SOB + Trauma Flashcards
RF for PE
DVT
Virchow’s triad: endothelial damage, venous stasis, hypercoagulability
Hospitalisation
Immobility
Trauma
Prev VTE
OCP
Postpartum
Pregnancy
Cancer
FDR
Sx of PE
SOB, pleuritic CP, syncope, hemoptysis
Tachypnea, tachycardia, hypoxemia
Ix for ?PE
Ix:
ECG: sinus tachy, RBBB, T wave inversion in anterior leads, right heart strain (big R waves in V1/ V2), S1Q3T3
D dimer for low risk Wells
CTPA for high risk Wells
VQ if pt unable to tolerate radiation
Rx for PE
O2
UFH or LMWH then switch to DOAC or NOAC
Prophylaxis of PE
Prophylaxis:
Risk assess all hospitalised pts
Early ambulation
Compression stockings
Intermittent pneumatic compressions
LMWH for high risk (pregnant woman w/ >2 RF)
Causes of SOB
Respiratory:
PE
FB aspiration
Anaphylaxis
Cardiac
MI
Hematological
Environmental
New pets
Dietary changes
Psychogenic
Anxiety
Gastro
Deconditioning
What is the MIST handover?
Mechanism of injury, injury found/suspected, symptoms/signs, treatments initiated
How to prep for incoming trauma
Warmed IV fluid (consider microwave if no fluid warmer)
Warm blankets
Chest tube tray
Adult chest tube sizes 28-32Fr
Intubation set
Supraglottic (LMA): Size 3 small female, 4 large female or small male, 5 large male
Cricothyroidotomy
Medication
Broselow tape for pediatrics
Fabric pelvic binders
Blood
Monitoring
Precautions (Face mask, eye protection, gown, gloves)
Airway assessment + management
clear, suction, O2, secure, assume C spine injury, use conscious sedation, plan for difficult airway
Breathing assessment + management
check trachea, jugular vein distension, chest wall expansion, RR, air entry, O2 sats O2 for all,
Circulation assessment + management
control bleeding, assess blood volume and cardiac output status, initiate blood/ fluids
Disability assessment + management
GCS, pupils, head injury, lateralising signs, blood glucose, temp
Exposure assessment + management
Exposure and environmental control - Undress but prevent hypothermia (warm blankets)
Microwave can be used to warm crystalloids (eg. 50s in 800W microwave), but not blood products
IV fluid warmer (Level One, Ranger) for blood products
What is in a secondary survey?
AMPLE history from patient, family, EMS
Allergies, Meds, PMH, Last meal, Events
Recheck ABCDE
Head to toe (including log roll, rectal exam, vaginal exam)
NG or OG tube if no sign of basal skull fracture
Urinary foley catheter if no blood at meatus or perineal ecchymosis
Urine output goal of 0.5mL/kg/h in adults (1mL/kg/h in pediatric, 2mL/kg/h in <1yo)
Pelvic binder
Immobilize deformed joints/bones
Resolve reversible arterial compromise (dislocations)
Bedside ultrasound (eFAST), Chest/Pelvis X-rays, DPL
Medications
Ix in trauma
ECG
Labs: CBC, coag, electrolytes, VBG, blood type and crossmatch, serum ETOH, bhCG
If stable, consider imaging
Rx for tension pneumo
Needle thoracostomy at 2nd ICS mid-clavicular line or 5th ICS anterior/mid axillary line, do not wait for X-ray (can do bedside ultrasound)
Chest tube at fifth intercostal space at anterior axillary line
Features of cardiac tamponade
Penetrating chest wound, Beck triad (hypotension, distended neck veins, muffled heart sounds), pulsus paradoxus, Kussmaul sign (rise in JVP on inspiration)
Complications of trauma
Tension pneumo
Cardiac tamponade
Hemothorax
Flail chest
Upper airway obstruction
Aorta lesion
Types of shock + causes
Hypovolemic
Hemorrhagic (Ectopic) until proven otherwise
Non-hemorrhagic (GI, skin-burns, renal, third space, pancreatitis)
Obstructive
Pulmonary vascular (PE)
Mechanical (Tension pneumothroax, pericardial tamponade)
Cardiogenic
Cardiomyopathic (MI)
Arrhythmogenic (tachy/bradyarrhythmia)
Mechanical (valvular)
Distributive
Sepsis
Neurogenic (TBI, spinal cord injury)
Anaphylactic
Inflammatory
Endocrine (adrenal insufficiency, thyrotoxicosis, myxedema coma)
Metabolic (acidosis, hypothermia)
Drugs (CCB, BB, Digoxin)
Adjuncts to primary survey
ECG
VS
Urine output
ABG
Pulse oximetry
Imaging
Abx for open fracture
cefazolin IV 3g plus ciprofloxacin or gentamicin IV for gram + and - coverage
Management of rhabdomyolysis
fluids to target urine >100ml/hr or administer mannitol
How to manage Bleeding
Give blood! Not crystalloids.
