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FRCEM Final SAQ > Major incident/pre-hospital/Environmental emergencies > Flashcards

Major incident/pre-hospital/Environmental emergencies Flashcards

1
Q

In a patient with heat stroke - what is your differential diagnosis for hyperthermia?

A
  1. Infections: sepsis/septic shock
  2. Infections: central nervous system infection
  3. Drugs: serotonin syndrome
  4. Drugs: neuroleptic malignant syndrome
  5. Drugs: sedative-hypnotic withdrawal ( alcohol
    withdrawal )
  6. malignant hyperthermia
  7. Endocrine- thyroid storm
  8. Endocrine - Pheochromocytoma
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2
Q

Can you differentiate heat stroke from heat exhaustion?

A

Heat stroke key clinical features include:

  1. temperature >40.5
  2. dry hot skin with absent sweating
  3. neurolgical features: ( confusion, coma, seizures )
  4. CVS features ( hypotension, long QT, RBBB )

Heat exhaustion:

  1. temperature < 40 degrees celcius
  2. sweating on skin
  3. not usual to have altered mental state
  4. haemodynamically stable
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3
Q

LIST 2 common methods of rapid cooling of a patient with heat stroke

A

A. EXTERNAL COOLING METHODS

  1. evaporative therapy -( spray water bottle and strong fan )
  2. immersion therapy - ( ice baths are difficult in ED, but a practical approach would be ice pack in the axilla and groin
  3. administration of cool peripheral IV fluids

B. INTERNAL COOLING

  1. Body cavity lavage ( gastric,peritoneal, thoracic )
  2. Ecmo - not practical in the ED
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4
Q

In a hypothermic patient with a temperature 28 degrees:

A. what drug modifications would you consider in the ALS algorithim?

B. what Defibrillation modifications would you consider?

A

A. Drug modifications:

withold drug therapy untill Temp > 30 degrees C. thereafter double the dosing interval untill temp > 35 degrees C. once temp is >35 ( normothermia ) , follow standard ALS protocol.

B. Defibrillation modifications:

If patient is in VF - deliver 3 shocks as per standard ALS. and then delay further attempts untill temp > 30 degrees Celcius

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5
Q

Can you name the rewarming techniques in a hypothermic patient?

Resource: FRCEMsuccess SAQ’s

A

A. passive re-warming techniques:

  • keep dry
  • warm environment
  • warm blankets
  • polyethylene sheets
  • aluminium foil & hat

B. active external:

  • warm air blanket i.e. bear hugger,
  • water bath 37-41 degrees celcius
  • chemical heat pads

C. active internal :

  • warm humidified oxygen at 40-45 degrees celcius
  • warm IV fluids ( In ALS 6th edition - warmed IV fluids is
    active external )
  • body cavity lavage ( peritoneal lavage , pleural or
    pericardial )
  • Renal replacement therapy
  • Extra corpeal life support ( ECLS ) re-warming in core
    temperature < 32 degrees celcius
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6
Q

What ECG abnormalities can you look for in a patient with hypothermia?

A
  1. osborne waves “ J-waves “ - delayed repolarisation
  2. bradycardia
  3. prolonged PR, QRS, QT intervals
  4. ventricular ectopics
  5. shivering artefact
  6. cardiac arrest
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7
Q

what are the complications of heat stroke that you would look for on lab investigations?

A
  • Hyperkalaemia
  • metabolic acidosis
  • raised CK - rhabdomylisis
  • Coagulopathy - DIC
  • hypoglycaemia ( due to liver failure )
  • raised liver transminases
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8
Q

What is the difference between absolute and relative entrapmnet?

A

ABsolute - the casualty is physically enclosed by the deformity of the vehicle. cutting of the vehicle is required to free the casualty

Relative Entrapmnet -

injury to the casualty prevents unassited exit from the vehicle. ( victim cannot free themself without assistance even if the deformity of thge vehicle is cut/removed )

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9
Q

2 major life threatening injuries to monitor pre-hospital in a patient involved in a RTC significant crush injuries to both lower limbs?

