Emergency medicine/surgery Flashcards
What do you hear on auscultation/percussion with effusion
Auscultation- absent breath sounds
Percussion- stony dullness
Acute severe asthma vs life threatening asthma
Acute severe: 33-55% of best PEF Can't complete sentences Resp >25/min Pulse>110 beats/min
Life threatening asthma: PEF <33% of best SpO2 <92% Silent chest, cyanosis, or feeble respiratory effort Arrhythmia/hypotension Exhaustion, altered consciousness
What is an important piece of info about an asthmatic in a&e
if they’ve ever been intubated… this means they were at the point of dying before so it is a big risk factor and you don’t want to send them home
Info to ask for asthma attack
Previous ITU
Other medical conditions
Allergies
Any infective symptoms
Pathophsiology of asthma
Reversible airway disease
Hyper reactivity
Airflow limitation
Clinical presentation of asthma
Wheeze?
-Other things which also cause wheeze. Not specific for asthma
Breathless?
Tachycardic?
Treatments for asthma
Nebulised salbutamol IV salbutamol Nebulised adrenaline Nebulised magnesium Oral steroids IV steroids (IV magnesium if they are terrible)
What would you give if he is an acute asthmatic
Give them whatever is in the nebuliser IV (if they’re not breathing properly it probably won’t go in)
Call for specialist help
What is the difference between severe vs life threatening asthma
Decompensation
Unable to maintain adequate PO2 and PCO2
Drowsy due to rising PCO2, hypotension or exhaustion (note co2 should be low in asthma!)
Need intubation
What should CO2 be in an acute asthmatic
LOW (because they blow it off)
If co2 is normal you worry,
if it’s high then this is very bad
What is included in asthma review
How pathology creates the clinical signs
How physiology is explained- compensation vs decompensation
Treatment
Started to understand how history, examination and treatment might fit together in one package
What is special about meningitis rash
It is a vasculitic rash…. it is nonblanching
What will happen if you press on an uritcarial rash
It will go away (i.e. blanching)
Pathophsyiology of anaphylaxis
IgE mediated activation of mast cells leading to mediator release and airway airway obstruction
What is the treatment for anaphylaxis
Adrenaline
500mcg
0.5ml 1;1000 (IM not IV as it can predispose to arrythmia)
Lie flat and put legs in the air
Piriton
Hydrocortisone
Fluids
How does adrenaline help you in anaphylaxis
α1 – vasoconstriction and relaxation of GI tract
α2 – platelet aggregation and reduction in noradrenaline release from nerve terminals
β1 – inotropic and chronotropic cardiac effects and relaxation of GI tract
β2 – bronchodilatation, increase in noradrenaline release from nerve terminals, increase in intracellular cyclic adenosine monophosphate (cAMP) production in mast cells and basophils, reduction in the release of cellular mediators
Priorities for MI
- Call for help
- Open his airway and start rescue breaths
- Get IV access
- Get a 12 lead ECG
You need to check for a pulse first (because an ECG could be normal despite no pulse and thus death)
What pulse should you check
Carotid pulse (close to the heart)
2 algoriths in CPR
Shockable or non-shockable rhythm
Which rhythms are shockable
VF or pulseless VT (check this)
What rhythms are non-shockable
PEA and asystole
Reversible causes of cardiac arrest
Hs: Hypoxia Hypovolaemia Hyper/hypokalamemia (& other electrolyte disturbance) Hypothermia
Ts: Tension pneumothorax Cardiac tamponade Toxins Thromboembolic
Learn to recognise cardiac tamponade on echo!
……
What do you do for a cardiac tamponade
An emergency pericardiocentesis (ultrasound guided)
What is the correct dose of adrenaline in anaphylaxis
0.5 1 in 1000
Primary survey for trauma
Catastrophic Haemorrhage? Airway with c spine control Breathing Circulation Disability Exposure ‘C-ABC’
When do you get a dilated pupil
What should you do
It means the brainstem is being pushed through the foramen magnum which compresses crainial nerves affecting pupils.
Usually 1 eye first and then the second
Before survery give mannitol
How to differentiate between subural and extradural
Subdural looks like banana
Extradural is convex
ED management of extradural haemorrhage
Optimise oxygenation -A, B, C Keep CO2 normal -A,B Maintain cerebral perfusion -(CPP= MAP-ICP) Make sure nothing more life threatening takes priority -Primary survey Neurosurgical input & theatre
Primary survey
Systematic approach
C- ABC
Treat life threatening problems as you find them
Trauma team – lead by a senior doctor
Simultaneous action
But we teach it in order so you remember the priorities
What is the strongest predictor of injury
Mechanism of injury is the strongest predictor of injury
Applies to all trauma- minor and major
Create a mental picture of events in your head
What do you want to know about airway
Are they breathing?
Is it normal or noisy?
- Noisy = obstructed
- Obstructed = do something!
Do they need a ‘definitive airway’
Palpate for surgical emphysema
You have an airway leak going into the surrounding tissue
Assessment of circulation
Pulse, BP, capillary refill time
General appearance
Source of haemorrhage
‘On the floor and 4 more’:
Abdomen (spleen and liver)
Into leg (femur can bleed lots)
Chest
Pelvis
What fluid should you give to hypertensive patients
Transfusion
red cells+platelets+FFP
Circulation with haemorrhage control
Turn off the tap Fluids (blood) Warfarin Coagulopathy to correct TXA (within 1hr)
Damage control surgery
Assessment of disability
GCS- Glasgow Coma Score
level of consciousness
Pupils
Blood sugar
Limb movements
Potential injuries for burns
Direct Burns Inhalation Injury Smoke Inhalation Carbon Monoxide Poisoning Cyanide Poisoning Trauma
