Flashcards in Emergency Deck (85):
what is the treatment protocol for febrile neutropenia?
Blood cultures, urine culture
Swabs for culture
IV antibiotics- high dose piperacillin and gentamicin OR cefoxtamine
+ or - flucloxacillin, vancomycin or metronidazole
what are the two features of spinal neurological emergency?
pain and neurological deficit
for somebody with suspected cervical spinal cord compression- what do you do to establish sensory neurological deficit?
you would look for a sensory level on the trunk. e.g. t7 is xiphisternum, T4 is nipple line, T10 is umbilicus
what are the four things we want to establish with suspected spinal cord compression?
2. sensory disturbance
4. sphincter disturbance
what might be the first presenting symptom of cauda equina syndrome?
urinary retention due to compression of the cauda equina
what blood parameter do we look for if a patient comes in haemodynamically unstable and we order the blood tests?
What constitutes the parameters of a blood test for trauma?
FBE, U and E, LFTs, Lipase, coags (to see if the patient has an underlying coagulopathy-risk of DIC)
why don't we use a nasogastric tube in trauma tubes?
we don't know if there is an underlying skull fracture.
what are pulmonary contusions?
bleeding in the lung tissue. appears like alveolar opacities on a CXR
how do we medically treat acute hypertension?
1. GTN infusion/patch
2. Dihydropyridine (Ca2+ channel blocker)
3. Ace inhibitor
Tell me the Eye scores for GCS
Eye response (E)
1. No eye opening
2. Eye opening in response to pain stimulus (a peripheral pain stimulus, such as squeezing the lunula area of the patient’s fingernail is more effective than a central stimulus such as a trapezius squeeze, due to a grimacing effect)
3.Eye opening to speech (not to be confused with the awakening of a sleeping person; such patients receive a score of 4, not 3)
4. Eyes opening spontaneously
Tell me the verbal scoring for GCS
Verbal response (V)
1. No verbal response
2. Incomprehensible sounds (moaning but no words)
3. Inappropriate words (random or exclamatory articulated speech, but no conversational exchange)
4. Confused (the patient responds to questions coherently but there is some disorientation and confusion)
5. Oriented (patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month)
Tell me the motor scoring for GCS
1. No motor response
2. Extension to pain (extensor posturing: abduction of arm, external rotation of shoulder, supination of forearm, extension of wrist, decerebrate response)
3. Abnormal flexion to pain (flexor posturing: adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response)
4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)
5. Localizes to pain (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied)
6. Obeys commands (the patient does simple things as asked, e.g. stick out tongue or move toes)
what do you think when you have raised APTT, INR but reduced platelets and fibrinogen?
Disseminated intravascular coagulation
which patients can you NOT send home who have renal colic?
1. People with an obstructed single kidney (calculus anuria)
2. People with signs of fever/sepsis
3. Continuing unremitting pain
how much crystalloid fluids would you give to a patient with 1 litre of blood loss?
3 L of crystalloid fluids
Why does Hartmann's solution have lactate in it instead of bicarbonate?
bicarb is becomes gaseous and so cannot be kept in liquid form like lactate. What happens is that the lactate goes through the liver and becomes bicarb. This then leads to physiological pH.
Can we give O+ blood in emergency cases?
In emergency blood transfusion, we use Group and Hold, then O- blood and in last resort, O+ blood. O+ blood can only be used in men as some women may have been exposed to Rhesus antigen during pregnancy
immediate management of renal colic
1. Analgesia- morphine 10 / pethidine 100 if allergic to morphine
2. Maxolon 10 (M and M) or stemitil 12.5mg
3. Alpha blocker (tamsulosin)
4. PR analgesia upon discharging
5. Outpatient appt in 1-2 weeks
what are the 5 criteria for TTP?
Thrombotic thrombocytopenic purpura
1. Hepatic dysfunction
2. Renal impairment
3. CNS involvement
4. Microangiopathic anaemia
5. Thrombocytopenia + fever
what are two symptoms of a base of skull fracture?
rhinorrhea + blood in the posterior chamber (retro-orbital haemorrhage with no posterior limit)
What do you think if you saw a patient who appeared plethoric head and torso and upper limbs but normal coloured lower limb and trunk in ED? Also they may be SOB, and have dilated veins across the body.
How will you manage them?
If malignancy or mediastinal mass- use methylprednisolone and anticoagulation
acute management of confirmed SAH?
• SAH= medical emergency
• Stabilise and monitor vital signs, including neuro obs and GCS
• Manage electrolyte imbalance
• Calcium channel blocker for vasospasm prophylaxis
• Early referral and admit to ICU
Finally- Surgery- coil or surgical clipping?
which heart rhythms are shockable?
which heart rhythms are NOT shockable
asystole or PEA (pulseless electrical activity)
when do we give amiodarone in ALS?
for VT/VF after the patient has been shocked 3 times and persists to be in VT/VF
what do we give during ALS when patient is not responding to defib?
