OSCEStop Emergencies 2 Flashcards
peritonitis summarise DDx, classic hx, classic exam, inv, management
DDx: perforated viscus
(peptic ulcer, tumour, diverticulum, gallbladder, appendix, spleen, AAA, ectopic)
severe generalised abdo pain
no movement with resp, guarding, firm abdo, rebound + percussion tenderness, severe pain on light palp
inv- standard acute abdo + erect CXR, urgent CT AP
standard acute abdo + urgent surgical repair + double cannulae
acute abdomen standard inv + management (obvs add specifics for diff causes)
FBC, U+E, LFT, CRP, INR, G+S, amylase
urine dip+culture
bHCG if female
IVF
catheter NGT
analgesi
VTE prophylaxis unless theatre within 2 hrs
if need surg:
check INR, G+S
stop anticaog/antiplatelets/ diabetic meds
ruptured AAA summarise DDx, classic hx, classic exam, inv, management
ddx - other peritonitism
elderly, severe generalised pain, back pain, reduced GCS
hypotensive, peritonitic, expansile mass
standard inv + bedsidde USS, CT angio
standard treat + double cannula, permissive hypotension, massive haemorrhage protocol, urgent open repair
renal colic summarise DDx, classic hx, classic exam, inv, management
ddx - pyelonephritis, biliary colic
spasms of loin to groin ppain, nausea + vom, can’t sit still
SNT abdo, renal angle tenderness
standard inv + CT KUB
standard treat + diclofenac, IV fluids, abx if necc
either tamsulosin + wait or surgical options
appendicits summarise DDx, classic hx, classic exam, inv, management
ddx: Meckel’s diverticulum, Chron’s, mesenteric adentitis, ovarian cyst, ovarian torsion,ectopic
young, periumbical pain localising to RIF, anorexic, nauseous, fever
tender RIF, McBurney tender
gurading
Rosving +Ve
standard inv + USS if gynae worry
general treat + urgent lap
gallstones summarise DDx, classic hx, classic exam, inv, management
biliary colic or cholecystitis or CBD stones or cholangitis
standard inv +a abdo USS, CT if req
standard treat + depends on condition
(either remove GB, ERCP or give abx)
acute pancreatitis summarise DDx, classic hx, classic exam, inv, management
ddx - gastritis, cholecystitis, pericarditis
severe epigastric / central pain
moves to back, relieved by sitting forwards, vom
epigastric tenderness, tachy, fever, shcok, GT+C signs
standard inv+ amylase /lipase, CT abdo if uncertain bloods
find cause with USS, triglycerides, Igs
standard treat + supportive, aggressive fluids, NBM, treat cause, consdier ITU
peptic ulcer summarise DDx, classic hx, classic exam, inv, management
ddx - pancreas, cholecystitis
epigastric pain linked to meals
tender epigastrium, SNT abdo
OGD+biospy
PPI, H pylori eradication
diverticulitis summarise DDx, classic hx, classic exam, inv, management
ddx - diverticular cyst, diverticulosis, mesenteric ischaemia, IBS, ovarian cyst/torsion
elderly LIF pain, pyerexia, diarrhoea
tender LIF
guarding
PR -ve
CT abdo if nec + standard inv
standard treat + clear fluids then build up
abx
bowel obstruction summarise DDx, classic hx, classic exam, inv, management
ddx - gastroenteritis
vomiting + abdo pain + non bowel or flatus motions
distended tender abdo
tinkling BS
standard inv + AXR then CT AP
gastrograffin if SBO
standard treat + NBM, wide bore NG on free drainage, lap if complte or non resolving
ectopic pregnancy summarise DDx, classic hx, classic exam, inv, management
ddx - appendicits, PID, Meckel’s diverticulum, Chron’s , mes adenitis, ovarian cyst / torsion
increasing iliac fossa / pelvic pain