A
  1. catastrophic haemorage

2. hyperkalaemia

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10
Q
  1. How can you classify hypothermia according to temperature?
A
  1. classifying hypothermia:

mild: 32- 35 degrees celcius
moderate: 28-32 degrees celcius
severe: less than 28 degrees celicius

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11
Q
  1. What are the complications of hypothermia?
A

complications of hypothermia:

  1. skin - frost bite with gangrene
  2. haematology - imparied coagulation and increased
    bleeding
  3. electrolytes- hypo - kalaemia, magnesaemia,
    calcaemia
  4. cardiac - arrythmias
  5. respiratory - pneumonia, pulmonary oedema
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12
Q

In children - what are the prognostic indicators in drowning?

APLS manual

A
  1. immersion time ( > 10 min is poor )
  2. Time to 1st respiratory effort ( if no effort after 40 min of CPR is poor )
  3. core temperature (< 33 degrees celcius on arrival and water temperature less than 10 degrees celcius is a good prognostic factor )
  4. Persisten coma ( GCS < 5/15 is poor prognosis )
  5. Arterial blood PH < 7.1 despite treatment ( poor prognosis )
  6. Arterial blood P02 if remains < 8kPA
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13
Q

How do you differentiate between deep and superficial frostbite?

resource: OHEM 4th edition

A

Superficial frostbite :

*involves skin and subcutaneous tissue
*area looks white and waxy
*feels numb, firm and hard but still pliable ( not hard )
*rewarming is painful, and oedematous hyperaemic skin
becomes purple with *serum filled blisters

Deep Frostbite

  • involves muscles, nerves +/- bone ( as well as skin and superficial tissue )
  • damaged area is hard and remains white after re-
    warming
  • blood - filled blisters develop
  • dead tissue mummifies and separates after weeks/months
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14
Q

what are the characterisitcs of full thickness burns?

resource: OHEM 4th edition

A

Looks:

white in colour
waxy in appearance
no blisters form

Feels:

painless to touch
dry skin
and non-blanching on pressure

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15
Q

In Partial thickness burns:

how do you differentiate between
superficial partial
vs
deep partial thickness burns?

A

in superficial partial thickness:
skin is pale pink
skin is painful
skin blanches on pressure

In deep partial thickness:
skin is red and motled
skin is painless
skin does not blanch on pressure

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16
Q
  1. what are the three main findings in a patient with heat stroke?
  2. How do you differentiate heat stroke from heat exhaustion?
A
  1. classic presentation involves three main findings:

Core body temperature above 40.0 C
Encephalopathy
Anhydrosis

  1. heat exhaustion will not have anhydrosis where as heat stroke - patient has anhydrosis
17
Q

WHat are the 4 main categories of diving emergencies?

A

diving emergency categories:

  1. Drowning
  2. barotrauma ( descent and ascent )
    descent barotrauma affects sinuses and middle ear
    ascent barotrauma affects lungs - get mediastinal emphasema
  3. decompression sickness -

pathophysiology:
divers ascend too quickly which does not allow nitrogen to be expelled naturally from the blood and skin and remains trapped causing build up of bubbles in tissues tissues and organs

risk factors:

  • failure of divers to comply with safe ascent regulations
  • obese
  • cold waters
  • vigourous exercise during the dive

common features:
* joint involvement- the bends ( joint aches/pain
especially shoulder and elbows
* skin involvement - peu de orange effect
* CNS - focal deficits, cereballar dysfunction, mood
changes
* spinal cord involvement

  1. marine bites and stings
18
Q

what is the elimination half life time of carbon monoxinde in room air, in 100% oxygen and at hyperbaric oxygen ?

A

in room air :
4-6 hours

in 100% oxygen:
76 minutes

hyperbaric oxygen at 2.5atmosphere:
23minutes

resource: rcem learning

19
Q

What clinical features would make you suspect a patient has carbon monoxide poisoining?

A
  1. Clinical features of poisoning are present, and
  2. Exposure to a potential source of carbon monoxide has occurred, particularly if
  3. Symptoms correlate with exposure
  4. There are unexplained symptoms that resolve on leaving a building
  5. There is an unconscious patient, especially if more than one and indoors

rcemlearning

20
Q

what are the severe clinical features of carbon monoxide poisoning?

A
  1. Any new objective acute neurological signs e.g increased tone, upgoing plantars, coma
  2. Need for ventilation
  3. ECG indication of infarction or ischaemia
  4. Clinically significant acidosis
  5. Initial carboxyhaemoglobin greater than 30%

rcem learning

21
Q

what are the indicators of severity in carbon monoxide poisoning?

