Exam course Flashcards
Discuss the sensitivity and specificity of eFAST in the context of multi-trauma?
Ultrasound can detect as little as 20ml in the pleural space
96% sensitive for pneumothorax
XR requires at least 200ml of fluid in pleural space
Ultrasound 98.1% sensitive for intra-abdominal fluid
Pericardial ultrasound 100% sensitive, 96.9% specific and 97.3% accurate
What are advantages of ultrasound?
Faster than CT or X-ray
Radiation free
Performed at bedside simultaneously with other medical care
A superior test in many cases (haemothorax, pneumothorax)
What are the limitations of eFAST in the context of multrauma?
Not reliable for detecting solid organ injuries
Obesity
-Fat obscures ultrasound and reduces sensitivity
Subcutaneous air can distort ultrasound images - subcutaneous emphysema
Retroperitoneum not able to be visualised
Cannot detect < 200ml of peritoneal free fluid
Pancreas not well visualized
What can increase sensitivity of eFAST?
Repeat scanning if clinical suspicion remains high
Trendelenburg positioning can make upper quadrant views more sensitive
Reverse trendelenburg can make pelvic views more sensitive
What are 5 false positives with eFAST?
Pericardial fat pads
Perirenal fat
Seminal vesicles with fluid
Fluid - lungs - ascitic abdomen
POD fluid
Explain your airway management algorithm in a patient with multiple traumatic injuries?
Assess airway is protected
-GCS > 8
-No vomiting
-No significant oropharyngeal bleeding
-Sufficient respiratory effort
If airway protected - supplemental oxygen, assess breathing
If airway not protected
-Assess for obstruction - suction etc.
If airway not protected then proceed to intubation
-PPV with BVM
-1st option RSI with video laryngoscope
-If unable to intubate then place LMA and repeat attempt with video laryngoscope + bougie or fiberoptic airway
-If unable to place LMA proceed to surgical airway
A patient with multi trauma arrives in ED with shock. State the priorities you will focus on in assessment. State your initial management.
Assess for cause of shock
Hypovolaemic - secondary to haemorrhage
-Primary survey including eFAST
-CXR, pelvis XR, CT scan
Resuscitation
-RBC, platelets, FFP in 1:1:1 ratio
-Prevent hypothermia
-TXA 1g IV followed by 1g over 8 hours
Targeted interventions
-e.g. pelvic binder, splint and reduce fractures, torniquet, laparotomy, thoracotomy
Non haemorrhagic
-Tension pneumothorax
-Cardiac tamponade
-Cardiogenic - myocardial contusion
-Neurogenic
-Septic
Treat etiology: ICC, thoracotomy, noradrenaline
State the criteria for a surgeon to attend a patient with trauma in ED?
Hypotension SBP < 90mmHg
Gunshot wounds to neck, chest or abdomen, proximal extremities
Respiratory compromise requiring urgent airway
Penetrating wound to neck/ chest/ abdomen/ pelvis
GCS < 8 attributed to trauma
What are the goals of a resuscitative thoracotomy?
Relieve cardiac tamponade
Perform open cardiac massage
Occlude descending aorta to increase blood flow to heart and brain
Control life threatening thoracic bleeding - hilar twist
Control broncho venous air embolism - hilar twist, trendelenburg position
How do you resuscitate a patient following a traumatic arrest?
Intubate
Insert bilateral chest drains (or thoracostomies)
Resuscitative thoracotomy
Limit fluid as this will worsen outcome unless hemorrhage controlled
Limit inotropes and pressors until circulation restored
Describe the AAST grading of liver injuries?
Most important to know grade III - V
Where is free fluid seen in the abdomen on an eFAST?
Morrisons pouch - hepatorenal space
Between liver and diaphragm
Right paracolic gutter
Splenorenal space
Rectovesical space
What is the AAST grading of splenic injuries?
What abdominal injuries are associated with a chance fracture?