6 weeks pregnant
spotting
tender RIF/LIF
guarding
adnexal tenderness
cervical excitation
standard inv + bHCG+trendline + TV USS
standard treat + double cannulae, lap salpingostomy /ectomy
methotrexate if uncomplicated
anti D PROPHYLAXIS if needed
initial approach to upper GI bleed pt
ABCDE approach IV fluid resus, permissive hypotension <100SBP massive haemorrhage protocol transfuse if Hb <70/80 must be stable before OGD
o/e - look for signs of common causes, do PR for melaena
bloods - G+S, XM, FBC, U+Es (urea raised), LFTs, clotting, glucose
catheterise
CXR, AXR once stable
regular obs and r/v
keep NBM, correct any clotting abnoramilites, stop anticaog/antiplt, treat cause
acute variceal bleed management
terlipressin pre OGD
prophylactic abx IV
OGD - variceal band ligatoin, sclerotherapy, ballon tamponade Sengstaken tube
acute non variceal bleed management
peptic ulcer, MW tear, oesophagitis
adrenaline injection into ulcer
IV PPI post OGD
scoring systems for GI bleed
Blatchford score - pre OGD = likelihood pt will need intervention
Rockall score - post OGD, assesses mortality risk
preventing further GI bleeding from varices
propanolol
variceal banding
TIPSS (shunt)
liver transplant
preventing further GI bleeding from peptic ulcer
PPI
H pylori eradication therapy
avoid precipitants (check drug chart)
DKA management protocol
- ABCDE approach
- confirm diagnosis - VBG, all 3 of the name are present
- IV fluids aggressively (start with 1L over 1 hr, then add bags with potassium over next 2 2 4 4 6 6 hrs consecutively)
- Regular U+Es (K+)
- Fixed rate insulin infusion 0.1U/kg/hr from 50U Actrapid in 50mlm 0.9% normal saline (max rate 15U/hr)
- Once glucose <14, add 10% IV glucose at 125ml/hr in addition to saline, but reduced saline rate.
- Investigate cause
- Treat cause
investigating cause of DKA
history top to tail exam bloods = FBC, UE,LFT, glucose, osmolality, CRP blood culture MSU CXR
when to consider ITU with DKA
if ketones 6+ bicarb <5 pH <7.1 GCS <12 SBP <90 sats <92%
follow up post acute phase DKA
manage cause continue daily long acting basal bolus insulin 2 hrly VBGs restart normal insulin regimen only when acid base corrected and able to eat and drink if not eating, VRII VTE prophylaxis NGT consider educated and review meds
targets bicarb glucose ketones in DKA recovery
increase bicarb by 3 an hour
reduced glucose by 3 an hour
reduced ketones by 0.5 an hour
if not going that rate, increase insulin by 1U/hr
common causes of hyperglycaemia
DKA HHS sepsis steroids missed insulin/meds pancreatitis dehydration meal/feeds
common causes of hypoglycaemia
not eating enough
vomiting
insulin/SU excess
dec renal function (So drug excess by proxy)
alcohol
abrupt steroid stoppage
Hyperosmolar Hyperglycaemic State what is it
slowly develops as a result of illness and dehydration
no acidosis / ketones
dx: 30+ sugars, osmolality 320+, hypovolaemic
management HHS
rehydrate aggressively, can be quicker than DKA as v v dehydrated
VTE prophylaxis - high risk
0.05U/kg/hr insulin if glucose not falling with fluids alone
look for cause
HOLD metformin until r/v
managing hypoglycaemia
unconsicous - 150ml 10% glucose IV stat, repeat as necc, glucagon IM 1mg if not IV access up to 2x max, recheck cap gluc
can’t swallow - glucose gel around teeth
can swallow - 12-30g fasta acting carb and long acting carbs too
correct cause and avoid omitting insulin/SU afterwards, just edit dose (ask pharmacist?)
