NEW Flashcards
1
Q
Unconscious patient evaluation and management
A
Initial response
- Call for help
- Attach vitals
- Primary survey
- Concurrent/Collateral history
- Bedside investigations
- Empirical management
- > pulses = CPR
Vitals
- Hypotension + tachycardia
- > shock
- Pulse ox
- > hypoxia
- Cushings reflex
- > raised ICP
- Temperature
- > febrile
- > hypothermia
Primary survey
- A
- > stridor
- > angio-oedema
- B
- > respiratory rate
- > equal entry
- > wheeze/crackles
- C
- > evidence of shock
- > irregular pulse
- D
- > GCS
- > decerebrate/decorticate
- E
- > evidence of trauma
- > rash
- > eyes (metabolic disturbance)
- > pupils (unilateral = herniation/bi-lateral = drugs)
- F
- > IV access
- > catheter
- G
- > check
Collateral hx
- Allergies
- Medications
- > opioids
- > benzos
- > anti-depressants
- Past
- > diabetes
- > seizures/epilepsy
- > heart disease/arrhythmias
- > psychiatric/substance use
- Last seen well
- Events
- > treatment already given
- > change in status
Investigations
- bHCG
- ECG
- VBG
- > glucose
- > acid/base
- > electrolytes
- > hypoxia/hypercapnoea
- FBC
- EUCs
- > uraemia
- LFTs
- TSH
- Tox screen
- Thiamine
- Imaging
- > RUSH
- > mobile chest
Management
- A
- > jaw thrust/chin lift
- > adjuncts
- > intubation
- B
- > support breathing
- > supplement O2
- C
- > fluid boluses if hypotensive
- D
- > IV glucose
- > IV naloxone
- > IV thiamine
- E
- > cooling for hyperthermia
- > warming for hypothermia
- Further
- > non con CT head
- > LP
2
Q
Burns evaluation and management
A
Initial response
- Call for help
- Vitals
- Primary survey
- Concurrent/collateral hx
- Bedside investigations
- Empiric management
Red flag Vitals
- Shock
- > hypotension
- > tachycardia
- Hypoxia
- > desaturation
Primary survey
- A
- > burns around face/mouth
- > stridor/change in voice
- B
- > respiratory rate (circumferential eschar)
- > wheeze (bronchospasm)
- > crackles (inhalation injury)
- C
- > shock
- D
- > altered level of consciousness
- E
- > burn depth (superficial/partial/full thickness)
- > burn distribution (TBSA/hands/face/genitalia/circum)
- > evidence of trauma/injuries
- F
- > IV access
- > insert catheter
- G
- > check
Hx
- PC
- > pain
- > SOB
- > nausea/vomiting/confusion/headache (CO)
- Details of event
- > thermal/chemical/radiation/electrical
- > cause (accidental/assault/illness)
- > exposure (smoke/steam/gases/furniture/chemicals)
- Past
- > lung/heart/kidney disease
- > immunocompromise
- > tetanus
Investigations
- ECG
- > CO
- VBG
- > glucose
- > electrolytes
- > hypoxia
- > carboxyhaemoglobin
- FBC
- CK
- EUCs
- > AKI
- CXR
- > atelectasis
- > air-trapping
Management
- Admit
- > monitor (temperature/hypoxia/pain)
- Transfer
- > call and discuss with burns centre
- > 10% TBSA/face/genitalia/circumferential/hands/feet/joint
- A
- > secure
- > intubation (stridor/hoarse/oral burns/60% TBSA)
- B
- > high flow O2 if inhalation injury suspected
- > escharotomy if restricted breathing
- C
- > IV crystalloid if >15% TBSA involved
- > parkland formula (4mL x TBSA x weight)
- > give half in first 8hrs/give rest over 16hrs
- D
- > serially monitor GCS
- > adequate analgesia
- E
- > remove adherent clothes
- > remove redundant skin/blisters
- > cool/running water for 30mins within 3hrs
- > avoid complex dressing/ointments (require removal)
- > saline soaked gauze/cling wrap
- F
- > monitor urine output (1mL/kg/hr)
- > insert NG if >20% TBSA (ileus)