Injuries
Duodenal
-First part intraperitoneal, remainder retroperitoneal
-Abdominal compression by seatbelt causes high intraduodenal pressures
-Penetrating injuries
-Shearing forces at duodenojejunal flexure or ampulla (points of fixation) lead to submucosal hematoma
-Diagnoses made by oral/ NG contrast study (XR/CT)
-Lower sensitivity on CT and AXR
Pancreatic injury
-Penetrating injury
-Rare following blunt injury - usually a blow to epigastrium
-Associated with duodenal rupture or severe multiple organ injury
-Seen in lap belt injuries, chance fractures
-CT scan 50% sensitive on initial scan, increases to > 80% with repeat CT at 8-12 hours
-Negative amylase and lipase is reassuring (95% sensitive)
Mesenteric injury
-Haematoma, vessel laceration
-CT 95% sensitive
Small bowel injury
-Jejunal or ileum tear
-Peritonism in 85%
-Erect CXR 25% sensitive
-CT: free intra-abdominal gas in 40% cases, free fluid without solid organ injury, free fluid in 80% of cases
-Mesenteric fat stranding
-Extravasation of oral contrast
-Can be normal in 5% of cases
-DPL > 95% sensitivity and specificity
-Laparoscopy highly sensitive and specific
Colonic injury
-Mortality 10%
-Operative repair for grade II-V injuries
Define abdominal compartment syndrome?
Other than abdominal trauma list 4 other groups of patients at risk of abdominal compartment syndrome?
Discuss the diagnosis of abdominal compartment syndrome?
State 5 key principles involved in the management of ACS?
Organ dysfunction caused by intra-abdominal hypertension
Intra abdominal pressure usually 5mmHg
APP = MAP - IAP
APP target is 60mmHg
Abdominal compartment syndrome is intra abdominal pressure > 20mmHg associated with organ dysfunction (raised lactate/ creatinine)
Risks
-Trauma and aggressive fluid resuscitation
-Burns > 30% TBSA
-Liver transplantation
-Massive ascites
-Retroperitoneal conditions: AAA, pelvic fracture, pancreatitis
-Sepsis with third spacing
Systemic effects
-Raised ICP, decreased CCP
-Hypotension, decreased venous return, decreased CO, increased SVR
-Decreased UO, renal blood flow, GFR
-Decreased coeliac blood flow/ SMA blood flow
-Decreased hepatic flow/ mitochondrial function/ lactate clearance
-Increased intrathoracic pressure, increased PIP, reduced compliance
Diagnosis
-CT may demonstrate extrinsic compression of IVC, massive abdominal distension, bilateral inguinal hernia
Measurement of intra-abdominal pressure
-Using intravesical catheter and pressure transducer
Management
-Surgical decompression of abdominal cavity if pressure > 25mmHg - delayed abdominal wall closure
-Escharotomy if abdominal burn
-Percutaneous catheter to decompress massive ascites
-Supine position
-Improve abdominal wall compliance: Pain control, sedation, paralysis, mechanical ventilation, permissive hypercapnia
What does damage control surgery/ resuscitation mean, what are its goals and what are its indications?
Pre op
-Prevent hypothermia / acidosis/ coagulopathy
In theatre / pre op indications for damage control resuscitation rather than definitive repair
-Severe physiological insult - hypothermia, coagulopathy (INR > 1.5), pH < 7.2, lactate > 5, dysrhythmia
-Inability to control bleeding using conventional methods
-Large volume resuscitation required (> 10U RBC)
Goals
-Arrest bleeding
-Prevent worsening hypothermia, acidosis, coagulopathy
List 6 CT findings that indicate need for surgery/ laparotomy in a haemodynamically stable patient with blunt abdominal trauma?
Diaphragmatic herniation
Sold organ injury - e.g. bowel, bladder
Vascular injury requiring repair if angiography not available
End organ devascularisation
Traumatic herniation of bowel or solid organs with ischaemia or infarction
Internal herniation of mesentery
List 5 indications for intercostal catheter with pneumothorax?
Traumatic pneumothorax
Moderate to large pneumothorax
Increasing size of pneumothorax after conservative management
Patient has a pneumothorax and requires ventilatory support or general anaesthesia
Pneumothorax with associated haemorrhage
Tension pneumothorax
What are risks of intercostal catheter?
