Likely Stations Flashcards
Paediatric Head Injury
2023.2 History Taking Station
take a focused history from a parent of a paediatric patient with a head injury
EM rapid bombs on concussion ep 9
Rule out child abuse
PECARN
Using CT responsibly
- Radiation exposure
ALARA “as low as reasonably achievable”
sedation for CT - IN midazolam
Concussion
Medical Expertise: Assessment (40%)
Elicit a focused relevant history de novo.
Clarify aspects and inconsistencies in a pre-obtained history to refine diagnosis generation.
Identify important historical details (red flags) diagnostic of an important condition.
Generate a differential diagnosis, with an inherent focus on conditions requiring time critical
management.
Medical Expertise: Management– 30%
Create an appropriate ongoing assessment and management plan.
Manage multiple problems simultaneously by prioritising treatment options while remaining
vigilant for other potential problems.
Provide a rationale to explain decisions about ongoing assessment.
Communication – 30%
Use language appropriate to the patient’s level of understanding e.g., avoid jargon, explain
medical terms.
Demonstrate a professional and respectful approach.
Summarise the encounter and confirm patient understanding.
Candidates were required to meet with the parent of the child (role player) and to:
Obtain a detailed history from the parent.
Explain your management plan to the parent.
Answer any further questions from the parent
PECARN:
age >2
*LOC
*Vomiting
*severe headache
*Severe mechanism
–> observation
*GCS < 15
*Altered mental status (Agitation, somnolence, repetitive questioning, or slow response to verbal communication)
*Signs of base of skull fracture
–> CT brain
HISTORY:
Exact mechanism of injury:
- when
- how
Severe Mechanism of injury includes:
- MVA with ejection
- MVA with roll over
- Death of passenger in same vehicle
- Pedestrian or cyclist w/o helmet struck by motorised vehicle
- fall >1m
- head struck by high impact object
Red flag symptoms:
- infant younger than 3 months
- abnormal behaviour
- drowsy/lethargic
- persistent irritability
- headache
- non-frontal scalp haematoma
- blood coming from ears (haemotympanum)
- clear liquid coming from ears or nose (CSR rhinorrhoea)
- bruising behind ears (battle sign)
- memory impairment
- loss of consciousness
- seizures (not impact seizures)
- difficulty walking
- intractable vomiting
- other injuries sustained
RED FLAGS FOR CHILD ABUSE:
- previous similar presentations
- changing story
- mechanism/pattern of injury inconsistent with developmental age
PMHx:
- bleeding disorders (haemophilia)
- VP shunts
- Neurodevelopmental disorders (autism) - difficult to assess –> lower threshold to CT
Meds:
anticoagulation
IMMUNISATIONS:
ALLERGIES
SOCIAL:
- where do you live
- who lives at home
- access to medical services, car, phone
EXAMINATION:
GCS:
Eye opening (4)
- spontaneous (4)
- to speech (3)
- to pain (2)
- none (1)
Verbal: (5)
- babbles/coos (5)
- irritable/cries (4)
- cries to pain (3)
- moans to pain (2)
- none (1)
Motor: (6)
- normal movements (6)
- withdraws to touch (5)
- withdraws to pain (4)
- abnormal flexion (3)
- abnormal extension (2)
- none (1)
mental status/behaviour - irritable, agitated, somnolent, repetitive questioning, slow response to questioning
Non-frontal boggy scalp haematomas >2cm in size
- high risk if occipital, parietal and temporal as opposed to frontal
- boggy suggestive of skull fracture
Signs of base of skull fracture:
- battle sign
- raccoon eyes
- CSF otorrhoea/rhinorrhoea
- haemotympanum
Assess for signs of raised ICP and brain herniation:
- reduced LOC
- blown pupil
- hemiparesis
- abnormal posturing (decorticate or decerebrate)
- cushings reflex (bradycardia, hypertension)
ASSESSMENT OF CERVICAL SPINE
ASSESS FOR NON-ACCIDENTAL INJURY:
- head to toe exam
MANAGEMENT:
- Child with head injury is a very common presentation to the emergency department. It is something that we see and treat a lot.
- The next step in my assessment is to decide whether or not we need to do a CT scan of the head.
- We perform CT scans to looks for serious injuries to the brain that may need urgent treatments. For example a bleed on the brain.
- As you may be aware, CT scans are not completely benign tests. They do expose the growing brain to radiation which does increase the lifetime risk of developing brain cancer. This risk is higher in younger children.
1: 1500 in 1yr old
1: 10,000 10yr old
We use a clinical decision tool to help us identify which patients need to have CT.
This tool helps us to balance the risk of missing a serious brain injury, and to minimise radiation induced cancer in the paediatric population.
Based on the information that I have gathered today. Your risk of having a serious injury inside your head is very low. Almost negligible. <0.05%.
Therefore we will not proceed to a CT scan. We will observe you for 6hrs from the time of injury, reassess you and check your progress.
CRITERIA FOR DISCHARGE HOME
- normal mental status with improving symptoms
-
CONCUSSION:
Concussion symptoms:
- poor balance, unsteady
- headache
- dizzy
- poor concentration “in a fog”
- sensitive to light and noisy
- fatigue
Cognitive rest - 1-2 day break from school with graded return to cognitive activities
Limit screen time
Physical rest - 1-2 days of physical rest with graded return to normal physical activity
sleep hygeine and adequate hydration are important aspects in the recovery
referral to multidisciplinary head injury team for children with prolonged concussion symptoms
return to contact sport and game play - need to be cleared by primary care physician
Paediatric Head Injury
2022.1 Case Based Discussion
discuss with an examiner, the assessment and
management of an 8 year old male who has presented to the ED following a fall at a playground.
Prioritisation and Decision Making: Assessment – 30%
* Provides a rationale to explain decisions about ongoing assessment.
Prioritisation and Decision Making: Management – 30%
* Provides an appropriate list of advantages and disadvantages (pros and cons) to explain
decisions made regarding management
* Provides a rationale to explain and justify decisions about ongoing treatment.
Medical Expertise – 40%
* Correctly interprets the results of an investigation within the scenario
* Correctly chooses time critical interventions based on assessment
* Initiates treatments specific to identified neurological pathologies.
Candidates were required to interact with the examiner and to:
* describe how they would decide if the child needed a CT brain
* answer further questions regarding the evolving case
* outline their reasoning or justify their rationale where appropriate.
PECARN identify patients at very low risk of intracranial injury who do not need a CT scan (all predictor variables negative, no CT required)
PECARN the only prospectively validated decision making rule
PECARN has highest sensitivity in ruling out serious pathology
It helps us to balance the risk of missing a significant injury, and to minimize the risk of radiation-induced cancer in the paediatric population
AGE <2yrs
GCS <14
Altered mental status
Loss of consciousness
Parietal, temporal, occipital haematoma
Not acting normal as per parent
Severe mechanism:
- MVC with patient ejection,
- death of another passenger
- rollover
- pedestrian or bicyclist w/o helmet struck by motorized vehicle;
- fall from >0.9m
AGE >2yrs
GCS<14
Signs of base of skull fracture (racoon eyes, battle sign)
Altered mental status
Intractable vomiting
Severe headache
Dangerous mechanism
- fall >1.5m
MODIFIED PAEDIATRIC GCS:
alteration in verbal response
coos or babbles = 5
irritable cry = 4
cries to pain = 3
moans to pain = 2
no response = 1
If PECARN negative:
CT is not required as per best practice evidence
The purpose of non-con CT brain is to detect critical intracranial injuries that require urgent neurosurgical intervention
Risk associated with procedural sedation required to obtain the CT scan - aspiration, respiratory depression
Radiation exposure increases lifetime risk of developing brain cancer
1: 1500 in 1yr
1: 10,000 10yr old
Concussion will reveal a normal CT scan and is managed conservatively
Paediatric Head Injury
2021.1 History taking station
take a history from the parent of an infant with a head injury.