history and examination of stroke and TIA
precise onset
when last well
any progression
risk factors (CVD)
full neuro exm
pulse, HS, carotids, bruising, bleeding
signs of RFs
management algorithm for stroke
Rosier score >1 - stroke likely
CT head within 1 hr
excluded intracran bleed
if<4.5 hrs give alteplase if no contraindications
otherwise: aspirin 300mg OD for 2 weeks, stat 300mg clopi then 75mg OD
consider clot retrieval
transfer to stroke ward
MDT: SALT assessment optimise nutrition early mobilisation treat infections, care for skin rehab consider carotid surgery
long term: antihypertensives clopidogrel 75mg OD anticoag if any AF statin 48hrs+ post stroke
DVLA advice with stroke
no driving for 4 weeks
tell DVLA if HGV driver or still sympto after 4 weeks or any complications
TIA algorithm
ABCD2 score
give aspirin 300mg OD for 2 weeks
OR 300mg stat clopi then daily 75mg
treat any AF
specialist r/v within 24 hrs
carotid endartectomy if ipsilateral stenosis >50%
inv long term: ECG, 24 hr tape, echo+/- bubble study for PFO, screen vasculitis, screen coag disorders
initial seizure management and assessment
recovery position jaw thrust airway consider NPA if doubts 15L o2 non rebreather secure IV access obs + cardiac monitor
cap glucose VBG FBC, UE, calcium drug levels clotting ECG - prolonged QTc?
definitive seizure managemetn
if 5 + minutes buccal midaz or rectal diazepam repeat multiple times if ongoing phenytoin IV then ITU
give 20% glucose if hypo, give pabrinex if alc
post seizure managemetn
find cause - CT, EEG, LP
treat cause
refer to neuro
driving advice
common causes of seizures
neuro: epilepsy, SOL, meningitis, post stroke, head trauma
metabolic: low sugar, high uric acid, electro abnormal
drugs: OD, abuse, alc withdrawal, toxins
febrile convulsion
eclampsia if preg
assessing traumatic wound initially
hx - who, hand dominance
what happened, mechanism, forces involved
clean wound and examine for damage + contamination
check tendon and NV status
check tetanus status
x ray if FB risk
wound management
clean wound, LA, debride, pressure irrigation if dirty,
thorough + deep inspection
if any damage risk, surgical input
closure: if clean and fresh wound, immediate primary closure
delayed primary: left open for 48 hrs post clean (for old or contaminated wounds)
secondary intention: let wound to close by itself (ulcers, tissue loss so can’t align edges)
skin grafts - burns
other aspects: abx tetanus rabies if bite pain relief rest ice elevation if swelling dressing
wound follow up
give advice
rest ice elevate
arrange follow up if delayed primary closure, diabetic, icomp, burns
when to remove sutures
head / face - 5 days
upper limb/trunk/abdo - 7 days
lower limb /diabetic/icomp - 10 days
most common ankle ligament sprain
lateral ligament
rules used to decide who needs an ankle x ray
Ottowa rules
x ray if malleolar pain + any of: pain over posterior tip of lat malleolus / medial malleolus, inability to weight bear immediately after injury and continuously after
examining an injured ankle
palpate deltoid ligament medially and lateral ligament complex
palpate fibula up to knee (check for assoc head of fib #)
squeeze test (squeeze tib fib lower parts together = checks for #)
watch walking / wt bear
distal neurovasc exam
generic management of ankle injury
ice, crutches, pain relief, advice to RICE
then mobilise
weight bearing encouraged if no fractures (daily)
grading of ankle ligament injuries
1 - stretch and micro tear (compression bandage, heals in 4 weeks max)
2 - stretch with partial tear (stirrup splint for 4 weeks, heals in 12)
3- complete rupture (aircast boot 6 weeks, may need surg, 3-6 months healing)
anterior cruciate ligament damage hx and symptoms
forced flexion, hyperextension or rotation injury to extended knee
knee collapses on weight bearing
immediate pain
can’t walk really
rapid haemarthrosis
