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MBBS IV - Supplementary Courses > JC Block C - Emergency Medicine (II) > Flashcards

JC Block C - Emergency Medicine (II) Flashcards

1
Q

4S for resuscitation preparation

A
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2
Q

Goals of initial trauma assessment

A

o To rapidly identify and treat life-threatening injuries
o To prevent secondary injury from hypoxia and decreased tissue perfusion (shock)
o To control pain (give morphine)
o To plan definitive care and patient transfer to appropriate facilities

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3
Q

General ED approach to all trauma patients**

A

1) Triage

2) Primary survey (in 5 mins) - identify and resuscitate life-threatening injuries one at a time
- ABCDE
- Adjunctive tests and investigations

3) Secondary survery
- Head to toe exam

4) Definitive care - on-site treatment or transfer

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4
Q

Emergency Assessment of airway patency

A

Assess quickly by talking to him:
 Ask the patient his/her name (confirm identity)
 Ask the patient what happened

A right answer confirms:

  1. Patent airway
  2. Adequate ventilation to permit speech
  3. Sufficient perfusion (adequate circulation to brain)
  4. Clear sensorium (at least not comatose)
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5
Q

Why is C-spine damage rapidly fatal

A

High C-spine injury (C3-5) impairs respiratory drive

Rapidly progress into respiratory arrest

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6
Q

Management of the following airway complications:

Blood / secretions in airway
Vomitus aspiration
Foreign objects in airway

A

Blood / secretions in airway - Suction with a Yankauer suction catheter

Vomitus
 Log roll to lateral position
 Suction with a Yankauer suction catheter

Foreign objects in airway - Removal with MaGill forceps/ suction

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7
Q

First line airway protection measures for comatose patient

A

 OPA – watch out for gag reflex which may induce vomiting

 NPA – avoid if basal skull fracture suspected (to avoid injuring the brain)

 Endotracheal tube (ETT) if GCS <8

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8
Q

First-line measure for thermal airway injury

Thermal airway injury signs

A

Prophylactic intubation (subsequent airway obstruction due to swelling (oedema) would make intubation impossible)

Thermal airway injury:
 Burnt nasal hairs
 Carbonaceous sputum
 Facial burns
 Stridor
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9
Q

First-line measure for Maxillofacial trauma patient

A

Surgical airway – cricothyrotomy (anticipate difficult airway because of bleeding, swelling, distorted anatomy)

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10
Q

Criteria for C-spine imaging

A

cervical spine imaging (prefer CT initially) if fail to meet any one of the
National Emergency X-Radiography Utilization Study (NEXUS) Criteria:

 No posterior midline cervical spine tenderness
 No evidence of intoxication
 Alert mental status
 No focal neurological deficits
 No painful distracting injuries
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11
Q

Breathing protection measure in a trauma patient

A

Give O2 15L/min via a non-rebreathing mask

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12
Q

Circulation assessment in emergency

Signs of poor circulation

A

Any source of bleeding:

1) Thoracic cavity, abdominal cavity, retroperitoneal cavity, pelvic cavity
2) Thigh bone fracture
3) External bleeding

Altered mental status (a lack of cerebral perfusion)

Tachycardia (1st sign) and hypotension

Skin colour and pale extremities

Auscultate: Muffled heart sounds, Unequal breath sounds

Palpate: 
 Pulse volume and rate
 Cold extremities
 Capillary refill >3s
 Tracheal deviation

Monitor: BP/P, pulse pressure, urine output

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13
Q

Causes of acute hypotension/ shock

A

 Haemorrhage (must be the cause in trauma until proven otherwise)
 Obstructive shock (tension pneumothorax, cardiac tamponade)
 Neurogenic shock: Due to cervical spinal cord injury above T6 level

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14
Q

Pathophysiology of neurogenic shock

A

 Due to cervical spinal cord injury above T6 level
 Loss of sympathetic arterial tone  vasodilatation (warm skin, non- sweaty), low BP
 Loss of sympathetic innervation to the heart  unopposed vagal parasympathetic innervation  slow pulse
 Slow respiratory rate

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15
Q

How to estimate blood pressure on P/E

A
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16
Q

Measures to control acute external bleeding in a trauma patient

A

Control haemorrhage (stop the bleeding):
 Direct pressure for external bleeding, elevate
 Apply tourniquet for exsanguinating limb bleeding not controlled by direct pressure (tighten till no radial pulse – maximum 4h)
 Pelvic binder for pelvic fracture (tamponade effect)
 Reduction and traction of thigh bone fracture
 Definitive surgery based on the underlying injury

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17
Q

Measures to preserve circulation in a trauma patient

A

Stop bleeding first

1) Set 2 large-bore IV catheters in the antecubital fossae (14 or 16 G) or intraosseous route in case of difficult venous access
 Crystalloid: normal saline 0.9% or Ringer Lactate solution 2L IV bolus
 When internal bleeding is not controlled, maintain ‘permissive hypotension’ with systolic BP ~90 mm Hg

