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Medicine finals Prithvi > Emergency medicine and critical care > Flashcards

Emergency medicine and critical care Flashcards

1
Q

Definition of major trauma?

A

Serious and often multiple injuries where there is a strong possibility of death or disability.

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2
Q

What is the Injury severity score and what score is defined as major trauma?

A

Developed to specifically score multiple traumatic injuries. Score of 15 or more is defined as major trauma.

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3
Q

Epidimiology of trauma

A

most trauma in elderly ppl (falls).

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4
Q

What is the primary survey mnemonic in major trauma care?

A 
C = Control catastrophic haemorrhage
A = Airway with C-spine protection
B = Breathing with ventilation
C = Circulation with haemorrhage control
D = Disability: Neurological status
E = Exposure/Environment
(and
DEFG - Don't Ever Forget GLUCOSE.)
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5
Q

What is the most common injury which causes long term morbidity (it is also the most expensive injury to the NHS)

A

Scaphoid injury

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6
Q

Give the different types of mechanisms of injury and examples of events that can cause each type of injury

A
  1. Blunt force (RTCs, assaults and falls from heights)
  2. Penetrating trauma (stabbings - injury follows track of knife - relatively predictable and better outcomes)
  3. Ballistic penetrating trauma (shootings - type of injury depends on bullets used, kinetics, bullets can tumble/cause displacement of tissues)
  4. Sporting injuries (specific injury risks for specific sports -
    splenic/renal injury - rugby
    open fractures- motorcross
    fighting - football)
  5. Blast injuries
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7
Q

What are the different types of injuries caused by a blast injury?

A
  1. Primary (blast disrputps gas filled structures in body eg small bowel perforation, pneumothoraces, etc.)
  2. Secondary (impact of airborne debris)
  3. Tertiary (transmission of body of patient)
  4. Quaternary (all other forces)
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8
Q

What are the priorities in major trauma care?

A

Stop bleeding
Prevent hypoxia
Prevent acidaemia
avoid traumatic cardiac arrest (very poor prognosis)

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9
Q

What is ATMIST? (SBAR equivalent used in trauma)

A 
Age
Time
Mechanism
Injuries
Signs (Obs)
Treatments
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10
Q

C Management

A 
Clear any clots obscuring the bleeding source
Direct pressure (VERY important)
More direct pressure
Indirect pressure
Torniquet
Haemostatic agents (ie celox)
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11
Q

Acc. to NICE, what is the expected time frame for securing an airway in Major trauma?

A

45 mins

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12
Q

What are some absolute indications for intubation?

A
  • Inability to maintain and protect own airway regardless of conscious lvl
  • Inability to maintain adequate oxygenation with less invasive manoeuvres (PaO2<10kPa)
  • Inability to maintain normocapnia (spontaneous PaCo2 should be between 4.0 kPa - 6.0kPa)
  • deteriorating conscious lvl (>/= 2 points on motor scale)
  • significant facial injuries
  • seizures
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13
Q

In a burns/blast patient, you want to intubate them before there is a problem with the airway so consider whether or not the airway is compromised or at risk of compromise.
Early teacheal intubation shd be considered in the presence of?

A
  • hypoxaemia or hypercapnia
  • deep facial burns
  • full thickness neck burns
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14
Q

What are some relative indications for intubation?

A
  • haemorrhagic shock, particularly in the presence of an evolving metabolic acidosis. Early and repeated blood gases crucial.
  • agitated patient (remember hypoxia and hypovolaemia are prime causes of agitation)
  • multiple painful injuries
  • transfer to another area of the hospital/expected clinical course (eg vascular angio/theatres/GITU)
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15
Q

What is the correct procedure to intubate?

A

RSI - Rapid sequence induction

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16
Q

Indications for immobilisation?

A
  • mechanism of injury
  • low GCS
  • head and neck injury
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17
Q

A+C management summary

A
  • immobilise C-spine
  • provide oxygen
  • assess airway - look listen feel
  • proceed to RSI if indicated
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18
Q

what is ATOM FC?