posterior cruciate ligament damage hx and symptoms
tibia forced backwards e.g. fall on object or against dashboard of car, may hear popping sound
knee collapses on weight bearing
immediate pain
can’t walk really
rapid haemarthrosis
medial collateral ligament injury hx and symptoms
blow to lateral side of knee
pain on inner/outer knee
immediate pain
diff to weight bear
instability symptoms if high grade injury
lateral collateral ligament injury hx and symptoms (uncommon)
blow to medial side of knee - check peroneal nerve
pain on inner/outer knee
immediate pain
diff to weight bear
instability symptoms if high grade injury
meniscus tear injury hx and signs
rotational injury to flexed knee
immediate pain diff to weight bear slowly forming effusion clicking and locking locking limits extension of knee
general management of acute knee injury
Ottowa rules decide on x ray needs = age >55, can’t weight bear, patellar tenderness, head of fib tender, can’t flex to 90
full exam after a week - often too painful at first
crutches, analgesia, RICE advice, NSAIDs, mobilise and weight bear if no trauma found
specific knee ligament injury management
lig stretch with micro tear - stable knee - bandage for 2 weeks
stretch + partial tear = lax but stable - 4 week knee brace
complete lig rupture - unstable joint - brace for 6-12 weeks if collaterals, cast and surgery if cruciates
meniscal damage - arthroscopic repair if locked knee or no improv in 2 weeks
4 stages of fracture management
Resuscitate
Reduce if displaced
Retain position for healing
Rehabilitate
general # hx and exam
age, job, hobbies, hand dominance what happened, mechanism, force when/where/why it happened examine for other injuries check NV status screen complications check SH and smoking (delays healing)
resuscitation of a fracture
ATLS if life threatened
look for other injuries - don’t get tunnel vision. may need to immobilise c spine
reduction of a fracture
if displaced
open reduction -> for if intra-articular # or assoc NV damage
closed manipulation -> for extra-articular # where acceptable reduction can be achieved with sedation
traction
retaining a fracture
to maintain the reduced position
external fixation - contaminated wound, severe open fractures, severe assoc ST injury
internal fixation - comminuted or displaced #, intra-articular #, bones that can’t be reduced otherwise, joint damage
conservative immobilsation - splint, cast, brace, traction
methods of internal fixation
intramedullary - nails for long bones, K wires for small bones
extramedullary - plates and screws (for comminuted # or compress)
femur and tib/fib #
if extra-articular can usually be cons management but often given IM nailing to reduced non weight bearing time
using splint / case
acutely - splint or backslab allowing for swelling
1 week post injury - full circumferential cast
callus takes 6 weeks to form on average
other tips aside from 4 Rs for # management
RIcE smoking cessation - slows analagesia (not NSAIDs) abx proph if open VTE proph treat cause
immediate/early/late # complictions
imm- bleed, local damage, fat embolus,compartment syndrome
early - (weeks) - local infection, loss of position, clots, chest infection,
late - (months-years) - malunion / non union, OA, AVN
define compartment syndorme
a rise in pressure in a myofascial compartement - pain out of proportion to injury. exarcerbated by passive stretching of muscles
fasciotomy
timings of healing of bones and imaging
callus at 6 weeks - same time as removal of temporary fixation (wires,cast)
full healing at 12 weeks
upper limb bones heal twice as quickly as lower limb, kids heal twice as quickly as adults
repeat x rays at post op and after cast application
3 fractures with avascular necrosis risk
head of femur
waist of scaphoid
neck of talus
clavicle#
broad arm sling, polysling
prox humerus #
collar and cuff
mid humerus #
collar and cuff +brace/slab cast
