week 1 - emergency medicine Flashcards
1
Q
what is ATLS protocol?
what are the 3 main elements?
A
Advanced Trauma Life Support of American College of Surgeons
- primary survey
- secondary survey
- definitive care
2
Q
what is primitive survey?
A
ABCDE airway breathing circulation disability/drugs/allergies
3
Q
what are the goals of airway step assessment?
A
to secure airway and protect the spinal
4
Q
in addition to airway what must be taken in consideration during an A step?
A
spinal mobilization of there is any suspicion of spinal injury
5
Q
what comprises an adequate spinal immobilization?
A
full backboard and rigid cervical collar
6
Q
in an alert patient, what is the quickest test for an adequate airway?
A
ask a question, if patient can speak the airway is intact
7
Q
what is the 1st maneuver to establish an airway?
A
chin lift and/or jaw thrust
*often nasal airway can be used to temporary maintain airway
8
Q
what is contraindicated while checking ABCDE?
A
neck manipulation if spinal trauma is suspected
9
Q
if patient’s airway cannot be established by 1st maneuver , what is next approach?
A
end-tracheal intubation, either nasal or oral
10
Q
what is contraindicated for nano-tracheal intubation?
why?
A
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
11
Q
if 1st maneuver and ends-tracheal intubation is unsuccessful, what is definitive approach to establish airway?
A
cricothyroidotomy (either by needle or surgical tube insertion)
12
Q
what are life thoracic injuries?
A
- cardiac injuries
- pnumomothorax
- pulmonary embolism
- bleeding of rupture of esophagus
- severe asthma
- anything in thoracic, etc…
13
Q
what must always be kept in mind during difficult attempts at establishing an airway?
A
spinal immobilization and adequate oxygenation
14
Q
…
A
thoracotomy
thoracentis - hemothorax
periocentisis if cardiac tamponade
15
Q
oxygenation
A
air coming in
16
Q
ventilation is
A
CO2 going out
17
Q
what comprises an adequate breathing assessment?
A
- inspection -
- auscultation
- percussion
- palpating
18
Q
what are you looking for in “inspection” in adequate breathing assessment?
A
- 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
19
Q
what are you looking for in “auscultation” in adequate breathing assessment?
A
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
20
Q
what are you looking for in “percussion” in adequate breathing assessment?
A
- hyper-resonance
- dullness over both lung fields (can be due to mass or fluid): ex lobar pneumonia, cancer, but LCHF
21
Q
what are you looking for in “palpation” in adequate breathing assessment?
A
- 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
22
Q
6 life-threatening conditions that must be dx and tx during B step are?
A
- airway obstruction - breathing is not possible
- tension pneumothorax
- open pneumothorax
- flailed chest
- cardiac tamponade
- massive hemothorax
23
Q
how does one dx tension pneumothorax?
A
- dyspnea
- tachypnea
- anxiety
- pleuritic chest pain
- unilateral decreased or absent breath sounds
- tracheal shift AWAY from affected side
- hyper-resonance on affected side
24
Q
how does one tx tension pneumothorax?
A
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
25
difficult of breathing on inspiration is called what type of pain?
pleuritic pain
26
what are goal in assessing circulation
securing adequate tissue perfusion, tx of external bleeding
27
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
28
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)
29
if urinary output and mental status are both insufficient (patient is not alert), then what can be the problem?
can be problem with circulation
30
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)
31
what is goals of disability assessment?
determination of neurological injury (think, neurological disability) along with current history of drugs and allergies
32
what comprises adequate assessment of disability?
assessment of mental status: Glasgow Coma Scale (GCS)
33
brown fixed pupil is an indication of
ipsi-lateral mass, as CN III is compressed
34
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
35
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
36
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
37
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
38
obtundation level of consciousness means?
decreased alertness with psychomotor retardation
39
stupor level of consciousness means?
little spontaneous activity, mostly to painful stimuli
40
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?
41
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
42
coma level of consciousness is?
state of being un-arousable and unresponsive to external stimuli and internal needs
43
what are the 3 forms of disturbed consciousness are ?
1. 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)
2. illusion - wrong/abnormal identification of EXISTING stimulus (ex: horizon line; deja-vu; scarf thought to be snakes)
3. delusion - abnormal thought process, which can not be corrected by judgement
44
what are the goals in obtaining adequate exposure?
1. complete disrobing of patient - for visual inspection & digital palpation during primary survey
45
rectal temperature is taken during primary survey to insure?
absence of hypothermia
46
Secondary survey includes?
1. complete physical exam
2. history (including all orifices exam - ear, nose, mouth, vagina, rectum, etc.)
3. interpretation of typical signs and symptoms of emergency/trauma
47
what are typical signs of basilar skull fracture?
1. raccoon eyes (bilateral black eyes)
2. battle's sign (bruise over mastoid process)
3. clear otorrhea
4. clear rhinorrhea
5. hemotympanum
48
sign of anterior eye chamber bleeding indicates?
traumatic hyphema
49
if nasal septal hematoma is not evacuated, it will become?
necrotic
50
what is the best indicator for mandibular fracture?
dental malocclusion
51
what are signs throacic and neck trauma?
