week 1 - emergency medicine Flashcards
what is ATLS protocol?
what are the 3 main elements?
Advanced Trauma Life Support of American College of Surgeons
- primary survey
- secondary survey
- definitive care
what is primitive survey?
ABCDE airway breathing circulation disability/drugs/allergies
what are the goals of airway step assessment?
to secure airway and protect the spinal
in addition to airway what must be taken in consideration during an A step?
spinal mobilization of there is any suspicion of spinal injury
what comprises an adequate spinal immobilization?
full backboard and rigid cervical collar
in an alert patient, what is the quickest test for an adequate airway?
ask a question, if patient can speak the airway is intact
what is the 1st maneuver to establish an airway?
chin lift and/or jaw thrust
*often nasal airway can be used to temporary maintain airway
what is contraindicated while checking ABCDE?
neck manipulation if spinal trauma is suspected
if patient’s airway cannot be established by 1st maneuver , what is next approach?
end-tracheal intubation, either nasal or oral
what is contraindicated for nano-tracheal intubation?
why?
maxillofacial fracture
*cavernous sinus - houses internal carotid artery, one of the 2 major root arteries of Circle of Willis along with 3 oculomotor group nerves
damage to internal carotid artery will compromise brain circulation
if 1st maneuver and ends-tracheal intubation is unsuccessful, what is definitive approach to establish airway?
cricothyroidotomy (either by needle or surgical tube insertion)
what are life thoracic injuries?
- cardiac injuries
- pnumomothorax
- pulmonary embolism
- bleeding of rupture of esophagus
- severe asthma
- anything in thoracic, etc…
what must always be kept in mind during difficult attempts at establishing an airway?
spinal immobilization and adequate oxygenation
…
thoracotomy
thoracentis - hemothorax
periocentisis if cardiac tamponade
oxygenation
air coming in
ventilation is
CO2 going out
what comprises an adequate breathing assessment?
- inspection -
- auscultation
- percussion
- palpating
what are you looking for in “inspection” in adequate breathing assessment?
- air mov’t normal rate of respiration 12-20
- cyanosis
- tracheal shift
- jugular vein distention (heart squeezed),
- asymmetric chest expansion (flailed chest)
- use of accessory muscle of respiration,
- open chest wounds
what are you looking for in “auscultation” in adequate breathing assessment?
abnormal upper airway sounds:
- stridor (low pitch, upper respiratory airways )
- gurgling - edema, water sounds
- wheezing (lower respiratory airway) : wheezing can be asthmas, bronchioles obstruction, aspiration pneumonia, pancreatitis with acute respiratory syndrome, HEART ATTACK
**what are normal sounds in auscultation: vesicular
what are you looking for in “percussion” in adequate breathing assessment?
- hyper-resonance
- dullness over both lung fields (can be due to mass or fluid): ex lobar pneumonia, cancer, but LCHF
what are you looking for in “palpation” in adequate breathing assessment?
- presence of subcutaneous emphysema (here we are talking about crepitus, when you palpitate neck or upper chest you feel you are pressing bubble wrap, you palpate - due to trauma to neck and air escaped)
- flailed segments - broken segments
6 life-threatening conditions that must be dx and tx during B step are?
- airway obstruction - breathing is not possible
- tension pneumothorax
- open pneumothorax
- flailed chest
- cardiac tamponade
- massive hemothorax
how does one dx tension pneumothorax?
- dyspnea
- tachypnea
- anxiety
- pleuritic chest pain
- unilateral decreased or absent breath sounds
- tracheal shift AWAY from affected side
- hyper-resonance on affected side
how does one tx tension pneumothorax?
immediate decompression by needle thoracosotomy in in the 2nd inter-costal space (mid clavicular line), followed by tube thoracotomy, placed in anterior mid-axillary line in the 4th inter-costal space
difficult of breathing on inspiration is called what type of pain?
pleuritic pain
what are goal in assessing circulation
securing adequate tissue perfusion, tx of external bleeding
what is initial test for adequate circulation?
palpation of pulses as rough guide: if radial pulse is palpable, then systolic pressure is at least 80 mm Hg, and if a femoral or carotid pulse is palpable, then systolic pressure is at least 60 mm Hg
what comprises adequate assessment of circulation?
heat rate, BP, peripheral perfusion, urinary output (30-55 ml/hr), mental status, capillary refill, skin exam (cold and clammy signifies hypovolemia)
if urinary output and mental status are both insufficient (patient is not alert), then what can be the problem?
can be problem with circulation
in assessing circulation of young adult, what should you be careful of?