A 
mnemonic used to assess immediately life threatening thoracic injuries asap as it may kill patient- 
Airway obstruction/disruption
Tension pneumothorax
Open pneumothorax
Massive haemothorax
Flail chest
Cardiac tamponade
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19
Q

Signs of tension pneumothorax

A

textbook –

  • diminished breath sounds
  • hyperesonance
  • distended neck veins
  • deviated trachea (late sign)
  • hypoxia
  • tachycardia
  • hypotension

practical –
-consistent history (blunt force trauma to chest)
-air hunger/agitation
-hypoxia
-hypotenstion
if all these present, tension pneumothorax until proven otherwise and treat before confirmation

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20
Q

Management of pneumothorax

A
  • Thoracostomy followed by large bore chest drain.
    OR
  • needle thoracocentesis - 2nd ICS midclavicular line. problem with this is with more overweight and muscular individuals, the needle doesn’t reach the thoracic cavity. If that doesn’t work, then try between 4th and 5th rib, 5th ICS mid-axillary line (triangle of safety)
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21
Q

Definition of massive haemothorax and signs and management?

A
  • defined as over 1500 mL blood
  • reduced air sounds, hyporesonant
  • obtain IV access prior to decompression
  • > 1500mL blood or >200mL/hr = consider urgent thoracotomy
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22
Q

What is an open pneumothorax?

A
  • wound to chest wall communicating with pleural cavity
  • more than 2/3 aperture of trachea
  • air moves down pressure gradient into pleural space
  • wound seals on expiration - which will eventually turn it into a tension pneumothorax
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23
Q

What is Flail chest?

A
  • fracture of 2 or more ribs in 2 or more places
  • floating section ribs
  • moves paradoxically during respiration
  • ventilatory failure
    tx - mechanical ventilation
24
Q

Signs of cardiac tamponade?

A

Beck’s triad -

  • hypotension
  • diminished heart sounds
  • distended neck veins

clinical clues -

  • blunt force or penetrating trauma to chest
  • hypotension
  • USS
25
Q

management of cardiac tamponade?

A

resuscitative thoracotomy

26
Q

What are some secondary survey injuries? (hard to diagnose in primary survey and do not cause immediate problems)

A
  • simple pneumothorax
  • aortic injuries
  • diaphragmatic injuries
  • fractured ribs
  • lung contusion
  • cardiac contusion
27
Q

What are the 3 components of anesthesia?

A
  1. hypnosis
  2. muscle relaxation
  3. Analgesia
28
Q

what are the 3 levels of hypnosis and what type of anaesthetic are each of them achieved using?

A

Awake (local anaesthetics) - sedated (sedation)- asleep (general)

29
Q

what types of local anaesthetic techniques are there?

A
  1. Local - minor surgery
  2. regional - target specific nerves eg brachial plexus, sciatic. usually for post op pain relief
  3. neuraxial - subarachnoid block (Spinal/epidural). for intraoperative and postoperative use
30
Q

What is the diff bw spinals and epidurals?

A
  1. spinal or subarachnoid block - needle goes into CSF THROUGH spinal ligaments and dura. anaesthetic agent given as a bolus and lasts around 2hrs. rapid onset and smaller dose required. injected at lumbar region, below where spinal cord ends. same target as LP. mainly used for anaesthesia
  2. epidural - needle goes BETWEEN spinal ligaments and dura and a catheter is passed and anaesthetic agent given as an infusion. slow onset and larger dose is required. thoracic or lumbar. can be used for anaesthesia or analgesia.
31
Q

For spinals and epidurals, where must the incision be facilitated?

A

Below the highest nerve root affected by the block (which normally means below T10 dermatome). for incisions above this level, a GA will be required.

32
Q

How do local anaesthetics work?

A
  • reversibly block Na+ channels and inhibit generation of action potentials within nerve cells.
  • small diameter and unmyelinated nerve fibres are blocked first. order of block -
    1. B fibres - autonomic (vasodilation)
    2. C and A delta fibres - pain and temperature
    3. A beta fibres - light touch and pressure
    4. A alpha and A gamma fibres - motor and proprioception
33
Q

What drug are local anaesthetics usually combined with and why?