Medical Expertise: Assessment – 40%
* Elicits a focused, relevant history de novo
* Clarifies aspects and inconsistencies in a pre-obtained history to refine diagnosis generation
* Identifies important historical details (red flags) diagnostic of an important condition
* Generates a differential diagnosis, with an inherent focus on conditions requiring time
critical management
Medical Expertise: Management – 30%
* Prioritises patient assessment and management
* Assesses clinical risk
* Justifies decision making
Communication – 30%
* Attempts to establish rapport and attempts to establishes the concerns/issues/needs of the
patient or carer
* Establishes the concerns/issues/needs of the patient or carer
* Uses appropriate verbal and non-verbal skills
* Actively listens and encourages questions
Candidates were required to meet with the child’s parent (role player) and to:
* obtain a detailed history
* explain their management plan, and
* answer any further questions from the parent (role player)
.
Head Injury Intubation
Prevent raised ICP - raise head of bed 30 degrees
Anticipate difficult intubation due to potential c-spine injury/in line immobilisation
Blunt sympathetic response from laryngeal manipulation - pre medication with fentanyl 1mcg/kg IV (need to give this 3-5min before induction)
Ketamine 1-2mg/kg for induction - haemodynamically stable
Rocuronium 1.2mg/kg IV
Avoid hypotension:
have vasopressors on stand by
adrenaline 1mcg/kg IV Q5min
adequately fluid resuscitate before induction
Avoid hypoxia - pre-oxygenate with high flow oxygen 15L NRBM
Treat raised ICP:
- 3% NS 3-5ml/kg IV following by infusion 0.1ml/kg/hr to maintain Na+ 155-165
OR
- Mannitol 0.5–1 gram/kg
Maintain SaO2 >90%, PCO2 35-40
Maintain normothermia 36-37
Maintain normoglycemia - check BSL Q1h - especially important in paediatric patients
Maintain SBP >70 + (age x2)
Invasive BP monitoring with arterial line
adrenaline infusion 0.05-1mcg/kg/min
Seizure prophylaxis:
levetiracetam 15-40mg/kg IV
Immediate Neurosurgical attendance to facilitate decompressive craniectomy
Brain Herniation
BRAIN HERNIATION:
uncal herniation:
- compression of the occulomotor nerve –> ispilateral fixed dilated pupil
- contralateral hemiparesis
Central transtentorial herniation:
- bilateral pin-point fixed pupils
- bilateral babiski
- increased tone
- progress to hyperventilation and decorticate posturing
Cerebellotonsillar herniation:
- flaccid paralysis
- bradycardia
- respiratory arrest
- sudden death
Obese Intubation & Ventilation
2022.1 Case based discussion
The intubation of an obese patient with impending respiratory failure
Medical Expertise: Preparation for intubation (40%)
* Recognises a difficult intubation scenario
* Makes appropriate preparation for a difficult intubation including adjusting patient, staff,
equipment and drug factors
* Optimises patient factors to minimise complications of the intubation.
Medical Expertise: Ventilator settings (20%)
* Adjusts ventilator settings to cater for initial patient clinical status
* Understands importance of ventilator parameters for an obese patient.
Prioritisation and Decision Making (40%)
* Prioritises the essential components of ongoing treatments
* Provides a rationale to explain and justify ongoing treatment
* Manages multiple problems simultaneously whilst remaining vigilant for patient deterioration.
Candidates were required to interact with the examiner and to:
* outline their preparation for the intubation of this patient
* establish ventilator settings and explain their rationale
* answer any questions the examiner may have.
Recognize DIFFICULT INTUBATION situation:
RAPID DESATURATION “safe apnoea time” is reduced
- Reduced FRC
- more fatty tissue = higher metabolic requirements
HIGHER AIRWAY PRESSURES TO VENTILATE
- reduced chest wall and pulmonary compliance
INCREASED RISK OF ASPIRATION:
- high intra-abdominal pressure
DRUG METABOLISM & PHARMAKOKINETICS ARE ALTERED
- Lipophilic drugs (eg. Propofol & suxamethonium) have a larger Vd since Vd is dependent on the amount of adipose tissue. Lipophilic drugs need to be dosed based on TOTAL BODY WEIGHT. Therefore these doses will be much higher than in average adults.
- Hydrophilic drugs (eg. Ketamine) are dosed based on IDEAL BODY WEIGHT
AIRWAY MANAGEMENT:
PREPARATION & OPTIMIZATION
Place arterial line for accurate BP readings
- BP cuffs often don’t fit properly and overestimate BP which is dangerous on induction)
- fluid resuscitate prior to intubation
- 2 large bore IV lines
- Vasopressors on stand by
PREOXYGENATE
- patient sitting upright
- NIV positive pressure ventilation with Bipap (FiO2 100%, IPAP 20, EPAP 10 target TV 7-8ml/kg IBW) - alveolar recruitment
- at least 5min
Obese patients are at an increased risk for ASPIRATION
- have decanto or yankauer suction catheters ready
POSITION:
- RAMPED position
- tragus in line with sternal notch
- face plane parallel with the ceiling
- Reverse trendelenburg
(Improves respiratory mechanics and glottic view)
PLAN FOR SURGICAL AIRWAY - identify landmarks and mark front of neck incase of CICO
SEDATION with ketamine 1-2mg/kg ideal body weight
PARALYSIS with succinylcholine 2-3mg/kg IV (increases tone in lower oesophageal sphinchter to help prevent aspiration), quick onset and offset in case of failed intubation
Rocuronium with reversal agent (sugamadex) on stand by
Apnoeic oxygenation with HFNP 60L 100%
INTUBATION PLAN:
Plan A - most experienced operator, video laryngoscope, bougie
Plan B - 2 person BVM ventilation
oxygenation with bilateral NPA and OPA
Plan C - attempt oxygenation with LMA
Plan D is officially declaring “cannot intubate, cannot oxygenate” and proceeding with a surgical airway
CRICOTHYROTOMY:
Immobilise the larynx with the non-dominant hand
Identify the cricothyroid membrane (cricoid cartilage below, thyroid cartilage above). It’s 1cm in height and 2-3cm wide)
Prep the skin with chlorhexidine
Infiltrate the skin with 2ml xylocaine with adrenaline
Make a 1.5 cm transverse incision (avoid injury to anterior jugular veins) through skin, subcutaneous tissue and the cricothyroid membrane
A rush of air will be heard and bubbling seen
pass bougie through trachea
rail road size 6 ETT over bougie
BVM ventilate
Confirm placement
- auscultate bilateral lungs
- symmetrical chest wall rise and fall
- ETCO2 trace
VENTILATOR SETTINGS:
TV should be adjusted to IBW not TBW - 8ml/kg
RR - increased to accommodate higher metabolic demands (from 12-14 to 18-20).
PEEP should be increased (can be up to 20)
- increase FRC
- alveolar recruitment
(reverse trendelenburg can help decrease the pressures required)
FiO2 100% and titrate down to achieve SaO2 >90%
Peak pressure limit - try to keep the Pplat under 35 cmH2O
Penetrating Chest Trauma
EM rapid bombs
- ep 61 Ketamine facts
- ep 57 Thoracotomy
- ep 63 Tension pneumothorax
2022.1 Case based discussion
Discuss the assessment and
management of a male patient who has presented with a single stab wound to the right axilla.
Patient has sucking chest wound - manage this
Patient becomes agitated - manage this
Trauma call, involve surgery
Medical Expertise: Assessment and diagnosis (20%)
* Correctly interprets the CXR in the context of the patient presentation
* Formulates a provisional diagnosis to match the immediate issues.
