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