distal humerus #
above elbow backslab/cast
Colle’s #
closed manipulation under haematoma blok then below elbow backslab + cast with wrist flexed and ulnar deviation
scaphoid #
futuro splint +/- thumb extension/splint
NOF intracapsular
displaced>60 yrs = total hip replacement / hemiarthro
undisplaced/displaced<60 = cannulated screws
NOF extracapsular
intertrochanteric = dynamic hip screw subtrochanteric = intramedullary nail
femur/tib shaft #
IM nail
lateral malleolus #
aircast boot with wt bearing
malleolus # disrupting syndesmosis
surgical fixation
identifying a patient with sepsis
consider if any suspicion of infection
systemic response evident
risk factors - extremes of age, recent trauma or surgery last 6 weeks, imparied immunity, indweling lines, IVDU, skin broken
lactate correlates with severity, severe = 4+
assessing a pt with sepsis
obs cap refill, skin temp, pulse o/e look for SOURCE - exam all major systems ABCDE approach, check all wounds + lines inv - FBC, CRP, platelets, INR, bili + VBG lactate blood cultures cap glucose urine dip and culture culture any lines/drains CXR consider CT abdo if ?surgical collection
high risk of severe illness/death from sepsis parameters
alterted mental state RR 25+ or new oxygen req HR 130+ systolic 40 below normal urine output less than 0.5ml/kg/hr or none in 18hrs cyanotic mottled, ashen non blanching rash
end organ dysfunction with sepsis by system
resp cardio renal liver coag CNS
resp- ARDS - infiltrates on CXR, obs off = mech ventil
cardio - heart failure, hypovol and shock, SBP v low = inotropes, vasopress
renal - AKI, UO <0.5ml/kg/hr (should be body wt in mls/hr+) - consider dialysis
liver - BR>35, doubled ALP/ALT
coag - DIC - low platelets, prolonged PT, low fibrinogen - blood products
CNS - encephalopathy - new confusion, low GCS
sepsis six
occurs WITHIN ONE HOUR
3 in:
oxygen
abx
fluids
3 out:
lactate
blood cultures + other bloods esp FBC
urine output - catheter
ABCDE approach
consider source and any need for sugery
consider need for organ support + ITU
if still hypotensive after 30ml/kg resus then need vasopressors
post - op complications - immediate
anaesthetic complications - arrhythmia, BP off, hyperthermia, resp probs, MI/stroke, allergy, teeth/lip/tongue damage)
bleeds - often not bovious externally - monitor drains, obs, FBC/Hct
early post op complications
fluid depletion electrolyte deviation local infection (wound or site)/ systemic infection (chest/UTI/sepsis) fluid collections atelectasis DVT/PE wound break down anastamotic break down bed sores
gastrectomy complications
dumping syndrome malabs anastomotic ulcer peptic ulcer/gastric ca small int bacterial overgrowth abdo fullness/bloat
small and large bowel ops complications
ileus anastomotic leaks adhesions obstruction damage to local structures intra abdo collections stoma retraction pre sacral plexus damage
(leaks present 5-10 days post op, but can be upto 21 days)
cholecystectomy complications
common bile duct injury / bile leak
biliary surgery complications
CBD injury/bile leak CBD stricture anastomotic leak bleeding into bil tree (jaundice) pancreatitis
CABG/stenting complications
reperfusion arrhythmias
post op ACS
inotropes post op may cause organ injury elsewhere
grafts/stents/bypass complications
failure of graft/stent bleed/clot infection rethrombosis limb/organ ischaemia AV fistula cholestrol embolism arteriopaths (stroke/MI/PE) contrast complications - anaphylaxis, AKI
thyroidectomy complications
airway obstruction secondary to bleed - urgent
hypocalc (damaged PT)
recurrent laryngeal n dam
parotidectomy complications
facial nerve damage
any ortho op complications
infection of prosthesis loss of position/failed fixation non union/malunion/delayed NV injury compartment syndrome
total hip arthroplasty complications
sciatic nerve damage, disloc, leg length difference, loosening, wear, need for revision
