Trauma/ Admin/ Special populations Flashcards
Discuss the role of resuscitative thoracotomy in the ED in the context of trauma under the following sections:
- Utility in the ED and principles involved
- Indications and contraindications
- Key steps in performing ED resuscitative thoracotomy
-Resuscitative thoracotomy is a procedure of last resort
-A temporising measure to definitive trauma surgeon intervention
-Discouraged in settings where an appropriately trained surgeon is not available to provide definitive care
-Nealy always performed in the emergency department
-Involves gaining rapid access to the heart and major thoracic vessels through an anterolateral chest incision to control exsanguinating haemorrhage or other life threatening chest injuries
-Reversible intrathoracic cause of death - thoracic life threats that can be addressed
-Pericardial tamponade, right ventricular bleeding
-Cross clamp aorta to reduce haemorrhage downstream
-Internal cardiac massage
-Evacuate air embolism
-Penetrating cardiac injury associated with the highest rate of survival
Indications for thoracotomy with penetrating trauma
Signs of life on arrival in the emergency department?
-Blood pressure or pulse or cardiac rhythm or respiratory effort or echo cardiac activity or tamponade
—> full resuscitation consider thoracotomy
No signs of life on arrival in ED
-Echo evidence of tamponade
—> full resuscitation, consider thoracotomy
No tamponade but signs of life at scene and CPR < 10 minutes
–> full resuscitation, consider thoracotomy
Contraindications
-No signs of life at scene
-Asystole presenting rhythm and no tamponade
-Prolonged pulselessness (>15 mins) at any time
-Massive nonsurvivable injuries
Indications for throacotomy with blunt injury
Signs of life on arrival in ED
-Signs of life and organized cardiac activity at any time
—> full resus consider thoracotomy
-Signs of life on arrival in ED and cardiac tamponade
–> full resus, consider thoracotomy
-Signs of life on arrival in ED but no organised cardiac activity or tamponade
—> needle decompression of chest bilaterally
No signs of life on arrival in ED
-Echo evidence of tamponade and < 10 mins CPR then full resus and consider thoracotomy
Contraindications
-> 10 mins of prehospital CPR
-No signs of life at scene
-Massive nonsurvivable injuries
3.
PPE
Activate massive transfusion protocol
A/B/C
-Intubation and large bore intravenous access
Disrobe patient
Quickly roll in both directions to locate entry and exit wounds
Insert a nasogastric or orogastric tube to aid localisation when clamping aorta
Place right sided intercostal catheter
Position patient supine with arms placed on arm boards laterally
Prep skin with iodine poured liberally over entire thorax, sterile drapes
Sterile thoracotomy tray
-Perform anterolateral thoracotomy incision starting at the right side of sternum at 5th intercostal space, make a curved incision extending to the posterior axillary line under the nipple/ breast
-Divide the intercostal muscle and anterior pleura with scissors along the superior aspect of the rib
-Place retractor and use the hand crank
-Left lung will be in field of view
-Control any bleeding with direct pressure
-Displace this and identify the phrenic nerve on lateral pericardium
-Incise pericardium with scissors anterior and parallel to the phrenic nerve
-Evacuate blood and deliver the heart, identify injuries
-Locate descending aorta and cross clamp
-Perform internal cardiac massage and repair injuries
-Infect intracardiac adrenaline every 3-5 mins
- State the important principles and criteria of the nexus criteria
- State the important principles and criteria of the Canadian C spine rules
- Discuss and compare the 2 rules
Nexus criteria for radiographic evaluation of the cervical spine following blunt trauma
- Midline cervical tenderness
- Focal neurological deficits
- Altered level of consciousness
- Evidence of intoxication
- Painful distracting injury
Canadian C-spine rules
High risk factors –> imaging
-Age > 65
-Fall > 1m
-Axial loading mechanism
-High speed MVA/ rollover/ ejection
-Motorized recreational vehicle or bike collision
-Presence of parasthesias
Low risk factors
-Simple rare end MVA
-Sitting position in ED
-Ambulatory at any time
-Delayed onset of neck pain
-No midline cervical tenderness
–> if low risk factors present then test if able to rotate neck 45 degrees left and right
3.
