1. Introduction to Emergency Medicine Flashcards
(34 cards)
Describe the purpose of the Emergency Medical Treatment and Labor Act (EMTALA) and the requirements for ED.
The act ensure public access to emergency services regardless of ability to pay.
Requires hospitals with operating ED to provide medical screening exams to identify an emergent medical condition.
List the four (4) components of negligence.
- DUTY - a contract of PA-physician relationship where PA must act according with standard of care to protect patient from unreasonable risks.
- BREACH OF DUTY - PA with an established duty fails to act in accordance with these standard of care by commission or omission of a certain act.
- DAMAGES - any actual loss, injury or deterioration sustained by plaintiff due to breach of duty.
- LEGAL CAUSATION - causation in fact and forseeability.
Explain informed consent, conditions required, and five (5) issues that should be documented should patient leaves ED against medical advice.
Informed Consent
- patient knows and understands risks, benefits and consequences of accepting/refusing treatment
- whenever an invasive, risky or complicated treatment or procedure is proposed
Conditions Required
- patient possesses decision-making capacity
- patient can make a voluntary choice free of undue influence
Five (5) Elements to Document in Patient Refusal
- Capacity - patient’s mental status
- Discussion - use and document clear terms (if death was possible, document)
- Alternative treatment - document if alternatives treatment is available
- Family involvement - document efforts to involve family/friends in decision process unless forbidden by patient
- Patient’s signature - document patient’s refusal to sign
Identify the Essential Characteristics of Level 1 Trauma Centers.
- 24 hour availability of surgeons in all subspecialties
- 24 hour availability of neuroradiology and hemodialysis
- Program establishing and monitoring effect of injury prevention and education efforts
- Organized trauma research program
What are the PHYSIOLOGIC ABNORMALITIES that serves as criteria for trauma system entry?
Systolic blood pressure < 90 mmHg
Glasgow coma scale score < 14
Inadequate airway or need for immediate intubation
What are the INJURY PATTERNS that serves as criteria for trauma system entry?
Penetrating wound to head, neck or torso Gunshot wound to extremities proximal to elbow/knee Extremity with neurovascular compromise Amputation proximal to wrist or ankle CNS injury or paralysis Flail chest Suspected pelvic fracture
What are the MECHANISM OF INJURY that serves as criteria for trauma system entry?
MVC with intrusion into passenger compartment > 12in.
MVC with major vehicular deformity > 20in
Ejection from vehicle
MVC with entrapment or prolonged extrication > 20min.
Fall of > 20 feet
MVC with fatality in same passenger compartment
Auto-pedestrian or auto-bicycle collision > 5 mph
Motorcycle crash > 20 mph
What is the purpose of Primary Survey?
Purpose
- quickly identify and treat immediately life threatening conditions with simultaneous resuscitation and treatment
What is the systematic “ABCDE” approach in the initial evaluation?
A - Airway
(Assess, clear and protect airway)
B - Breathing
(Assess O2 saturation, oxygenate, auscultate lung sounds, inspect for problems)
C - Circulation
(Assess for circulation, consider IV fluid, direct pressure)
D - Disability
(Screen for mental status/neurologic exam, blood glucose)
E - Exposure
(disrobe patient and inspect for injuries, logroll to inspect)
Identify the specific injuries that should be immediately identified and managed in the initial trauma assessment.
- Severe head and spinal trauma.
- Pneumothorax (tension v. open v. massive)
- Penetrating abdominal trauma
- Impaled objects
- Traumatic cardiac arrest
Describe the initial evaluation and considerations for management of the AIRWAY in trauma patients.
Maintain inline stabilization of cervical spine and open airway with jaw thrust maneuver (patency, obstructions).
Airway adjuncts for patients with inadequate respiratory effort:
- Nasopharyngeal airway (NPA) - conscious
- Oropharyngeal airway (OPA) - unconscious; can’t tolerate with gag reflex
Identify the patient presentations in which endotracheal intubation should be considered.