A

Adrenaline because it causes local vasoconstriction resulting in -

  • reduced bleeding
  • prolonged local anaesthetic effect through reduced systemic absorption from tissues.
  • DO NOT use adrenaline near end arteries - fingers, toes, penises, etc.*
34
Q

give details about Lidocaine

A

local anaesthetic agent.
immediate onset. 15 mins duration
small procedures - laceration repair, chest drains, big cannulae

35
Q

give details about Bupivacaine

A

local anaesthetic agent. regional, spinal and epidural.

10 min onset. 2 hrs anaesthesia. 12-24 hrs analgesia.

36
Q

What’s important to remember about opioids and epidurals?

A

Epidural infusions usually have opioids running through them as well so don’t prescribe additional opioids for these pts by any route.

37
Q

Sedation means any drugs given to acheive?……

A
  • reduce anxiety (anxiolysis)
  • reduce conciousness
  • reduce irritability (of the airway)
  • induce amnesia
38
Q

An example of short term sedative

A

IV Midazolam. used in endoscopy, regional anaesthesia

39
Q

An example of long term sedative

A

Infusions: IV propofol +/- alfentanil. used in intensive care, intubated patients for theatre or transfer

40
Q

what are the 2 steps of General anaesthesia?

A
  1. induction (sending to sleep) and

2. Maintenance (keeping asleep)

41
Q

What are the modes of administration used for hypnotic drugs?

A

Inhalation and IV.

both can be used to induce or maintain anaesthesia

42
Q

Give examples of inhalational hypnotic agents

A
  1. Isoflurane - cheapest and used to maintain sedation
  2. Desflurane - used to maintain sedation and wears of quickly
  3. Sevoflurane - used to induce and/or maintain anaesthesia
43
Q

Give examples of intravenous hypnotic agents

A
  1. Propofol - quick onset, commonest, aslo an anti-emetic, fast redistribution -> rapid recovery of consciousness
  2. Thiopental - quick, mostly for emergency anaesthetics
  3. Ketamine - used in CVS instability. also an analgesic
44
Q

Give the differences bw IV and INH induction

A

IV -

  • most commonly used method
  • requires a cannula
  • rapid onset
  • depresses airway reflexes (cough/gag)
  • apnoea common

INH -

  • good for needle phobia
  • slow onset
  • may irritate airway
  • usually keep breathing
45
Q

Clinical signs to look for to assess airway?

A

obvious obstruction, patient able to speak?, see-saw respiration, use of the accessory muscles of respiration and drawing in (recession) of the intercostal muscles of the chest wall, Central cyanosis, complete airway obstruction - no breath sounds at the mouth or nose. partial obstruction - air entry is diminished and often noisy. In the critically ill patient, depressed consciousness often leads to airway obstruction. Listen to the patient’s breath sounds a short distance from his face: rattling airway noises indicate the presence of airway secretions, usually caused by the inability of the patient to cough sufficiently or to take a deep breath. Stridor or wheeze suggests partial, but significant, airway obstruction.

46
Q

Clinical signs to look for to assess breathing?

A

respiratory rate - The normal rate is 12–20 breaths min-1. A high (> 25 min-1) or increasing respiratory rate is a marker of illness and a warning that the patient may deteriorate suddenly. depth of each breath, the pattern (rhythm) of respiration and whether chest expansion is equal on both sides. Note any chest deformity (this may increase the risk of deterioration in the ability to breathe normally); look for a raised jugular venous pulse (JVP) (e.g. in acute severe asthma or a tension pneumothorax); note the presence and patency of any chest drains; remember that abdominal distension may limit diaphragmatic movement, thereby worsening respiratory distress.

47
Q

reversible causes of cardiac arrest?

A

4Hs and 4Ts -

  • Hypoxia
  • hypothermia
  • hypovolaemia
  • hypo/hyper kalaemia and other metabolic disurbances
  • Toxins
  • cardiac Tamponade
  • Tension pneumothorax
  • Thromboembolism
48
Q

What are the 4 main categories of shock?