2) Draw blood for T&S, prepare for blood transfusion
- still unstable after 2 L of fluid or having on-going blood loss, transfuse unmatched type O blood:
- If transfuse >10 units of packed red cells within 24 hours of trauma, transfuse at an 1:1:1 ratio of packed red cells, platelet, and fresh frozen plasma to minimize coagulopathy

3) If presented within 3 hours, give IV tranexamic acid 1 g IV bolus followed by 1g over 10 min, followed by 1 g IV over 8 hours

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18
Q

Emergency treatment of cardiac tamponade

A

 Subxyphoid pericardiocentesis (aspirating 15-20 ml of blood may improve the condition)
 IV fluid bolus
 Definite care – surgery

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19
Q

How to assess disability in a trauma patient

A
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20
Q

Emergency management of disability (e.g. low GCS, Low blood glucose…)

A

Disability management:
 If GCS <8, intubate for airway protection to prevent asphyxia and aspiration
 Assume C-spine injury for patient with altered mental status
 Maintain oxygenation and perfusion
 Correct hypoglycaemia and maintain euglycaemia
 CT brain after stabilization of the patient
 Definitive care based on the CT findings

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21
Q

Measures for adequate exposure in a trauma patient

A

o Remove/ cut all clothing - examine the entire body for evidence of injury (including axillae, groin)

o Perform log-roll maneuver - examine the patient’s back (perform per rectal examination for anal tone)

o Cover patient with warm blankets to:
 Prevent heat loss/ maintain normal temperature (hypothermia can lead to coagulopathy)
 Protect patient’s privacy

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22
Q

Primary survey adjunctive tests

A

Primary survey adjuncts:
1) Trauma series: CXR, X-ray pelvis (AP) +/- X-ray C-spine (lateral)

2) Blood for CBC, L/RFT, clotting profile, T&S, ABG
3) E-FAST (focused assessment with sonography for trauma) scan
4) ECG if indicated
5) Foley catheter for urine output monitoring (avoid in urethral injury)
6) Nasogastric tube to empty the stomach (orogastric tube if basal skull fracture)
7) Urine for pregnancy test if indicated

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23
Q

E-FAST (focused assessment with sonography for trauma) scan

Views?

A

Any fluid is blood until proven otherwise

  1. The pericardial view - for cardiac tamponade
  2. The right upper quadrant view (including interfaces of the diaphragm, liver, right kidney, Morrison’s pouch)
    - For diaphragm, liver and kidney, as well as the entire hepatorenal fossa or Morrison’s pouch, looking for fluid.
    - presence of fluid between the diaphragm and liver or liver and kidney is blood until proven otherwise
  3. The left upper quadrant view (including the diaphragm-spleen interface, spleen-kidney interface)
  4. Suprapubic view (bladder, bowel)
    - obtain prior to placement of a Foley catheter.
24
Q

Head exam for acute trauma

A

Scalp wound bleeding/ haematoma

Evidence of skull base fracture (e.g. haemotympanum)

Epistaxis/ septal haematoma

Facial wounds and instability
o Airway protection for significant mid-face trauma

Teeth fracture, avulsion

Surgical emphysema/ haematoma over the neck

25
Q

Trunk exam for acute trauma

A

Full CVS

Full Abdominal exam

Pelvis stability

Perineum and genital:
 Blood in urethral meatus (urethral injury)
 Per-rectal exam:
o For anal tone, blood, high-riding prostate (for man)
o Not performed in alert patients without evidence of pelvic/ spinal injury

Back Log roll for wounds

26
Q

Limb exams for acute trauma

A

 Extremities deformity, fractures, wounds
 Peripheral pulse for vascular compromise

Complete neurological examination

27
Q

Outline SAMPLE history in trauma

A
28
Q

Pain management options for acute trauma

A
29
Q

Open pneumothorax **

  • Key features
  • Treatment option
A 
Key features: 
Respiratory distress
Tachypnea
Sucking chest wound****
Tachycardia only (no hypotension) *****
Decreased breath sound on affected side

Treatment:

1) Three-sided occlusive dressing over the sucking chest wound (use impermeable material, e.g. plastic gauze package, to create a one-way valve)
2) Followed by chest drain insertion

30
Q

Tension Pneumothorax **

  • Key features
  • Treatment options
A 
Key features: 
Respiratory distress
Tachypnea
Distended neck veins ****
Shock: Tachycardia, hypotension ****
Tracheal deviation to opposite side ****
Hyper-resonance on the affected side ****

Treatment:

1) clinical diagnosis (no time for X-ray)
- Needle decompression: 14 or 16 G needle at 2nd ICS, mid-clavicular line
- Diagnosis confirmed by gust of air, return of breathing

2) Followed by chest drain insertion (at safety triangle)

31
Q

Massive hemothorax

  • Key features
  • Treatment options
A 
Key features: 
1.5L blood in thoracic cavity
Tachycardia, hypotension
obtundation
Percussion Dull on the affected side

Treatment:

1) Replace loss, stop bleeding
2) IV fluid resuscitation (large bore: 14 or 16 G)
3) Blood transfusion
4) Chest drain insertion
5) Definitive surgery – thoracotomy/ video- assisted thoracic surgery

32
Q

Flail chest

  • Key features
  • Treatment options
A

Key features:

  • > 2 rib fractures in >2 places
  • Associated with underlying pulmonary contusion
  • Paradoxical chest movement (segment is disconnected with the rest of ribcage)
  • Decreased breath sound on the affected side

Treatment:

1) Supplemental O2
2) Judicial use of IV fluid (overzealous fluid replacement can lead to pulmonary oedema (ARDS))
3) Pain control (IV morphine)
4) Early intubation, mechanical ventilation (positive pressure)

33
Q

Why is cervical spine immobilization important in trauma care?