3
Q
Stabbing evaluation and management
A
Initial response
- Call for help
- Vitals
- Primary survey
- Concurrent/Collateral hx
- Investigations
- Empiric management
Vitals
- Shock
- > hypotension
- > tachycardia
- > narrow pulse pressure
- Hypoxia
- > desaturation
Primary
- A
- > patent and protected
- B
- > tracheal deviation
- > symmetrical chest rise
- > equal breath sounds
- > resonance to percussion
- C
- > evidence of shock
- > elevated JVP (tension/tamponade)
- D
- > GCS
- E
- > site/number/depth/size of wounds
- > subcut emphysema/ecchymoses in flanks
- > log roll
- > additional injuries
- F
- > two IV cannular
- > insert catheter
- G
- > check
Hx
- Allergies
- Mediations
- > anti-coagulation
- > anti-platelets
- Past medical
- > tetanus
- > coagulopathy
- > chronic illness
- Last meal
- Events
- > details of event (assault/self-inflicted)
- > resuscitation/medications already given
Investigations
- Blood group and cross match
- VBG
- > glucose
- > Hb
- > lactate
- Trop
- > if thoracoabdominal injury
- FBC
- Coags
- > thromboelastography
- EUCs
- LFT
- Lipase
- Tox screen
- Fast/eFAST
- Xray
- > chest = pneumo/haemothorax
- > abdo = perforation
- CT angio
- > abdo = free gas/solid organ injury
- > chest = diaphragm injury/great vessels
Management
- Consult
- > general surgeon
- > trauma
- > tertiary referrral
- IV access
- > fluids
- > transfusion +- MTP
- > analgesia
- Haemostasis
- > external pressure to superficial
- > tranexamic acid
- Equivocal FAST scan = local wound exploration
- > local anaesthesia in OR
- > query penetration of deep fascia
- Haemodyanamiccally stable = direct peritoneal lavage
- > peritoneal catheter via umbilical port
- > positive tap draws blood
- > negative gets flush and aspirate
- > microscopy RBC/WCC/bilirubin/amylase/faecal/food
- Laparotomy
- > multiple wounds/peritonitis
- > positive FAST/CT abdo/DPL/LWE
- > suspected diaphragm injury (thoracoabdominal trauma)
- Monitoring
- > vitals for haemodynamic stability
- > serial physical exams for peritonitis
4
Q
MVA
A
Initial response
- Call for help
- Attach vitals
- Primary and secondary survey
- Concurrent/Collateral hx
- Investigations
- Empirical management
Vitals
- Shock
- > hypotension
- > tachycardia
- > narrow pulse pressure
- Hypoxia
- > desaturation
- Febrile
Primary survey
- A
- > secure (beware manoeuvres)
- > switch to phili collar/place on spinal board
- B
- > support/supplement O2
- > pneumothorax
- > haemothorax
- C
- > shock
- > JVP (tension/tamponade)
- D
- > GCS
- E
- > penetrating injuries
- > head/ribs/pelvis
- > seat belt sign
- > log roll
Secondary survey
- Spinal injury
- > weakness or loss of sensation
- NEXUS criteria (NSAID)
- > focal neurological deficit
- > midline c spine tenderness
- > altered mental status
- > intoxication
- > distracting injury
Hx
- Mechanism of injury
- > speed >50km/hr
- > use of seat belts/airbags
- > rollover
- > extrication time
- > fatality at scene
- Injuries sustained
- > head/abdomen/chest
- > penetrating/blunt wound
- Signs on admission
- > vitals
- > sites of pain
- Treatment given
- > blood
- > analgesia
- Allergies
- Medications
- > anticoagulants/antiplatelets
- > sedatives
- > substances
- Past medical
- > pregnant
- > MI/arrhythmias
- > seizures
- > diabetes
- > OSA
- > mental health
- > substance use
- > tetanus
- Last meal
- Events
- > LOC
- > tongue biting/urinary incontinence
- > palpitations
Investigations
