Emergency Medicine Flashcards

Question

Answer 1

Right middle lobe pneumonia with loss of right heart border but preservation of right hemidiaphragm

Answer 2

Subcutaneous emphysema (free air in skin and soft tissues) demonstrated by free air seen in left and right lower chest wall soft tissues and right upper neck soft tissues. eg from chest trauma, free air leaking from lungs into soft tissues

Answer 3

Pneumomediastinum (free air in mediastinum involving the pericardial sac), eg from Boerhaave’s syndrome perforated oesophagus. Incidentally, note the subcutaneous emphysema in right lateral chest wall soft tissues and neck soft tissues.

Answer 4

Acute pulmonary oedema demonstrated by opacification of both lung fields in the context of no fever or cough. Note: If clinical history suggested fever and cough then this Xray could be interpreted as bilateral pneumonia!

Answer 5

Right lower lobe pneumonia with preservation of right heart border

Answer 6

Large bowel obstruction with dilated loops of bowel. Large bowel because there are plicae semilunares that do not cross bowel lumen.

Answer 7

Small bowel obstruction with dilated loops of bowel. Small bowel because there are plicae circulares that cross the entire lumen.

Answer 8

Small bowel obstruction with dilated loops of bowel AND air fluid levels. Small bowel because there are plicae circulares that cross the entire lumen.

Answer 9

NAILED Neuromuscular - Guillian Barre - Motor neuron - Snake bite Airway obstruction - Anaphylaxis - Trauma ICP Raised - Stroke - Head injury Lung Pathology - COPD - Pneumonia - APO - Severe asthma Epilepsy - Post seizure Drugs - Sedatives or analgesics e.g. morphine or diazepam - Paralytics

Answer 10

ABCD Adrenal insufficiency - Addison’s disease Bicarbonate Loss - Renal tubular acidosis - GI diarrhoea - Ileal conduits Chloride Excess - Sodium chloride IV Drugs - Acetazolamide - Spironolactone

Answer 11

KARMEL Ketones - Diabetic ketoacidosis Aspirin Renal Failure Methanol Ethylene Glycol Lactate - Sepsis

Answer 12

GLARE Gut losses - Vomiting / NG losses Lung COPD - COPD chronic hypercapnia with metabolic alkalosis then acute hyperventilation Alkali excess - Antacids, milk alkali - HCO3 infusion Renal - Diuretics e.g. frusemide - Barters syndrome Excess Endocrine - Aldosterone excess - Cushing’s - Steroids

Answer 13

5P’s Pain Panic Pregnancy asPirin hyPoxia

Answer 14

Dx: NAGMA with adequate resp compensation, expected CO2 17 via Winters (8+1.5x6=17) thus adequate compensation, AG 14 (140-120-6=14) which is upper limit but normal. DDx for NAGMA = ABCD, bicarbonate loss from diarrhoea. Bonus mark if recognised hypoglycaemia BSL <4

Answer 15

Dx: Metabolic acidosis with mild respiratory alkalosis compensation. Winters expected CO2 1.5x16+8=32, but actual CO is 38, thus there is a resp acidosis second disorder. AG 132-92+16=24, DDx for HAGMA = KARMEL = likely diabetic ketoacidosis. Overall diagnosis of DKA metabolic acidosis with inadequate respiratory compensation and concurrent respiratory acidosis due to hypoventilation from reduced level of consciousness (part of severe DKA)

Answer 16

Dx Resp Alkalosis, with mild renal / metabolic compensation. DDX resp alkalasis = 5Ps eg panic attack hyperventilating, consider chest pain causing hyperventilation. DDx for chest pain include PE, amphetamines/cocaine causing angina, pericarditis, pancreatitis

Answer 17

1. Resuscitationist (e.g. cardiac arrest, thrombolysis, severe sepsis, severe trauma, intubation, defibrillation, thoracotomies, IO) 2. Generalist (e.g. ingrown toe nails, diarrhoea, chronic back pain, drug seekers, suicidal ideation, FB from ears/ noses, coughs and colds, miscarriages) 3. Diagnostician (e.g. always looking for the red flags or the life threats)

Answer 18

1. Elderly (>65 years; medications, don’t mount immune response) 2. Paediatrics (<3months; neonates rapidly deteriorate, might look well initially) 3. Pregnancy (different vital signs, 2 lives involved) 4. Mental health (may have normal vitals but have behavioural disturbances which pose a risk to them and those around them) 5. Poisonings (can have normal vitals initially, but may rapidly deteriorate)

