Emergency medicine and management of trauma Flashcards
Clinical features of thoracic aorta rupture?
Contained haematoma: persistent hypotension
Detected mainly by history, CXR changes
CXR changes of thoracic aorta rupture?
Widened mediastinum
Trachea/Oesophagus to right
Depression of left main stem bronchus
Widened paratracheal stripe/paraspinal interfaces
Space between aorta and pulmonary artery obliterated
Rib fracture/left haemothorax
Diagnosis of thoracic aorta rupture?
Angiography, usually CT aortogram.
treatment of thoracic aorta rupture?
Repair or replacement. Ideally they should undergo endovascular repair.
Main causes of chest pain in pregnancy?
Aortic dissection
mitral stenosis
Pulmonary embolism
Management of aortic dissection in pregnancy?
Gestational timeframe Management
< 28/40 Aortic repair with the fetus kept in utero
28-32/40 Dependent on fetal condition
> 32/40 Primary Cesarean section followed by aortic repair at the same operation
When is surgical exploration of haemothorax warranted?
if >1500ml blood drained immediately
Signs of cardiac tamponade?
Becks triad:
elevated venous pressure, reduced arterial pressure, reduced heart sounds
Pulsus paradoxus
May occur with as little as 100ml blood
Indications for fluid resuscitation in burns?
> 15% total body area burns in adults (>10% children)
The main aim of resuscitation is to prevent the burn deepening
Most fluid is lost 24 hours after injury
What is the parkland formula?
2 ml Hartmanns x kg x % TBSA
half given in first 8 hours
other half given over next 16
How is the parkland formula altered for electrical burns?
4 ml Hartmanns x kg x % TBSA until urine clears
[1-1.5 ml/kg/hr until urine clears]
How is the parkland formula altered for patients under 14 years?
3 ml Hartmanns x kg x % TBSA
[UO 1ml/kg/hr]
How is the parkland formula altered for patients <30kg?
3 ml Hartmanns x kg x % TBSA. Plus a sugar-containing solution at maintenance rate
How to estimate % burn?
Lund Browder chart: most accurate even in children
Wallace rule of nines
Palmar surface: surface area palm = 0.8% burn
When to transfer to a burns centre?
Need burn shock resuscitation
Face/hands/genitals affected
Deep partial thickness or full thickness burns
Significant electrical/chemical burns
When are Escharotomies indicated?
Indicated in circumferential full thickness burns to the torso or limbs.
Careful division of the encasing band of burn tissue will potentially improve ventilation (if the burn involves the torso), or relieve compartment syndrome and oedema (where a limb is involved)
What does sudden anaemia and a low reticulocyte count indicate?
parvovirus
When is thrombolysis with alteplase indicated?
Thrombolysis is 1st line for massive PE (ie circulatory failure) and may be instituted on clinical grounds alone if cardiac arrest is imminent; a 50 mg bolus of alteplase is recommended.
When is UFH given for PE?
(a) as a first dose bolus,
(b) in massive PE
(c) where rapid reversal of effect may be needed
Standard duration of oral anticoagulation?
4 to 6 weeks for temporary risk factors, 3 months for first idiopathic, and at least 6 months for other
ECG changes in PE?
S1, Q3, T3
Tall R waves: V1
P pulmonale (peaked P waves): inferior leads
Right axis deviation, Right bundle branch block
Atrial arrhythmias
T wave inversion: V1, V2, V3
Right ventricular strain
Features of total anterior circulation infarcts?
Involves middle and anterior cerebral arteries (15% of stroke)
3Hs- ALL THREE
Hemiparesis/hemisensory loss
Homonymous hemianopia
Higher cognitive dysfunction e.g. Dysphasia
Features of partial anterior circulation strokes?
(25% strokes)
Involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
Higher cognitive dysfunction or two of the three TACI features
Features of lacunar infarcts?
25% strokes
Involves perforating arteries around the internal capsule, thalamus and basal ganglia
Present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
Features of posterior circulation infarcts?
25% strokes
Vertebrobasilar arteries
Presents with features of brainstem damage
Ataxia, disorders of gaze and vision, cranial nerve lesions
Features of Posterior inferior cerebellar artery strokes?
Lateral medullary syndrome
Wallenberg’s syndrome
Ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy
Contralateral: limb sensory loss
What is Webers syndrome?