cystoscopy/TURP complications
high UTI risk TURP syndrome (absorb irrigation fluid causing hyponatraemia) impotence retrograde ejac external sphincter damage (incontinence) urethral stricture
endovascular surgery complication
retroperitoneal bleed
lymph node dissection complications
lymphoedemea
neck dissection of a lump compolication
cranial nerve damage - 11, 12
assessing unwell post op patient
use ABCDE approach
consider op, pre op fitness and post op progress
think about specific and general op risks
special review of op site, newly placed drains + their contents
assessing pyrexial post op patient
assess all obs
consider sepsis but operative intervention cause low grade fever anyway
pay particular attention to chest infection and UTI
5 causes of post op fever by timing
<2 days - atelectasis,pneumonia
2-4 days - UTI
5-7 days - wound infection, collections
8-10 days - VTE
ANY time - transfusion/drug reactions
2 aims when assessing hypotension
assess for cause and evidence of end organ dysfunction
look at lactate ABG, UO catheter, confusion GCS
cap refill, periphries, tachy
causes of post op hypotension
sepsis + anaphylaxis
decreased volume - long op + evap, third space losses, bleeds, poor intake
pump failure - surgical stress inc risk of MI around 48hrs post op, consider fluid overload +HF
sympathetic shock - if epiderual analgesia and high block (T5 and above), assess using cold sprays
causes of resp difficulty post op
RT infections - pneumonia
PE
PO - at risk due to large fluid shifts, low albumin, cardiac dysfunction
assess fluid status
calves
investigate infection
low urine output post op
must be 0.5ml/kg/hr +++
consider causes
pre renal - volume depletion or cardiac probs
renal - nephrotoxics
post renal - BPH, raised IAP compressing
fluid status incl drains and third spaces (bowel, tissues), DH review, catheter exam + bladder scan
common causes of anaphylaxis
abx, gelofusine, NAC, IV contrast
nuts, strawbs, eggs, shellfish
wasps/bees
latex
anaphylaxis, what now/
call for help, call 2222 and remove allergen!
A - secure
then give 0.5ml of 1 in 1000 IM, repeated at 5 min intervals (inj come as 1ml so discard 1/2 ml first)
B - attach 15L non rebreather, give 5mg salbutamol nebs if wheeze
C - secure double IV access, give stat 500ml fluid challenges
hydrocortisone 200mg IV
chloramphenamine 10mg IV
3 lead cardiac monitor
short term and long term management post anaphylaxis attack
short term - seek ITU input if still not improving on intervention
admit for 6 hrs obs post adrenaline (biphasic reactions risk)
continue 30mg pred daily for 5 days post event
Piriton 4mg QDS if itchy
monitor ECG
IVfluids PRN
document fully
mast cell tryptase confirms
update records, red bracelet
long term - educate, teach epipen, medic alert bracelet, allergy clinic + skin prick testing, clinical incident form if caused by known abx allergy
what do you do if a patient is agitated and a risk to self or others?
try to calm them + move them to a safe place / remove other pt and staff
call security for backup
1 - turn on the lights, offer hearing aid/glasses
2-explain where they are, the time, ask their concerns
3 - see if a relative can come or has advice
4- rapid tranq is last resort!!!
rapid tranquilisation protocol
only if at risk to themselves or others
lorazepam 1-2mg PO/IM
or haloperiodol 2-5mg PO/IM
offer oral route if possible
give half doses if elderly or in renal failure
follow up after rapid tranq agitated patient
offer oral route if possible
give half doses if elderly or in renal failure
NO HALOPERIDOL if Parkinson’s, LBD, alcohol, heart probs (check prev ECG)
ensure you have procyclidine to counteract any dystonia from haloperidol
REPEAT doses - only if needed, at 30-60 min intervals, 3x maximum
oral therapy needs 45mins to an hour to work
obs every 30 mins in light sedation, 15 mins if deep
clearly DOCUMENT WHY NEEDED POST EVENT