Canadian C-spine rules more sensitive 99%
Nexus rules 90%
Canadian C-spine rules are also more specific
Canadian C-spine rules also leads to less imaging
A 20 year old male presents with pleuritic chest pain after a moto-cross accident
Vital signs as follows:
RR: 35
Sats: 97% on RA
HR: 110
BP: 120/75
Temp: 37.4
CXR is reproduced below
- Please list 2 important findings on this CXR
- List the 3 major manifestations of extra pleural intrathoracic gas and the CXR features that allow you to discriminate between these causes
- Shortly after his CXR he becomes acutely more dyspnoeic, hypotensive and tachycardic although still has equal air entry bilaterally
a. What has happened?
b. What procedure does he require?
- List the steps in performing this procedure?
-Pneumopericardium
-Left sided haemothorax
Pneumopericardium
-Air does not go beyond the aortic root (limited to pericardial reflection)
-Pericardium lifted off the heart
-Halo sign
-Changes with position
Pneumomediastinum
-Continuous diaphragm sign
-Subcutaneous emphysema
-Linear density parallel to heart border
-Extending above aortic root
Pneumothorax
-Loss of peripheral lung markings +/- collapse or tension
-Change in location with position
-Erect CXR apical
-Never outlines mediastinal structures
a. Tension pneumopericardium
b. Pericardiocentesis
4.
Equipment
-Chlorhexidine, drapes and sterile gloves
-Wire, dilator and single lumen catheter, 3 way tap
-Syringe, 18g introducer needle
-Cardiac monitoring
-Sterile technique
-Attach needle to syringe
-Insert between xiphisternum and left costal margin
-Aim towards left shoulder
-Approximately 30-45 degree angle to the skin
-Continuously aspirate as needle introduced
-Stop if fluid / air aspirated and observe ECG for ST changes (withdraw if do)
-Aspirate fluid/ air until improvement in haemodynamics
-Continue seldinger technique to pass single lumen CVC line into pericardial space
If ultrasound guided
-Subcostal or parasternal long access view
Parasternal long axis
-Locate effusion
-In plane technique
-Insert needle 3-5cm lateral to sternum at 45 degree angle in 4th or 5th intercostal space (over top of bottom rib)
A 45 year old man is involved in an MVC and was found to have an altered LOC on scene. He was intubated and brought to your tertiary ED. His CXR is reproduced.
- List 4 important findings on the CXR
- State your investigative plan for this patient; provide rationale
- State your management (no other injuries have been found)
-Fractures of posterior 5th, 6th, 7th ribs consistent with a flail segment
-Opacification in right mid and upper zones concerning for pulmonary contusions
-Pneumomediastinum - continuous diaphragm, linear density parallel to the heart
-Subcutaneous emphysema
-Likely haemopneumothorax on right
-ET tube in situ - too high
Concerning for flail chest - clinical correlation needed
CTA/ CT chest
-Delineate flail segment
-Assess pulmonary contusions
-Assess for cardiac contusion
-Assess for aortic or pulmonary artery contusions or tears
ECG
-Dysrhythmias due to contusion
-Traumatic STEMI
Echo
-Myocardial contusion
-Pneumo/haemopericardium
High sensitivity troponin
-Myocardial damage/ ischaemia
MRI - cardiac damage
-ETT needs repositioning 1cm further down
-ICC for flail chest segment/ air leak syndrome
-Left and right
-Splint the flail segment, prevent ARDS, manage hypoxia due to pulmonary contusion
-Internal operative fixation of flail segment
-Ventilation - CMV - volume control
-Sedated and paralysed
-TV 6ml/kg -RR: 10-12
-Titrate FiO2 down to maintain sats > 92%
-LPV for thoracic trauma
-Permissive hypercapnoea pH > 7.25
-IE ratio 1:2
-At risk of ARDS due to pulmoanary contusion but not want to worsen pneumomediastinum so PEEP 5-10cmH20
-Consider selective lung ventilation
MTP 1:1:1 ratio
MAP > 65, UO 1ml/kg/hr
Hb > 70
TXA 1g
Warm to 36-37
Noradrenaline
Ceftriaxone 2g IV
Fentanyl infusion
Propofol infusion
You are the director of the emergency department and you receive a letter of complaint from a patient. It is alleged that one of your junior registrars prescribed penicillin despite the patient having a documented penicillin allergy. The patient had life-threatening anaphylaxis and was admitted to the intensive care unit.
- What are the elements of open disclosure?
