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Flashcards in Emergency Deck (43):
1

Post splenectomy organism likely to cause infection

Following splenectomy a person is particularly at risk from capsulated organisms. The most important are:
Streptococcus pneumoniae
Haemophilus influenzae
Neisseria meningitides. Vaccination may be given.

Other important infections with increased risk are: Staphlococcus aureus, Escherichia coli, Pseudomonas aeruginosa, Capnocytophagia canimorsus (from dog bites) and malaria.

By far the most common is Streptococcus pneumoniae which can cause life-threatening infection. The mortality of post splenectomy septicaemia can be up to 50%.

2

Poor prognostic indicators in the first 48 hours of acute pancreatitis include

Poor prognostic indicators in the first 48 hours of acute pancreatitis include:

Age >55 years
WCC >15 ×109/L
Glucose >10 mmol/L
Urea >16 mmol/L
Albumin 200 U/L
Calcium 600 U/L
PaO2

3

A 47-year-old female presents with a decreased conscious level, headache and vomiting. Fundoscopy reveals subhyaloid haemorrhages.

Spontaneous subarachnoid haemorrhage most frequently results from the rupture of an intracranial 'berry' aneurysm (85%). Patients in their fifth decade are most frequently affected. Typically, the patient complains of a sudden onset of severe headache that peaks in intensity within one minute. Other symptoms include neck stiffness and photophobia. The patient's conscious level is variable.

4

A 29-year-old man presents unconscious. His wife tells the emergency depaartment officer that he has been experiencing worsening headaches and vomiting over the previous two months. His wife also informs the doctor that her husband's personality has also changed over the same period of time with episodes of unexplained aggression. Fundoscopy reveals papilloedema.

Meningioma
Parasagittal menigiomas often occur in front of the central sulcus and typically produce frontal or parietal lobe symptoms. These tumours are discrete, well encapsulated and arise from the arachnoid layer outside the brain. They are usually slow growing and can reach a considerable size before causing any symptoms. The increasing intracranial pressure causes the headache and vomiting. Papilloedema results from the raised cerebrospinal fluid (CSF) pressure. Unconsciousness results from herniation of the brain stem due to the raised intracranial pressure.

5

A 29-year-old man presents unconscious. The police have arrested him for aggressive behaviour following his being ejected from a nightclub. He smelt strongly of alcohol and vomited a number of times. He was found to be unconscious when checked one hour later in his police cell.

Neurotrauma
This man is most likely to have sustained a head injury. He has become unconscious due to rising intracranial pressure due to bleeding.

6

A 22-year-old male involved in an automobile accident complains of chest pain. He was wearing his seat belt.
He is maintaining his own airway, his respirations are 25/min, his pulse is 120/min, blood pressure is 90/60 mmHg and oxygen saturations on pulse oximetry are 96% on air.
Multiple fractures are noted on the chest x ray with no evidence of haemopneumothorax.

Urgent blood transfusion/resuscitation
This young man has multiple chest fractures and demonstrates some degree of haemodynamic instability. Prior to FAST to evaluate his solid organs, this patient should be resuscitated and stabilised.

7

A 21-year-old male patient has had an alcoholic binge of about 10 pints in the evening. He has now come to the Emergency Department in the late evening with complaints of a small amount of haematemesis. He is haemodynamically stable and his GCS is 15/15.

Full blood count next morning
This male is a haemodynamically stable haematemesis and so does not need an urgent endoscopy. However, it is appropriate to re-check his haemoglobin the next day to assess any occult loss.

8

A 40-year-old male was involved in a brawl, and has been kicked in the chest. He presented the next day to the Emergency Department, and after a thorough examination he is markedly tender over the right lower chest.

This man has been found to have a probable fractured rib after examination. Assuming he is haemodynamically stable, he needs a chest x ray to confirm the diagnosis and exclude a pneumothorax or haemothorax, before discharging him with analgesics.

9

An 18-year-old male was brought to the Emergency Department after a road traffic accident. He was breathless and pale.
On examination, he is maintaining his own airway, his blood pressure is 50/00 mmHg, pulse 116/min, and CVP was 2 cm H2O.

This patient is clearly shocked and so requires resuscitation along the ATLS protocol.

