emergency surgery and medicine

Question 1

ddx

Answer 1

• anaphylaxis
• panic attack
• pneumothorax
• asthma
• pneumonia
• cardiac failure
• ARDS
• pleural effusion
• PE – HR is so high. RR v high though, unless massive it would be unlikely to have such a massive RR. BP is really good too.

Question 2

which numbers are worrying

Answer 2

HR

RR

BP - not worring but need to keep an eye on - if PE it will plummet

Question 3

how could you get cardiac failure in a 24yr old

Answer 3

if had pericarditis previously -> myocarditis

Question 4

why would you get pleural effusion in young male

Answer 4

testicular cancer?

Lymphoma can get effusion, not classically

TB, doesn’t often get pleural effusion can get marked changes

Question 5

acute asthma

Answer 5

PEF 33-50% of best

cant complete sentences

RR >=25/min

pulse >=110 beats/min

Question 6

life threatening asthma

Answer 6

PEF <33% of best

SpO2 <92%

silent chest, cyanosis, feeble resp effort

arrhythmia/hypotension

exhaustion and altered consciousness

Question 7

important info to get if someone presents with asthma attack

Answer 7

previous ITU - more important in moderate asthmatics – borderline and whether to send them home.

DHx

medical conditions

allergies - trigger exposure – need to remove the trigger and will be a different treatment – will need to give adrenaline

infective sx

Question 8

pathophysiology of asthma

Answer 8

reversible airway disease

hyperreactivity = vasoconstriction

airflow limitation

Question 9

clinical presentation of asthma

Answer 9

wheeze

breathless

tachycardic

Question 10

ddx for wheeze

Answer 10

Anaphylaxis

Airway obstruction – foreign bodies

Anatomical cause of squeaky noise – epiglottis – not a wheeze, it is stridor

Stridor seen in children – floppy epiglottis, and whole area big

Stridor in adult – epiglottitis/supraglottitis – need ITU

Question 11

Mx of asthma

Answer 11

nebulised salbutamol - Better to have inhaler through spacer than nebuliser – material into lungs smaller particles into lungs. Drops in nebuliser cant get as far into lungs

IV salbutamol

nebulised adrenaline

nebulised Mg

oral steroids

IV steroids

Question 12

severe V life threatening asthma

Answer 12

decompensation

unable to maintain adequate PO2 and PCO2

drowsy due to rising PCO2, hypotension or exhaustion

need intubation

Question 13

dx

Answer 13

Anaphylaxis

BP is very low and high HR and urticarial rash suggest anaphylaxis

• Anaphylaxis over sepsis – sudden onset, temperature (although can get cold sepsis), Hx.*
• Non-blanching rash would = meningococcal meningitis*

Question 14

Answer 14

urticarial rash

Question 15

pathophysiology of anaphylaxis and consequences

Answer 15

One of issues is the massive swelling and fluid and effect on body – airway swell, no BP

Big tongue so hard to even intubate

Resp sx can be quite late

Lip and mouth tingling is the key sign

Episode of diarrheoa – Can lose control of bowel function

Question 16

Mx of anaphylaxis

Answer 16

adrenaline

500mcg

0.5ml 1:1000 more conc dose because less volume of drug – IM less painful and distributes quicker

lie flat and legs in air – redistribution of fluid – get fluid back into the heart to improve venous return and the BP

IV piriton

hydorcortisone - kicks in later

fluids

Question 17

dx

Answer 17

Tomb stoning – ST in anterior leads

Mx

• Cathlab and resus
• Need to be on a monitor and then local cath lab
• Check for signs of life – cardiac arrest: PEA – pulseless electrical activity

Question 18

Mx of cardiac arrest

Answer 18

call the arrest team

start compressions

attach to defibrillator and checking rhythm

Before start CPR with VT and VF – shock

Question 19

Answer 19

VF

chaotic in all leads

Question 20

Answer 20

2^nd – have to check the pulse – if pulse it is bradycardia with complete heart block because no p wave