- List the steps you would take to investigate this adverse event
- Identify ways to prevent a recurrence of this adverse event
-An apology or expression of regret
-Factual explanation of what happened
-An opportunity for the patient/ their family to relate their experience
-A discussion of the potential consequences of the adverse event
-A discussion of steps being taken to manage the event and prevent recurrence
Investigation
-Perform a route cause analysis
-Interview involved staff and provide support
-Check medical records, drug chart, labels, documentation
-Liaise with pharmacy
-Review policies - allergy alert
-Review procedures and documentation of allergies
Resolution
-Report to hospital clinic risk management unit
-Closed loop communication back to patient, ED and hospital
-Feedback to all staff involved
-Education
-M and M
A 3 year old child presented to your urban regional mixed ED at 2am in the morning with severe acute stridor and fever. One emergency registrar and one resident were on duty in a very busy department. Despite maximal medical management the child subsequently developed complete airway obstruction and became apnoeic and unresponsive. During the ensuing resuscitation the night duty emergency registrar was unable to secure an effective airway despite 5 repeated attempts at intubation with an endotracheal tube over a 30 minute period
The child suffered a hypoxic cardiac arrest and died
A day later you are tasked with managing this incident
- Outline 10 important steps you will follow in reviewing this incident
- From the limited information available list 3 factors that contributed to the childs death
Authorisation from hospital / legal department
Root cause analysis
SAC 1 investigation
Coroners investigation
Stakeholders
-CEO, ED director, paediatric director, anaesthetic department, ENT, nursing, legal
Care of family - open disclosure, social worker support
Care of the doctor / nurse
Establish a multidisciplinary independent team - paediatrics, ENT, ICU, ED expertise
Arrange meetings and liaise with family/ parents of child to keep them informed
Investigate
Gather relevant data
-Assess personnel factors: interview doctors, nurses
-Review documentation, bloods, xrays
-Assess departmental factors/ environment
-Assess patient and disease factors
-Assess departmental processes such as resus protocols, access to ENT/ anaesthetics, staffing levels on night shift
Focus on systems failures
List conclusions
-Severe disease, determine if any errors were made by doctor, other factors such as supervision, teaching, staffing and business of department that night
Make recommendations/ solutions
-Paediatric emergency call, difficult airway trolley
Detailed confidential report
Feedback to relevant parties including all staff involved
Involve M and M process and educational programs as necessary
Monitor implementation of recommendations
-Inadequate night staffing
-Inadequate access to timely help - ED consultant, ICU, anaesthetics or ENT expertise
-Very difficult clinical problem - likely severe croup or epiglottitis
-Inadequate training for managing a difficult airway - options for laryngoscopy or needle cricothyrotomy
A 27 year old female G1P0M0 at 28 weeks gestation presents to ED with 2 days of persistent vomiting. She has no other background medical problems.
- State 6 important goals in your assessment of this patient
- The patients ABG is reproduced:
pH: 7.55
pCO2: 27
pO2: 100
HCO3: 30
K: 2.0
Na: 134
Cl: 86
BSL: 2.3
State the key abnormalities and provide explanation
- You decide the patient has hyperemesis gravidarum. State your management of this patient; include options for managing her vomiting
Assess for shock and dehydration
Consider differentials to nausea and vomiting in pregnancy
-Consider surgical issues
-Consider gastrointestinal and medical conditions
-CNS lesions
-Metabolic illness
Consider diagnosis of hyperemesis gravidarum
-Starvation metabolism, dehydration, weight loss > 5% of TBW and prolonged ketonaemia and ketonuria
-Risk of micronutrient deficiency and their respective sequelae (vitamin B1 deficiency, Wernicke encephalopathy)
Labaratory studies should assess;
-Volume status
-Reversible electrolyte abnormalities
-Urinalysis should look for presence of ketones, elevated specific gravity and infection
-Hypokalaemia
-Contraction alkalosis
-Elevated anion gap and or other metabolic abnormalities
AG = 134 - 86 - 30 = 18 (HAGMA)
BG = 134 - 86 - 39 = 9 (metabolic alkalosis)
PCO2 27 - Respiratory alkalosis secondary to hyperventilation
-Baseline PaCO2 in pregnancy is 32
Metabolic alkalosis, hypokalaemia, hypochloraemia secondary to vomiting
High anion gap metabolic acidosis secondary to hypovolaemia
Hypoglycaemia secondary to reduced substrate
-IV thiamine 200mg then replace glucose with 50ml 50% glucose followed by 10% dextrose infusion aiming glucose > 4mmol
-IV normal saline 10ml/kg IV aiming for HR < 110, SBP > 100, UO > 1ml/kg/hr, normal AG
-Replace potassium 0.2-0.3mmol/kg/hr aiming potassium > 4
Antiemetics
-1st line: metoclopramide 10mg IV TDS, cyclizine 50mg IV, prochlorperazine 12.5mg IM
-Consider ondansetron if severe 8mg IV TDS
-Corticosteroid use should be limited to woman with intractable nausea and vomiting during pregnancy
-Consider starting pyridoxine (vitamin B6) 25mg PO TDS
A 42 year old man presents to ED 5 weeks post a renal transplant. He complains of abdominal pain, nausea and vomiting. His vital signs are normal.