10

A 22-year-old male driver has been involved in a high speed collision with another car. The fire service were required to cut him free from the wreckage as the steering wheel was pining him in his seat. He is in fast atrial fibrillation with a normal blood pressure. He is tender over the sternum on examination.

Myocardial contusion results from deceleration trauma, with the right ventricle most often being damaged when associated with a sternal fracture. The diagnosis is made from the history, serial cardiac enzymes and ECG changes. If suspected an echocardiogram should be performed and the patient treated in the same way as a patient with a myocardial infarction. Cardiac rupture requires urgent surgical repair or cardiopulmonary bypass.

11

A 19-year-old man has been stabbed in the upper abdomen. On admission he is tachycardic and hypotensive. On examination he has distended neck veins with the heart sounds being difficult to hear.

Cardiac tamponade most frequently results from penetrating trauma and causes bleeding into the fixed fibrous pericardium. Patients usually exhibit 'Beck's triad', which consists of elevated central venous pressure, hypotension and muffled heart sounds.

Kussmaul's sign of paradoxical elevated venous pressure on inspiration may be present.

The patient should be treated with immediate needle pericardiocentesis followed soon after by surgical exploration.

12

A 39-year-old male builder has fallen from scaffolding landing heavily on his left chest. He is tachycardic and hypovolaemic, examination of his chest reveals absence of breath sounds and dullness to percussion on the left.

A massive haemothorax is defined as occurring when more than 1000 mls of blood is lost into the chest. An ongoing blood loss of greater than 100 mls/hr necessitates a thoracotomy.

13

A 25-year-old man who was involved in a high speed motorbike crash is brought to the emergency department with respiratory distress and left-sided chest pain. On examination, he has distended neck veins and there is decreased air-entry on the left side of the chest. His blood pressure is 100/72 mmHg, pulse rate 110/min and respiratory rate 20/min.

Tension pneumothorax is a life-threatening surgical emergency, since failure to relieve the tension may result in a cardio-respiratory arrest. It usually occurs following penetrating or blunt injuries to the chest, and frequently following major traumas.

In tension pneumothorax, the air is drawn into the pleural space with each inspiration, but has no route to escape; thus acting as a one-way valve.

Patients present with

Respiratory distress
Tachycardia
Hypotension
Distended neck veins
Decreased air-entry in the affected lung
Deviation of trachea and mediastinum to the opposite side.
However, not all these signs and symptoms are always present.

14

A 56-year-old man is brought by ambulance to the emergency department after being found lying in the street. He complains of severe pain over the retrosternal and epigastric region following a bout of heavy drinking. He also gives a history of vomiting blood before the onset of pain.
On examination he is hypotensive with a tachycardia. A chest x ray shows gas in the mediastinum and subcutaneous tissues.

Boerhaaves syndrome

The classical history of Boerhaave's syndrome is of severe vomiting and retching followed by extremely severe retrosternal and upper abdominal pain. Shock develops rapidly.

There is a history of alcoholism or heavy drinking in 40% of patients. The site of rupture is usually in the left posterolateral distal oesophagus and is several centimetres long. Subcutaneous emphysema (crepitus) is only present in 27% of patients and is a relatively late sign.

An initial chest x ray will show mediastinal or free peritoneal gas. After hours or days, pleural effusion(s), often with a pneumothorax, and a widened mediastinum develops. The diagnosis is confirmed with a CT scan followed by a gastrografin swallow to assess the extent of the oesophageal leak.

The main treatment is surgery, which should be within 24 hours. Mortality is 20-50% and is increased with delay in treatment. The oesophagus is repaired or resected and the mediastinum drained. Occasionally contained leaks may be managed conservatively. Endoscopic covered stents have been used. Surgery is the only effective option when there is extensive mediastinal contamination or delay in diagnosis.

Mallory-Weiss syndrome is the cause of bleeding in 5% of patients with upper gastrointestinal haemorrhage. Longitudinal mucosal lacerations in the distal oesophagus and proximal stomach cause bleeding from submucosal arteries. Most tears are single. The condition was originally described in 1929, related to vomiting in alcoholic patients.

Other associations include

Coughing
Epileptic convulsions
Closed chest massage
Blunt abdominal injury
Hiccups under anaesthesia.
Hiatus hernia appears to be a predisposing factor (40-100%). Some patients have epigastric or back pain. The blood loss is usually small and self-limiting.