Answer 19

1. Look at the pH - Is there Acidaemia? (pH is down) - Or is there Alkalaemia? (pH is up) 2. What is the primary disturbance? - Is it a metabolic (CO2) processes that is causing the disturbance? - Or is it a respiratory (HCO3) process that is causing the disturbance? 3. Is their compensation? - That is, has the body made steps to reverse the current pathological blood gas state through compensation - The body can compensate through either metabolic or respiratory processes - If there is a metabolic acidosis, compensation is determined through the Winters Formula (provides the expected carbon dioxide level should be for a specific metabolic acidosis, basically so we can determine if there is adequate compensation letting us know if there is a secondary respiratory disorder) 4. Determine a differential diagnosis - This is done using a differential diagnosis table

Answer 20

metabolic acidosis The formula is as follows; Winters formula=(1.5*Bicarbonate)+8 Step 3: Because the patient is in metabolic acidosis, we use Winter’s formula to decipher whether there is appropriate respiratory compensation. (1.5*6) + 8 = 17. As the actual CO2 is 18 there is appropriate respiratory compensation (it is important to note that if CO2 levels where below 40 but not close to 17, it would show a metabolic acidosis with a concurrent respiratory acidosis

Answer 21

1. Metabolic Acidosis NAGMA (Normal Anion Gap) 2. Metabolic Acidosis HAGMA (High Anion Gap)  Using the above example, the following is true; - Anion Gap = Na – HCO – Cl  Using the normal anion gap range of 6 to 14

Answer 22

 When interpreting ECGs, the acronym RRABI can be used. The breakdown is as follows; 1. Rate - Find the heart rate - One method of determining rate is by counting the QRS complexes in rhythm strip and multiplying by 6 - Can be either Tachycardia (faster than normal) or Bradycardia (slower than normal) 2. Rhythm - Check for P waves before each QRS complex and ensure there is regularity - The best leads to check this are V1 and V2 - Can be Sinus Rhythm, SVT, AF, Aflutter, VF or VT 3. Axis - Can be either normal, left axis or right axis - This is found by checking the QRS complex’ in leads 1 (left) and aVF (right) - If there are ‘two thumbs up’ it is normal - If they are leaving each other it is left axis - If they are pointing towards each other it is right axis 4. Block - There are two different types of blocks, AV blocks and Bundle branch blocks - When the PR interval is more than 200ms, it indicates an AV block (5 small squares as each square is 0.04 seconds so 5 small squares) - When the QRS interval is more than 120ms it indicates a Bundle branch block (3 small squares) - AV blocks can further be classified as; 1st degree, 2nd degree (type 1 and 2) and 3rd degree heart block - Bundle branch blocks can further be classified as either LBBB or a RBBB 5. Infarction - Is shown by our ST Segment Elevation - Can indicate the following; Anterior STEMI, Lateral STEMI, Inferior STEMI or Pericarditis

Answer 23

 As with CPR, when interpreting chest X-rays the acronym DRS ABCDE is used 1. Details - Patient Name and Date of Birth - Date and Film Type 2. RIPE Image - Rotation: When checking if the film is rotated, look at the distance from the edge of the clavicle to the spinous processes. If equal on both sides, the image is not rotated - Inspiration: When checking for normal inspiration, count the number of anterior ribs shown (normal is between 5 – 6) - Projection: Refers to the direction in which a chest x-ray is taken. It can be either AP (anterior to posterior) or PA (posterior to anterior). This is important because the heart appears 25% bigger than its actual size in AP. A PA film will never show the scapula’s (as they are externally rotated due to the position taken by the patient during imaging) - Exposure: An x-ray with normal exposure should show the lumbar vertebrae. If the photo is underexposed, they won’t be visible (too white). In a clinical scenario this could mean pathologies appear more serious than they are 3. Soft Tissues and Bones 4. Airways and Mediastinum - Check the trachea midline (is it shifted suggesting a pneumothorax) - Measuring the mediastinum occurs at the carina (level of the bifurcation of the left and right bronchus) from the left to right margins. If it is more than 8cm it is pathological (possible aortic dissection) 5. Breathing - Observe the various Lung fields, comparing from left to right - Observe the pleura 6. Circulation - Look for heart position, its borders, shape and size (diameter should be less than 50% of the diameter of the entire chest. In other words, the cardio-thoracic ratio should be less than 50%) 7. Diaphragm - Observe both hemidiaphragms (meaning each half of the diaphragm) 8. Extras - Any extra thingamajigs in there e.g. plastic, PICC lines etc.