Medical Expertise: Management (40%)
* Initiates treatments specific to identified abnormalities of airway and ventilation
* Initiates treatments specific to identifies abnormalities of circulation
* Outlines an overall plan for the ongoing treatment of the patient
* Adapts and initiates standard therapies to that patient, including drugs, fluids, gases, and
monitoring.
Prioritisation and Decision Making (40%)
* Summarises and prioritises key issues that must be addressed during and following the
emergency encounter
* Provides a rationale to explain and justify decisions about ongoing treatment
* Provides an appropriate list of advantages and disadvantages (pros and cons) to explain
decisions made.
Candidates were required to interact with the examiner and to:
* interpret the CXR in the context of the patient’s presentation
* answer further questions from the examiner.
Check list:
Analgesia -
Treat agitation -
Supine CXR - hard signs of trauma, check interventions (ETT, ICC, NGT)
CT chest with contrast is gold standard
Massive haemorrhage protocol
Trauma call
Cardiothoracics - surgical repair
Transfer to trauma centre by plane
Pathology:
- pneumothorax
- tension pneumothorax
- open sucking chest wound
- haemothorax
- diaphragm laceration/disruption with visceral herniation
- oesophageal disruption
- tracheobronchial disruption
- myocardial laceration with pericardial tamponade
HISTORY:
EXAMINATION:
eFAST - pericardial fluid
INVESTIGATIONS:
CT chest with contrast is the gold standard
MANAGEMENT:
Analgesia - ketamine
Agitation - ketamine
INTUBATION prior to transfer to CT
Optimize prior to intubation
- Resuscitate with blood products with rapid infuser
- Pre-oxygenate with nasal prongs and NRBM
Half dose ketamine in shocked state
- 0.5mg/kg IV
Higher dose paralytic in shocked state so that they reach the neuromuscular junction
- rocuronium 1.2-1.6mg/kg
DISCUSS THE EFFECTS OF POSITIVE PRESSURE VENTILATION IN PNEUMOTHORAX
PPV causes the patients intrathoracic pressures to exceed atmospheric pressure, worsening the pneumothorax.
Penetrating Chest Injuries
EM rapid bombs:
- ep 70 traumatic aortic injury
Open pneumothorax:
- A “sucking” chest wound exists when air enters the pleural cavity preferentially via an open chest wound, rather than the lungs via the trachea. Placement of an occlusive dressing, taped on three sides, over a sucking chest wound can seal off air entry into the pleural cavity and prevent the expansion of a pneumothorax.
Aorta laceration/disruption:
-
Diaphragm Laceration
- bowel can herniate into chest cavity
- diagnosed on CT or MRI OR laparoscopy/laparotomy
- requires surgical repair
Tension pneumopericardium:
- rare
- hypotension, Jugular vein distension
- requires urgent pericardiocentesis
MASSIVE HAEMTHORAX:
Large volume blood loss – >1500mls on initial chest tube placement
Ongoing blood loss from chest tube >200mls/hr for >2hrs
The need for ongoing blood transfusion due to haemodynamic instability
- second to lung laceration or intercostal artery laceration
- large 32F chest tube
Tracheobronchial injury:
- pneumomediastinum
- cervical surgical emphysema
- investigate with bronchoscopy
- needs surgical repair
Myocardial laceration and cardiac tamponade:
- eFAST
- hypotension, Jugular vein distension, diminished heart sounds
- resuscitative thoracotomy
Resuscitative thoracotomy
- penetrating chest injury
- signs of life in the field or on arrival
- cardiac arrest within 10min
- cardiothoracic surgeon within 30min
Chest Drain Insertion
2023.2
EM rapid bombs ep 132 - re-expansion pulmonary oedema
“Tension pneumothorax is a clinical diagnosis—ideally before a radiograph—and is immediately treated by needle decompression, finger thoracostomy and/or a tube thoracostomy”
“A site that is being more commonly used is the fourth to fifth intercostal space at the anterior axillary line, which is the shortest distance from the skin to the pleura”
Needle decompression
- 2nd intercostal space in the midclavicular line OR
- 4th intercostal space at the anterior axillary line
Safe triangle bordered by:
- 5th intercostal space
- pectoralis major
- latissimus dorsi.
SIZE
erect PA film measure apex - cupula <3cm = small
The British Thoracic Society definition:
Interpleural distance at the level of the hilum
2cm = 50% pneumothorax
<2cm = small
>2cm = large
Pneumothorax and POCUS
Absence of lung sliding.
Absence of Comet tails
Presence of the “lung point” or “transition point”
Absence of seashore sign in M mode (presence of
barcode sign)
Pregnant Trauma
2023.1 CBD station
the management of a pregnant patient who has been involved in an accident
interpret the chest xray
- Do not defer radiology for concerns of fetal radiation exposure
- Risk to fetus is highest during first 15 weeks of pregnancy
*Discuss with radiologist can request low radiation dose protocol
Domestic violence:
- Incidence is increased in pregnancy
* Most commonly struck area is abdomen
* Consider domestic violence
as a cause of trauma
OBSTETRIC RELATED INJURIES:
Placental abruption - USS cannot rule out placental abruption
Uterine rupture
Preterm labour
Fetal-maternal haemorrhage
- Kleihauer test used to detect and quantify extent of FMH
- administer Rh D immunoglobulin if
Rh D negative
Amniotic fluid embolism
DIC
Premature rupture of membranes
Foetal demise
PREGNANCY RELATED INJURIES:
- liver and splenic injury (enlarged in pregnancy)
- bladder rupture
- ureteric rupture
- ovarian vein laceration –> retroperitoneal haemorrhage
Pelvic fractures –> high rate of foetal demise
Pneumothorax:
If chest tube indicated → insert 1–2 intercostal spaces higher than usual
Use cryoprecipitate early and aim to
maintain fibrinogen levels above 2.5 g/L
Cardiac monitoring and pulse oximetry
AIRWAY + BREATHING:
- HFNP 60L/min + 15L NRBM
Lateral displacement of uterus to left or left lateral tilt with a wedge
2x large bore IV lines
BSL, VBG, FBC, UEC, LFT, Coags including fibrinogen, Calcium, Group and Screen
Tranexamic Acid 1g IV, followed by 1g over 8hrs
Early cryoprecipitate
Early activation of Massive haemorrhage protocol
Perform eFAST
- free fluid is just as easy to see as non-pregnant patients
- foetal assessment - FHR, placenta, presentation, estimate gestational age
FOETAL MONITORING
- CTG in >23 weeks
CXR
Pelvic XR
Will need CT scans for chest trauma:
- rib fractures can injure the liver and spleen
- ovarian veins can rupture and cause retroperitoneal bleeding which cannot be detected with USS
INTUBATION PLAN:
POSITION:
- RAMPED
- Reverse trendelenburg
- Tragus in line with sternal notch
- Face parallel with ceiling
Increased risk of aspiration
- decanto or yankauer suction catheters
Increased risk of CICO
- prepare for surgical airway
- assess landmarks and mark front of neck
most experienced operator, video laryngoscope, hypercurved D blade with ETT preloaded onto a fixed stylet
Two person BVM
Rescue LMA
FONA
DRUGS:
Ketamine 1mg/kg IV
Suxamethonium 2mg/kg IV
Early involvement of obstetrics and neonatal teams
Steroids for premature labor
Rib Fractures
Rib fractures
” it takes great force to fracture the first and second ribs, Such fractures prompt investigation for myocardial injury, bronchial tears and major vascular injuries”