Transfusions may be needed and endoscopic haemostatic treatment may be required. Rarely, with protracted vomiting, perforation may occur.

15

A 37-year-old man is brought into to the emergency department with penetrating injury to the left side of his chest wall following a road traffic accident. He complains of severe left-sided chest pain and on examination his jugular venous pressure (JVP) is raised and the heart sounds are muffled. His blood pressure is 98/74 mmHg and his chest x ray reveals a globular heart.

Cardiac tamponade may occur following

Penetrating or blunt injuries to the chest wall and/or heart
Lung or breast carcinomas
Pericarditis
Myocardial infarction.
The classical signs of cardiac tamponade include a rising JVP, falling BP and muffled heart sounds (Beck's triad).

The other recognised features include a rising JVP with inspiration (Kussmaul's sign), tachycardia and hypotension.

Chest x ray reveals a globular heart and the left heart border may be convex or straight with the right cardiophrenic angle reduced to less than 90°.

16

A 12-year-old girl attends clinic with an earring embedded in the lobe of her ear.
Which nerve must be blocked with local anaesthesia in order to remove the stud?

Greater auricular nerve

The greater auricular nerve from C3 supplies sensation to the inferior part of the ear.

It can be blocked with infiltration of local anaesthesia 1 cm below the ear lobe from the posterior border of sternocleidomastoid muscle to the angle of the mandible.

The upper lateral surface of the external ear is supplied by the auriculotemporal nerve and the skin posterior to the ear is supplied by the lesser occipital nerve.

17

A 47-year-old man was struck on the left temple with a cricket ball during a match.
He lost consciousness at the scene but quickly regained full consciousness and has been waiting to be seen in the casualty waiting area.
You are called to assess him urgently as he is now unresponsive.
What is the most likely source of the intracranial bleeding?

Middle meningeal artery
The thin squamous part of the temporal bone is grooved by the middle meningeal artery.

It is easy to fracture and the underlying artery can also be torn or punctured.

This results in the slow accumulation of blood in the extradural space.

18

A farmer attends the emergency department with a hand injury. He has a large contaminated wound on his left hand sustained from a fall whilst herding livestock between fields.
Which of the following is the most suitable antibiotic to administer for the prevention of tetanus?

Penicillin given intravenously or intramuscularly would be the most suitable antibiotic to administer for the prevention of tetanus.

Tetanus toxoid should also be given as appropriate.

19

A 30-year-old female attends the emergency department following a head injury.
You assess her on arrival and her GCS is 14. The nurse looking after the patient calls you back to see her 30 minutes later. The GCS is now 10, the patient has a blown pupil, is vomiting and confused.
The bleeding is most likely to be from which of the following?

Extradural haematomas most commonly occur from arterial haemorrhage into the potential space superficial to the dura.

The bleeding is usually due to injury to the middle meningeal artery in the temporal area.

Patients with extradural haematoma are commonly known to "talk and die" because they usually have a lucid phase followed by rapid deterioration.

20

A 32-year-old male attends the emergency department following an assault.
He sustained multiple blows to his face and chest. You are concerned that he may have an underlying facial fracture.
On examination you note that the right cheek is very swollen and that there is a right subconjuctival haemorrhage. There is also sensory deficit over the right cheek.
Which nerve has been damaged?

Infraorbital nerve

Zygomatic fractures and orbital blow out fractures can result in damage to the infraorbital nerve as it runs forward between the orbit and maxillary sinus and emerges at the infraorbital foramen.

Injury to the nerve results in absent or altered sensation of the cheek, side of the nose and upper lip.

21

A patient you are seeing in the ENT clinic has recently had some dental surgery performed and asks you for some advice about symptoms she has experienced since.
On examination you see that a lower third molar has been removed.
Which nerve has been damaged?

The lower third molars often have roots in close proximity to the inferior alveolar nerve.

This nerve enters the mandible at the mandibular foramen and exits at the mental foramen.

The inferior alveolar nerve supplies sensation to the lower teeth on half of the dental arch as well as sensation to one side of the chin and lower lip.

22

A 16-year-old girl presents with bilateral cervical lymphadenopathy. Her lymph node biopsy reveals a nodular sclerosing Hodgkin's disease.
Which one of the following features indicates a poorer prognosis?