A

 Cervical spine has a high flexibility and mobility and is prone to injury
 Cervical spinal cord injuries can cause permanent paralysis and can be fatal
 All trauma patients were presumed to have neck injury until proven otherwise

34
Q

Techniques for manual grips for in-line C-spine immobilization

A

o Keep the head and spine in the neutral position manually
o Avoid traction or compression as it increases the risk of spinal cord injury

Techniques:

1) Head grip
2) Trap squeeze
3) Chin grip

35
Q

Head grip C-spine immobilization technique

A
36
Q

Trap squeeze C-spine immobilization technique

A
37
Q

Chin grip C-spine immobilization technique

A
38
Q

Contraindications to C-spine neutral position

A 
 Patient resistance to movement
 Neck muscle spasm
 Increased neck pain
 Commencement/ increase of neurological deficit
 Compromise of the airway/ ventilation

In these situations, the patient’s head must be immobilized in the position in the which it was initially found

39
Q

Rigid neck collar

Correct sizing method **
Correct movement restriction
Is rigid collar alone enough for immobilization??

A

Sizing: measure the gap between the top of the shoulder to the bottom of chin**

Movement restriction: If properly sized, can limit:
 Flexion by 90%
 Extension, lateral flexion, and rotation by 50%
The neck collar must not inhibit the patient’s ability to open the mouth or the provider’s ability to open the patient’s mouth

Rigid neck collar alone does not provide adequate immobilization – must always be used with manual/ mechanical immobilization

40
Q

Detrimental effects of poorly fitted rigid neck collar

A
41
Q

Methods for applying rigid neck collar

A

Posterior-first method

Anterior-first method

42
Q

Log - roll

Function
Indications

A

Principle: turn the patient in one piece (log) and minimize lateral/ rotational force onto the spine during turning (keep the patient’s entire body in neutral alignment)

Indications:
o Positioning a trauma patient onto a spinal board to facilitate patient transport
o Turning a trauma patient with suspected spinal injury to exam the back

43
Q

Explain the roles of person A,B and C during log-roll

A
44
Q

Log-roll

Procedure

A
45
Q

spinal board and straps

Procedure

A
46
Q

Complications of prolonged spinal board immobilization

A

o Pressure ulcers on bony prominence (>1h)
o Impaired respiration (due to excessive strapping over the chest)
o Risk of aspiration if the patient vomits - log roll the patient and the board as a unit and suction the airway as needed

47
Q

Pelvic fracture

  • Risk of mortality
  • Treatment
A

Unstable pelvic fractures can result in life-threatening haemorrhage
blood loss as high as 2-3 units per break
mortality >25% esp elderly

Treatment: pelvic binder – SAM sling
Principle:
 Limit the volume of the pelvic cavity to create a tamponade effect  stop further bleeding
 Provide safe and effective reduction and stabilization of pelvic fractures

48
Q

SAM sling

Procedure

A
49
Q

Femur fracture

  • Risk
  • Treatment
A

Risk: 1-2 L of blood can accumulate in the thigh at the site of femur fracture

Treatment:
Apply a traction splint(aka hare splint) - a metal frame that extends from the proximal end of the thigh to a point distal to the heel

Functions:
 Realign fracture fragments and decrease the potential space in the thigh for blood loss
 Immobilize a fractured femur
 Reduce pain
 Prevent further damage to neurovascular structures

50
Q

Traction splint/ hare splint

  • Indications
  • Contraindications
A

Indication: suspected femur shaft fracture, as suggested by limb shortening/ deformity/ swelling/ crepitus/ ecchymosis of the injured thigh

Contraindications:
 Pelvic fractures, hip injuries with gross displacement
 Open femur fracture
 Significant knee injuries
 Avulsion/ amputation of the ankle/ foot
 Distal tibia-fibula or ankle fracture in the same extremity

51
Q

Procedure for traction splint

A
52
Q

SAM splint

  • Construction
  • Use
A

 Used for temporary splinting in A&Es and ambulances in Hong Kong
 = thin core of soft aluminum alloy sandwiched between two layers of foam
 Malleable (creating curves can add strength to the splint), lightweight, waterproof, radiolucent, and reusable

53
Q

SAM splint for wrist

Procedure

A
54
Q

Procedure for roller bandage on SAM wrist splint

A
55
Q

Arm sling procedure

A

MBBS IV - Supplementary Courses (54 decks)

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