Answer 24

 When practicing emergency medicine, it is important to realise that the airways differ significantly between paediatric patients and adult patients  The key differences are outlined below; 1. Occiput size - The occiput is the back of the head, in paediatrics patients this will be much larger in relation to their body when compared with adults - As a result, paediatrics heads are typically flexed when lying down, occluding the airway 2. Tongue size - Paediatric patients have a bigger tongue in relation to their size when compared with adults - This larger tongue impedes the view 3. Soft palette - A child’s soft palette is much more friable (tissue that readily tears, fragments or bleeds when palpated or manipulated) making intubation difficult - This increases risk of bleeding from laryngoscope etc. 4. Epiglottis - A child’s epiglottis is much bigger and floppier compared to adults 5. Larynx - The larynx is much more anterior (forward) in a child making intubation more difficult due to reduced cord visibility 6. General shape - A child’s airway resembles a funnel shape (compared to the cylinder shape in an adult) with the narrowest part at the level of the cricoid (known as the cricoid ring) - This means that often you can navigate through the vocal cords well, but once the Endotracheal tube passes through it may get stuck at the cricoid - In adults the vocal cords are the narrowest point

Answer 25

 There are 3 types of risk factors for atherosclerosis; 1. Non-Modifiable - Age - Family History of Cardiovascular disease - Male Gender - Hereditary (e.g. ethnicity) 2. Modifiable - Hypertension - Atherogenic dyslipideamiaa - Microalbuminuria - Diabetes mellitus 3. Lifestyle Modifiable - Diet and Nutrtion - Physical inactivity - Stress - Smoking and alcohol - Obesity and overweight

Answer 26

PULMONARY EMBOLISM  Is a condition caused by a blockage of one of the pulmonary arteries in your lungs  80% of pulmonary embolism cases are caused by clots in the periphery (particularly your lower limbs) which moves up into the Inferior Vena Cava, into the right ventricle and finally becomes lodged in one of the pulmonary arteries  The relevant risk factors for this condition include (HAD CLOTS); - H: Hormone - A: Age less than 50 - D: Deep Vein Thrombosis or pulmonary embolism history - C: Cough blood - L: Leg swelling - O: Oxygen low - T: Tachycardia - S: Surgery

Answer 27

1. Septic and Distributive shock (an issue with blood vessels vasodilating, effecting the distribution of the blood, not the volume) - Septic shock (sepsis) - Anaphylactic shock (anaphylaxis) - Neurogenic shock 2. Hypovolaemic shock (not enough blood) - Haemorrhagic - Fluid loss 3. Obstructive shock (vessels being blocked) - Tamponade - Tension Pneumothorax - Thromboembolism (pulmonary embolism) 4. Cardiogenic shock (issue with the pump) - Rhythm (Tachy VF / VT, Bradycardia 3DHB - Ventricles (STEMI, Cardiomyopathy, Myocarditis) - Valves (Mitral regurg, Aortic Stenosis, Endocarditis) 5. Kemicals kill you shock (Dissociative shock as they cause oxygen to become dissociated off the Haemoglobin because of the chemicals) - Carbon Monoxide - Cyanide - Methemoglobinemia

Answer 28

1. Class 4 - HR: >140 - Blood Pressure: Hypotensive - Blood Loss: more than 40% (more than 2L of blood) 2. Class 3 - HR: 120 - 140 - Blood Pressure: Hypotensive - Blood Loss: 30 – 40% (1.5 – 2L of blood) 3. Class 2 - HR: 100 – 120 - Blood Pressure: No hypotension - Blood Loss: 15 – 30% (0.75 – 1.5L of blood) 4. Class 1 - HR: <100 - Blood pressure: No hypotension - Blood Loss: up to 15% (up to 0.75L of blood)  Whenever a patient has hypotension (below 90/60), they are automatically at a class 3 of haemorrhage

Answer 29

HAEMORRHAGIC SHOCK  Is a type of hypovolaemic shock that is characterised by reduced tissue perfusion due to a loss of blood resulting in inadequate tissue perfusion of oxygen  If the blood loss is caused by trauma, there are 6 possible sources of bleeding (SCALPR); 1. Skin 2. Chest 3. Abdomen 4. Long bones (e.g. fractured femur can lose 2L of blood) 5. Pelvis 6. Retroperitoneum (e.g. aortic ruptures)

Answer 30

1. Haemostatic resuscitation (which are all lost during blood loss, and are replaced to try and normalise the blood volume) 2. Permissive hypotension - Means we are not trying to get a normal blood pressure, we are trying to get a decent blood pressure - The target is a Systolic Blood Pressure of 90 - This prevents hydrostatic clot disruption (of the clots occluding the smaller vessels stopping bleeding) - The exception is head trauma, where we want a high blood pressure to get perfusion to the brain 3. Damage control surgery - Means you stitch up what you have to do to save the patient - Fix physiology not anatomy - E.g. Stop bleeding, reduce contamination from bowel perforation or interventional angiography

Answer 31

QUICK SOFA (qSOFA)  Is not a diagnostic tool for sepsis, but instead is a predictor of mortality  The Quick SOFA score does this through using the following 3 parameters; 1. Low Blood Pressure - Systolic Blood pressure less than or equal too 100mmHg (1 point) 2. Respiratory Rate high - 22 or more breaths per minute (1 point) 3. Altered consciousness - Glasgow Coma Score of less than 15 (1 point)  If a patient has a score of 2 or more with sepsis, the patient has a 10% mortality  It is important to remember the qSOFA score does not diagnose sepsis, but is instead a predictor of mortality (tells us which patients with sepsis we need to watch closely) Assessment qSOFA Score Low Blood Pressure (SBP ≤ 100mmHg) 1 High Respiratory Rate (>/= 22 breaths/min) 1 Altered mentation (GSC <15) 1

