emergency surgery and medicine Flashcards
ddx
- anaphylaxis
- panic attack
- pneumothorax
- asthma
- pneumonia
- cardiac failure
- ARDS
- pleural effusion
- PE – HR is so high. RR v high though, unless massive it would be unlikely to have such a massive RR. BP is really good too.
which numbers are worrying
HR
RR
BP - not worring but need to keep an eye on - if PE it will plummet
how could you get cardiac failure in a 24yr old
if had pericarditis previously -> myocarditis
why would you get pleural effusion in young male
testicular cancer?
Lymphoma can get effusion, not classically
TB, doesn’t often get pleural effusion can get marked changes
acute asthma
PEF 33-50% of best
cant complete sentences
RR >=25/min
pulse >=110 beats/min
life threatening asthma
PEF <33% of best
SpO2 <92%
silent chest, cyanosis, feeble resp effort
arrhythmia/hypotension
exhaustion and altered consciousness
important info to get if someone presents with asthma attack
previous ITU - more important in moderate asthmatics – borderline and whether to send them home.
DHx
medical conditions
allergies - trigger exposure – need to remove the trigger and will be a different treatment – will need to give adrenaline
infective sx
pathophysiology of asthma
reversible airway disease
hyperreactivity = vasoconstriction
airflow limitation
clinical presentation of asthma
wheeze
breathless
tachycardic
ddx for wheeze
Anaphylaxis
Airway obstruction – foreign bodies
Anatomical cause of squeaky noise – epiglottis – not a wheeze, it is stridor
Stridor seen in children – floppy epiglottis, and whole area big
Stridor in adult – epiglottitis/supraglottitis – need ITU
Mx of asthma
nebulised salbutamol - Better to have inhaler through spacer than nebuliser – material into lungs smaller particles into lungs. Drops in nebuliser cant get as far into lungs
IV salbutamol
nebulised adrenaline
nebulised Mg
oral steroids
IV steroids
severe V life threatening asthma
decompensation
unable to maintain adequate PO2 and PCO2
drowsy due to rising PCO2, hypotension or exhaustion
need intubation
dx
Anaphylaxis
BP is very low and high HR and urticarial rash suggest anaphylaxis
- Anaphylaxis over sepsis – sudden onset, temperature (although can get cold sepsis), Hx.*
- Non-blanching rash would = meningococcal meningitis*
urticarial rash
pathophysiology of anaphylaxis and consequences
One of issues is the massive swelling and fluid and effect on body – airway swell, no BP
Big tongue so hard to even intubate
Resp sx can be quite late
Lip and mouth tingling is the key sign
Episode of diarrheoa – Can lose control of bowel function
Mx of anaphylaxis
adrenaline
500mcg
0.5ml 1:1000 more conc dose because less volume of drug – IM less painful and distributes quicker
lie flat and legs in air – redistribution of fluid – get fluid back into the heart to improve venous return and the BP
IV piriton
hydorcortisone - kicks in later
fluids
dx
Tomb stoning – ST in anterior leads
Mx
- Cathlab and resus
- Need to be on a monitor and then local cath lab
- Check for signs of life – cardiac arrest: PEA – pulseless electrical activity
Mx of cardiac arrest
call the arrest team
start compressions
attach to defibrillator and checking rhythm
Before start CPR with VT and VF – shock
VF
chaotic in all leads
2nd – have to check the pulse – if pulse it is bradycardia with complete heart block because no p wave
asystole
shockable and non-shockable heart rhythms
Non-shockable
- PEA
- Asystole
Shockable
- VT
- VF
reversible causes of cardiac arrest
- hypothermia
- hyperK/hypoK - and other electrolyte disturbances
- hypoxia
- hypovolaemia
- thomboembolism
- toxins
- Tension pneumothorax
- tamponade
Mx of tension pneumothorax
cannular/cut and hole in chest
dx of tamponade
US
dx and mx
Dislocated fracture
Sedation and pull back into joint, no XR
Quickly get necrosis of the skin – need to put it back to take the pressure of the skin.
If anything breaks down in lower leg – ulcers that take years to get better.
characteristic sx of epidural haemorrhage
lucid interval
Might lose consciousness then normal GCS then lowers again
concern with this injury
Middle meningeal artery in this area – really delicate, thinnest part of the skull. Bone doesn’t need to break – artery can just rupture on the mere process of landing on the floor.
Doesn’t matter what the GCS is – need to CT head. Based on Hx. Less than 30sec to CT
Low impact Ix
concerns with this trauma
Airway – first focus
- Tried to get tibe in through nose but been unsuccessful so gone through the trachea
C spine injury
Arterial injury
Nerve injury
Wood might be tamponading a ruptured vessel – so don’t remove
approach to trauma
A-E
approach
Call anaesthetics -don’t take to CT w/o tube – nosy breathing = obstriucted airway. If vomit -> aspirate.
Dilated L pupil – sign head injury putting tension in the brain
HR 100 – blood bank on standby – young person who compensated and so can very quickly decompensate
dx
Extradural – huge because there is the midline shift, and ventricles squeezed over.
And have blown pupil – classic sign
approach to epidural
Optimise the oxygen – doesn’t need to be 15L but needs to be >95% sats
Keep CO2 normal – tube so can monitor – capnograph give them the readings
Cerebral perfusion – 30degrees (CCP=MAP-ICP)
Other injuries – group and save cross match
With extradural haemorrhage HR should be normal and then bradycardic when cone because hypertensive BP 200, and bradycardic. High HR worry for other injury.
Panscan CT and then theatre
neurosurgical input
predictor of outcomes in head injuries
GCS
if low - outcome is low, even if same scan as higher GCS
things in airway assessment
are they breathing
is it normal or noisy
- noisy = obstructed
do they need a definitive airway
things to assess in breathing assessment
look
palpate
percuss
auscultate
feel for surgical emphysema - crackles, feels like bubble wrap - Subcutaneous mottly on L – air into the soft tissues
things in assessment of circulation
pulse, BP, cap refill
general appearance
source of haemorrhage - on the floor, chest, abdo, pelvis, long bones
pelvic binder - stop haemorrhage in pelvis
Need to give blood – pre-empt the blood loss so have rapid infuser set up before the pt arrives, can get unit in really quickly
Need FFP and plts and calcium
haemorrhage control
stop the bleed
fluids
warfarin
coagulopathy to correct
TXA
disability assessment
GCS - level of consciousness
pupils
blood sugar
limb movements
dx
tension pneumothorax
cardiac tamponade
pneumonia
thoracic haemorrhage
Hole in 5th ICS in both sides and pair of scissors – cut across and join the thoracosostmy. See if anything wring with the heart
Here – blood in lung – worry about hilar injury – hand stopping the hilum bleedinbg
Clamshell thoracostomy – life saving
Take lung and twist it on itself – stop blood into lung – bad for BP and pulse = but lifesaving