*beware of relying only on blood pressure: young patients are able to maintain their blood pressure until cardio-vascular collapse is imminent (they have robust autonomic system)
what is goals of disability assessment?
determination of neurological injury (think, neurological disability) along with current history of drugs and allergies
what comprises adequate assessment of disability?
assessment of mental status: Glasgow Coma Scale (GCS)
brown fixed pupil is an indication of
ipsi-lateral mass, as CN III is compressed
Alert normal level of consciousness is?
- 3 - orient to self, time and place
- and to be able to perceive and respond/remembers to new/current stimuli
(internal stimuli - are you hungry, cold, hot?)
full rage *2 cerebral hemispheres and brain stem in tact
content of consciousness
- short term memory
-long term memory
-abstract thinking
(interpretation, what do people think - apple does not fall far from the tree?)
-intellectual functioning
-judgment (what do you wear when it is hot outside?)
-speech
-content of thought
-mood and affect
confusion level of consciousness means?
disturbed level of consciousness with impaired ability to think clearly, and to perceived, respond to, and remember current stimuli, somewhat disoriented
delirium level of consciousness means?
**motor AND psychological agitation (level and content of consciousness)
disturbed stated of consciousness with motor restlessness, hallucinations, severe disorientation, sometimes, delusion
obtundation level of consciousness means?
decreased alertness with psychomotor retardation
stupor level of consciousness means?
little spontaneous activity, mostly to painful stimuli
level of consciousness are determined by?
1) PERLA
pupils are equal, reactive to light and accommodation
2) 3 times oriented (I know who I am, where, and what time it is?
what is anisocoria?
when is it an emergency?
*anisocoria - when pupil size is unequal for more than 1mm
anisocoria + declining level of consciousness - emergency
w/o decreased level of consciousness and just have anisocoria it is okay
coma level of consciousness is?
state of being un-arousable and unresponsive to external stimuli and internal needs
what are the 3 forms of disturbed consciousness are ?
- hallucination - perception of NON-EXISTING stimulus (ex: migraine accompanied by aura;
* *migraine is a vascular HA In temporal lobe in limbic system that is very visual and creative area of brain) - illusion - wrong/abnormal identification of EXISTING stimulus (ex: horizon line; deja-vu; scarf thought to be snakes)
- delusion - abnormal thought process, which can not be corrected by judgement
what are the goals in obtaining adequate exposure?
- complete disrobing of patient - for visual inspection & digital palpation during primary survey
rectal temperature is taken during primary survey to insure?
absence of hypothermia
Secondary survey includes?
- complete physical exam
- history (including all orifices exam - ear, nose, mouth, vagina, rectum, etc.)
- interpretation of typical signs and symptoms of emergency/trauma
what are typical signs of basilar skull fracture?
- raccoon eyes (bilateral black eyes)
- battle’s sign (bruise over mastoid process)
- clear otorrhea
- clear rhinorrhea
- hemotympanum
sign of anterior eye chamber bleeding indicates?
traumatic hyphema
if nasal septal hematoma is not evacuated, it will become?
necrotic
what is the best indicator for mandibular fracture?
dental malocclusion
what are signs throacic and neck trauma?
- crepitus / subcutaneous emphysema from tracheal or bronchial trauma
- tracheal deviation and/or jugular vein distention
- indicators for tension pneumothorax and/or cadiac tamponade
- carotid bruit (indicating carotid artery injury, which can be due to seat belt neck trauma)
what is the best exam for broken ribs/sternum?
lateral and anterio-posterior compression of thorax will elicit pain
guarding, rebound tenderness, and other signs of peritoneal irritation, progressive distention, and absent bowel sounds are indication of injury to?
signs of intra-abdominal injury
these signs indicate?
GCS
signs of increased intra-cranial pressure
what are the Cushing’s Triad
hypertension + bradycardia + dysrhythmic depressed respiration
what condition is an extremely deficient arterial circulation, which is unable to keep up with the metabolic demands of the body?
Shock
failure of FLUIDS is what type of shock?
hypovolemic
failure of PUMP is what type of shock?
cardiogenic
failure of TUBES is what type of shock?
distributive
the failure of tubes (dilatation of peripheral arterioles due to bacterial toxin action) causes which type of shock?
sepsis
blood and fluid loss causes what type of shock?
hypovolemia
which type of condition causes obstruction of flow causing shock?
cardiac tampoade (as failure of pump; thromosis/embolism)
Cardiac shock is caused by?
MI, carditis, CHF
below are clinical manifestations of which condition?
hypotension tachycardia altered mental status decreased urinary output (normal 30-55 mL/Hr) cool and clammy skin
shock (regardless of etiology)
what tests can be done to rule out diagnosis of shock? (differential dx)
H & P ABCDE blood pressure temperature neck vein assessment lung sounds (rales, wheezing, asymmetry on auscultation) cardiac auscultation abdominal palpation (GI bleeding? peritonitis?) rectal exam skin inspection neurological exam
this is laboratory work-up of which condition?