Question 21

Answer 21

asystole

Question 22

shockable and non-shockable heart rhythms

Answer 22

Non-shockable

• PEA
• Asystole

Shockable

• VT
• VF

Question 23

reversible causes of cardiac arrest

Answer 23

• hypothermia
• hyperK/hypoK - and other electrolyte disturbances
• hypoxia
• hypovolaemia
• thomboembolism
• toxins
• Tension pneumothorax
• tamponade

Question 24

Mx of tension pneumothorax

Answer 24

cannular/cut and hole in chest

Question 25

dx of tamponade

Answer 25

US

Question 26

dx and mx

Answer 26

Dislocated fracture

Sedation and pull back into joint, no XR

Quickly get necrosis of the skin – need to put it back to take the pressure of the skin.

If anything breaks down in lower leg – ulcers that take years to get better.

Question 27

characteristic sx of epidural haemorrhage

Answer 27

lucid interval

Might lose consciousness then normal GCS then lowers again

Question 28

concern with this injury

Answer 28

Middle meningeal artery in this area – really delicate, thinnest part of the skull. Bone doesn’t need to break – artery can just rupture on the mere process of landing on the floor.

Doesn’t matter what the GCS is – need to CT head. Based on Hx. Less than 30sec to CT

Low impact Ix

Question 29

concerns with this trauma

Answer 29

Airway – first focus

• Tried to get tibe in through nose but been unsuccessful so gone through the trachea

C spine injury

Arterial injury

Nerve injury

Wood might be tamponading a ruptured vessel – so don’t remove

Question 30

approach to trauma

Answer 30

A-E

Question 31

approach

Answer 31

Call anaesthetics -don’t take to CT w/o tube – nosy breathing = obstriucted airway. If vomit -> aspirate.

Dilated L pupil – sign head injury putting tension in the brain

HR 100 – blood bank on standby – young person who compensated and so can very quickly decompensate

Question 32

dx

Answer 32

Extradural – huge because there is the midline shift, and ventricles squeezed over.

And have blown pupil – classic sign

Question 33

approach to epidural

Answer 33

Optimise the oxygen – doesn’t need to be 15L but needs to be >95% sats

Keep CO2 normal – tube so can monitor – capnograph give them the readings

Cerebral perfusion – 30degrees (CCP=MAP-ICP)

Other injuries – group and save cross match

With extradural haemorrhage HR should be normal and then bradycardic when cone because hypertensive BP 200, and bradycardic. High HR worry for other injury.

Panscan CT and then theatre

neurosurgical input

Question 34

predictor of outcomes in head injuries

Answer 34

GCS

if low - outcome is low, even if same scan as higher GCS

Question 35

things in airway assessment

Answer 35

are they breathing

is it normal or noisy

• noisy = obstructed

do they need a definitive airway

Question 36

things to assess in breathing assessment

Answer 36

look

palpate

percuss

auscultate

feel for surgical emphysema - crackles, feels like bubble wrap - Subcutaneous mottly on L – air into the soft tissues

Question 37

things in assessment of circulation

Answer 37

pulse, BP, cap refill

general appearance

source of haemorrhage - on the floor, chest, abdo, pelvis, long bones

Question 38

Answer 38

pelvic binder - stop haemorrhage in pelvis

Need to give blood – pre-empt the blood loss so have rapid infuser set up before the pt arrives, can get unit in really quickly

Need FFP and plts and calcium

Question 39

haemorrhage control

Answer 39

stop the bleed

fluids

warfarin

coagulopathy to correct

TXA

Question 40

disability assessment

Answer 40

GCS - level of consciousness

pupils

blood sugar

limb movements

Question 41

dx

Answer 41

tension pneumothorax

cardiac tamponade

pneumonia

thoracic haemorrhage

Question 42

Answer 42

Hole in 5^th ICS in both sides and pair of scissors – cut across and join the thoracosostmy. See if anything wring with the heart

Here – blood in lung – worry about hilar injury – hand stopping the hilum bleedinbg

Clamshell thoracostomy – life saving

Take lung and twist it on itself – stop blood into lung – bad for BP and pulse = but lifesaving