Complications:
- Pneumothorax
- Hemothorax
- Pulmonary contusion
Imaging
CXR
- 30% sensitive, 90% specific
- “for each fracture that is visualised, there is another that is not”
- Harder to see fractures that are not displaced
US
- Time consuming to image all ribs
- Uncomfortable for patient
CT
- CTA is the gold standard
- Indicated in any patient with 3 or more rib fractures seen on plain CXR
- Detects complications and may identify source of bleeding
o Intercostal and internal mammary arterial injuries may be suitable for interventional radiology
Management
Intercostal nerve blocks
Epidural if multiple lower rib fractures
Criteria for admission
- 3 or more rib fractures
- COPD, asthma, smokers
- Have complications (pneumothorax, haemothorax, pulmonary contusion)
- Pain not controlled with oral analgesia (must be able to deep breath and cough)
- Inability to cope at home with no social supports
HDU/ICU admission for high risk groups
- > 3 fractures
- Flail chest
- Elderly
- Respiratory compromise
Erector spinae block
- Preferred for 3 or more rib fractures
- Ropivacaine through a catheter placed deep to the erector spinae muscle
- Performed under US guidance
- 15ml 0.2% ropivacaine every 3hrs
- Simpler to perform than epidural
- Avoids potential to cause pneumothorax from intercostal blocks
Intercostal nerve blocks
- Bupivacaine 0.5% with adrenaline
- Inject 2ml each segment (max 20ml)
- Anaesthetise level above and below the fracture, posterior to mid-axillary line,
- Suitable for 1-2 rib fractures
- Limitations:
o Only temporary relief, bupivacaine lasts 8-12hrs, bd injections required
o Risk of pneumothorax performing block 1.5% incidence for each rib blocked
o Difficult to block 1st-7th ribs and posterior rib fractures
o Bupivacaine cardiotoxic if accidental intravascular injection
Epidural - HDU/ICU setting - Reduces mortality and pulmonary complications - Complications o Total spinal anaesthesia o Hypotension o Masking of abdominal injuries
Chest wall stabilisation surgery - Not commonly performed - Possible indications o Flail chest with >3 rib fractures in >2 places o Especially if fractured and displaced o Chest wall deformity o Open rib fractures
FLAIL CHEST
- 3 or more ribs fractured with at least 2 fractures of the same rib
- Paradoxical chest wall motion
- Pulmonary contusion common
- Ventilatory support
Massive Transfusion Protocol
2023.2 RMO discussion
Teach a junior doctor about blood
transfusion protocols.
“7T’s of MTP”
Trigger
Team
TXA
Testing
Target
Temperature Control
Termination
know your local MTP protocol
HEPARIN
- 1mg protamine per 100 units heparin
- give maximum of 50mg protamine slow IVI as initial dose
CLEXANE (ENOXAPARIN):
- 1mg protamine per 1mg clexane
- give maximum of 50mg protamine slow IVI as initial dose
Warfarin reversal:
- prothrombinex 50IU/kg
- vitamin k 10mg IV
Dabigatran
- prothrombinex 50IU/kg IV
- tranexamic acid 1g IV
- idarucizumab (praxbind) 5g IV
Apixaban & Rivaroxaban
- prothrombinex 50IU/kg
- tranexamic acid 1g IV
- adexanet alpha (factor 10a) - not available in australia yet
Prothrombinex contains factors 2, 9, 10
- European countries give PCC’s and Cryoprecipitate instead of giving FFP
- can consider if you are in a rural hospital that does not have FFP
- PCC kept at room temperature (can be kept in resus)
- don’t need blood group
- no pathogens
- don’t cause TRALI
Studies currently looking at the use of whole blood instead of blood products - evidence is not out yet
BLOOD PRODUCT VOLUMES:
PRBCs 260mls +/- 15mls
Platelets 367mls +/- 16mls
FFP 278mls +/- 13 mls
Cryoprecipitate 36mls +/- 2mls
cryoprecipitate contains:
0.2g fibrinogen in each unit
von willebrand factor
factor 8
factor 13
give it if fibrinogen <1
tranexamic acid 1g IV bolus, then 1g IV in 100ml NS over 8hrs
**most beneficial if given in the <1h post trauma (needs to be given within 3hrs of trauma)
CRASH2 trial
TRIGGER: (when to activate the MTP)
Clinical Judgement:
- bleeding in shocked state
(positive shock index)
The Revised Assessment of Bleeding and Transfusion (RABT)
Score – 1 point each
1. Shock index > 1.0
2. Pelvic Fracture
3. Positive FAST
4. Penetrating Injury
A 2018 study showed that RABT score ≥ 2 performed better than
ABC score in predicting need for MHP.
Lower threshold to activate:
- elderly
- anticoagulation medication
- medications that blunt the sympathetic response (beta blockers)
TEAM:
Lab and blood bank notification
Haemorrhage control/Source control
- early notification of surgeon, gastroenterologist, interventional radiologist
TXA:
1g IV, followed by 1g over 8hrs within the first 3hrs in trauma (CRASH2 reduce mortality)
TESTING:
Baseline bloods:
- Fibrinogen
- Coags (INR & PT)
- VBG - pH
- FBC - Hb, platelets
- Calcium
- K+
- Bhcg (o negative blood)
Q1 hour bloods
- fibrinogen
- INR
- FBC (Hb & platelets)
- VBG (pH, lactate)
- Calcium
- K+
TARGETS: (haematologic and metabolic targets)
*Hb > 80
*Platelets >100
*Fibrinogen >1.5
*INR <1.5
*Ionised calcium >1
*pH >7.2
Fibrinogen needs to be >2g/L in obstetric patients
The citrate preservative in blood products binds to serum calcium making it inactive. Calcium is important in regulating coagulation and haemostasis.
TEMPERATURE:
36.5-37.5
TERMINATION:
- normalising haematological and metabolic parameters
- haemodynamic stability
Prevent blood wastage:
- return products as soon as you know you don’t need them
Pelvic Fractures
2016 station
PR exam to assess for open pelvic fractures - will need antibiotics and operative management of bowel transection
Retrograde urethrogram - to look for urethral injury that may warrant suprapubic catheter placement
RADIOLOGY
Lateral compression fracture
AP compression (open book)
Vertical shear
Acetabular fractures
XRAY FINDINGS:
- Pelvic binder in-situ
- Disruption pelvic ring
- Superior and inferior pubic rami
- Pubic symphysis diastasis (open book pelvic fracture)
- SIJ widening
- Disruption of arcuate lines –> sacral alar fracture
- Disruption of superior acetabular margin
- Disruption of shentons line - right
- Disruption of illeopectineal lines
- Disruption of ischiopectineal lines
- Femoral head dislocations
b)
Activate massive transfusion protocol - 1:1:1 PRBC: Platelet: FFP
Rapid infusion catheter or 2x large bore IVC at least 18G
1g tranexamic acid IV stat
Temperature control 36.5-37.5
Targets:
ionised calcium >1
INR < 1.5
Fibrinogen >1.5 (>2 in obstetric patients)
Hb >80
Plt >50
pH >7.2
lactate <4
Pelvic angiography +/- embolization internal illiac
REBOA (Resuscitative endovascular balloon occlusion of the aorta)
Pelvic packing in OT
ORIF in OT
Preparation for transfer:
- blood products
- analgesia - ketamine
- arterial line and monitoring
- IDC
- update family of plan
Teaching: Pelvic binder management
2022.1 - Teaching Station
*EM Board Bombs ep 11, 33, 106
*EM quick hits 30
*EM cases ep 119 trauma
*Emergency medicine procedures
Medical Expertise: Use and application of pelvic binders (45%)
* Selects an appropriate procedure after considering indications, contraindications, and
potential complications
* Describes the important features of common procedural equipment.