Intercostal artery tear
Haemothorax
Cardiac contusion
Empyema/ pneumonia
Parenchymal injury
Pulmonary oedema
Bronchopleural fistula
What are options for managing VT?
DC synchronised cardioversion
-Use as first option if underlying comorbidity such as heart failure or unstable
Procainamide
-25mg/min IV
-Use as first option if patient stable as will also treat SVT with aberrancy, AVRT WPW and monomorphic VT with safety and efficacy
-Avoid if unstable or patient has heart failure
Amiodarone
-300mg IV over 30 mins
-Treatment of choice in unstable patient or in setting of cardiac arrest.
-Avoid if prolonged QT or WPW suspected
Lignocaine 1mg/kg IV
-Third line agent in VT which is stable
-Agent of choice in patients with suspected toxicological cause of VT
What are structural causes of VT?
What are causes of VT in a structurally normal heart?
Structural heart disease
-Ischaemic cardiomyopathy
-Non ischaemic cardiomyopathy: HCM, cardiac sarcoid, arrhythmogenic right ventricular cardiomyopathy
Structurally normal heart
-Idiopathic VT - RVOT VT, fascicular VT
-Primary arrhythmic syndromes: brugada, long QT, short QT, catecholamine polymorphic VT
What are causes of grey turners and cullens sign?
Periumbilical ecchymoses
Causes
-Pancreatitis
-Retroperitoneal bleeding
-Anticoagulation complication
-Rectus sheath haematoma
-Ectopic pregnancy
-Ishcaemic bowel
-Ruptured AAA
-Peforated duodenal ulcer
What are causes of erythema nodosum?
How is it treated?
Streptococcal infection
TB
Mycoplasma pneumonia
EBV
Penicillin
Lymphoma
Sarcoidosis
COC
Treatment
-NSAIDS
-Corticosteroids
-Potassium iodide
What are the major and minor criteria for acute rheumatic fever?
Major: Carditis (murmur), polyarthritis, chorea, erythema marginatum, subcutaneous nodules
Minor: Fever, raised ESR or CRP, polyarthralgia, prolonged PR on ECG
Diagnosis: 2 major or 1 major and 2 minor and evidence of preceding GAS
Causes of limp in a 20 month old indigenous child?
NAI - metaphyseal corner fracture
Septic arthritis
Acute rheumatic fever
Malignancy - leukaemia
Juvenile rheumatoid arthritis
Toddlers fracture
What makes septic arthritis more likely?
Non weight bearing
Temp > 38.5
ESR > 40
WBC > 12
If 2 positive 40% likelihood
If 3 93% probability
If 4 99%
Causes of conjunctivitis in neonates?
Tests?
Treatment?
Gonococcus infection
Chlamydia
Streptococcus/ staph
HSV
Adenovirus
PCR swab for gonorrhoea and chlamydia
Vaginal swab or urine testing of mother
Treatment
-IV cefotaxime 50mg/kg
-PO azithromycin 10mg/kg
-Eye toilet: Normal saline or breast milk
-Topical chloramphenicol ointment
Treat mother and all sexual contacts for STD
IM ceftriaxone 500mg and 1g azithromycin PO, metronidazole 400mg BD for 14 days
What are risk factors for subdural haematoma?
What are the clinical differences between chronic and acute subdural presentations?
Treatment?
Risk factors
-Alcohol misuse
-Elderly
-Coagulopathy
-Brain mass
Acute < 3 days, sub acute 3 days to 3 weeks
-More likely to present with focal neurological signs e.g. hemiparesis
Chronic > 3 weeks
-More likely to present with non focal symptoms
-Cognitive impairment, headache, presyncope, ataxia, seizures
Treatment
-HOB up 30 degrees
-RSI
-Urgent neurosurgical consultation
-Reverse anticoagulation
-Maintain SBP > 100mmHg
-Maintain SBP < 220 (labetalol)
What are secondary causes of atrial fibrillation / flutter?
Acute coronary syndrome
Thyrotoxicosis
Electrolyte abnormalities - hypokalaemia
Infection
Dehydration
Exacerbation of COPD, pulmonary embolism
Alcohol
Myocarditis
Approach to treatment of atrial fibrillation?