1 mg of adrenaline IV every 3-5 mins (every 2nd loop)
what does PEA stand for? what do we mean by this?
pulseless electrical activity. These are rhythms of the heart which are supposed to generate a pulse but for some reason there a pulse cannot be detected. So electrical system intact although heart muscle is not contracting leading to no cardiac output
what blood test would you order for anaphylaxis?
tryptase enzyme levels (released from mast cells)
Describe an acute management plan for anaphylaxis in a hospital setting.
1. Remove allergen if known
2. Call for assistance (MET call)
3. Secure the airway and ensure O2 sat is 100%- BVM
4. Obs vitals
5. Call code blue if required
6. Gain intravenous access
7. Prepare IM injections of adrenaline 500 micrograms= 0.5mls
8. Give intravenous fluids CSL/ N.Saline
9. Deliver the IM injections of adrenaline every 4-5 mins until 2mls/patient responds
10. Continually monitor obs vitals, GCS and airway
11. Additional measures- IV adrenaline, bronchodilators, hydrocortisone
Once patient is stabilised, admit to hospital under close monitoring
CODE during ALS?
Once defib pads are on:
C- compressions continue
O- oxygen away
D- defib charging
E- everyone away
Assess rhythm and if shockable- SHOCK
what is the classical metabolic tetrad for tumour lysis syndrome?
what are the 4 Ts of reversible causes for cardiac arrest?
1. tension pneumothorax
4. thrombosis (Arterial or Venous)
What are the 4 Hs of reversible causes for cardiac arrest?
which cancer patients are more likely to get febrile neutropenia?
leukaemias or any bone marrow infiltrating cancer
72 year old man with metastatic prostate cancer presents with acute back pain. What oncological emergency are you thinking of?
acute spinal cord compression
Elderly lady is in a cinema. As the lights dim down, she notices blurring of vision, severe pain behind the eye and redness of the eye. Also feels nauseated and was vomiting. What do you think is happening?
Acute closed angle glaucoma
how might we managed Acute closed angle glaucoma?
• Acetazolamide (carbonic anhydrase inhibitor) to reduce IOP
• Timolol (beta blocker) to reduce IOP +/- alpha blockers as well
• Pilocarpine (parasympathomimetic) to constrict the pupils
• Mannitol if required
Laser iridotomy if required
what do we mean by sepsis?
infection, either suspected or confirmed, with systemic features such as fever, tachycardia, tachypnoea or elevated white cell count.
what do we mean by septic shock
Sepsis complicated by hypotension that does not respond to intravenous fluid administration. In elderly patients, neonates and younger children, some of these signs may be masked.
what do we mean by severe sepsis?
sepsis complicated by acute organ dysfunction or hypoperfusion
what antibiotic should we prescribe for a suspected gram negative multi drug resistant infection?
do steroids and antihistamines have a role in the management of anaphylaxis?
no for antihistamines
- steroids can be used 2nd line although onset of action is delayed 3-4 hrs
what does FAST mean in a trauma setting?
FAST stands for Focused assessment with sonography in Trauma- essentially using ultrasound as a means of detecting internal injuries
if you have a high clinical suspicion of meningitis, what is your management?
Obviously admit the patient
1. Blood cultures
2. Administer benzylpenicillin/ceftriaxone + dexamethasone
3. Perform a LP asap
4. CT scan of the head if required
What is AMPLE in a trauma setting?
The 5 most important things you need to ask the trauma patient=
P- past medical hx
L- last meal
what gets scanned in a FAST U/S?
• FAST ultrasound--> Morrison's pouch looking for free fluid (indicates bleeding in the liver)
• FAST ultrasound--> Pouch of douglas in the abdomen
• FAST ultrasound--> Look at the spleen
• FAST ultrasound--> Look under the xiphoid process to look for pericardial fluid / tamponade
FAST ultrasound--> Look at the ribs to look for pneumothorax
what are the parameters for trauma call?
HR more than 125; BP less than 90; penetrating Neck injury, GCS less than 9, pregnant trauma with PV bleeding
where do we put in a chest tube without imaging guidance
5th intercostal space in the mid-anterior axillary line
male- approximately in line of the nipple
what is the normal size Chest tube for trauma patient
ED orthopaedic assessment VONCHOP?
Cauda equina syndrome/ Compartment syndrome
Osteomyelitis/ septic arthritis
Pelvic bone fractures or long bone fracture
Acute management of fracture in ED?
4. fracture reduction and immobilisation
6. DVT prophylaxis
what do we mean by rapid sequence induction and intubation?
Rapid airway control
Rapid sequence induction and intubation (RSII) should be considered for the patient who is at increased risk of aspiration with induction of anesthesia.