Medical Expertise: Management after binder application (30%)
* Anticipates and manages common complications during and after a procedure
* Adapts the performance of a procedure in response to unforeseen complications when
performing a procedure.
Scholarship and Teaching (25%)
* Effectively delivers a teaching session which teaches procedural skills and use of equipment
* Integrates basic principles of adult learning to proficiently deliver a teaching session to a
small audience.
Candidates were required to meet with the junior registrar (role player) and to:
* teach them about the use of pelvic binder systems
* describe the fitting of a pelvic binder system
* explain post pelvic binder application management
* answer any questions they may have.
TEACHING:
- introduce
- establish rapport
- enquire about level of experience
- prior learning
- check understanding
- opportunity to ask questions
- summarise
- suggested reading/learning resources
INDICATIONS:
- blunt trauma
- hypotension/cardiac arrest
- suspected pelvic fractures
HOW IT WORKS:
- decrease pelvic diameter,
- decreasing the anatomic bleed space in open book and vertical shear fractures
CONTRAINDICATIONS:
- lateral compression fracture
COMPLICATIONS:
- painful to apply if fractures are present
- incorrect application is common
- may cause further harm in lateral compression fractures
- pressure sore with prolonged use
Clinical assessment of pelvic injuries is unreliable
Early pelvic binding if shocked or suspect pelvic fracture
Place pelvic binder on bed prior to patient arrival
Given analgesia - ketamine 10mg IV
- this is painful for the patient
need to bind the greater trochanters
binding the legs together to further reduce the pelvic diameter
check correct position - greater trochanters
check tension
document time of application
Pitfalls:
- helps tamponade venous bleeding and cancellous bone bleeding, won’t tamponade arterial haemorrhage
- incorrect placement is common - need to bind the greater trochanters
WHEN TO REMOVE:
- if haemodynamically stable with no fractures on imaging
don’t log roll the patient
PR and PV exam for blood = open fracture requiring antibiotics
IDC - haematuria = bladder injury
(need for CT cystourethrogram)
Bronchiolitis
- Viral respiratory tract infection
- Affects infants <12 months of age
- Peak severity is usually at around day 2-3 from the onset of increased work of breathing
- self limiting illness with resolution over 7-10 days
- cough may persist for weeks
- treatment is supportive
- ventilatory support with oxygen/NIV, mechanical ventilation
- nutritional support support with feeding (NGT of IV fluids)
Cause:
*Respiratory syncitial virus (RSV) - most common
- Influenza
- parainfluenza
- covid
- human metapneumovirus
- rhinovirus
HISTORY:
Prodrome of coryzal symptoms
Followed by:
- cough
- fever
- increased work of breathing
- reduced feeding
- irritable/unsettled
Feeding
Urine output
Lethargy
ASSESS PARENTAL COPING
RISK FACTORS FOR SEVERE BRONCHIOLITIS:
- Chronic lung disease (cystic fibrosis
- Congenital heart disease (tetralogy of fallot)
- Chronic neurological conditions
- Premature
- Age < 6 weeks
- Failure to thrive/growth restriction
- Indigenous
- Immunodeficiency
- Trisomy 21
- Exposure to cigarette smoke
SOCIAL HISTORY:
- Exposure to cigarette smoke
REASONS FOR ADMISSION:
- oxygen requirement
- marked increased work of breathing with potential need for positive pressure ventilation / NIV
- poor feeding requiring NGT placement (<50% normal intake with evidence of dehydration)
- early in illness i.e. day 1 with potential to deteriorate
INVESTIGATIONS:
not for chest xray
- CXR only indicated if superimposed bacterial infection, alternative diagnosis considered
not for blood tests
not for respiratory viral swabs
- viral swabs only indicated if patient is going to be admitted –> isolation to prevent cross infection between children on the ward
MANAGEMENT:
supportive:
monitoring of apnoea.
DISCHARGE ADVICE:
- reassurance
- smaller volume feeds more frequently (ensure adequate hydration)
- monitor feeding and urine output
- SMOKING
Paediatric Elbow Fracture
EM Rapid Bombs ep 225
2022.1 Teaching station
Medical Expertise: X-ray analysis and interpretation (40%)
* Analyses the results of an investigation to identify relevant findings or patterns
* Correctly interprets the results of an investigation within the scenario.
Medical Expertise: Examination and management – 40%
* Describes a focused structured and relevant physical examination for a paediatric patient
* Initiates appropriate initial supportive treatment for any presenting problem
* Anticipates and manages common complications during and after a procedure
* Provides clear instructions for the patient/carer on discharge and ensure comprehension.
Scholarship and Teaching – 20%
* Checks for level of prior knowledge/understanding, establishes rapport, encourages learner participation and allows questions
* Demonstrates well-paced communication, covers the topic in appropriate detail,
demonstrates a structured approach, gives clear explanations, explains rationale
* Ensures the learner has received and understood the information, checks understanding
* Invites questions and clarifies any areas of uncertainty.
Candidates were required to meet with a junior doctor (role player) and to:
* explain an approach for paediatric elbow X-ray interpretation
* interpret the X-rays
* explain an approach to examining a 5 year old with an elbow injury
* describe a management plan for the patient.
Interpret and teach approach to paediatric elbow xray to junior doctor
- Explore what they know about xray interpretation and paediatric elbow fractures
- Suggest radiopedia lectures for further learning
Explain your approach to elbow examination in the distressed child
- importance of establishing rapport with the parent and child
- consideration of the developmental age
- analgesia
- distration - ipad
- getting the parents on board
- minimal handling examination
Key Points:
*Approach to elbow xray
*Examination approach in distressed child - analgesia, distraction technique and minimal handling examination
*Gartland’s criteria - determines management
*Complications
*Discharge advice
*Fracture clinic follow up
APPROACH TO ELBOW XRAY:
Mechanism
Demographic
Likely pathology
AP and Lateral films
Soft tissue swelling
Joint effusion
Cortex disruptions
Trabeculae pattern disruptions
Alignment
Ossification centres
CRITOE - ossification centres appear at different stages
Capitellum 1yr
Radial head 3yr
Internal condyle 5yr
Trochlea 7yr
Olecranon 9yr
External condyle 11yr
MANAGEMENT is based on the GARTLAND’S CLASSIFICATION.
Type 1 fractures:
Nondisplaced
long arm back slab with elbow at 90deg, collar and cuff
fracture clinic follow up in 10days with repeat xray
Type 2 fractures:
- Displaced with posterior cortex intact
- needs orthopaedic review as type 2b fractures (>20 degrees angulation) require operative management
- Closed reduction and immobilisation in ED + orthopaedic consultation
Type 3 fractures:
- Complete displacement
- Operative management - k wires or open reduction
COMPLICATIONS:
Incidence of nerve injuries associated with supracondylar fractures is 10-20%. The median nerve and the radial nerve are most often injured.
Anterior interosseous nerve - inability to make “OK” sign
(loss of strength of the thumb interphalangeal joint in flexion as well as the index DIP joint in flexion. This injury renders the patient unable to perform the “OK” sign)
Radial nerve - inability to extend at the wrist
Brachial artery injury (spasm/kinking) can lead to Volkmann’s contracture - compartment syndrome of the forearm.
EXAMINATION:
Analgesia:
- paracetamol 15mg/kg,
- ibuprofen 10mg/kg,
- IN fentanyl 1.5mcg/kg
- Nitrous oxide - relatively weak dissociative anaesthetic gas with anxiolytic, analgesic and amnesic properties. rapid onset, rapid offset. don’t require fasting.
Distraction techniques:
- music on parents smart phone of tablet device
- guided visual imagery
Engage and involve the parents
Neuropraxias – usually resolve spontaneously
- Anterior interosseous nerve (branch of median nerve) – most common injury
o Unable to flex interphalangeal joint of the thumb or flex DIP of index finger. Can’t make OK sign.