1. crepitus / subcutaneous emphysema from tracheal or bronchial trauma
2. tracheal deviation and/or jugular vein distention
3. indicators for tension pneumothorax and/or cadiac tamponade
4. carotid bruit (indicating carotid artery injury, which can be due to seat belt neck trauma)
52
what is the best exam for broken ribs/sternum?
lateral and anterio-posterior compression of thorax will elicit pain
53
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
54
these signs indicate?
| GCS
signs of increased intra-cranial pressure
55
what are the Cushing's Triad
hypertension + bradycardia + dysrhythmic depressed respiration
56
what condition is an extremely deficient arterial circulation, which is unable to keep up with the metabolic demands of the body?
Shock
57
failure of FLUIDS is what type of shock?
hypovolemic
58
failure of PUMP is what type of shock?
cardiogenic
59
failure of TUBES is what type of shock?
distributive
60
the failure of tubes (dilatation of peripheral arterioles due to bacterial toxin action) causes which type of shock?
sepsis
61
blood and fluid loss causes what type of shock?
hypovolemia
62
which type of condition causes obstruction of flow causing shock?
cardiac tampoade (as failure of pump; thromosis/embolism)
63
Cardiac shock is caused by?
MI, carditis, CHF
64
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)
65
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
```
66
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
67
what is the ultimate goal of treatment of shock?
ultimately get 90mm Hg for systolic BP
68
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
1. get patient in Trendelenburg position (head down)
2. oxygen
3. IV fluids
4. Foley catheter
5. vasopressors
69
what are some causes of CHEST PAIN?
1. Skin: shingles
2. chest wall: musculo-skeletal; chest wall metastasis; breast pathology; nerve root compression
3. Lungs / pleuritic pain (pneumothorax, pulmonary embolism, pneumonia, cancer, pulmonary fibrosis)
4. heart and great vessels (pericarditis, angina, MI, aortic dissection)
5. GIT: esophagitis, spasm and rupture; peptic ulcers, pancreatitis, biliary disease
70
what are the FOUR killers chest pains?
1. MI or Angina pectoris
2. pulmonary embolism
3. aortic dissection
4. spontaneous pneumothorax
71
pleuritic chest pain (sharp, stabbing, worse on inspiration and with coughing) indicates chest pain due to?
pulmonary embolism
72
"crushing", "stone- like"m or mild chest pain indicates?
MI
73
tearing/ripping chest pain that radiates to the back indicates?
aortic dissection
74
chest pain with radiation to neck and/or left arm - you should consider what?
cardiac unless proven otherwise
75
if the chest pain pain is abrupt, you should consider?
aortic dissection or Pulmonary embolism
76
T or F: MI can develop gradually or acutely
True
77
spontaneous pneumothorax and Pulmonary embolism usually occurs in which position?
at rest
78
MI and aortic dissection may occur when?
at rest or on exertion
79
if the chest pain lasts seconds or more than 24 hours then ?
it is not Four Killer pain
80
if the patient shows what signs should you take his/her chest pain seriously?
if patient is diaphoretic and/or lightheaded
81
when the chest pain is worse with inspiration, it indicates?
pleura or pericaridum
82
when chest pain is worse on exertion, it indicates?
MI or aortic dissection
83
if chest pain is better with rest, it indicates?
angina pectoris
84
if chest pain is worse in supine position, it indicates?
pericarditis, pancreatitis, CHF, musculo-skeletal
85
if chest pain is worse with food intake, it indicates?
GIT or MI
86
if chest pain is better with nitroglycerine, it indicates?
Angina or DES
87
Acute Dyspnea caused by Pulmonary issues can be due to:
```
pneumothorax
PE
asthma attack
COPD
aspiration
pneumonia
upper airway obstruction
ARDS
```
88
Acute Dyspnea caused by Cardiac issues can be due to?
MI
CHF
Arrhythmias
cardiac/pericardial tamponade
89
Acute Dyspnea caused by Metabolic issues can be due to?
sepsis
metabolic acidosis
anemia
psychiatric (anxiety or panic)
90
what are 3 types of pneumothorax?
1. spontaneous : osteoporosis, emphysema, idiopathic in tall young male teens, endometriosis/catamenial
2. "flail Chest" - traumatic due to broken ribs and/or sternum, puncturing the lung pleura
3. Tension - mediastinal organs are shifted to opp side
91
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
92
how do you approach patient with ACUTE DYSPNEA?
1. ABCDE
2. H & P: focus on 5 areas (VS, LU, HT, Extremities, Mental status)
3. Labs: ECG, ABG, Chest x-rays, CBC
4. TX: oxygen, diuretics, beta-agonists, mechanical ventilation
93
with patients who have abdominal pain, what are some causes?
```
GIT prgans
hepato-billary organs
kidney
abdominal aorta
pancreas
chest and pelvic organs
```
94
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
```
95
what is the approach to patient with abdominal pain?
1. ABCDE
2. 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
3. Time course: appendicitis always starts with pain; gastroenteritis - with nausea