This includes the patient with a full stomach, gastrointestinal pathology, increased abdominal pressure, or pregnancy after 20 weeks gestation
how do we manage acute pancreatitis?
1. fluid resuscitation, IV fluids
3. PPI (pantoprazole)
4. Analgesia- panadol/endone/PCA/morphine/fentanyl
acute appendicitis management?
Lap appendicetomy ASAP
what type of fracture is an orthopaedic emergency?
acute management of open fracture?
• Fast the patient
• Morphine IV
• Tetanus status- ADT? Or Tetanus antibodies?
• IV antibiotics (very important)
• Immobilise fracture for pain management (RICE)
Direct pressure on the bleeding vessel with blood loss apparent.
what is the most time critical thing to worry about in the setting of an open fracture?
time to antibiotics.
Infection is the thing you DONT want.
management of DVT?
Anticoagulation--> start on enoxaparin, then warfarin
Or can now use rivaroxaban providing LFT/renal function okay
Anticoagulation for 3 months.
If the clot is DISTAL to the knee, and the patient is asymptomatic, you can watch and wait. Regularly monitor for proximal clot movement
Two or more of the following
4. Elevated WCC
what is sepsis?
SIRS + suspected or confirmed dx of infection
what is severe sepsis?
sepsis + acute organ failure
what is septic shock?
severe sepsis + hypotension not responding to fluid therapy
what do we do for septic shock?
refer to ICU
what do we do when we can't ventilate can't Intubate a patient?
Emergency cricothyroid airway or thoracotomy
name some anaesthetic emergencies
a patient comes in acutely unwell after eating a handful of apricot kernals. What are you thinking? What is the mechanism of action?
How might you manage this patient?
cyanide poisoning--> uncouples the ATP process of oxidative phosphorylation leading to energy depletion on a cellular level
Admit the patient, IV fluids
Avoid acidaemia- if present, administer sodium bicarb to increase pH
Look at lactate levels
ADMINISTER nitrates OR thiolsulfates or derivative of B12
If we are administering nitrate or thiolsulfates then also administer IV methylene blue dye to avoid rising met Hb
when would we do a gastric lavage after ingestion of toxin?
if it is in a fairly short time frame from ingestion of toxin to presentation at the hospital
if the toxin is not corrosive
if the airway can be controlled (i.e. if patient is semiconscious we would NOT do a gastric lavage
A young patient comes in after a traumatic MVA and you suspect she has an intracapsular fractured NOF. Plan of action? What are you worried about?
Go through ABCDEFG
Call the Ortho reg/consultant ASAP
An operation for open reduction internal fixation/ THR is required.
We are worried about avascular necrosis occuring to the head of femur
symptoms of APO?
Poor peripheral pulses
No urine output
when would you NOT give adrenaline with local anaesthetic lignocaine?
when you need to apply lignocaine to fingers, ears, nose, penis, toes bc risk of vasculature insufficiency
what is the 4 electrolyte abnormalities found in Tumour lysis syndrome?
how to manage compartment syndrome?
remove any bandages around the limb
--> until you see skin
If the pain still continues--> bring to theatre for fashiotomy
which cancers are more associated with tumour lysis syndrome?
haematological malignancies such as lymphoma and leukaemia.
Sometimes solid tumours like testicular cancer
how to manage ascites in ED?
• Treat underlying disease
• Avoid NSAIDs and ACE inhibitors
• Sodium restriction
• Fluid restriction
• Diuretics= SPIRONOLACTONE 50 g/d titrate to 400 mg/d
• May add frusemide
• Watch serum K+ and renal function (hypokalemia)
• Therapeutic ascitic tap
• Abstinence from alcohol
signs of strangulated hernia?
red, firm, tender irreducible mass
what do you think when you have a patient who comes in with:
Should you give flumazinil to all patients who come in with benzodiazepine overdose?
NO!. Worry about Benzodiazepine withdrawal so may lead to SEIZURES. You may be unable to stop these seizures bc you have blocked the benzodiazepine receptors.
So DO NOT USE IN CHRONIC BENZODIAZEPINE OVERDOSE
okay to use in acute one off benzo overdose
Why do we do an ECG for patients with benzodiazepine overload?
We look for prolonged QT interval.
If the interval between the Q and the end of T wave is greater than half the RR interval= prolonged.
may lead to toussades
what do you think of abdominal pain + hypotension?
ruptured abdominal aortic rupture (AAA)
what are the early complications of acute pancreatitis?
pancreas necrosis and sepsis
what is ARDS
lungs generic response to insult/injury/inflammation
when would you consider IV antibiotics in patients admitted with pancreatitis?
IV antibiotics are only indicated in patients with associated cholangitis or infected necrotising pancreatitis
so do not give prophylactic antibiotics!!
what sort of psoriasis medical emergency is there?
generalised pustular psoriasis
- loss of barrier function, thermoregulation and protein loss
risk of pre-renal impairment and sepsis