- Provide a comprehensive differential diagnosis of 10 important conditions you would seek to exclude in this patient. For each condition state 3 important clinical features to assess for and state how you would investigate confirm or exclude the condition
Normal problems
-Appendicitis, cholecystitis
Renal artery or vein stenosis
-Presents with oliguria, anuria, rising creatinine
-Duplex ultrasound
Hydronephrosis from ureteric obstruction due to haematoma or stricture
-Duplex ultrasound
Infection - UTI, pyelonephritis, E.coli
Opportunistic infection
-Viral, fungal and bacterial infections secondary to reduced cell mediated immunity
-CMV, hepatitis B, HSV, VZV, EBV, adenovirus, TB, pseudomonas, listeria , candida, aspergillus, pneumocystis,
–> Blood cultures, urine cultures, viral PCR
Acute graft rejection
-Fever, HTN, oedema, tenderness over allograft and decreased UO
-Duplex US
-IV methylprednisolone +/- plasma exchange
Immunosuppressive medication toxicity
-Cyclosporine –> HTN, GI upset, nephrotoxicity
-Tacrolimus –> Nephrotoxicity, neurotoxicity, HTN, GI upset
-Azathioprine –> hepatotoxicity, bone marrow depression, GI upset
-Mycophenolate –> hepatotoxicity, bone marrow depression, GI upset
-Corticosteroid –> glucose intolerance, GI bleeding, osteoporosis
A 78 year old man presents to ED after a motor vehicle accident. He has head, chest and abdominal injuries and his vital signs include
HR: 100
BP: 110/70
RR: 18
GCS: 13
Sats: 90%
- State 10 important differences in the approach to geriatric trauma that needs to be incorporated into his care
Decreased ability to compensate to physiological demands of hypovolaemia
-Cannot mount a tachycardia, also often on beta blockers, calcium channel blockers, digoxin
-SBP of 108 lower limit of acceptability
-Difficulty mounting a tachypnoea, develop hypercarbia
-Oxygen saturations: baseline 93-94%, if underlying COPD/ CHF, fibrosis may sit around 90-92%
–> Rapid progression to hypoperfusion and organ failure
-High flow supplemental oxygen to all patients including those with COPD
-Therapeutic window for cardiac preload is narrow so initially begin resuscitation with blood if significant bleeding, signs of haemodynamic instability
-Promptly reverse anticoagulation
-GCS: delirium common in elderly can be cause of TBI or occur as a consequence of trauma, due to brain atrophy raised ICP and herniation syndromes develop later
—> CT head in all elderly with head trauma
Osteoporosis –> higher risk of cervical spine fractures
-Lower threshold to image cervical spine
-Central cord syndrome, odontoid fractures, ankle, hip, pelvis and tibial plateau fractures
-Ceilings of care, advanced care directive and end of life considerations
Comorbidities
-IHD, COPD, CKD, Liver disease
Polypharmacy: beta blockers, ccb, digoxin, aspirin, anticoagulants, antihypertensives, diuretics
Communication
-Hearing difficulty, dementia
Need detailed history for cause of trauma
-Dysrhythmia, MI, stroke, seizure
Interventions
-Airway: dentures, reduced neck movements, restricted mouth opening (TMJ joint), reduced chest wall compliance, use video laryngoscope
-Cricothyrotomy more likely complex due to scarring from neck surgery, radiation or tumors distorting anatomy
-Drugs: avoid ketamine, dose adjust propofol
-Narrow therapeutic window for preload, use small volume boluses of fluid
A 36 week pregnant woman presents to your rural ED in established labour with a fully dilated cervix. On examination it is apparent that the presenting part is breech. There is no obstetric service in your hospital and the nearest referral centre is 30 minutes away
- State the 3 types of breech that may present and explain there significance
- State 4 important complications that need to be avoided
- State your management of this patient including the key steps needed
1.
