Acute Flashcards
(30 cards)
CT head guidelines - criteria for immediate CT?
Immediate: initial GCS <13
<15 2hrs post injury
Suspected open/ depressed skull #
signs of basal skull # - haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign
post traumatic seizure
>1 ep of vomiting.
Focal neurological deficit
Summary of brain herniation
Brain structures forcefully displaced. Compression.
Subfalcine: cingulate gyrus displaced under falx cerebri
Central: downward displacement.
Transtentorial: uncal, expanding IC haematoma may cause temporal lobe (uncus) to herniate through tentorial notch.
Foramen magnum/ tonsillar: BS compression, coning.
Transcalvarial: brain displaced through defect in skull
Transtentorial: compression of CN3, ipsilat pupil dilation, loss of eye movement, down + out gaze. Compression of ipsilat CS tracts in brainstem/ cerebral peduncle. Contralat hemiparesis.
Foramen magnum: ↓LOC, posturing, irregular resp, loss of BS reflexes. Bilat fixed + dilated pupils. Cushing’s response
Neurosurgical emergency
Osmotherapy: hypertonic saline or mannitol
Surgical decompression
Canadian C spine rule:
high RF (>65, dangerous MOI, numbness/ tingling in extremities).
Absence of low risk (simple rear-end MVC, ambulatory at any time at scene, no neck pain at scene, no pain during midline c-spine palpation).
Pt unable to voluntarily actively rotate neck 45° L+R.
Need immobilisation
1st degree burns (superficial)
Superficial epidermis only
Pain, erythema
Dry
No blisters
Heals within 1-2 wks no scarring
2nd degree, superficial dermal - partial thickness
Papillary layer of dermis
Epidermis + upper dermis
Extremely painful
Skin pale pink
Blistering
Blanches, rapidly returns
Brisk bleeding on pinprick
Slow CRT
Takes 2-8 wks
2nd degree, deep partial thickness
Deep reticular layer of dermis
Epidermis + upper + deeper layer of dermis
Varies colour, white, yellow, cherry red
Blisters
Wet or dry
Patches of non-blanching erythromycin
May only be pain due to pressure bc of nerve/ BV damage.
↓sensation
Blanches with sluggish return or doesn’t blanch
3rd degree, full thickness
Hypodermis
Extends through all layers of skin to SC tissues.
No pain, no blisters Dry, white leather, grey, black Non blanching, no CR Elastin damage, burn stiff/ inelastic No/delayed bleeding on pinprick
Surgical Tx
Skin grafting
Inhalation injury (burn)
Burn anywhere in rest tract
Laryngospasm > hypoxia + straining, hypoxic cord relaxation.
Explosion burns to head/ torso, confined space.
Singed nasal hairs Carbon particles in sputum Inflamed oropharynx Hoarseness/ voice change Harsh cough Stridor Burns to face Impaired LOC
↑CO in blood
ET tube
Swelling worsens 1st 24-48hrs after injury
100% O2
RFs for paracetamol poisoning
liver inducing drugs rifampicin, phenytoin, carbamazepine, chronic alcohol XS, st John’s Wort, malnourished
Acute alcohol XS protective
Tx of paracetamol poisoning
Staggered: all pts have acetylcysteine
> 10mg/L Tx: acetylcysteine, infused over 1hr
<1 hr: activated charcoal
SEs of acetylcysteine: anaphylaxis (non IgE mediated mast cell release, stop infusion, restart at lower rate, chorphenamine if rash.
