacement for a burn calculated?
Parkland formula
Volume of Ringer’s lactate = 4ml x BSA x weight (kg)
Give half of this in the first 8 hours and the rest over the next 16 hours
How should the fingers be assessed for tendon injury?
FDP - keep PIP of the finger being tested extended and ask the patient to flex DIP
FDS - keep all fingers extended except one being tested, ask patient to flex PIP
What signs are indicative of flexor tenosynovitis?
Kanavel’s signs - tenderness over flexor tendon, symmetrical swelling of the finger (sausage), finger held in flexion, extreme pain on passive extension
How should a toxicology presentation be assessed?
A-E assessment Call for help Local guidelines/algorithms Interventions and re-assessment Documentation Check TOXBASE
Define a toxidrome
Classic constellation of signs and symptoms caused by a dangerous level of toxins in the body, often the consequence of an overdose, which can be used to help identify the culprit drug
Give 3 signs/symptoms of an anticholinergic overdose
Confusion Agitation Hallucination Hyperthermia Dry mouth Urinary retention Reduced bowel sounds Mydriasis Flushed skin Tachycardia Hypertension Tachypnoea Shaking Myoclonus
How is an anticholinergic overdose managed?
Supportive measures
Benzodiazepines for agitation
Sodium bicarbonate for QRS prolongation
Name an anticholinergic drug which could potentially be the cause of an overdose
Antihistamines
Tricyclic antidepressants
Antipsychotics
Name a sympathomimetic drug which could potentially be the cause of an overdose
Cocaine
Amphetamine
Methamphetamine
Give 3 signs/symptoms of sympathomimetic overdose
Mydriasis Hyperthermia Lacrimation Urination Diaphoresis Hypertension Tachycardia Tachypnoea Increased bowel sounds Agitation Diarrhoea Hallucinations Paranoia
How is sympathomimetic overdose managed?
Benzodiazepines
Aspirin and GTN for chest pain
Cooling +/- dantrolene
Name a opioid drug which could potentially be the cause of an overdose
Heroin
Morphine
Methadone
Give 3 signs/symptoms of opioid overdose
Coma CNS depression Pinpoint pupils Respiratory depression Needle marks Hypothermia Bradycardia Hypotension
How is opioid overdose managed?
Naloxone
Name a benzodiazepine drug which could potentially be the cause of an overdose
Diazepam
Street valium
Give 3 signs/symptoms of benzodiazepine overdose
Coma CNS depression Respiratory depression Hypotension Bradycardia Rhabdomyolysis Hypothermia
How is a benzodiazepine overdose managed?
Supportive measures
Flumazenil (try to avoid)
What information is important to ascertain in paracetamol overdose?
Timescale - within 1 hour, 1-8 hours, 9-24 hours, >24 hours
Type - staggered, therapeutic, all at once
Give 3 signs/symptoms of paracetamol overdose
Nausea and vomiting Lethargy RUQ pain Hepatomegaly RUQ tenderness Abnormal LFTs Confusion Jaundice Encephalopathy Hypoglycaemia Lactic acidosis Coagulopathy AKI
What dose limits can guide likelihood of toxicity?
<75mg/kg over 24 hours - unlikely
75-150mg/kg over 24 hours - uncommon but possible
>150mg/kg over 24 hours - risk of serious toxicity
How is paracetamol overdose managed?
N-acetylcysteine (most effective within 8 hours of ingestion)
SNAP protocol
Need to plot dose
What are the indications for N-acetylcysteine in paracetamol overdose?
Above nonogram line
Dose >150mg/kg
Biochemical evidence of liver injury
Clinical evidence of liver failure
What serious adverse effect can N-acetylcysteine have?
Anaphylaxis
Give 3 signs/symptoms of salicylate overdose
Nausea Vomiting Tinnitus Deafness Lethargy Dizziness Sweating Pyrexia Respiratory alkalosis Seizures Coma
How is salicylate overdose managed?
Urinary alkalinisation with IV sodium bicarbonate
Haemodialysis
Give 3 signs/symptoms of beta-blocker overdose
Bradycardia Hypotension AV block Syncope HF Bronchospasm Hypoglycaemia Hyperkalaemia Coma Seizure
How is beta-blocker overdose managed?
Bradycardia - atropine Resistant - glucagon, high dose insulin Propranolol - IV sodium bicarbonate if wide QRS Sotalol - monitor for Torsades Consider pacing
What one thing do you want to know about a beta-blocker or calcium channel blocker overdose?