If INR high give Vit K 10mg IV x1 and stop Warfarin if pt is taking it.
If PTT high and pt on heparin give 25-50mg Protamine
If fibrinogen low give fibrinogen 1g IV
TXA 1g IV
What is the YEARS criteria?
Criteria for pregnant pts with ?PE:
- clinical signs of DVT? if yes = US
- hemopytsis?
- PE most likely?
- YES to 0 r/o PE w/ D Dimer <1000
- YES to 1, 2 or 3 r/o PE w/ D Dimer <500
Basic workup for SOB
ECG, echo, trop, CXR, PFTs, office pulse ox, exetional post ox, BNP
COPD end stage treatments
mucomist, azithromycin, daytime BiPAP, PDE4 inhibitors (roflumilast)
PERC criteria
3 numbers + 5 nos
age <50
pulse <100
o2 >94
no unilateral leg swelling
no hempptysis
no trauma
no prev VTE
no estrogen use
What criteria to use to determine if COPD pts should get abx?
Winnipeg
What can worsen COPD in the home?
Biofuels
COPD function tools
COPD assessment test + mMRC (modified medical research council)
Dyspnea Scale
Rx for chronic hypercapnia in COPD
daytime BiPAP
COPD chronic management (aside from puffers)
daily macrolide (azithromycin) reduces exacerbations, written action plan, CPAP for COPD + OSA
Blood eosinophils >300 cells in COPD - what to add
use steroid
When to avoid steroids in COPD
Avoid steroid if eosinophils <100, hx of mycobacterium or repeated PNA
What criteria for whether to give abx in COPD, and what score would you give abx for?
Winnipeg criteria: sputum purulence, sputum volume, dyspnea.
Abx for COPD if 2 or more Winnipeg sx or if CRP >40
monoclonal antibodies for asthma
mepolizumab resilizumab benrulizamab
What is a risk of LTRA?
Suicidality
1st line treatment for asthma
symbicort (formeterol) - use daily and as a reliever
CATCH 2 tool
CT head for child w/ minor head injury and 1) GCS <15 2 hrs post injury, open skull fracture, worsening HA, irritability, sign of basal skull fracture, boggy scalp hematoma, dangerous mechanism, >4 episodes of vomiting
Rx for thermal burns
cool running water x20 mins
How to determine burn fluids?
Modified brooke formula = 2ml x BSAB x weight. Half in first 8 hrs then half next 16 hrs
Burn areas that are more complex + need referral
face, hand, foot, genitals, perineum, joint
Frostbite rx
rapid rewarming in water bath, consider thrombolysis, heparin and iloprost, sterile wound care, consult surgery, tetanus vax
Trauma imaging
US, CXR, C spine XR, chest/ abdo/ pelvis CT if pt is stable
Points for trauma response in pregnant pts
chest tube 1-2 spaces higher, NG tube, left lateral position, no vaginal exam until previa ruled out