Liver transplant criteria: arterial pH <7.3 24hrs after ingestion. Or ALL of: PT >100s, Cr >300, grade ¾ encephalopathy
Tx of ecstasy poisoning
Supportive
Dantrolene for hyperthermia
Tx of methanol poisoning
Fomepizole (competitive inhib of alcohol dehydrogenase) or ethanol
Haemodiaysis
Cofactors with folinic acid to reduce opthalmoplegic SE
Summary of organophosphate poisoning
Inhib ACh upreg of cholinergic neurotransmission
Insecticides, herbicides, nerve agents
Salivation/ sweating Lacrimation Urination, defecation/ diarrhoea Bradycardia, hypotension Abdo pain, vom Bronchorrhea, chest crackles, ronchi/wheezes >pul oedema bronchospasm Small pupils, visual disturbance Muscle fasciculation, weakness, spasms, paralysis
Plasma cholinesterae: decreased activity
ECG: QT prolongation
SLUD: salivation, lacrimation, urination, diarrhoea
Pt decontamination eg remove clothes, wash skin
Atropine
Pralidoxime: administered after atropine risk of transient worsening acetylcholinsterase inhibitors
BDZ for seizures
Summary of CO poisoning
Badly maintained house eg student house
CO high affinity for HB + myoglobin, left shift of O2 dissociation curve, tissue hypoxia + tissue hypoxia
Headache, confusion N+V Vertigo Subjective weakness Severe: ‘pink’ skin + mucosa, hyperpyrexia, arrhythmia, extrapyramidal, coma, death
Pulse Ox, may be falsely high due to similarities between oxyhemoglobin + carboxyhaemoglobin
ECG for cardiac ischaemia
ABG
Carboxyhaem: <3% non smokers, <10% smokers, 10-30% symptomatic, >30% severe toxicity
100% O2 via non rebreather mask min 6hrs, target sats 100%
Tx continued until no Sx
Hyperbaric O2
Summary of TCA poisoning
Early: dry mouth, dilated pupils, agitation, blurred vision, dry eyes
Ophthalmic signs: divergent squint, gaze, paralysis, inter nuclear ophthalmoplegic, nystagmus
Warm, dry, flushed skin
Decreased/ absent BS
Urinary retention
Dizziness, palpitations, pyrexia w/o sweating
Confusion, LOC, delirium, agitation, visual/aud hallucinations
Ataxia, myoclonic, choreathetoid movements
Metabolic acidosis
ECG: sinus tachy, widening of QRS, prolongation of QT
Increased tone, hypereflexia, extensor plantar responses
QRS >100ms seizures, >160 ventricular arrhythmia
IV bicarb IV fluids 1a (quinidine) + 1c (flecainide) CI as prolong depolarisation Class 3 amiodarone avoided as prolong QT IV lipid emulsion to bind free drug Dialysis removes TCA O2 Diazepam for convulsions
Summary of opioid poisoning
Rhinorrhoea, watering eyes Needle track marks Pinpoint pupils Apnoea, RR<12, shallow Unconscious, drowsy, coma Confusion, yawning Pruritus, N/V/C, abdo pain Bradycardia, hypotension, vasodilation Unresponsive
IV/IM naloxone: competitive opioid receptor antagonist, ½ life 60-90 mins. Initial 400mg, if no response 800mg for up to 2 doses
Ventilation
Summary of BDZ poisoning
Effects potentiated if taken another CNS depressant such as alcohol or opioids
XS sedation
Impaired mental state, attention or memory (esp loss of anterograde memory)
Inappropriate behav or judgement + labile mood
Drowsiness, slurred speech, ataxia
Diminished postural stability + reflexes
Nystagmus
ECG: transient 1st degree heart block, 2nd degree HB, QT prolongation
CK: elevated rhabdomyolysis
Poss met acidosis
Supportive
Observe pt for min of 4hrs
Activated charcoal if present within 1hr
Flumazenil: risk of seizures
Summary of beta blocker poisoning
CVS: hypotension, bradycardia, AV block
Bronchospasm, breathing trouble (SOB, gasping), wheezing (asthma)
Stupor, coma, weakness, nervousness, XS sweating, drowsiness, confusion, fever, delirium, syncope
Hypoglycaemia
Hyperkalaemia
Fluid, secure airways Salbutamol Atropine Bicarb for met acidosis, dialysis Glucagon if resistant
Summary of salicylate overdose
Direct stim of resp centre, overbreathe, resp alkalosis. Kidney attempts to compensate by excrete alkali to give met acidosis
Inhibits normal met pathways so get failure of normal met of carbs, fats + proteins. Build up of organic acids, ketones, lactate + pyruvate
V/N, dehydration Vertigo Sweating, pyrexia Bounding pulses HTN Hyperventilation Lethargy Hyper/hypoglycaemia
Resp alkalosis 1st, then met acidosis
In kids met acidosis predominant
Reg VBG
Supportive
Activated charcoal <1hr
IV Na Bicarb: strict supervision
Haemodialysis: ITU, in severe LT overdose. Serum conc >700, met acidosis resistant IV bicarb, acute resp failure, pul oedema, seizure, coma.
Summary of lithium poisoning
Narrow therapeutic index (0.4-1mmol/L) + long plasma ½ life. 2 = serious toxicity
Toxicity precipitated by: dehydration, RF, drugs (thiazides, other diuretics, ACEi, ARB, NSAIDs, deterioration of renal functions, infection, metronidazole
Coarse tremor: fine tremor in therapeutic levels Hyperreflexia Acute confusion, apathy, restlessness Polyuria, V/D Ataxia, weakness Dysarthria Muscle twitching
Volume resus
Haemodialysis
IV bicarb: urinary alkalisation promotes lithium excretion
Tx of warfarin overdose
vit K, prothrombin complex
Tx of heparin overdose
protamine sulphate
Tx of iron overdose
desferrioxamine, chelating agent
Tx of lead overdose
dimercaprol, Ca edetate, EDTA, DMSA