A
  1. Any new objective acute neurological signs e.g increased tone, upgoing plantars, coma
  2. Need for ventilation
  3. ECG indication of infarction or ischaemia
  4. Clinically significant acidosis
  5. Initial carboxyhaemoglobin greater than 30%

rcem learning

MEMORY AID:

30% in blood, causes significant acidosis, affects brain, heart and lungs

22
Q

WHat characteristic burn features would you look for in a patient with electrical burns?

A
  1. Lichtenberg figures — transient ferning or feathering patterns pathognomonic of lightning strike (onset <1 hour, duration <24 hours)
  2. linear – “flashover” (sweat turns to steam)
  3. punctate burns – multiple circular burns due to current leaving the body e.g. tip-toe sign
  4. full thickness contact burns – due to fire or heated object in contact with skin (NB. deep thermal burns are rare, unlike HV electrical injuries)
23
Q

What are the indications for admission in patients with electrical burns?

A

all patients with HIGH RISK FEATURES:

loss of consciousness
focal neurological deficits
chest pain or dyspnea
pregnancy
burns to head, legs or to >10% BSA
major trauma or blast injury
24
Q

In near drowning of adults -

  1. can you name the poor prognostic factors ?

2, what are the good prognostic indicators?

A
  1. poor prgonostic indicators:
    * extreme of age
    * immersion time > 5 min
    * coma on admission
    * severe acidosis
  2. good prognostic
    * older child /adults
    * with a brief immersion time
    * hypothermia
    * who receive rapid on scene BLS and respond to initial
    resuscitation measures
    * are alert on admission
25
Q

What is a mass casualty incident in the UK?

A

A mass casualty incident for UK health resources is an incident (or series of incidents) causing casualties on a scale that is beyond the normal resources of the emergency and healthcare services’ ability to manage.

26
Q

What is a major incident?

A

A major incident is any occurrence that presents serious threat to the health of the community or causes such numbers or types of casualties, as to require special arrangements to be implemented

27
Q

When a major incident is on standby - what 3 actions should the ED take?

A

 Initiate staff call in

 Locate and check the pre-printed/collated patient registration documents for a major incident

 Establish an ED Triage Station.
Consider a location outside the ED (eg ambulance loading bay or external entrance)

28
Q

In a major Incident - what 5 questions should you ask when triage the patient?

A
  1. is there a catastophic haemorrage?
    if no go to ( 2 )
  2. are they walking
    if yes - then green
    if no - then go to ( 3 )
  3. are they breathing
    if no-
    if yes
  4. are they responding to voice
    if no -
    if yes- ( go to 5 )
  5. what is the respiratory rate?
    if 12 -23 bpm then go to ( 6 )
    if < 12 or > 23 :
  6. what is the heart rate?
29
Q

In major incident triage in Emergency department triage of (paediatric <12 years) - what system would you use to triage children <12?

A

jumpSTART

30
Q

Classify hypothermia using the swiss staging system?

A

Stage 1 - clear Level of conciousness with shivering
stage 2 - impaired LOC with no shivering
stage 3 - unconcious
stage 4 - no breathing
stage 5 - death due to irreversible hypothermia

31
Q

In a hypothermic cardiac arrest - give 4 indications to withold Resuscitation?

A
  1. in cases of lethal injury
  2. fatal illness
  3. prolonged asphyxia
  4. or if chest is incompressible
32
Q

What modifications to the ALS algorytym will you make in hypothermic cardiac arrest?

A
  1. Drugs -
    * withhold drugs untill temp is > 30deg C and then double the dosing intervals untill temp is > 35 deg C
    * give drugs via a central vein
  2. Defibrillate -
    * if VF/VT detected - give a shock, and if it persists after 3 shocks then delay further defibrillation attempts untill core temp is > 30 deg C
  3. OTHER modifications:
  • use warmed and humidified oxygen ( 40-46 degrees C)
  • be careful when intubating due to precipitating VF
  • palpate a MAJOR artery and look at the ECG for up 1 minute for signs of life before concluding no cardiac output

FRCEM Final SAQ (16 decks)

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