Important prognostic features in Hodgkin's disease (HD) are stage B symptoms:

Fever
Night sweats, and
Weight loss.
A mass of >10 cm in size is also a poor prognostic factor.

Therefore although fatigue and pruritus are common, they have no prognostic significance.

EBV infection commonly is associated with HD but has no prognostic significance.

23

A 40-year-old male presents with a six hour history of profuse vomiting and over the last two hours had developed left sided chest pain and dyspnoea.
On examination he had a pulse of 110 beats per minute regular and a blood pressure of 168/90 mmHg.
On palpation, he had crepitus over the left supraclavicular region and neck, reduced heart sounds and left basal sided crackles, plus some dullness to percussion over the right base of the chest.
What is the most appropriate initial investigation?

Gastrograffin swallow

This man has a history of vomiting which then progressed to chest pain.

The most relevant finding on examination is the crepitus over the chest indicating surgical emphysema. The most probable cause is therefore spontaneous rupture of the oesophagus.

Mackler's triad (vomiting, chest pain and surgical emphysema) is classical but absent in almost half the cases.

The chest x ray (CXR) may reveal the surgical emphysema and a gastrografin swallow is diagnostic.

A CT scan should be performed if a gastrografin swallow is not possible or negative.

Lateral neck x rays may be useful in the early stages where the diagnosis is uncertain and surgical emphysema is not seen on a plain CXR.

Oesophagoscopy has a role in trauma but not in small mucosal tears as here.

24

A 32-year-old female who takes the oral contraceptive pill presents with acute chest pain and dyspnoea. Examination reveals a pulse of 110 bpm, a blood pressure of 92/68 mmHg and oxygen saturations of 88% on air. Investigations confirm a large pulmonary embolism (PE).

Thrombolysis
The woman has a life threatening PE as suggested by low blood pressure and low saturations on oxygen. The most appropriate therapy for this patient would be thrombolysis with streptokinase/tPA.

25

A 70-year-old male who has successfully undergone right hip replacement for osteoarthritis. He has a past history of hypertension and is a smoker of five cigarettes daily. He has a blood pressure of 148/82 mmHg and a pulse of 88 beats per minute.

Prophylactic LMWH
This man has a high risk of VTE following hip surgery, and prophylactic low molecular weight heparin (LMWH) is the most appropriate therapy to prevent VTE. Specifically, LMWH is advocated in guidelines for hip replacement surgery. The major risk factors in this patient are the orthopaedic surgery, age above 60 and smoking.

26

A 32-year-old woman presents with dyspnoea and left-sided chest pain. She is 22 weeks pregnant. Examination reveals a pulse of 92 beats per minute, blood pressure of 120/82 mmHg and oxygen saturations of 95% on air. Ventilation perfusion scan suggests a high probability of pulmonary embolism.

Treatment dose LMWH
The pregnant woman has a PE but is not compromised. Consequently treatment dose LMWH should be used initially and this will need to be continued throughout her pregnancy. Warfarin is contraindicated during pregnancy as it is teratogenic.

27

A 55-year-old male who is to have transurethral resection of the prostate (TURP) for prostatic hypertrophy under regional anaesthesia. He is a non-smoker and there is no past medical history of note.

Prophylactic low molecular weight heparin
It is a balance of risk of bleeding from the surgery and the risk of DVT from operative position and a day or more of reduced mobility.

28

A 62-year-old male presents six days after TURP with a swollen and painful left lower leg. Dopplers confirm a distal deep vein thrombosis (DVT).

Treatment dose low molecular weight heparin
This case has a DVT following TURP. Even though it is distal, there is an approximately 30% chance of progression and should be treated.

Treatment doses of low molecular weight heparin (LMWH) would be the most appropriate prior to commencing warfarin. Warfarin should not be used initially on its own in cases of VTE as it may have a prothrombotic effect. Thus LMWH should be used until the INR is in the desired range, usually 2-3.

29

A 47-year-old woman presents three weeks after a laparoscopic cholecystectomy with chest pain and breathlessness. On examination, she is comfortable with oxygen saturations of 92% on air, a blood pressure of 142/90 mmHg and a pulse of 86 bpm. A ventilation perfusion scan suggests a high probability of a pulmonary embolism (PE).