- Median nerve
o Loss of sensation over volar index finger
- Radial nerve – second most common
o Inability to extend wrist, MCP’s, thumb IP joint
- Brachial artery
o Palpate radial and ulnar artery
o Can use biphasic doppler
o Hand well perfused - warm, pink, OR poorly perfused – cold, pale, CRT >2sec
Sexually Transmitted Infections
EM Rapid Bombs ep 395
2022.1 History Taking
Medical Expertise: Assessment and management – 50%
* Elicits a focused history and identifies important historical details diagnostic of an important
condition
* Generates differential diagnoses
* Creates a focused investigation plan to confirm or exclude time critical diagnoses
* Outlines a treatment plan for the patient
* Outlines a clear discharge plan for the patient including safety net return advice.
Communication – 25%
* Demonstrates a professional and respectful approach
* Uses language appropriate to the patient’s level of health literacy to explain the treatment
and management plan
* Summarises the encounter and confirms the patient’s understanding.
Health Advocacy – 25%
* Demonstrates the ability to use medical expertise to protect and advance the health and
well-being of the patient
* Demonstrates the ability to integrate the broad range of factors that affect this patient
beyond the ED encounter
* Proactively engages in health promotion using available resources to intervene in order to
improve the health outcomes of this patient and those within his social circle.
Candidates were required to:
* take a focused history from the patient (role player)
* provide their differential diagnoses
* advise the patient of the investigation and management plan.
HISTORY:
*Reassure privacy and confidentiality
*Non-judegemental
*Screen for sexual assault
Symptoms:
- discharge (penile, rectal)
- ulcers
- lumps or sores
- genital rashes
- itching/burning
- abnormal vaginal or rectal bleeding
- irregular periods
- dysuria, difficulty passing urine
- dyspareunia (painful sex)
- pelvic pain
- joint pain
- mouth ulcers, throat pain
- occular symptoms
- vaccination history (Hep B, Hep A, HPV)
Partners:
- male or female or both
- stable partner
- last sexual encounter
- how many partners in the last year
Practices:
- type of intercourse - vaginal, anal, oral (insertive or receptive or both)
- **sex overseas in high risk countries (africa, asia)
- IVDU - sharing needles
Prevention:
- barrier protection
- Prep
- regular STI testing
Pregnancy:
- Contraception
Contact tracing
PMHx:
Medications:
Allergies:
Social:
- smoking
- drugs
- alcohol
- job (sex worker?)
- friends/family
- access to follow up?
DIFFERENTIAL DIAGNOSES:
Genital ulcers:
- Herpes Simplex Virus
- Syphilis
- Lymphogranuloma venerium - chlamydia
- Chancroid - Haemophilus ducreyi
- Granuloma inguinale - Donavanosis
INVESTIGATIONS:
HIV
Hepatitis C
Hepatitis B
Syphillis
NAAT/PCR
*Vaginal/endocervical swabs
*Urethral swabs
*First pass urine
*Pharyngeal swabs
*Rectal swabs
- Trichomonas
- Gonorrhoea
- Chlamydia
- Mycoplasma genitalium
Additional gonorrhoea culture and sensitivity due to increasing antibiotic resistance
MANAGEMENT:
- Offer emergency contraception
- Counsel on safe sex practices (abstinence, barrier protection)
- Abstain from sexual intercourse for 7 days after treatment
- Follow up with community sexual health - review results, discuss contraception, Prep
- Address contact tracing - directly or through contact tracing website “Let them know” “the drama down under”
- Immunisation against HPV, Hep A, Hep B (if not immune already)
- PrEP for men who have sex with men
Sexually Transmitted Infections
PID:
Complications:
- infertility
- ectopic pregnancy
- chronic pelvic pain
History:
- sexually active
- pelvic pain
- abnormal vaginal discharge
- irregular periods
- dyspareunia
Exam:
- pelvic tenderness
- cervical motion tenderness
- adnexal tenderness
USS:
- thickened fallopian tubes >5mmg
- tubo-ovarian abscess
- cogwheel sign on cross section tubal view
Admission criteria:
- systemically unwell with fever or sepsis
- pregnancy
- surgical cause not excluded
- severe pain requiring IV opiates
- inability to tolerated outpatient regimen
- failed outpatient treatment
IUD removal with PID:
- can safely leave IUD in place
- PID second to IUD insertion occurs in the first 3 weeks of insertion
- Remove IUD if no clinical improvement within 72hrs of starting treatment
Fitz Hugh Curtis Syndrome
- PID with RUQ pain
- perihepatitis
- inflammation of liver capsule leading to adhesions
- LFT’s normal or mildly elevated transaminases
- seen on laparoscopy or laparotomy
SYPHILIS:
- on the rise among men who have sex with men
- associated with HIV infection
Primary Syphilis:
- painless ulcer to genitals, anus, mouth
- appears about 3 weeks after contact
- painless and usually solitary so often missed by patient
- ulcer heals over in 6 weeks
Secondary Syphilis:
- 4-10weeks after ulcer heals
- painless lymphadenopathy
- non-puritic maculopapular rash that also affects the palms and soles of feet
- condylomata lata
- aseptic meningitis
- nephrotic syndrome
- moth eaten allopecia
- ocular manifestations (uveitis, iritis, optic neuritis)
Latent phase (asymptomatic)
- lasts years
Tertiary phase
- gumma (skin and bone)
- syphilitic aortitis (aortic aneurysm, aortic regurgitation)
- neurosyphilis
*endarteritis leading to ischemic stroke
*tabes dorsalis (spinal cord wasting)
*dementia
Ix:
Swab ulcer - treponema pallidum NAAT or PCR
non-treponemal test (VDRL), if positive –> perform treponema pallidum particle agglutination assay or the IgM/IgG enzyme immunoassay
If both tests are positive = the patient is syphilis positive
LYMPHOGRANULOMA VENEREUM (LGV):
- chlamydia
- may have proctitis or rectal bleeding
- Untreated can lead to tenesmus, fistulas and strictures
- Rx doxycycline 100mg bd 21 days
CHANCROID:
- haemophilus ducreyi
- diagnosis of exclusion of syphilis and HSV
- treat with ceftriaxone 500mg IM
Granuloma inguinale - Donavanosis
- caused by klebsiella granulomatis
- requires punch biopsy
- Rx doxycycline 100mg bd 21 days
Herpes Simplex Virus:
- swab HSV NAAT
- rx valaciclovir 1g bd 7 days
Organophosphate / Carbamate Toxicity
2022.1 discussion with registrar station
Medical Expertise: Assessment – 40%
* Elicits a focused, relevant history of organophosphate exposure
* Performs a focused, structured and relevant physical examination of the patient with
organophosphate poisoning
* Identifies risks of deterioration/need for intervention in the patient with organophosphate
toxicity.
Medical Expertise: Management – 40%
* Outlines an appropriate plan regarding decontamination of a patient with organophosphate
poisoning
* Outlines an overall plan for the management of the patient with established organophosphate
toxicity.
Prioritisation and Decision Making – 20%
* Lists specific triggers for intubation in a patient with organophosphate toxicity.
Candidates were required to interact with a junior registrar (role player) and to:
* answer the registrar’s questions regarding this patient’s presentation.
Pesticides & insecticides used in agriculture
- carbamates are less toxic than organophosphates and have shorter duration of action
- any ingestion in children can be lethal
- deliberate ingestion in adults will cause life threatening toxicity
- accidental dermal or inhalational exposure causes toxicity but is rarely life threatening
***Large amounts of atropine, hundreds of milligrams, may be necessary in massive ingestions. Proactive contact with the hospital pharmacy (or even other centres) may be necessary to ensure access to adequate amounts of atropine.