Answer 32

2. Golden hour of Sepsis (FOCCALS) - Fluids: Usually up to 30ml/kg - Oxygen: Reduces their oxygen demand - Cultures: Blood, urine, sputum, skin, throat, faeces - Catheter: Monitor urine output - Antibiotics: Give broad spectrum within 1 hour (single thing that improves mortality of sepsis. Every hour you delay, the patient’s mortality increases by 5 – 10%) - Lactate: monitor lactate levels - Source Control: Get the pus out e.g. drain abscess, if cholecystitis (gall bladder infection) then theatres, if necrotising fasciitis then debride, if infected renal stone then remove

Answer 33

1. The 4 Hs - Hypoxia - Hypovolaemia - Hyperkalaemia and Hypokalaemia (metabolic disorders) - Hypothermia and Hyperthermia 2. The 4 Ts - Tension Pneumothorax - Tamponade - Toxins - Thrombosis (pulmonary or coronary)

Answer 34

SYNCOPE  Is a temporary loss of consciousness related to insufficient blood flow to the brain (also known as cerebral hypoperfusion) that results in the following 4 features; 1. Brief loss of consciousness 2. Loss of muscle tone 3. Spontaneous recovery without treatment 4. Completely back to baseline

Answer 35

DIZZINESS  Is a vague term used to describe a range of sensations  The most common sensations include Pre-syncope (light-headedness of feeling faint), Vertigo (A false sense of motion or spinning), Disequilibrium (Unsteady or a loss of balance) or it can be Nonspecific (feeling of floating, wooziness/heavy headedness, going to pass out)

Answer 36

VERTIGO  Is a false sense of motion or spinning  The fundamental pathology that causes vertigo is some issue with a person’s balance

Answer 37

 If the patient has sudden onset vertigo that comes and goes and gets better when they sit still (as is a classic history of BPPV), you should perform a Dix-Hallpike Test to confirm BPPV; VERTIGO – DIX HALLPIKE MANOEUVRE  The process of the examination is outlined above  A positive Dix Hallpike would suggest BPPV  The actual clinical findings that suggest a positive Dix-Hallpike manoeuvre are outlined below; 1. Latency period (Nothing will happen for the first 3 seconds. Then 3 – 5 seconds there will be Nystagmus) 2. Rotational and Upward nystagmus 3. Decay (findings resolve after 30 seconds) 4. Fatigability (vertigo decreases with repeated testing because crystals are moved into the correct place) 5. Recurs on sitting back up  It is important to note that the downward ear is side of pathology  The treatment for EPPV is the Epley manoeuvre, which basically just involves turning their head to the other side and bringing it back up (after the Hallpike manoeuvre) which moves the crystals back around the semicircular canal into the utricle and saccule via gravity

Answer 38

 A positive Head Impulse Test indicates Vestibular Neuritis (peripheral); - You take the patients head in your two hands and ask them to fix their eyes on a point behind you - You then rotate her head to one side slowly, then quickly rotate it back to the centre - If her eyes can’t focus and they overshoot or twitch, she has a positive head impulse sign with a catch-up/corrective saccade - This indicates Vestibular Neuritis (excludes stroke)

Answer 39

 A positive HINTS exam indicates Stroke (central) - HINTS exam stands for Head Impulse (1) Nystagmus (2) Test of Skew (3) - First step is a Head Impulse Test. A positive Head Impulse Test (meaning they have a catch-up saccade) indicates Vestibular neuritis (stop the exam) - If you have a negative Head Impulse Test, they don’t have a catch-up saccade which it is bad. You move onto the second step - You check for Nystagmus (look left look right). If they have positive bidirectional Nystagmus (both when looking left and right) it indicates a central cause of vertigo - The final test is the Test of Skew. Involves covering one eye and checking for vertical skew deviation when you remove the cover. If the eye moves, it is a positive test of skew indicating a central cause of vertigo

Answer 40

 Is a clinical sign of abdominal blunt trauma caused typically by a lap belt which compresses the abdominal organs and hyperflexes the thoracolumbar spine during a crash  The seatbelt sign is commonly associated with; 1. Solid organ damage - Pancreas - Liver - Spleen laceration 2. Hollow organ damage - Duodenal perforation 3. Vascular injury - Mesenteric tears - Iliac thrombosis - Aortic rupture 4. Diaphragm injury - Usually left diaphragm 5. Bony injury - Chance fracture, which is a horizontal vertebral body fracture caused by hyperflexion of the chest whilst the seatbelt holds the lumbar vertebrae in place causing a traction injury of the thoracic vertebra going over the lumbar vertebra (usually T12 or L1) 6. Nerve injury - Spinal cord injury  It is important to note that bowel perforations can have a delayed presentation of up to 8 hours (despite the initial CT being normal) due to micro perforations  It is therefore important that all patients that present with the seatbelt sign are considered for admission and observation for 24 hours

