Myhow Flashcards
Rapid primary survey
Airway Breathing Cirulation Disability Exposure/ environmental control
Airway & cervical spine control
Initial mx
1- assess? 5
2- create and maintain airway? 5
3- position
1- assess airway patency
- speak in full sentences
- no foreign body ij object
- no facial injuries
- no cervical tenderness & full ROM
- c-collar on
2- create or maintain airway by
- looking with suction
- chin lift or jaw thrust
- naso/oropharyngeal airway
- orotracheal intubation
- cricothyroidectomy
3- check for cervical spine injury
-maintain spine in safe neutral position (c-collar) until clinical exam and radio findings exclude injury
Breathing
- give what?
- what to assess? 4
-what to recognize & treat?
1- high flow oxygen
2- assess chest
- inspection- breathing spontaneous
- palpation and feeling of trachea- trachea not deviated, chest rise equal, chest spring negative, no crepitus, no chest wall trauma
- percussion- percussion resonant
- auscultation-lungs clear air entry equal
3- recognise and treat ATOM-FC
ATOM-FC
Airway obstruction or disruption Tension pneumothorax Open pneumothorax Massive pneumothorax Flail chest Cardiac tamponade
Disability? - - - -
1- GCS & DXT
2- pupillary size and response
3- examine lateralising sign and signs of cord injury
4- moving all four limbs?
Circulation
What to assess?
- inspect
- palpation 8
- auscultation
Assess circulation
Inspect:
-looking for external hemorrhage or active bleeding
Palpation:
- skin color, temperature & capillary refill
- pelvic spring
- abdominal trauma
- pulse
- blood pressure
- neck veins
Auscultation: muffled heart sound
5 N
Noggin- raccoon eyes, Battle’s sign
Neck- C spine, neurogenic shock, nuchal ridgidity
eNt- otorrhea, rhinorrhea, tongue biting, hemortympanum
Needles- iv drug abuser
Neurological- GCS, posture, movement, pupils, reflexes, corneal reflex, gag reflex, doll’s eye reflex, oculovestibular reflex
Airway maintenance with C-spine control
- airway normal? Compromised?
- cervical spine- normal? Suspect injury?
1) airway patency
- NORMAL breathing/speech
- Compromised: stridor, cyanosis
2) Cervical Spine
- NORMAL: non tender, ROM full - Suspect Injury: tender
Breathing and ventilation
Vitals: SpO2, RR
NORMAL: spontaneous
Compromised: stridor, unequal chest rise
Inspection: trachea deviation, chest rise, flail chest
Palpation: chest spring, crepitus/emphysema
Auscultation - normal breath sound/Crepts/Silent Chest?
Percussion - resonant/hyperresonant/dull
Intervention- breathing
- head tilt-chin lift / jaw thrust
- remove foreign body by sweeping - O2 mask
- oropharyngeal airway + bag
- Intubation
-protect C spine with collar
Circulation
Pulses, hemorrhage control
Vitals: HR, BP / CRT, peripheries warm?
Inspection: active bleeding/bruises/open wound
Palpation: pelvic spring/PA tender
Ausc: muffled heart sounds
Perc: PA dullness
Intervention- circulation
- 2 large bore branula
- FBC/RP/VBG/Coagulation/RBS
- IV fluids
- Hemorrhage control- compression bandage/tourniquet
Disability
Neurologic status
Vitals: DXT
1) GCS: EVM
2) Pupils equal/reactive to light?
3) Gross Motor fn: Limbs – movement / deformity
4) Spinal injury? priapism, loss of anal sphincter tone/ bulbocavernosus reflex
Exposure and environment
Vitals: Temperature
1) Remove clothes, inspect for wounds
2) warm blanket and saline
Intervention- environment control & exposure
- Cover with blanket
- Analgesic
Adjuncts
1- Log roll
2- FAST scan
Intervention- disability
- Hypoglycemia: Dextrose 50% 50cc stat + IVD D10%
- Seizure control: midazolam 5-10mg IV, followed by phenytoin 18mg/kg IV over 30 minutes
- Fracture: immobilization/splint
- GCS
Log roll
A) Involves at least 3 person:
Stabilize head + pelvis + limbs
- turn body together at the count of 3, turn away form injured limb
B) Examine back
- check for bruises/open wound
- check for spinal tenderness/step deformity
- PR – anal tone, high riding prostate (in semi-conscious pt, CBD tug can elicit anal tone –BCR-bulbocavernous reflex)
FAST exam
Where does blood collect?