Ipsilateral III palsy
Contralateral weakness
Features of anterior cerebral artery infarct?
Contralateral hemiparesis and sensory loss, lower extremity > upper
Disconnection syndrome
Features of middle cerebral artery infarct?
Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral hemianopia
Aphasia (Wernicke’s)
Gaze abnormalities
Features of posterior cerebral artery infarct?
Contralateral hemianopia with macular sparing
Disconnection syndrome
How to manage anaphylactic shock?
- Remove allergen
- ABCD
- Drugs:
Adrenaline 1:1000 0.5ml INTRAMUSCULARLY (not IV). Repeat after 5 mins if no response.
Consider antihistamine if ongoing local symptoms.
consider infusion
When to immobilise full spine?
GCS < 15
- neck pain/tenderness
- paraesthesia extremities
- focal neurological deficit
- suspected c-spine injury
If a c spine injury is suspected what is indicated?
a 3 view c-spine x-ray
When is c spine CT preferred?
- Intubated
- GCS <13
- Normal x-ray but continued concerns regarding c-spine injury
- Any focal neurology
- A CT head scan is being performed
- Initial plain films are abnormal
When is an immediate CT head (within 1h) indicated?
GCS < 13 on admission
GCS < 15 2 hours after admission
Suspected open or depressed skull fracture
Suspected skull base fracture (panda eyes, Battle’s sign, CSF from nose/ear, bleeding ear)
Focal neurology
Vomiting > 1 episode
Post traumatic seizure
When to contact the neurosurgeon for head injury?
Persistent GCS < 8 or = 8
Unexplained confusion > 4h
Reduced GCS after admission
Progressive neurological signs
Incomplete recovery post seizure
Penetrating injury
Cerebrospinal fluid leak
When should patients on anticoagulants be scanned?
within 8 hours
Management of hyperkalaemia?
Stabilisation of the cardiac membrane:
Intravenous calcium gluconate
Short-term shift in potassium from extracellular to intracellular fluid compartment:
Combined insulin/dextrose infusion
Nebulised salbutamol
Removal of potassium from the body:
Calcium resonium (orally or enema)
Loop diuretics
Dialysis
Why are higher volumes of fluid given in electrical burns?
risk of rhabdomyolysis
Management of addisonian crisis?
1.Hydrocortisone 100 mg im or iv
2. 1 litre normal saline infused over 30-60 mins or with dextrose if hypoglycaemic
3. Continue hydrocortisone 6 hourly until the patient is stable. No fludrocortisone is required because high cortisol exerts weak mineralocorticoid action
4. Oral replacement may begin after 24 hours and be reduced to maintenance over 3-4 days
what does prilocaine toxicity cause and what is the reversal method for this?
methaemoglobinaemia
methylene blue will revert the haemoglobin to the ferrous type and reverse this effect.
Management of local anaesthetic toxicity?
Stop injecting the anaesthetic agent
High flow 100% oxygen via face mask
Cardiovascular monitoring
Administer lipid emulsion (Intralipid 20%) at 1.5ml/Kg over 1 minute as a bolus
Consider lipid emulsion infusion, at 0.25ml/ Kg/ minute
If toxicity due to prilocaine then administer methylene blue
Management of craniomaxillofacial injuries?
Mannitol 1g/Kg as 20% infusion, Osmotic diuretic, Contra-indicated in congestive heart failure and pulmonary oedema
Acetazolamide 500mg IV, (Monitor FBC/U+E) Reduces aqueous pressure by inhibition of carbonic anhydrase (used in glaucoma)
Dexamethasone 8mg orally or intravenously
In a traumatic setting an urgent cantholysis may be needed prior to definitive surgery.
Consider
Papaverine 40mg smooth muscle relaxant
Dextran 40 500mls IV improves perfusion
What does retrobulbar haemorrhage present with?
Rare but important ocular emergency. Presents with:
Pain (usually sharp and within the globe)
Proptosis
Pupil reactions are lost
Paralysis (eye movements lost)
Visual acuity is lost (colour vision is lost first)
May be the result of Le Fort type facial fractures.
In nasal fractures how do you know if the cribiformplate has been breached?
CSF rhinorrhoea implies that the cribriform plate has been breached and antibiotics will be required.
Usually best to allow bruising and swelling to settle and then review patient clinically. Major persistent deformity requires fracture manipulation, best performed within 10 days of injury.