Answer 41

1. Eye opening - Spontaneously (4) - To verbal command (3) - To pain (2) - Nil (1) 2. Verbal response - Orientated (5) - Confused (4) - Inappropriate words (3) - Incomprehensible sounds (2) - Nil (1) 3. Motor response - Obeys command (6) - Localises the pain (5) - Withdraws to pain (4) - Abnormal flexion (3) - Extension to pain (2) - Nil (1) 1. Mild (GCS of 14 - 15) - Likelihood of positive CT scan is 10% - 1% will require neurosurgery 2. Moderate (GCS of 9 – 13) - Likelihood of positive CT scan is 40% - 8% will require neurosurgery 3. Severe (GCS of less than 9) - Mortality is around 40%

Answer 42

Cushing’s Triad; Bradycardia, Hypertension and Apnoea. Eventually this leads to death  As well as this Cushing’s triad, there are 5 neurological red signs which indicate herniation; - GCS drop by 2 points - Unilateral dilated pupils 3. Heart: Cushing’s triad - Dystonic posturing - focal limb seizures

Answer 43

1. C-spine collar off - Prevent jugular venous congestion and back pressure to the brain 2. Hypotension and Hypoxia AVOID - A single episode of hypotension increases mortality by up to 25% - Target a higher MAP of 80 – 90 to maintain CPP in high ICP - Avoid hypoxia to avoid secondary brain injury 3. Intubate and Hyperventilate - Target CO2 of 35 which causes rapid cerebral vasoconstriction, reducing cerebral blood flow, reducing bleeding and reducing herniation (temporarily) - “Carbon dioxide is a potent vasoactive agent, and lowering the arterial carbon dioxide partial pressure (PaCO2) by hyperventilation results in a rapid reduction of Cerebral Blood Flow of 2% for every 1-mm Hg decrease in the PaCO2. Because reductions in CBF reduce total cerebral blood volume, hyperventilation quickly lowers ICP. Induced hyperventilation can transiently abort brainstem herniation in the presence of critically elevated ICP until an alternative therapy can be initiated. However, the vasoconstriction and increased CVR caused by hyperventilation can lead to dangerous reductions in CBF, with resulting cerebral ischemia.” 4. Seizure prevention - Increased rigidity and muscle tone means there will be decreased cerebral venous return from the head back to the heart which will increase their ICP - Give anti-convulsant as seizure prophylaxis 5. Saline 3% - Hypertonic saline to increase MAP and draw water out from the brain to reduce intracerebral oedema 6. Sedation - If patient wakes up and coughs on tube, there will be a raised ICP 7. Elevate head 30 degrees - Reduces intracerebral pressure by increasing venous drainage from brain due to gravity 8. Last resort use a chisel (neurosurgery) - Burr hole or craniotomy

Answer 44

 Is a combination of the Canadian and NEXUS C-spine rules that is used in clinical practice  It has 3 main steps; 1. Mechanism - If there are any high-risk factors, you need to do radiography - E.g. Age above 65 years, dangerous mechanism, paraesthesia’s in extremities 2. Nexus Criteria (acronym NSAID) - Neurology? - Spinal Tenderness in midline? - Altered level of consciousness? - Intoxicated? - Distracting injury? (mask the pain of spinal injury e.g. broken bone) - If none of the above move to step 3. If even one of the above, perform radiography 3. Move neck - Rotate neck 45 degrees left and right, ask them to put chin to chest while applying axial load to top of head - If no pain on any of the above the C-Spine is clinically cleared (take c-spine collar off, there is no need for radiography)

Answer 45

 Is the next step of the dealing with an emergency trauma case  You should only start the secondary survey when; - The immediate life-threatening injuries have been identified and treated - The patient’s vitals are returning to normal  That is, if the patient is still unstable, then you are still in the primary survey so go back to ABCDE  The key components of the secondary survey include; 1. History 2. Physical exam (head to toe) 3. Complete neurologic exam 4. Special adjunct diagnostic tests (e.g. CT scan, MRI scan) 5. Re-evaluation

