Emergency Presentations Flashcards
What is included in the A section of the primary survey?
Stabalising the C spine
Assess for any signs of obstruction - is the airway patent
Management - jaw thrust/chin lift or use airway adjuncts to establish an airway
What is included in B of the primary survery?
Assess to determine respiratory rate, check for bilateral chest movement, percuss, auscultate
Management: If no resp effort then treat as cardiac arrest, intubate and ventilate. If breathing compromised then give high flow O2 and manage according to findings e.g. relieve tension pneumothorax
What is included in C of the primary survey?
Assessment: check pulse and BP, check if peripherally shut down, check cap refill and for evidence of haemorrhage - if in shock this needs to be treated
What is included in D of the primary survey?
Assess the patients level of consciousness with AVPU, check pupils - size, equality and reactions
GCS if time allows
What is included in E of the primary survey?
Assess by exposing patient to look for any rashes or bleeding points etc.
What red flags do you want to ask for headache and what could they suggest?
First worst headache or thunderclap headache - subarachnoid haemorrhage
Scalp tenderness in over 50s - giant cell arteritis
Head with fever/stiff neck - meningitis
What presentation would suggest increased intracranial pressure?
Cough induced headache, made worse by bending forwards
What are your differentials for a headache with decreased conscious level?
Stroke Encephalitis Subarachnoid haemorhage Venous sinus occlusion Tumour TB meningitis
What differentials does wheezing suggest?
Asthma
COPD
Heart failure
Anaphylaxis
What differentials does stridor suggest?
Upper airway obstruction:
- Foreign body or tumour
- Acute epiglottitis (younger patients)
- Anaphylaxis
- Trauma e.g. laryngeal fracture
What differentials does crepitations suggest?
Heart failure
Pneumonia
Bronchiectasis
Fibrosis
What respiratory differentials does a clear chest suggest?
Pulmonary embolism Hyperventilation Metablic acidosis e.g. diabetic ketacidosis Anaemia Shock
What are the key emergency respiratory investigations?
OBS - o2 sats, pulse, temperature, peak flow ABG if sats <94% ECG CXR Baseline bloods
What are the main life threatening chest pain differentials?
MI Angina/Acute coronary syndrome PE Oesophageal rupture Tension pneumothorax Aortic dissection
What are the metabolic causes of coma?
Drugs, poisoning e.g. carbon monoxide Hypoglycaemia Hypoxia, CO2 Septicaemia Hypothermia Addisonian crisis Hepatic/ureamic encephalopathy
What are the neurological causes of coma?
Infection Trauma Tumour Vascular - stroke Epilepsy - non convulsive status
What is the management of coma?
A-E primary survey
Consider intubation if GCS is less than 8
Protect c spine unless known not to be trauma
Give IV fluids to support circulation if required
Check blood gluose and give 200mL of 10% glucose IV stat if hypoglycaemic
Give naloxone if opioid intoxication
Give flumazenil for benzodiazepine intoxication if airway compromised
Give IV thiamine if there is wernicke’s encephalopathy
What are the three categories of the glasgow coma scale?
Best motor response
Best verbal response
Eye opening
What are decorticate and decerebrate postures and what do these imply?
Decorticate posture is everything in flexion and implies midbrain injury above the level of the red nucleus
Decerebrate posture is everything in extension and implies midbrain injury below the level of the red nucleus
What is shock?
Circulatory failure resulting in inadequate organ perfusion
What are the clinical features that define shock?
A systolic BP of less than 90 with evidence of tissue hypoperfusion e.g. mottled skin, urine output <0.5mL/kg/h, serum lactate >2mmol/L
What are the signs of shock?
Decreased GCS, Tachycardia, cool peripheries, slow capillary refill, oligouria and tachypnoea
What are the two main types of shock?
Inadequate cardiac output
Peripheral circulatory failure (loss of vascular resistance)
What are the two types of shock resulting that involve inadequate cardiac output?
Pump failure (cardiogenic shock) - heart not pumping properly Hypovolaemic shock - there is not enough circulating blood for the heart to pump properly
What are some causes of hypovolaemic shock?
Bleeding - trauma, ruptured aneurysm, GI bleed
Fluid loss - vomiting, burns, heat exhaustion
What are some of the causes of pump failure in shock?
ACS Aortic dissection Arrhythmias PE Tension pneumothoorax Cardiac tamponade
What are the causes of peripheral circulatory failure leading to shock?
Anaphylaxis Sepsis Neurogenic e.g. spinal cord injury Endocrine failure e.g. addison's Drugs e.g. anesthetics, antihypertensives
How would you assess a patient you think may be in shock?
A-E approach
Circulatory problem in shock so get 2 large bore cannulae in
Check ECG for rate and rhythm and signs of ischaemia
General review - cold and clammy suggests a cardiogenic or hypoperfusion shock
Warm and well perfused with bounding pulse points to a septic shock
BP can remain normal in the young and fit up to 30% blood loss
If a shocked individual has a raised JVP what is the likely cause?
Cardiogenic shock
How do you manage a hypovolaemic shocked patient?
Treat according to cause:
-Hypovolaemic - treat underlying cause, raise legs, give fluid bolus 10-15mL/kg crystalloid, if shock improves then repeat - aim for systolic BP over 90
How do you manage a haemorrhagic shocked patient?
-Haemorrhagic shock - Attempt to stop bleeding, if still shocked with 2L crystalloid then crossmatch - give FFP with red cells 1:1 ratio, aim for platelets >100 and fibrinogen >1
How do you manage a shocked patient from heat exhaustion?
Tepid sponging + fanning, avoid ice
Resuscitate with IVI of 0.9% saline +/- hydrocortisone 100mg IV, get core temp <39degrees
What causes anaphylactic shock?
It is a Type 1 IgE-mediated hypersensitivity reaction
What are the signs and symptoms of anaphylactic shock?
Itching, sweating, diarrhoea and vomiting, erythema, urticaria, oedema
Wheeze, laryngeal obstruction
Tachycardia, hypotension
What is the management of anaphylactic shock?
Secure the airway and give 100% O2
Remove the cause and raise the feet to help improve circulation
Give 0.5mg adrenaline (0.5mL of 1:1000)
Repeat every 5 min until better
Secure IV access
Chlorphenamine 10mg IV and hydrocortisone 200mg IV
IVI saline infusion to increase blood pressure
If wheeze treat for asthma
If still hypotensive - get expert help
Measure serum tryptase 1-6hr after suspected anaphylaxis