Exclude and manage secondary causes e.g. hypokalaemia, hyperthyroidism, PE
Unstable patient
-Urgent synchronised electrical cardioversion
Known LV systolic dysfunction or clinical heart failure
-Amiodarone
No systolic dysfunction or heart failure
Rate control vs rhythm control
Rhythm control
-Use if patient preference, highly symptomatic or physically active, difficulty achieving rate control, LV dysfunction, paroxysmal or early persistent AF, absence of severe atrial enlargement, acute AF
-Electrical cardioversion acutely if low thromboembolic risk
-Flecainide if structurally normal heart and low thromboembolic risk
-Amiodarone can be considered in those with structural heart disease
Rate control (80bpm goal but accept < 110)
-Use if advanced age, longstanding AF, severe LA enlargement, minimal symptoms, multiple previous attempts to restore sinus rhythm
-Beta blockers (avoid in severe COPD) e.g. 2.5-5mg IV q 10 mins, up to 3 doses, or calcium channel blocker diltiazem 0.25mg/kg IV (avoid if LVEF < 40%)
-Digoxin can also be considered if above contraindicated
Describe the CHADS VASC score?
Point for each of
Congestive heart failure
Hypertension
Age > 65 = 1 > 75 =2
Diabetes
Stroke
Vascular disease
Female
Score 1 consider anticoagulation
Score > 1 require anticoagulation
What is the HAS-BLED score?
Hypertension
Abnormal renal function
Abnormal hepatic function
Haemorrhagic stroke
History previous major bleeding
Labile INR
Elderly
Alcohol use
Score > 2 associated with increased bleeding risk
Important differences between atrial fibrillation and flutter?
Atrial flutter is less serious it tends to revert back to sinus rhythm spontaneously and has less risk of embolisation
List 8 risk factors for blunt carotid/ cerebrovascular injury?
List 5 clinical features suggestive of blunt carotid/ cerebrovascular injury?
Treatment?
Risk factors
-High energy transfer mechanism
-Displaced midface fracture (Le Forte II or III)
-Complex skull fracture/ base of skull fracture
-C-spine fracture/ subluxation/ ligamentous injury
-Near hanging / anoxic brain injury
-Clothesline type injury
-Upper rib fractures
-Direct blow to neck
Signs/ symptoms
-Cervical bruit in patient < 50
-Headache/ facial pain
-Tinnitus
-Horners syndrome
-Expanding cervical haematoma
-Focal neurological deficit: hemiparesis, horners syndrome
-Neurologic findings unexplained by intracranial findings
-Stroke on CT or MRI
Treatment
-Surgical options such as stenting or bypass if > 70% occlusion or expending pseudoaneurysm
-Aspirin for minimum of 3 months
Describe how to test how 5 nerves which could be injured with a knee dislocation?
Common peroneal
-Tibialis anterior, foot dorsiflexion
-Peroneus longus and brevis, foot eversion
Tibial nerve
-Gastrocnemius, soleus, foot plantarflexion
Femoral nerve
-Quadriceps, knee extension
Sciatic nerve
-Hamstrings, weakness of knee flexion
-Loss of power of all muscles below the knee causing foot drop
Five causes of foot drop?
L4/5 root lesion
Sciatic nerve palsy
Peripheral neuropathy
Motor neurone disease
Common peroneal nerve palsy
Treatment of tumour lysis syndrome?
IV fluid to promote renal clearance of unwanted metabolites
-5-6L/day of normal saline
-May require diuretics or renal replacement therapy if UO does not improve or gets hypervolaemia
Only treat hypocalcaemia if dysrhythmia/ heart block, seizure
Mange hyperkalaemia the same as for any other etiology
Treat hyperuricaemia with rasburicase IV and allopurinol
How do you improve ED access block and overcrowding?