Answer 46

PHYSICAL EXAM (head to toe)  Is a vital part of the secondary survey which aims to find all injuries, across the entire body  A complete outline is given below; 1. Head - Scalp - Hemotympanum (blood behind eardrum) - Battles sign (blood in mastoid) - Eye movements - CSF leak (nose, mouth and ears) 2. MaxFax - Bony tenderness (mandible – get to open and close mouth) - Malocclusion 3. Neck - Hoarse voice - Crepitus - Haematoma - Stridor and bruit 4. Chest - Inspect - Palpation - Percussion - Auscultation - X-rays 5. Abdo - Inspect - Palpation - Percussion - Auscultation - CT 6. Pelvis - Pain - Leg length discrepancy - Instability 7. Perineum - Bruising - Urethral blood - Rectal bleeding - Vaginal bleeding - Anal tone 8. Extremities - Pain - Bruising - Deformity - Pulses - Reflexes - Neurology

Answer 47

 Is a fracture of the distal portion of the radius / ulna with dorsal angulation  This is common in patients who fall upon a an outstretched hand bending the forearm backwards  Features present on exam will include; 1. Dinner fork deformity 2. Median nerve injury - Numbness over the thenar eminence 3. Ulna nerve injury - Froment’s sing - Ulna claw

Answer 48

 Is a fracture of the distal radius through the dorsal aspect to the articular surface  This is common in patients who fall onto a dorsiflexed wrist  Features present on an exam will include; 1. Median nerve injury - Numbness on thenar eminence 2. Ulna nerve injury - Frogment’s sign - Ulna claw  This fracture effects the intra-articular surface of the wrist making it an unstable fracture  On the X-ray it is known as a dorsal cortex break (a break of the cortical bone)

Answer 49

 Is a fracture of the distal portion of the radius/ulnar with volar angulation  This is common in patients who fall upon an outstretched hand  Features present on an exam will include; 1. Garden-spade deformity 2. Median nerve injury - Numbness over the thenar eminence 3. Ulna nerve injury - Froment’s sign - Ulna claw

Answer 50

MONTEGGIA FRACTURE (MU)  Is a fracture of the proximal third of the ulna with dislocation of the proximal head of the radius  History is usually a fall on a dorsiflexed wrist  Features present on an exam include; 1. Median nerve injury - Numbness on the thenar eminence 2. Ulna nerve injury - Froment’s sign - Ulna claw  Features on an X-ray include a fracture in the proximal third of the ulna, an intact radius and a dislocation of the proximal head of the radius

Answer 51

GALLEAZZI FRACTURE (GR)  Is a fracture of the distal third of the radius with dislocation of the distal radioulnar joint as well as dislocation of the ulna styloid from the radioulnar joint  History is usually a fall on a dorsiflexed wrist  The features present on an exam are; 1. Median nerve injury - Numbness over the thenar eminence 2. Ulna nerve injury - Foments sign - Ulna claw  The signs on an X-ray will be a fracture in the distal third of the radius, an intact ulna bone with dislocation of the ulna styloid process from the radioulnar joint

Answer 52

MOTOR  Thumbs up = radial nerve  ‘Ok’ sign = median nerve  Star fish = ulna nerve SENSORY  1st dorsal webspace = radial nerve  Lateral index finger = median nerve  Medial 5th finger = ulna nerve

Answer 53

 Appears as the inability to extend the 4th and 5th digits at the interphalangeal joints whilst the metacarpophalangeal joints are in flexion whilst at rest  It is caused by a distal injury to the ulna nerve  It will be associated with; - Loss of function of the 3rd and 4th lumbricals and interossei - Sensory loss of the 4th and 5th digits

Answer 54

 Is characterised by an inability to flex the 2nd and 3rd digits and oppose the thumb whilst attempting to create a fist  It is caused by proximal median nerve injury (specifically to the anterior interosseous nerve)  Associated with supracondylar fracture

Answer 55

 Is a sign test for the function of adductor pollicis  It involves placing paper between finger and thumb, whilst asking the patient to grip the paper and resist the paper being pulled away - A normal result involves holding the paper without difficulty - Abnormal result involves patient flexing flexor pollicis longus to maintain grip pressure forming a beak  Froment’s sign indicates an abnormal function of adductor pollicis (ulna nerve injury)

Answer 56

 4 red flags on examination that suggest a fracture and the need for an X-ray: 1. Posterior malleolar tenderness 2. Base of 5th metatarsal tenderness 3. Navicular tenderness 4. Non-weight bearing (both immediately and in ED)  Lateral ligaments rupture first and from anterior to posterior in the order of: 1. Anterior talofibular (grade 1) 2. Calcaneofibular (+ 1 = grade 2) 3. Posterior talofibular (all 3 = grade 3)  Medial ankle ligaments are very strong so if rupture high likely to also have fracture 1. Deltoid

Answer 57

 Are fibular fractures that are classified into 3 different types relative to the syndesmosis (is the immovable fibrous joint between the distal fibula and tibia)  In other words, are fractures of the fibular classified based on where they occur  The more proximal the fracture, the higher the risk of syndesmotic disruption and ankle instability  There are 3 types; 1. Weber A - Below syndesmosis (Is at the tip of the lateral malleolus) - Most stable 2. Weber B - At the level of the syndesmosis (in the middle of the lateral malleolus) 3. Weber C - Above the level of the syndesmosis (above the lateral malleolus) - Is the most unstable - Requires immobilisation and surgical repair