MECHANISM:
- inhibits acetylcholinesterase
- accumulation of acetylcholine at muscurinic and nicotinic receptors
HISTORY:
Which agent ingested?
When?
How much?
Co-ingestion?
Self decontamination with emesis?
Symptoms since ingestion?
“Cholinergic crisis”
Muscurinic effects ‘DUMBBELS’
- diarrhoea & diaphoresis
- urinarion
- miosis
- bronchorrhoea & bronchospasm
- bradycardia & hypotension
- emesis
- lacrimation
- salivation
Nicotinic effects:
- fasciculations
- tremor
- weakness
- respiratory muscle paralysis
- tachycardia/hypertension
CNS effects- agitation, coma, seizures
Respiratory effects:
- progressive neuromuscular junction dysfunction and respiratory failure over 1 to 4 days
- Chemical pneumonitis (if contains hydrocarbons)
Intentional - Will need psychiatric assessment
EXAMINATION:
Bradycardia or tachycardia
hypotension or hypertension
Respiratory distress - dyspnoeic, hypoxic, wheeze
GCS - coma, confused, delirius
seizures
diaphoresis
miosis
lacrimation
salivation
vomiting
incontinent - urine, diarrhoea
INVESTIGATIONS:
ECG - arrythmia
CXR - chemical pneumonitis
*plasma cholinesterase activity - if the diagnosis is unclear
*red cell cholinesterase activity - better correlation with severity of poisoning
MANAGEMENT:
PPE - impervious gown, gloves, mask, eye protection for resus team
DECONTAMINATION:
- no role for activated charcoal with oral ingestion as rapidly absorbed and distributed
- remove and dispose of clothing, wash skin with water and detergent for dermal exposures
ENHANCED ELIMINATION:
- none
ANTIDOTE:
atropine 1.2mg (0.05mg/kg) IV
double dose every 5min until adequate atropinisation - chest clear, no wheeze
- HR 80
- SBP >80
then use 10-20% of the loading dose per hour infusion
reduce infusion if over atropinisation
- confusion
- pyrexia
- mydriasis
- absent bowel sounds
*Atropine has no effects on the neuromuscular junction
PRALIDOXIME:
- controversial
- causes reactivation of acetylcholinesterase with SOME organophosphate poisonings (not carbamate poisonings)
- studies have shown that although it does increase red cell cholinesterase activations, it does not improve survival or intubation rates
- if poisoning is refractory to atropine, discuss use of pralidoxime with toxicologist
CHEMICAL PNEUMONITIS
- oxygen
- ventilatory support
- steroids
SEIZURES:
- midazolam 5mg IV
AGITATION:
- midazolam
RESPIRATORY FAILURE:
- Intubation and mechanical ventilation
EARLY INTUBATION:
*atropine improves wheeze and clears secretions but DOES NOT reverse respiratory muscle paralysis
*also many have an aspiration pneumonitis
OPTIMISE PRE-INTUBATION:
- Preoxygenate
- Fluid resuscitation
- Noreadrenaline infusion
- using ketamine 1mg/kg and rocuronium 1.2mg/kg
***A non-depolarizing agent should be used when neuromuscular blockade is needed.
Succinylcholine is metabolized by plasma butyrylcholinesterase; therefore, prolonged paralysis may result.
- using video laryngoscope and experienced operator to increase likelihood of first pass success.
DISPOSITION:
ICU
Abdominal pain + Hypotension
EM Rapid bombs ep 164 - AAA
2022.1 Case based discusssion
Rural hospital, elderly patient with abdo pain and hypotension
Medical Expertise: Assessment and diagnosis – 30%
* Generates a differential diagnosis, with an inherent focus on conditions requiring time
critical management
* Identifies important historical details (red flags) diagnostic of an important condition
* Differentiates expected physical signs for different conditions.
Medical Expertise: Management – 30%
* Outlines an overall plan for resuscitating a patient
* Correctly chooses time critical interventions based on assessment
* Outlines an overall plan for ongoing treatment of a patient
* Creates a safe and clear discharge plan for a patient.
Health Advocacy – 40%
* Incorporates the patient’s chronic clinical state and the patient’s wishes when making
decisions
* Explains to patients and/or their guardians the rationale for management decisions
* Incorporates the patient’s belief system to create a personalised management plan
* Integrates specific communication skills relevant to the patient’s culture, to enhance delivery
of health advice to patients.
Candidates were required to interact with the examiner to:
* outline their differential diagnosis
* describe how to assess the patient to differentiate between possible diagnoses
* manage the patient within the limitations of the available resources.
DIFFERENTIAL DIAGNOSES:
Vascular:
- ruptured AAA
- aortic dissection
- mesenteric ischemia
Infection:
- urosepsis
Surgical:
- perforated viscous with peritonitis
- cholecystitis
- appendicitis
- diverticulitis
- pancreatitis
- acending cholangitis
Trauma:
- solid organ injury with haemorrhage
ASSESSMENT
HISTORY:
SOCRATES
- fever
- nausea, vomiting
- diarrhoea
- GI bleeding
surgical history
known AAA
- previous endovascular aneurysm repair (EVAR) have 25% chance of leaking at the graft site
gallstones
renal stones
UTI’s
Alcohol
Abdominal trauma
Anticoagulation
AF or coagulopathy predisposing to ischemic gut
EXAMINATION:
pulsatile abdominal mass at umbilicus
signs of lower limb ischemia
- thromboembolism to lower limbs
Neurological finding due to spinal cord ischemia (T10-T12)
signs of rupture - shock, pallor, peritonism with ruptures into intraperitoneal cavity
POCUS:
ED AAA POCUS - studies shown 99% sensitive 98% specific for ED physicians
curvilinear probe
xiphoid to bifurcation
IVC on patients right side
aorta on patients left side
vertebral body deep
measure largest transverse diameter (outer wall to outer wall)
normal < 2cm
can’t exclude AAA rupture (can’t assess for retroperitoneal haemorrhage)
rupture usually occurs >5.5cm
limitations of POCUS:
- obesity
- overlying bowel gas
- need to see aorta in entirety
- can’t assess for retroperitoneal haemorrhage
INVESTIGATIONS:
Urianlysis - WCC, nitrites, blood
VGB - lactic acidosis with end-organ hypoperfusion and ischemic gut
Lipase - pancreatitis
LFT’s - obstructive hepatitis in cholangitis
Inflammatory markers - CRP, WCC
UEC - renal failure with hypoperfusion
FBC - Hb in haemorrhage
Group and Screen - for transfusion
CT abdomen with contrast:
- only if haemodynamically stable
- can diagnose rupture or impending rupture
- useful in surgical planning
MANAGEMENT:
Resuscitation room
continuous cardiac monitoring
pulse oximetry and Q2min BP
high flow oxygen 15L NRBM
2x large bore IV cannulae or rapid infusion catheter
urgent vascular or general surgery attendance
activation of massive haemorrhage protocol - 4 unit o negative blood
place arterial line - permissive hypotension MAP 50-60 to maintain organ perfusion
- assess mentation, UO,
IDC - monitor UO/end-organ perfusion (target 30ml/hr)
Analgesia - morphine 5mg IV - reassess and titrate to patient comfort
PROGNOSIS:
Poor prognostic factors for open repair
- age >80
- hypotension SBP <90
- acute renal failure
- cardiac arrest
- LOC/syncope
- IHD
multiple risk factors for poor outcome should prompt consideration for comfort care
DECISION TO TRANSFER FOR SURGERY:
For patients who present to a facility where local surgical expertise is not available, transfer is appropriate.