Reduce demand
In community
-Improved funding for complex care for GPs
-Integrated and coordinated care of frequent attenders
-Hospital outreach - hospital in the home
In ED
-Senior decision making 24/7
-Short stay units
-Accelerated evidence based protocols
-Access to consultations and investigations
Increase capacity
ED
-Fast track
-Short lab and radiology turn around times
-Senior staffing 24/7
-Full capacity protocol (send patient to ward)
ED department beds
Ward processes
-Bed coordinator
-Daily coordination rounds
-Clinical inpatient rounds at least once daily
-Improved speed of investigations and consultations
Ward beds
-> 3 acute hospital beds per 1000 population
Improving exit
Ward processes
-Morning discharge
-Weekend discharge
-Improved allied health and pharmacy access
-Better use of transit lounge
Community capacity
-Increase residential age care beds
What are the causes, XR findings and US findings of pneumomediastinum?
Causes
-Blunt or penetrating chest trauma
-Neck, thoracic or retroperitoneal surgery
-Oesophageal perforation (boerhaave syndrome)
-Tracheal or bronchial perforation
-Laryngeal fracture
-Vigorous exercise
-Child birth
-Asthma
-Barotrauma - diving
-PPV
-Retropharyngeal infection
XR features
-Linear density parallel to heart border
-Extending above aortic root
-Does not change with position
-Subcutaneous emphysema
-Pneumopericardium
-Gas around pulmonary artery
-Continuous diaphragm sign
Ultrasound
-Cervical subcutaneous emphysema - ‘dirty’ posterior acoustic shadow
-Loss of the parasternal and apical views on TTE, preservation of subxiphoid window
-Air gap sign
Causes, XR features and US features of pneumopericardium?
Causes
-PPV
-Thoracic surgery/ pericardial fluid drainage
-Penetrating trauma
-Blunt trauma
-Infectious pericarditis with gas producing organisms
XR features
-Heart partially or completely surrounded by gas
-Continuous diaphragm sign
-Halo sign
-Limited to pericardial reflection
-Changes with position
US
-Reverberation artefacts similar to A-lines
-Heart remains obscured throughout cardiac cycle
-Involves subxiphoid window
Causes, XR features and US features of pneumomediastinum?
Perforated hollow viscous
-Peptic ulcer disease
-Ischaemic bowel
-Bowel obstruction
-Diverticulitis
-Malignancy
-IBD
-Perforation
-Peritoneal dialysis
-Vaginal aspiration - water skiing
-PPV
AXR
-Double wall sign ‘Riglers sign’
-Telltale triangle sign
-Periportal free gas sign
-Falciform lifament sign
CXR
-Subdiaphragmatic free gas
-Continuous diaphragm sign
-Cupola sign
US
-Enhancement of peritoneal stripe sign
-Discrete hyperechoic foci representing gas bubbles
Sensitivity of different criteria for detecting VT?
Brugada 89%
Griffith 94%
Vereckei aVR 87%
What is the dose of verapamil for SVT?
5mg IV, followed by 1mg/min up to 15mg
How do you treat antidromic AVRT?
If stable then procainamide first line
Alternative is DC cardioversion
When can adenosine be used with WCT?
In general avoided with WCT
Can be used for RVOT VT
Probably safe in antidromic WPW but need to beware of adenosine induced AF
Cannot treat WPW with antidromal conduction with atrial fibrillation with AV nodal blockers
-Avoid adenosine, amiodarone, beta blockers, CaCh blockers
-Options are cardioversion or procainamide
Use of procainamide?
Excellent success rates for all types of WCT
More effective than amiodarone for monomorphic VT
VT
SVT or AF with BBB
SVT or AF with WPW
Side effects
-Hypotension
-Prolong QRS/ QT interval
What are contraindications to amiodarone?
Pregnancy
Prolonged QT
Rapid AF + WPW
Accelerated idioventricular rhythm
Other slow VT conditions
What causes a negative / low anion gap?
Explain how you differentiate causes of NAGMA?