4 potential spaces where fluid collects
- Morison’s pouch - blood in RUQ - hepatorenal recess (Morison’s pouch) between liver and right kidney, will also flow into right paracolic gutter into pelvis blood in LUQ - often between diaphragm and spleen, will also flow into splenorenal recess, then into left paracolic gutter into pelvis
- Subdiaphragmatic - blood in LUQ, // the phrenocolic ligament often shunts fluid to Morison’s pouch before filling the left paracolic gutter
- Pericardial - blood around heart
- Posterior cul de sac - blood in pelvis; rectovesical or rectouterine pouch, then into paracolic gutters
Secondary survey
Head
Scalp: laceration
Skull: depression/basal #
face: L/w or #, midface or maxilla instability eyes: Orbit/globe/eyelid injury
ears: haemotympanum, CSF leak
nose: bleeding
Mouth: Tooth #
Neck - C spine injury, soft tissues (larynx)
Chest
- chest wall injury, # ribs, flail chest, open Pneumothorax, emphysema, Haemothorax, pulmonary contusion
Abdomen
- skin contusion/abrasion, distension, tenderness, guarding PR: lax anal tone, blood, high prostate
PV: injury/bleed
Perineum : blood at urethra, hematuria
Extremities: limb fractures/deformities
ATOM FC 2
Aortic dissection
Thorax injuries
(non-massive haemothorax, simple pneumothorax),
Oesphageal perforation,
Muscular diaphragmatic injury,
Fistula (bronchopleural) and other tracheobronchial injury
Contusion to the heart or lungs
Rapid sequence intubation 9P’s
1) Preparation
- Yourself: PPE-Mask, apron, gloves, - Your team
- Equipment
2) Preoxygenation
- HFM 15L/min for 3-5mins
3) Position
- sniffing position, flex neck, extend head
4) Premedication
IV Fentanyl 3mcg/kg
IV Lignocaine Lidocaine 1.5mg/kg
5) Put to sleep (Induction agent)
IV Etomidate 0.3mg/kg IV Ketamine 1-4.5mg/kg IV Propofol 2-2.5mg/kg IV Midazolam 0.3mg/kg
6) Pressure (cricoid) - BURP” Backward, Upward, Rightward Pressure
7) Paralysis
IV Succinylcholine 1-1.5mg/kg IV Rocuronium 0.6-1.2mg/kg
8) Placement confirmation
Auscultation, Lung expansion, Spo2
9) Postintubation care
Secure ETT
Initiate mechanical ventilation
Sedation
CXR
Equipments
1- ETT tube
2- Stylet
3- syringe 10cc
4- Suction catheter
5- Carbon dioxide detector
6- Oral and nasal airways
7- Ambu bag and mask attached to oxygen source
8- Assistant for cricoid pressure
Indications for intubation
- unable to protect airway
- inadequate spontaneous ventilation
- O2 saturation
COMA
GCS
Eyes 1 2 3 4
Verbal 1 2 3 4 5
Motor 1 2 3 4 5 6
COMA
Approach
1) ABCs
* Airway: take into account:
Trauma- C-spine injury, facial trauma, fall/collapse
Reversible cause - Hypoglycemia or narcotic overdose
Poisoning – eg carbon monoxide
COMA
Resuscitation components
1) IV acesss + Blood Ix (DXT, RBS,FBC, RP,LFT, ABG/VBG)
2) ECG
3) Universal Antidotes:
IM Thiamine 100mg (alcoholic/cachectic/malnourished),
50% Dextrose 50cc (hypoglycaemia) Naloxone 0.4-2.0mg IV (narcotics overdose)
SHOCK
Shock in trauma is HEMORRHAGIC until proven otherswise
See classification
SHOCK
Estimation of degree of shock
See table
SEPSIS
Diff berween SIRS, sepsis, severe sepsis and septic shock
See image
SEPSIS
Organ disfunctions
Organ dysfunction (before fluids resus)
- sBP 2 hours
- Creatine > 2.0
- INR > 1.5 or aPTT >60s
- Plt 20
- Lactate > 2
- Bilateral pulmonary infiltrates
Sepsis bundle
To be completed in 3 hours
1) Measure lactate level
2) Obtain blood cultures prior to administration of antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L
Sepsis bundle
To be completed in 6 hours
5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mm Hg
6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥4 mmol/L (36 mg/dL):
- Measure central venous pressure (CVP)*
- Measure central venous oxygen saturation (ScvO2)* 7) Remeasure lactate if initial lactate was elevated*
*Targets for quantitative resuscitation included in the guidelines are CVP of ≥8 mm Hg; ScvO2 of ≥70%, and normalization of lactate.