Answer 58

MAISONNEUVE FRACTURE  Is a spiral fracture of the proximal third of the fibula with an unstable ankle (typically representing a ligamentous injury)  History includes an eversion injury, inability to weight bear and pain the median ankle  Also shows a foot drop due to peroneal nerve injury  Features on an x-ray include; - Talar shift leading to widening of the joint space between talus and medial malleolus (deltoid ligament rupture) - No fracture in the ankle - Spiral fracture of the proximal fibula

Answer 59

FOOT DROP  Is characterised by the inability or impaired ability to dorsiflex the foot leading to plantarflexion at rest  It is caused by an injury to the peroneal nerve resulting in the loss of function of the anterior compartment of the leg

Answer 60

 Is characterised by wrist flexion at rest and the inability to extend the wrist (as well as the inability to extend the fingers at the metacarpophalangeal joint)  It is caused by damage to the radial nerve

Answer 61

YOUNG-BURGESS CLASSIFICATION  Are pelvic fractures are typically associated with extremely traumatic events (falling off a roof, getting hit by a bus etc.)  This type of fractures are very serious, and require serious medical attention  There are 3 important types; 1. Lateral compression (hit from the side) - Show reduced pelvic volume - Typically caused by a side impact motor vehicle accident or pedestrian hit on the side of the hip by a car 2. Anterior posterior compression (hit from the front or back) - Show symphysis pubis widening - Motorbike head on collision causing pelvis to hit fuel tank - Have a high mortality from bleeding 3. Vertical shear (force from below) - Shows raised level of femoral heads - Jumping from height landing on one leg or motor vehicle accident knee into the dashboard - Have a high mortality from bleeding  These patients can bleed to death as the area is highly vascular  Bleeding is stopped via embolization

Answer 62

 Parietal pain is registered by the somatic plexus, visceral pain is registered by the visceral plexus  Parietal pain is much more sharp, localised and worse on movement  Visceral pain is much more dull, vague and can be colicky in nature

Answer 63

 Is pain originating in the viscera that presents in undamaged areas of skin  This occurs when afferent/sensory fibres of viscera and skin converge onto the same second order neurons within the spinal cord (common dermatomes)  Thus, when nociceptive information is triggered by the viscera, the body cant differentiate between the two locations, so we feel it on our skin  In other words, it is visceral peritoneum pain that is perceived as parietal pain due to a shared nerve root segment  It can be well localised or vague, sharp or dull, colicky or constant

Answer 64

1. C – Coagulopathy: Anticoagulants which make the animal bleed to death - Bleeding from bite sight, gums, rectum and cannula sites - Enlarged tender proximal lymph nodes - Can cause death from intracerebral bleeds 2. R – Renal failure: Nephrotoxins which cause organ failure to kill the animal - Reduced urine output - Intrarenal injury from the nephrotoxins (as well as indirectly by myotoxins) 3. Anaphylaxis to anti-venom: - Occurs in 1 – 4% of patients when given antivenom - Can cause death 4. M – Muscle breakdown: Myotoxins which tenderise the meat - Patients will feel muscle tenderness and myalgia - Urine will be Coca-Cola coloured from myoglobin’s (from muscle breakdown) 5. P – Paralysis: Neurotoxins which stop the animal from running away - Paralysis will be descending, that is, it will start from the small muscles of the face, and progress down into the respiratory muscles and limb weakness - Patients will be fully conscious but unable to speak, swallow or move

Answer 65

MENTAL STATE EXAM  Is a structured way of observing and describing a patient’s current state of mind  The components of a mental state exam are outlined below (ASEPTIC); 1. Appearance and behaviour 2. Speech 3. Emotion – mood and affect 4. Perception 5. Thoughts form and content 6. Insight and judgement 7. Cognition

Answer 66

 Consent must voluntary, informed and competent

Answer 67

 Competency is a global assessment and legal determination made by a judge in court  It is a legal decision made in court that states whether a person is or is not competent

Answer 68

 Capacity is a functional assessment and a clinical determination about a specific decision that can be made by any clinician familiar with a patient’s case CAPACITY  Capacity is a functional assessment and a clinical determination about a specific decision that can be made by any clinician familiar with a patient’s case  The way you test whether a patient has the capacity to make rational decisions is by the following 3 step process; 1. No CHIPS - Child - Handicapped - Intoxicated / Injured / Infection - Psychotic - Sedated 2. Normal vitals / GCS - Full name, DOB, Date, Time to the nearest hour, Place - Normal vitals - No sign of head injury or toxidrome or sepsis 3. Three questions - Understanding: What is your understanding of your illness? - Choices and Why: What do you want to do next and why? - Pros and Cons of each choice: What are the benefits and risks of each choice?