Normal anion gap 4-12
Depends on normal serum albumin and phosphate
Reduced concentration of unmeasured anions such as albumin
Increased concentration of unmeasured cations
-Magnesium
-Calcium
-Lithium
Certain populations
-Myeloma
-Hypertriglyceridaemia
-Bromide OD
NAGMA causes
Chlorine (chloride excess)
Acetazolamide/ Addisons
Gastrointestinal (diarrhoea, fistulae, ileostomy)
Extras (RTA)
Calculate urinary anion gap to differentiate between GI and renal cause of NAGMA
AG > 30 HAGMA, 20-29 (1/3 not have acidosis)
How to manage a patient with multiple ICD shocks?
Phantom - reassurance
Inappropriate
-Magnet
-AF or SVT - B blockers, CaCh blockers, activate SVT discriminators, ablation
Lead oversensing
-Magnet
-ICD reprogramming
Appropriate
-Evaluate and treat reversible causes (electrolytes, ischaemia)
-Antiarrhythmic agents
-Sedation
-IABP and ablation for refractory VT
What factors predict deterioration after blunt chest trauma?
How do you manage patients after blunt chest trauma?
Risk factors
-Age > 55
-Uncontrolled pain
-Lung disease: smoker, COPD, asthma
-Obesity
-Respiratory compromise: increased WOB, RR, reduced saturations
-3 or more rib fractures
-Inability to cough
-Associated pneumothorax or haemothorax, pulmonary contusion, flail chest
Management
-Incentive spirometry
-Analgesia: paracetamol/ NSAID/ opioids/ PCA/ epidural
-Prevent complications: mobilise, chest physiotherapy, VTE prophylaxis
Management of chest trauma?
If haemodynamically unstable and concern for tension
–> immediate needle decompression, intercostal catheter
Primary survery
-eFAST
-If lung sliding absent then CT or erect CXR
If CXR/ CT show large pneumothorax then small tube thoracostomy or pigtail. If small can observe.
Management of haemodynamically unstable PE?
Tenecteplase up to 50mg IV (weight adjusted dose) or alteplase 100mg over 2 hours
1L 0.9% saline bolus
Enoxaparin 1mg/kg subcutaneous
Analgesia - fentanyl 1mcg/kg
Adrenaline or noradrenaline infusion
Liaise with respiratory/ ICU/ cardiothoracics re ECMO, open thrombectomy
Approach to PE diagnosis?
Use wither wells or geneva rules to assess pretest probability
If low risk (wells score < 2)
-Apply PERC rule and if all 8 criteria -ve then no further testing required
-Risk of testing greater
If intermediate risk (wells score 2-6) or PERC +ve
–> D-dimer
-Age adjusted for patients over 50
-D-dimer x 10
-If normal then PE excluded
-If positive –> CTPA
If wells score > 6
–> CTPA
If contraindication to CTPA (contrast allergy, thyroid disease, renal failure) then V/Q scan
What are the YEARS criteria?
Validated in pregnant and non pregnant
If no clinical DVT and no hemoptysis then proceed to D-dimer testing
If PE unlikely and D-dimer < 1000ng/ml then PE excluded
If PE likely and D-dimer < 500ng/ml then PE excluded
Approach to PE diagnosis in pregnancy?
CXR to assess for alternate diagnosis such as pneumonia
If clinical DVT then can order an DVT duplex US and if DVT present treat with enoxaparin and assume PE
If no DVT then can use YEARS criteria (no DVT, no haemoptysis)
-If felt to be likely and< 500ng/ml excludes diagnosis, or < 1000ng/ml if PE felt to be unlikely
Alternative
-Request bilateral DVT duplex US - if DVT then treat and assume PE
-If no DVT but PERC negative can with shared decision making order a D-dimer and interpret as per trimester
-1st < 750ng/ml
-2nd < 1000ng/ml
-3rd < 1250ng/ml
—> PE excluded
Investigations
-If imaging required then options are V/Q scan or CTPA
-Shared decision making with patient
-Need normal CXR to have accurate V/Q scan
-CTPA is lower risk of radiation to fetus but higher to breast tissue of mother than V/Q scan
-Both are low risk overall to fetus
-If undergo CTPA shield abdomen, if undergo V/Q scan then IDUC and fluids to clear isotope
Describe supraperiosteal, infraorbital and inferior alveolar nerve blocks?
Describe the Ellis classification of dental fracture?