What is superior orbital fissure syndrome?
Severe force to the lateral wall of the orbit resulting in compression of neurovascular structures
Symptoms of superior orbital fissure syndrome?
Complete opthalmoplegia and ptosis (Cranial nerves 3, 4, 6 and nerve to levator palpebrae superioris)
Relative afferent pupillary defect
Dilatation of the pupil and loss of accommodation and corneal reflexes
Altered sensation from forehead to vertex (frontal branch of trigeminal nerve)
ECG changes for thrombolysis or PCI?
ST elevation of > 2mm (2 small squares) in 2 or more consecutive anterior leads (V1-V6) OR
ST elevation of greater than 1mm (1 small square) in greater than 2 consecutive inferior leads (II, III, avF, avL) OR
New Left bundle branch block
What do thrombolytic drugs do and what are some examples?
activate plasminogen to form plasmin. This in turn degrades fibrin and help breaks up thrombin
alteplase
tenecteplase
streptokinase
Contraindications to thrombolysis?
active internal bleeding
recent haemorrhage, trauma or surgery (including dental extraction)
coagulation and bleeding disorders
intracranial neoplasm
stroke < 3 months
aortic dissection
recent head injury
pregnancy
severe hypertension
Common findings of Le Fort II fractures?
infraorbital parasthesia, palatal mobility malocclusion
enophthalmos
What ratios are used for haemostatic transfusion?
packed cells, FFP and platelets 1:1:1
CXR findings in diaphragmatic rupture?
Hemidiaphragm is not visible
Bowel loops in the lower half of the hemi-thorax
Mediastinum is displaced
[tend to occur more on left]
What are curlings ulcers?
Curlings ulcers typically occur secondary to thermal injuries and are caused by loss of GI protective mechanisms
Which two main fractures cause compartment syndrome?
supracondylar fractures and tibial shaft injuries
Symptoms and signs of compartment syndrome?
Pain, especially on movement (even passive)
Parasthesiae
Pallor may be present
Arterial pulsation may still be felt as the necrosis occurs as a result of microvascular compromise
Paralysis of the muscle group may occur
Diagnosis of compartment syndrome?
measurement of intracompartmental pressure measurements. Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic
Treatment of compartment syndrome?
extensive fasciotomy
Myoglobinuria may occur following fasciotomy and result in renal failure and for this reason these patients require aggressive IV fluids
debridement and ?amputation
When to manage splenic trauma conservatively?
Small subcapsular haematoma
Minimal intra abdominal blood
No hilar disruption
When to consider splenic resection?
Hilar injuries
Major haemorrhage
Major associated injuries
What can precipitate oculogyric crises?
Phenothiazines
Haloperidol
Metoclopramide
Postencephalitic Parkinson’s disease
Best test to identify presence of CSF?
Beta 2 transferrin is a carbohydrate free form of transferrin that is almost exclusively found in the CSF
what is the definition of hypothermia and severe hypothermia?
hypothermia (below 35)
severe hypothermia (below28)
Which hormones are increased in mild hypothermia?
corticosterone, glucagon and aldosterone
Drug therapy for VT?
amiodarone: ideally administered through a central line
lidocaine: use with caution in severe left ventricular impairment
procainamide
Which drug should be avoided in VT?
verapamil
Treatment for torsades des pointes?
Treatment IV magnesium sulphate (2g over 10 mins)
Causes of long QT?
-congenital: Jervell-Lange-Nielsen syndrome, Romano-Ward syndrome
-antiarrhythmics: amiodarone, sotalol, class 1a antiarrhythmic drugs
-tricyclic antidepressants
-antipsychotics
-chloroquine
-terfenadine
-erythromycin
-electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia
-myocarditis
-hypothermia
-subarachnoid haemorrhage
Causes of hypocalcaemia?
Vitamin D deficiency (osteomalacia)
Acute pancreatitis
Chronic renal failure
Hypoparathyroidism (e.g. post thyroid/parathyroid surgery)
Pseudohypoparathyroidism (target cells insensitive to PTH)
Rhabdomyolysis (initial stages)
Magnesium deficiency (due to end organ PTH resistance)
Management of hypocalcaemia?
intravenous calcium gluconate, 10ml of 10% solution over 10 minutes
ECG monitoring is recommended
Further management depends on the underlying cause
Calcium and bicarbonate should not be administered via the same route