Immediate or modified release
Give 3 signs/symptoms of calcium channel blocker overdose
Bradycardia First degree heart block Hypotension Refractory shock MI Mesenteric ischaemia Hyperglycaemia Hyperkalaemia Acidosis Vomiting Seizures Pulmonary oedema Renal failure
How is calcium channel blocker overdose managed?
IV fluids
Atropine
10% calcium gluconate
High dose insulin
Give 3 signs/symptoms of tricyclic antidepressant overdose
Drowsiness Tachycardia Hypotension Dry mouth Blurred vision Constipation Urinary retention Seizure Prolonged GT Broad complex arrhythmia Coma Anticholinergic syndrome
How is tricyclic antidepressant overdose managed?
IV bicarbonate
Intubate ASAP
What are the antidotes for digoxin, iron, methotrexate and sulphonylureas?
Digibind
Desferrioxamine
Folic acid
Octreotide/glucose
What are the antidotes for antipsychotics, lithium, warfarin and heparin?
Procyclidine
IV fluids/haemodialysis
Vitamin K/prothrombin complex
Protamine sulphate
What are the 2 main toxicology emergencies?
Serotonin syndrome
Neuroleptic malignant syndrome
Name 2 drugs which can cause serotonin syndrome
SSRIs TCAs MAOIs Cocaine MDMA
Give 3 signs/symptoms of serotonin syndrome
Altered mental status Autonomic hyperactivity Neuromuscular abnormality Spontaneous clonus Tremor Hyperreflexia Ocular clonus and agitation, sweating or hypertonia with fever
How is serotonin syndrome managed?
Consult TOXBASE Stop all serotonergic agents ECG Bloods including CK Agitation - diazepam/midazolam Hyperthermia - fans/ice packs Severe - cyproheptadine/chlorpromazine
What are the 2 main causes of neuroleptic malignant syndrome?
Recently started antipsychotics
Stopping Parkinson’s drugs abruptly
Give 3 signs/symptoms of neuroleptic malignant syndrome
Pyrexia Diaphoresis Tachycardia Hypertension Muscle rigidity Agitated delirium with confusion Reduced reflexes Lead pipe rigidity Normal pupils Reduced GCS
How is neuroleptic malignant syndrome managed?
Stop antipsychotics
IV fluids
Dantrolene
Bromocriptine
Give 3 signs/symptoms of carbon monoxide poisoning
Pounding headache Nausea and vomiting Vertigo Ataxia Confusion Tachycardia False elevation of O2 saturation Pink skin and mucosa Rhabdomyolysis Lactic acidosis DIC
How can O2 saturation be checked in carbon monoxide poisoning when falsely elevated?
VBG/ABG - carboxyhaemoglobin levels
How is carbon monoxide poisoning managed?
High flow/hyperbaric O2
Manage complications
Define frailty
Health state related to ageing Increased vulnerability to stressors Loss of biological reserves Failure of homeostatic mechanisms Accumulation of damage to cells in multiple organs
Why is frailty important to consider in EM?
Frail patients have disproportionate changes in their health following seemingly small stressors, with a prolonged recovery period, and potential inability to return to previous functional levels
Why is it important to identify frailty in EM?
Frailty should trigger a comprehensive geriatric assessment (CGA) - MDT approach
How should a falls history be approached?
Before
During
After
Collateral history
What investigations should be done in a patient with a fall?
ECG XR (chest, limb, pelvis)/CT Urinalysis Bloods - FBC, U&Es, CRP, LFTs, CK, troponin, D-dimer, INR, G&S FAST scan
What should be considered in the management of a fall in ED?
Treat consequences
Social circumstances preventing safe discharge
PT/OT assessment
What drugs cause meiosis?
Opiates Clonidine Antipsychotics Ondansetron Mirtazepine
What drugs cause mydriasis?
Benzodiazepines Alcohol Anticholinergics Seretonergics Cocaine Amphetamines MDMA
What is the toxidrome for anticholinergics?
Blind as a bat (mydriasis) Hot as a desert (hyperthermia) Mad as a hatter (delirium) Red as a beet (flushed skin) Dry as a bone (dry mucous membranes)
What is the treatment for anticholinergic toxicity?
Cooling
Benzodiazepines (agitation)
Sodium bicarbonate (QRS prolongation)
What is the toxidrome for cholinergics?
Pin point pupils Frothing at the mouth Sweating Crying Running nose Vomiting Urination Diarrhoea
What is the treatment for cholinergic toxicity?
Intubate (respiratory depression)
Atropine (severe)
Pralidoxime (neuromuscular dysfunction)