CBC Chem 7 (chemistry panel, including electrolytes, creatinine, BUN) LFTs Urinalysis Blood cultures ABGs ECG others: by suspicion (CT, ECHO, ENDOSCOPY, ENDOCRINE, PA catheterization)
for SHOCK
what is the ultimate goal of treatment of shock?
ultimately get 90mm Hg for systolic BP
what is immediate/initial goal in treating Shock?
how do you accomplish this?
initially get at least 60 mmHg for systolic BP, while investigating cause
- get patient in Trendelenburg position (head down)
- oxygen
- IV fluids
- Foley catheter
- vasopressors
what are some causes of CHEST PAIN?
- Skin: shingles
- chest wall: musculo-skeletal; chest wall metastasis; breast pathology; nerve root compression
- Lungs / pleuritic pain (pneumothorax, pulmonary embolism, pneumonia, cancer, pulmonary fibrosis)
- heart and great vessels (pericarditis, angina, MI, aortic dissection)
- GIT: esophagitis, spasm and rupture; peptic ulcers, pancreatitis, biliary disease
what are the FOUR killers chest pains?
- MI or Angina pectoris
- pulmonary embolism
- aortic dissection
- spontaneous pneumothorax
pleuritic chest pain (sharp, stabbing, worse on inspiration and with coughing) indicates chest pain due to?
pulmonary embolism
“crushing”, “stone- like”m or mild chest pain indicates?
MI
tearing/ripping chest pain that radiates to the back indicates?
aortic dissection
chest pain with radiation to neck and/or left arm - you should consider what?
cardiac unless proven otherwise
if the chest pain pain is abrupt, you should consider?
aortic dissection or Pulmonary embolism
T or F: MI can develop gradually or acutely
True
spontaneous pneumothorax and Pulmonary embolism usually occurs in which position?
at rest
MI and aortic dissection may occur when?
at rest or on exertion
if the chest pain lasts seconds or more than 24 hours then ?
it is not Four Killer pain
if the patient shows what signs should you take his/her chest pain seriously?
if patient is diaphoretic and/or lightheaded
when the chest pain is worse with inspiration, it indicates?
pleura or pericaridum
when chest pain is worse on exertion, it indicates?
MI or aortic dissection
if chest pain is better with rest, it indicates?
angina pectoris
if chest pain is worse in supine position, it indicates?
pericarditis, pancreatitis, CHF, musculo-skeletal
if chest pain is worse with food intake, it indicates?
GIT or MI
if chest pain is better with nitroglycerine, it indicates?
Angina or DES
Acute Dyspnea caused by Pulmonary issues can be due to:
pneumothorax PE asthma attack COPD aspiration pneumonia upper airway obstruction ARDS
Acute Dyspnea caused by Cardiac issues can be due to?
MI
CHF
Arrhythmias
cardiac/pericardial tamponade
Acute Dyspnea caused by Metabolic issues can be due to?
sepsis
metabolic acidosis
anemia
psychiatric (anxiety or panic)
what are 3 types of pneumothorax?
- spontaneous : osteoporosis, emphysema, idiopathic in tall young male teens, endometriosis/catamenial
- “flail Chest” - traumatic due to broken ribs and/or sternum, puncturing the lung pleura
- Tension - mediastinal organs are shifted to opp side
this list of causes, indicates which condition?
Age > 40 history of DVT cancer prolonged immbobility CHF MI Stroke fracture of long bone/hip obesity major surgery blood disorders
pulmonary embolism
how do you approach patient with ACUTE DYSPNEA?
- ABCDE
- H & P: focus on 5 areas (VS, LU, HT, Extremities, Mental status)
- Labs: ECG, ABG, Chest x-rays, CBC
- TX: oxygen, diuretics, beta-agonists, mechanical ventilation
with patients who have abdominal pain, what are some causes?
GIT prgans hepato-billary organs kidney abdominal aorta pancreas chest and pelvic organs
what are some systemic/metabolic causes of abdominal pain?
diabetic ketoacidosis Mediterranean fever Addison's disease Lead poisoning Uremia Neurogenic Hypercalcemia (due to KD stones, GIT gorans, psychiatric moans) shingles black widow spider bites
what is the approach to patient with abdominal pain?
- ABCDE
- H & P
who is patient?
alcoholic: hep / LV cirrhosis
IV drug user: hep C or B
HTN: abd aneurysm, MI, bowel ischemia
history of abd surgery, adhesions - Time course: appendicitis always starts with pain; gastroenteritis - with nausea