ETT
- Comatose patients (GCS = 8 –> intubate)
- Pending airway obstruction/occlusion
- Consider severe head injury/agitated/intoxicated/hypoxia
Identify the importance of cervical spine stabilization and list the NEXUS criteria.
NEXUS
N - neurologic deficit S - spinal midline tenderness A - alertness I - intoxication D - distracting injury
List the Canadian C-spine Rules for cervical spine imaging.
High Risk Factors (>65, dangerous mechanism, paresthesias) - YES = image
Low Risk (rear-end MVC, ambulatory, delayed neck pain, absence of C-spine tenderness) - NO = image
Move Neck? - NO = image
Identify significant clinical findings and apply subsequent interventions in evaluation and management of chest injuries during primary survey.
Significant findings:
- Tracheal deviation (tension pneumothorax/hemothorax)
- Paradoxical movement (flail chest)
- Sucking chest wound
- Abosence of breath sounds
- Crepitus
- Fractured sternum
Immediate Interventions
- Open pneumothorax: occlusive dressing
- Tension pneumothorax: needle thoracentesis
- Hemothorax: tubal thoracostomy
- Right main stem intubation
- Surgery if >1000mL blood loss or > 200ml/hr
Describe the approach to CIRCULATION assessment and management in the primary survey of a trauma patient.
Level of consciousness
Skin color
Presence and strength of peripheral pulse
HR, pulse pressure particularly in young healthy patients
What are the assessment strategies for identifying major sources of hemorrhage and modalities used to control hemorrhage for external/internal bleeding.
Direct pressure, compression bandage, hemostatic dressing for external hemorrhage.
Quick Clot Combat gauze, tourniquet
Hypotension management: lactated ringer’s or normal saline; transfuse if no improvement
Describe rapid assessment of hemodynamic status using vitals and physical findings.
LOC, skin color, presence/strength pulse, HR, pulse pressure
Blood loss (750mL-1500mL-2000ml) Blood loss (15% - 30% - 40%) Pulse rate (100 - 120 - 140 beats/min) Blood pressure (Normal - Decreased) Pulse pressure (Normal/Increased - Decreased)
Describe the neurologic evaluation and management of the DISABILITY phase of the primary survey. What is the limitation to the Glasgow Coma Scale (GCS)?
Assess:
- level of consciousness (including glucose levels and intoxication)
- pupillary size and reactivity
- motor function
- Glasgow Coma Scale (GCS)
GCS is insensitive in patients with normal scores; score of 15 does not completely exclude traumatic brain injury.
Avoid hyperventilation. Mild hyperventilation may reduce intracranial pressure, although at expense of cerebral vasoconstriction and hypoperfusion.
Describe components of the EXPOSURE phase of primary survey of trauma patient including assessment of the spine, rectum and perineum. What is the initial assessment of hypothermia.
Completely disrobe patient to inspect for burns, toxic exposure, bruising, laceration, foreign bodies, open fractures.
Logroll patient to inspect posterior side keeping neutral and inline neck stabilization. Also, examine perineum for bruising, laceration or bleeding.
Cover patient with warm blankets to prevent hypothermia.
Identify clinical assessment pearls associated with:
A. Suspected intracranial injuries
Identify if patient may benefit from operative treatment.
Defer any procedures that do not correct a primary survey problem until after the head CT is performed.
Identify clinical assessment pearls associated with:
B. Tension pneumothorax, open pneumothorax and hemothorax.
Should be apparent in primary survey.
Tube thoracostomy or needle thoracostomy in a timely manner.
Identify clinical assessment pearls associated with:
C. Penetrating abdominal trauma
Exploratory laparotomy –> Operating room
- abdominal tenderness or distention on palpitation
- coupled with hypotension
Delay placement of nasogastric, urinary, and IV catheters if operative intervention is available and should be performed in the OR.
EXPLORATORY LAPAROTOMY!
Identify clinical assessment pearls associated with:
D. Impaled objects
Objects should be left in place and patient transported to operating room for surgical removal under direct visualization to ensure vascular control and hemostasis.