Sepsis pressors
Sepsis Pressors
1. Noradrenaline Start 0.5-1mcg/min (max 30mcg/min)
2. Vasopressin 0.04units/min
3. Dopamine 2-50mcg/kg/min (normal stable dose 20mcg/kg/min)
Chest trauma
The A & E HO guide
<div class="page"> </div>
Chest tube insertion
See images
Abdominal pain
Ddx
GIT: gastritis, appendicitis, PUD, hepatitis, PUG
GUT: UTI, calculi, pyelonephritis
Gyn: ectopic pregnancy, PID, endometriosis
Vasc: AAA, bowel/splenic infarct
Others: DKA, MI , intraab abscess, pneumonia
Abd pain
Assessment
Isp: Jaundiced, pallor
Ausc: bowel sound, bruits
Perc: dullness,
PA: tenderness/guarding/rebound epigastric Gastritis/pancreatitis SuprapubicUTI (UFEME-Leu+,Nit+,Hb+) RIF +,Rovsing+appendicitis (WCC raised) Rebound +perforated bowel / PGU
Renal punch+pyelonephritis
Abd pain
Mx
Ix:
FBC/RP/LFT/Amylase/UFEME
ECG: TRO MI
AXR – calculi, fecal loaded, bowel distension
CXR PA erect – Free air, gas pattern
USG: free fluid, ectopic preg, biliary colic
plan:
IV ranitidine 50mg stat Syr MMT 10ml stat
* IV Tramal 50mg stat
Fever
Dengue fever
Hx: Dengue prone area
Warning sx:
Decreased Plt + raised HCT
Enlarged tender Liver
Nausea , persistent Vomiting
GIT (abdominal) pain
Unrest, lethargy
Erythema (gum/mucosa bleeding)
Fluid accm (ascites/effusion)
Dengue fever
o/e:
Hydration fair
Pulse volume good
Warm peripheries
Tachycardia?
Dengue fever
Mx
FBC: Plt + TWC low, HCT
raised LFT: elevated liver enzymes (hepatitis)
Tx: Hydration as per protocol
Fever
Leptospirosis
Hx: Jungle trekking swimming in calm water
Leptospirosis
Ix
CK raised > 1000 Leptospirosis
RP: deranged lepto w renal involvement
Leptospirosis
IVD hydration
IV Doxycycline 100mg ; or IV Rocephine 2g
Lepto IgM / MAT
Malaria
Hx: recent travel foreigners
Malaria
Ix
BFMP
LFT
FBC: +/- Hb drop
Malaria
IV Artesunate
IV Primaquin/Chloroquin
Tonsilliopharyngitis
vomiting after eating poor oral intake
Tonsillopharyngitis
Ix
Grade I-IIsymptomatic tx
Grade III-IVKIV ENT
Tonsillopharyngitis
Mx
Syr PCM 15mg/kg, Supp PCM 125mg T PCM 1g QID
T Amoxy 500mg / Syr 15mg/kg tds 5/7
Thymol gargle
UTI
sx
Dysuria, frequency, cloudy urine, painful urine
UTI
Ix
suprapubic pain+
UFEME: Leu+, Nit +, Hb+/-
UTI
T cephalexin 500mg TDS
Ural sachet
Abscess / DFU / Cellulitis - DM
Sx
Ttt
- WI: tender, swollen, warm, fluctuant, pus, foul smelling
T Cloxacilin 500mg QID
DKA
Effective serum osmolality
Total osmolality
Effective serum Osmolality 2(Na +K) + RBS + Urea = > 320mmol/L
Total Osmolality
2(Na) + RBS + urea = >330mmol/L
Anion gap = Na – (Cl+bicarb)
DKA
criteria
Ix
Hyperglycemia (>14mmol/L ) + Metabolic Acidosis (pH
DKA regime
1)1 pint NS over 1H, 2H,4H,6H,8H when DXT
HHS
Hyperglycemia >33mmol/L
pH >7.3 ,
Bicarb
AF
IV Digoxin 0.25-0.5g
Cardiovert 120 J
VT/Pulseless VF
Continous CPR
Shock 200J (B) / 360 J (M)
IV Adrenaline 1mg every 2mins
IV Amiodarone 300mg bolus (rpt 150mg) or IV Lignocaine 1.5mg/kg (rpt 0.75mg/kg)
SVT
Carotid massage
Cardiovert 50 J
IV adenosine 6mg / 12mg / 12mg
Indication for cervical collar
N-neurological deficit
S-spinal tenderness
A-altered mental status
I-intoxication (alcohol or drugs)
D-distracting pain