If transfer is chosen, the patient and their family should be informed of the risk of deterioration during transfer, and the transfer should be accomplished as soon as possible.
ADVANCED CARE DIRECTIVES/PATIENT WISHES
It is unclear whether endovascular repair decreases mortality in patients with ruptured AAA.
A decision must be made according to the wishes of the patient (if known) and family whether to proceed with repair or provide comfort measures.
ASSESS CAPACITY:
- Cognitive ability to understand and retain information in regards to their medical situation
- Compare the treatment options and understand the consequences of each
- Engage in rational deliberation about the proposed treatment and communicate a choice
RESPECT FOR PATIENT AUTONOMY
- every competent patient has the moral right to choose what happens to their body
- therefore patients have the right to freely accept or reject a physicians recommendations
DUTY OF CARE:
Common Law has established that doctors have a ‘duty of care’ to act in the best interest of their patients.
Bowel Obstruction
2023.2 Case based discussion
Medical Expertise: Investigation Interpretation – 30%
Analyse the results of an investigation to identify relevant findings or patterns.
Correctly interpret the results of an investigation within the scenario.
Act on time critical investigation results as they arise.
Medical Expertise: Treatment Including Resuscitation – 30%
Outline an overall plan for resuscitating a patient.
Recognise and expedite any specific intervention to resuscitation.
Initiate treatments specific to identified abnormalities in airway, ventilation or circulation.
Adapt and initiate standard therapies to that patient.
Prioritisation and Decision Making – 40%
Manage multiple problems simultaneously by prioritising treatment options whilst remaining
vigilant for other potential problems.
Summarise and prioritise the key issues that must be addressed during and following the
emergency encounter.
Provide a rationale to explain and justify decisions about ongoing treatment.
Candidates were required to interact with the examiner and to:
Describe and interpret the patient’s abdominal X-rays.
Outline their management of this patient.
Answer further questions asked by the examiner.
Mechanical bowel obstruction vs. paralytic illeus
Small bowel vs. large bowel obstruction
Complete vs. partial obstruction
Complicated vs. uncomplicated
SMALL BOWEL OBSTRUCTION
Causes:
- adhesions
- intussusception (lymphoma as lead point)
- malignancy
- incarcerated hernia
- strictures (inflammatory bowel disease)
- gallstone illeus (obstructs illeo-caecal valve +pneumobilia)
- radiation enteritis
- bezoars
- blunt abdominal trauma (duodenal haematoma)
LARGE BOWEL OBSTRUCTION:
- malignancy
- strictures
- fecal impaction
- volvulus (caecal, sigmoid)
COMPLICATIONS:
Intestinal ischemia
Perforation & peritonitis
Sepsis & multiorgan failure
Malabsorption & Dehydration
Electrolyte disturbance
ASSESSMENT:
History:
Symptoms:
- abdo pain, distension, vomiting, passing flatus, opening bowels, pr bleeding, weight loss, fevers, urine output
Risk factors:
- Previous abdominal surgeries
- Previous bowel obstructions
- Malignancy, lymphoma
- Inflammatory bowel disease
- Hernias
- Volvulus common in institutionalised elderly
- Preveious radiation therapy
Consider other differential diagnoses:
- pancreatits
- AAA
EXAMINATION:
GCS
Airway patent
Breathing spontaneously + Oxygenation
Circulation - maintaining HR & BP
Temp
BSL
Hydration - mucous membranes, skin tugor, POCUS assessment of IVC
Abdominal distension
Tenderness
Peritonism
Resonant to percussion
High pitched tinkling bowel sounds
LABORATORY:
VBG - lactate, BSL
Electrolytes -
IMAGAING:
Xrays:
Erect CXR and erect/supine AXR films (or lateral decubitus film if the patient cannot sit upright) - these have a sensitivity of 70-83% and specificity of 67-83% for small bowel obstruction.
Small bowel obstruction:
- Dilated loops of small bowel > 3 cm
- Central dilated loops
- Valvulae conniventes or plicae circulares are present
- Gas-fluid levels
Large bowel obstruction:
- Distended colon >6cm or 9cm at caecum
- contains gas and faecal matter (no fluid because water is absorbed)
- Located peripherally
- Haustral folds
Pneumoperitoneum
Pneumotosis intestinalis
Riglers sign
Lead pipe colon - chronic inflammation
Thumbprint sign - bowel wall oedema
CT abdomen:
More sensitive and specific
Can identifying transition point
Can determine the cause (hernias, adhesion, tumours, inflammation etc)
Can identify complications - necrosis, perforation
Can distinguish between true obstruction and pseudo-obstruction
MANAGEMENT:
NBM
Fluid resuscitation guided by HR, BP and POCUS assessment of IVC
IDC placed to monitor urine output aiming for 0.5ml/kg/hr
Analgesia
- Morphine 2.5-5mg IV - reassess and titrate to patient pain level
- IV paracetamol 1g
Consider NG tube for gastric decompression (vomiting or severe symptoms of gastric distension)
IV antibiotics
Surgical consultation
DEFINITIVE MANAGEMENT:
Small bowel obstruction often managed conservatively initially for 48-72hrs then surgery if no resolution. Surgery for perforation or strangulated hernia.
Gastrografin may be diagnostic and therapeutic in SBO due to adhesions
Large bowel obstruction often requires surgical management
Sigmoid volvulus –> decompression with flexible or rigid sigmoidoscopy + insertion of rectal tube
Closed loop obstruction, Caecal volvulus and bowel necrosis, perforation and peritonitis require emergency surgery
TOXIC MEGACOLON
- inflammatory bowel disease and C. diff colitis
- colon dilatation and systemic toxicity
Diagnosis:
Radiology:
- dilated colon >6cm
- multiple air fluid levels
- loss of haustral folds
PLUS at least 3 of the following:
- fever
- tachycardia
- neutrophilia
- anaemia
PLUS at least 1 of the following:
- hypotension
- dehydration
- altered mentation
- electrolyte disturbance
The main goal of treatment is to reduce the severity of colitis in order to restore normal colonic motility and decrease the likelihood of perforation.
PSEUDO-OBSTRUCTION/PARALYTIC ILLEUS/Ogilvies syndrome
- functional obstruction (uncoordinated muscle contraction)
Causes:
- post abdominal surgery
- peritonitis
- drugs (anticholinergics, opiates)
- trauma
- ischemic bowel
exacerbated by electrolyte disturbance (hypokalemia)
- disturbance of enteric nervous system or intestinal smooth muscle
MANAGEMENT:
Aim is to restore motility and prevent ischemia and perforation
Neostigmine and erythromycin.
Endoscopic Decompression in patients with Ogilvie’s syndrome
Bowel Obstruction
2021.2 Case based discussion
assessment and management of previously well adult who presented with a 24 hour
history of severe generalised abdominal pain and profuse vomiting.
Medical Expertise: Investigation interpretation – 30%
* Analyses the results of an investigation to identify relevant findings or patterns
* Correctly interprets the results of an investigation within the scenario
* Acts on time critical investigation results as they arise
Medical Expertise: Treatment including resuscitation – 30%
* Outlines an overall plan for resuscitating a patient
* Recognises and expedites any specific intervention to resuscitation
* Initiates treatments specific to identified abnormalities in airway, ventilation or circulation
* Adapts and initiates standard therapies to that patient
Prioritisation and Decision Making – 40%
* Manages multiple problems simultaneously by prioritising treatment options whilst remaining
vigilant for other potential problems
* Summarises and prioritises the key issues that must be addressed during and following the
emergency encounter
* Provides a rationale to explain and justify decisions about ongoing treatment
Candidates were required to:
* describe and interpret the patient’s abdominal X-rays for the examiner
* outline their management of the patient
* answer further questions asked by the examiner.
.