- bHCG
- Blood group and cross match
- VBG
- > glucose
- > Hb
- > lactate
- Trop
- > if thoracoabdominal injury
- FBC
- Coags
- > thromboelastography
- EUCs
- LFT
- Lipase
- Tox screen
- Fast/eFAST
- Xray
- > chest = pneumothorax/haemothorax
- > abdo = perforation
- > pelvis = fracture
- CT angio
- > abdo = free gas/solid organ injury
- > chest = diaphragm injury/great vessels
- CT axial cervical spine
- > if any NEXUS criteria
Management
- Consult
- > general surgeon
- > trauma
- > tertiary referal
- IV access
- > fluids
- > transfusion
- > analgesia
- Haemostasis
- > pressure for superficial
- > tranexamic acid
- Laparotomy
- > haemodynamically unstable
- > multiple pentrating wounds
- > positive FAST/CT
- No CT c-spine abnormality
- > dynamic neck exam (pain on voluntary movement)
5
Q
Hand laceration evaluation and management
A
Collateral hx
- Allergies
- Medications
- > anti-platelet/anti-coagulant
- > substances
- Past medical
- > coagulopathy/chronic liver disease
- > substance use disorder/mental health
- > tetanus
- > handedness
- Last meal
- Events
- > details of event
- > deliberate/accidental
- > harm to self/others
- > occupation
Exam
- Look
- > site/number
- > depth/structures involved
- > pale
- > deformity
- > dirt/glass/foreign bodies
- Feel
- > pulses
- > sensation (median/ulnar/radial)
- Move
- > median/ulnar/radial
- > FDP/FDS
Management
- Haemostasis
- > direct pressure with gauze pack
- > elevation
- > arterial tourniquet
- Anaesthesia
- > 1% lidocaine (+- adrenaline)
- > wrist block (radial/medial/ulnar)
- > aspirate back
- Consult
- > orthopaedics/plastics
- > consider depth/complications/occupation
- Wound care
- > irrigate under tap/saline syringe
- > sponge/brush scrubbing if debris
- > alcohol swab surrounding skin
- > debride loose dead tissue
- Delayed primary closure
- > skin tense
- > prolonged opening (>6hrs)
- > active infection
- > retained foreign bodies
- > no delay in healing time with revision at 4 days
- Primary closure
- > 5O-60 monofilament
- > steri strips
- Dressing
- > wet gauze (soaks up dead space)
- > foam pad dressing with elastic gauze
- > seperate fingers and leave tips visible
- Imobolisation
- > splint in position of hand function (finger flex/wrist ext)
- > sling promotes venous drainage and healing
6
Q
Anorectal abscess evaluation and management
A
Hx
- PC
- > increasing anal/peri-anal pain (occasionally abdo/pelvic)
- > worse with movement/cough/sneeze/defecation
- > swelling and warmth
- > constipation
- Past
- > crohns
- > diabetes
- > immunocompromise
- > haemorrhoids
- Sexual
- > receptive anal sex (proctitis)
- > foreign body
Exam
- Vitals
- > sepsis
- > SIRS
- Abdo
- > tender
- Inspect
- > erythema
- > oedema
- > degree of spread
- DRE
- > may not be possible without anaesthesia
- > induration + tenderness = abscess
- > hard + cordlike = fistulae
- > peri-anal/anal canal/above anorectal ring
Investigation
- If concerned for necrotising fasciitis
- > VBG
- > FBC
- > EUCs
- > Blood culture
- Imaging
- > if severe/complicated
- > ultrasound/CT/MRI
Management
- Admit
- > general surgical consult
- IV access
- > fluids
- > analgesia
- Antibiotics
- > ampicillin + metronidazole IV
- Surgical drainage
- > perianal = local anaesthesia in ED
- > remainder = general anaesthesia in OR
- Fistula
- > fistulotomy
- > seton
- Non-operative
- > warm baths 2-3 times daily post op
- > high fibre diet
- > adequate hydration