Frank breech
-60-65% of all breech presentations
-Hips flexed, knees extended
-Buttocks acts as a good dilating wedge
-Incidence of cord prolapse 0.5%
Complete breech
-Least common 5% of breech presentations
-Hips and knees flexed
-Buttocks acts as a good dilating wedge
-Incidence of cord prolapse 5-6%
Incomplete breech
-25-35% of all breech presentations
-Incomplete hip flexion, single or double footling
-Poor wedge
-Increased incidence of prolapsed cord (15-18%)
2.
-Cord prolapse
-Head entrapment
-Brachial plexus injury
Focused history
Position
-Lithotomy position, hips abducted and flexed
-Evaluate for prolapsed cord
-Perform episiotomy
-Flex knees and sweep out legs
-Pull out 10-15cm of cord after umbilicus clears the perineum (room to work)
-Deliver the more accessible arm
-Perform the Mauriceau maneuver - flex infants head
Do not
-Arrange transfer prior to delivery
-Iatrogenic ROM
-Traction the fetus during delivery
-Hyperextend neck
A 10 year old boy with known sickle cell disease presents with severe pain in the arm, abdomen and back, headache with associated crying and refusing to open his eyes.
His vitals are:
RR: 22
HR: 110
GCS: 15 (in pain)
BP: 133/88
Temp: 37.8
- State the conditions you would look for in this patient
- State your management
Acute chest syndrome
-Fever, cough, chest pain, SOB
-Infiltrates on CXR, pulmonary effusion
-Reduced haemoglobin
-Treat with antibiotics ceftriaxone 50mg/kg, clarithromycin 7.5mg/kg
-1-1.5x maintenance fluids 5% dextrose with 0.45% sodium chloride
Vaso-occlusive crisis
-Sudden onset of pain in both legs and lower back
-Fever and leukocytosis
-Treat with NSAIDs, paracetamol, morphine
-Supplemental oxygen if sats < 95%
-PO rehydration or 1-1.5x maintenance fluids 5% dextrose with 0.45% sodium chloride
Stroke
-Focal neurological deficits, hemiparesis, aphasia, seizure
-Exchange transfusion
Splenic sequestration
-LUQ pain, fever, splenomegaly
-Anaemia, thrombocytopenia
-Raised reticulocytes
-Supportive mangement including RBC transfusion 10ml/kg, and aggressive fluid rehydration
Sepsis - encapsulated organisms
Meningitis - Neisseria
-Fever, Meningism, raised WBC
Osteomyelitis
Cholecystitis
Pulmonary embolism
Acute anaemia
-Aplastic crisis
-Parvovirus B19
-Reticulocytes < 1
High flow oxygen
Rehydration
Antibiotics
A 55 year old man presents with malaise, dyspnoea and fatigue for 1 day. He is a cardiac transplant patient with a history of orthotopic bi-atrial transplantation 6 months previously
His vital signs are:
BP: 126/77
RR: 22
Sats: 95% on RA
GCS 15
Temp: 37
- State 4 important physiological changes that need to be considered in transplanted heart patients when presenting to or managed in the ED
- What important transplant specific conditions need to be considered? His ECG has been provided. State the important points
Immunocompromised may not mount an inflammatory response
Denervation of heart
-Without parasympathetic tone the resting HR faster (95-110), HR can increase with exercise or stress though the effects of endogenous catecholamines up to 70% of the maximum heart rate for age
-Medications affecting the ANS such as atropine will not have an effect
-Upregulation of beta-adrenergic receptors in the graft, slightly enhanced response to NA, isoprenaline
-Beta blockers can worsen autonomic dysfunction and exercise tolerance, so they are typically avoided in treating HTN in post transplant patients but may be used to treat SVT
-Transplanted heart sensitive to adenosine so reduce dose by half
-Do not experience typical chest pain with ischemia, have silent infarctions or present with hear failure symptoms or sudden cardiac death
Anatomy - can have single or biatrial anastomoses
-May have abnormal ECG in this example which shows native sinus beats and sinus beats from transplanted heart
Rejection - chronic allograft vasculopathy
-Dysrhythmias, heart failure
Infection
-Viral infections: CMV, EBV, HCV, HBV, HSV, VZV
-Opportunistic infections: Listeria, mycobacteria, candida, aspergillus, pneumocystis
Drug toxicity