Treatment dose low molecular weight heparin
This case requires treatment dose LMWH for PE. PE is a potentially fatal condition and LMWH should be initiated prior to commencing warfarin.

30

A 25-year-old male was brought into the Emergency department following a motorbike accident. He was found unconscious lying prone about 25 meters from the bike. He had been intubated at the site. His neck was protected with a collar. He was being mechanically ventilated with 100% oxygen in the emergency department. He had a thready pulse of 100/min, blood pressure of 70/50 mmHg, SaO2 of 90%. Trachea is central but air entry is decreased on the left side with a tympanic note on percussion.

In situations of trauma, it will help to remember ABCD.

In all circumstances management of airway comes before breathing; breathing before circulation; circulation before dysfunction/disability. The answers to above scenarios are based on these principles.

Clinically this young male in a road traffic accident has a pneumothorax on the left side. The immediate treatment of this is needle thoracotomy/decompression buying time for a more definitive insertion of an intercostal drain.

31

A 20-year-old female horse rider was brought into the emergency department on a spinal board having fallen of her horse. She was complaining bitterly about being restrained on the spinal board because her back was hurting. On examination, she had a pulse of 120/min, blood pressure of 84/30 mmHg, normal chest examination. Abdominal examination showed a bruise and tenderness on her left hypochondrium and lumbar regions. She had a decreased sensation below her knees and she could not move her toes.

The female involved in a horse riding accident probably has a spinal injury and may also have a splenic haemorrhage but before proceeding further she needs venous access and fluid resuscitation.

32

A 55-year-old male was admitted after having a high speed accident in his car. He was found with his head on the steering wheel. His airway was patent, neck protected with appropriate collar and intravenous (IV) access secured. His primary survey revealed severe facial injuries, Glasgow Coma Scale (GCS)of 13/15 and probable pelvic and bilateral femoral fractures. During secondary survey, his respiration was noted to be laboured with gurgling sounds and GCS suddenly dropped to 6/15.

Endotracheal tube intubation
The 55-year-old male has developed an airway problem and so needs definitive airway management prior to urgent CT head scan.

33

A 3-year-old boy presents with fever and ear pain. He was treated last week with antibiotics for acute otitis media, and initially improved. On examination he has swelling and tenderness behind the ear.

Acute mastoiditis
This child had symptoms of acute otitis media, and now has mastoid inflammation, mastoiditis.

34

A 14-year-old presents with a history of chronic ear pain and discharge. On examination he has a right perforated eardrum with whitish protrusion through it.

Acquired cholesteatoma
In this child there are chronic middle ear problems and a visible cholesteatoma.

35

A 6-year-old girl presents with left ear pain. On examination there are vesicles in the left ear canal and left facial weakness.

In this girl there are vesicles in the ear canal and facial weakness. This is likely to be herpes zoster (Ramsay-Hunt syndrome).

Ear pain can be associated with abnormal external ear findings, abnormal middle ear findings or neither.

36

Fat embolism

Fat embolism is associated with major trauma and may manifest as increasing dyspnoea, hypotension and falling saturations.

PO2 and PCO2 are low.

It is associated with embolisation to the skin and a typical petechial rash.

37

Regarding animal bites

Eighty percent of mammalian bites are due to dogs. The majority follow provocation and affect the hand. Crush injuries may accompany dog bites. Cats' teeth are sharper so may penetrate joints and bone. Osteomyelitis may occur from penetrating hand wounds or crush injury.

Up to 20% of dog bites and 80% of cat bites become infected. One study found a median of five bacterial isolates, with 56% involving both aerobic and anaerobic organisms.

Pasteurella species are the most commonly identified organism, canis in dog bites and multocida in cat bites. Other commonly identified organisms are Streptococci, Staphylococcus aureus, Neisseria sp. and Bacteroides sp.

One rare but important organism is Capnocytophaga canimorsus. If septicaemia occurs with this infection mortality is 25% - 30%.

Potential complications include:

Osteomyelitis
Septic arthritis
Abscesses
Bacterial tenosynovitis.
Immuno-compromised patients may develop bacteraemia and meningitis. Cosmetic and functional damage may be severe. Psychological fear may persist long term.