Answer 69

 Allows involuntary treatment of a patient against their will if they have a medical problem  Patients must satisfy the following criteria; 1. Medical problem 2. Not competent 3. Risk to self or others  How: Write in notes, “under the guardianship act, patient is deemed not competent and at risk to self and others due to medical diagnosis. Physical restraint and IM medication administered with patients’ best interests in mind”  E.g. Patient with a head injury, meningitis, drug induced, delirium, dementia

Answer 70

 Allows involuntary treatment of a patient against their will if they have a psychiatric problem  Patients must satisfy the following criteria; 1. Psychiatry problem 2. Not competent 3. Risk to self or others 4. No less restrictive way 5. Approved mental health facility 6. Needs immediate assessment  How: There are a number of formal forms to complete known as a Mental Health Recommendation  E.g. Patient with psychosis, depression

Answer 71

1. Verbal de-escalation - Space - Pals – build rapport - Affirm and empathy - Check understanding – check health literacy - Ease into negotiation – focus on what you CAN do them, not what you cant 2. Chemical restraint - If verbal de-escalation doesn’t work - Can be achieved by Oral sedation, Intramuscular or Intravenous injection 3. Physical restraint - Seclusion in isolation room - 5 point take down (one on each limb, one on the head) - Soft wrist restraints, police handcuffs - If a patient has a weapon, call the police (not security) - Then administer IV or IM sedation

Answer 72

1. Seizure 2. Head - Head injury (intracerebral bleed) - Stroke - Brain tumour 3. Infection - UTI - Pneumonia - Cellulitis - Encephalitis - Meningitis - Sepsis 4. Toxins/Drugs - Alcohol - Benzodiazepines - Opiates 5. Electrolytes - Hyponatraemia - Hypercalcaemia - Hypoglycaemia - Hyperthyroidism - B12 / Folate deficiency

Answer 73

SAD A FACES – SCREENING TOOL  Is a screening tool used for depression  The SAD A FACES screening tool is outlined below; 1. Sleep - Do you have difficulty falling or staying asleep? - Do you sleep too much? 2. Appetite - Has your appetite or weight changed? 3. Dysphoria - Have you been feeling sad or irritable recently? - Are they down in the dumps 4. Anhedonia - What do you do to enjoy yourself? - Has your interest in whatever changed at all? 5. Fatigue - How is your energy levels? 6. Agitation / retardation - Do you feel restless or slowed down? 7. Concentration diminished - Are you have trouble concentrating? 8. Esteem is low / guilt - Have you been down on yourself recently? 9. Suicide / thoughts of death - Do you sometimes feel life is not worth living? - Do you ever have thoughts about hurting yourself?  If you have 5 or more that are persistent over a month, it may suggest clinical depression

Answer 74

 Is a useful screening tool that is particularly useful for dealing with adolescent patients who may be dealing with a mental illness  The heads adolescent psychosocial assessment consists of the following components; 1. Home - Who lives at home with you? 2. Education - What are you good at in school? - What is hard for you? 3. Activities - What do you do in your free time? 4. Drugs - Many young people experiment with drugs, have your friends ever tried? 5. Sexuality - Are you involved in a relationship? 6. Suicide - Have you ever had thoughts of wanting to kill yourself?  The answers to these questions make up part of a psychological assessment

Answer 75

The process by which a clinician assesses a group of patients and sorts them according to the urgency* of which they need care.

Answer 76

Urgency is categorised using a standardised urgency rating scale such as the Australian Triage Scale. Urgency is independent of the severity or complexity of an illness or injury.

Answer 77

Urgency based on 3 factors: general appearance, focussed clinical history, physiological parameters ABC/vitals

Answer 78

1. Triage is a measure of urgency, not severity or complexity of a disease/illness. 2. Urgency is based on general appearance, history and physiological parameters. 3. Triage is a dynamic process. 4. Special populations exist eg elderly, paediatrics, pregnancy, mental health, poisonings.

Answer 79

Special populations: elderly >65 (medications, don’t mount immune response), paediatrics (neonates rapid deterioration, might look well initially), pregnancy (different vital signs, 2 lives involved), mental health (normal vitals but behavioural disturbance), poisonings (normal vitals, time critical then death)

Answer 80

Category 1 because abnormal vitals Resp rate <10 from heroin, hypoxic, life threatening. needs immediate review

Answer 81

Category 4 - Infected diabetic ulcer with normal vitals

Answer 82

Category 5 - 120mins

Answer 83

Mod/Severe asthma with abnormal vitals sats <90%, abnormal vitals means at least a Cat 3, however also has respiratory effort and is a child so Cat 2. Not a cat 1 because not immediately life threatening needing resus room.

Emergency Medicine Flashcards

EM MD3012 (124 cards)