A

There are only four major categories of shock, each of which is mainly related to one of four organ systems. Hypovolemic shock relates to the blood and fluids compartment while distributive shock relates to the vascular system; cardiogenic shock arises from primary cardiac dysfunction; and obstructive shock arises from a blockage of the circulation

49
Q

What are the features of tricyclic antidepressant overdose?

A

Early features relate to anticholinergic properties: dry mouth, dilated pupils, agitation, sinus tachycardia, blurred vision.
Features of severe poisoning include:
arrhythmias
seizures
metabolic acidosis
coma
It can also cause hypotension, hypothermia, hyperreflexia, extensor plantar responses, convulsions, respiratory failure, cardiac conduction defects, arrhythmias and metabolic acidosis. (Metabolic acidosis may complicate severe poisoning; delirium with confusion, agitation, and visual and auditory hallucinations are common during recovery)

50
Q

What ECG changes can be caused by tricyclic overdose?

A

sinus tachycardia
widening of QRS
prolongation of QT interval

Widening of QRS > 100ms is associated with an increased risk of seizures whilst QRS > 160ms is associated with ventricular arrhythmias

51
Q

Management of Tricyclic overdose

A

assessment in hospital. Supportive measures to ensure a clear airway and adequate ventilation during transfer are mandatory. IV lorazepam or IV diazepam (preferably in emulsion form) may be required to treat convulsions. Activated charcoal given within 1 hour of the overdose reduces absorption of the drug.

Management of arrhythmias: avoid antiarrhythmics, correct hypoxia and acidosis. IV infusion of sodium bicarbonate can arrest arrhythmias or prevent them in those with an extended QRS duration.
Dialysis is ineffective in removing tricyclics.

52
Q

worrying features in trauma

A

increased RR, shock, reduced GCS, significant mechanism of injury (fall from >1m or 5 stairs; axial injury to head; motor vehicle/bicycle accident)

53
Q

trauma

A

ABCDE apparoach
think about - head and neck injury, concealed bleeding, incisional wounds, lacerations, abrasions, foreign bodies, strains/sprains, fractures and dislocations.
hx
exam (skin, bone, muscle and neurovascular assessment)
Ix - X-ray if fracture/dislocation/radio-opaque foreign body (eg glass, metal) possible
Mx - analgesia to be given asap before exam and ix. senior help and review

54
Q

soft tissue injury - sprains/strains mx

A

sprain - minor damage to ligament. strain - minor damage to muscle. both managed same way - POLICE
Protection from further injury
Optimal Loading - rest initally but weight bear as soon as symptoms allow
Ice - over 1st 48hrs do not apply directly on skin
Compression
Elevation
analgesia and re-assure

symtpms often worsen over 1st 24-48 hrs then start to improve. usually takes 6w to resolve completely. if notm physio strengthening exercises may help

55
Q

dislocations mx

A

provide adequate analgesia
assess neurovascualr status and senstion over at risk nerves
EXCLUDE fracture. XR before and after reduction.
recheck distal circulation and sensation post reduction. immobilise/strap appropriately, provide analgesia and discharge with orthopaedic follow up if necessary.
further dislocation is common and may need physio or surgery

56
Q

fracture types and diff mx options

A

hairline - very small #, no bony displacement
simple - 2 bone sections. these shd heal over 6 weeks
comminuted - 3 or more bone sections
compound/open - break in skin overlying a fracture - ABCDE, immediate senior help, strong analgesia (eg IV morphine), take photo with ED camera, cover wound with iodine/saline soaked swabs, start IV abx as per local hospital policy, review tetanus status, X-ray and refer urgently to orthopaedics.

analgesia only in single rib or coccyx fracture and these do not need imaging unless a complication (eg pneumothorax) is suspected
If unstable, neurovascular compromise or compound fracture - urgent orthopaedic review
for other fractures that do not need urgent orthopaedic review - X-ray, immobilization (backslab, sling) analgesia and # clinic follow up

Medicine finals Prithvi (22 decks)

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