Rabies from a dog bite has not occurred in the UK since 1906. Since 1946 there have been 24 cases, all contracted abroad (usually in the Indian sub-continent). However, in 2002 a licensed bat handler died of European bat Lyssavirus 2, a rabies-like virus.

38

Pulmonary oedema

Causes a raised JVP

Patients with pulmonary oedema present with

Dyspnoea
Anxiety
Orthopnoea
Tachycardia
Tachypnoea
Productive cough
Blood-tinged (pink) sputum
Wheeze.
Signs include

Pulsus alternans
Raised jugular venous pressure
Gallop rhythm
Fine lung crackles.
Both arterial PO2 and PaCO2 fall in the early stages, but later the PaCO2 increases because of impaired gas exchange.

The chest x ray may reveal

Cardiomegaly
Bilateral diffuse haziness owing to alveolar fluid
Small effusion at cost-phrenic angles
Fluid in the lung fissures
Kerley B lines (linear opacities).
Collapse is a feature of atelectasis, whilst consolidation is a feature of pneumonia.

39

Head injury in children

Head injury is the commonest cause of trauma death in children aged 1-15 years. In infancy (up to 12 months of age) the commonest cause of fatal head injury is child abuse.

Primary brain damage is caused by

Cerebral lacerations
Cerebral contusions
Dural sac tears
Diffuse axonal injury.
Secondary damage occurs because of the consequences of the brain injury, or from associated injuries and stress.

Causes of this include

Ischaemia from poor cerebral perfusion due to raised intracranial pressure
Ischaemia due to blood loss and hypotension.
Hypoxia and hypoglycaemia are other causes.

40

Pulmonary embolism associations

Venous thromboembolism is more common in obese patients due to poor mobility and venostasis.

Orthopaedic operations on the hips and pelvis increase the risk of thromboembolism as does trauma to the lower limb. This is due to venostasis in prolonged cases, hypercoagulability and blood transfusion.

A pulmonary infarct may develop in the territory of a pulmonary embolism and will appear as a wedge-shaped area of consolidation on the chest radiograph.

Pelvic surgery increases the risk of thromboembolism due to

Trauma to the pelvic veins
Prolonged procedures
Hypercoagulable states often associated with malignancy.
Surgical termination of pregnancy is a short procedure and does not increase the risk of thromboembolism.

41

Adult burns

Irrigate chemical burns

All clothing should be removed as soon as possible; any skin that is adherent and peels off with the clothing is 'dead' and it is essential to remove all dead tissue.

Like other forms of burns, chemical burns should be irrigated with copious amounts of water, ensuring, as far as possible, that this irrigation does not come in contact with undamaged skin (alkaline burns will need irrigation for longer duration).

Application of silver sulfadiazine before the patient is transferred to the burns unit is not recommended since this makes it difficult accurately to assess the burn depth.

Crystalloids or colloids could be used in the initial resuscitation of a burns patient. Adequate hydration is more important than the precise type of fluid used.

Nasogastric tubes help to decompress the stomach. This ensures mucosal integrity thus minimising the risk of endogenous infection and bacterial translocation. There is no evidence to suggest that NG tube causes gastric ulcers in burn patients.

42

Assessing burns severity

There are four stages to the assessment of burns for severity:

Associated smoke inhalation:
All affected children should be admitted for observation.

Depth of burn:
Superficial: epithelium intact, exquisitely painful
Partial thickness: blistering, pink mottled skin
Full thickness: skin is destroyed down to and including the dermis, and healing is from the margins. Skin is white, charred and painless.

Surface area of burn:
This is worked out from a special chart, since the percentage for each area of the body changes with age (for example, Lund-Browder chart).

Percentages are calculated independently for each level of burn. Greater than 50% burns have a limited chance of survival.
Involvement of special sites:
The face, the mouth and the hands and the perineum are particularly important.

43

Childhood accidents

Unintentional injuries including poisonings are the most common cause of death between the ages of 1 and 14 years.

Reduction in the rate of accidents in children under 10 by 33% by the year 2005 was a Health of the Nation target.

The causes reflect the child's stage of development and ability to understand danger, in addition to the degree of exposure to various hazards.

Motor vehicle accidents (particularly pedestrian) are the most common, followed by fire and flame, and followed by drowning, followed by inhalations and ingestions.

There is a marked social class gradient. This partly reflects different environmental circumstances (for example, playing on roads).