Emergency Medicine

Question 1

What is involved in a rapid primary survey

Answer 1

Airway maintenance with C spine control

Breathing and ventilation

Circulation (pulses, hemorrhage control)

Disability (neurological status)

Exposure (complete) and Environment (temperature control)

• Continually reassessed during secondary survey
• Changes in hemodynamic and/or neurological status necessitates a return to the primary survey beginning with airway assessment

Question 2

Approach to cardiac arrest (hint: letters)

Answer 2

CAB

Chest compressions

Airway

Breathing

Question 3

Approach to the critically ill patient

Answer 3

1. Rapid Primary Survey (RPS)
2. Resuscitation (often concurrent with RPS)
3. Detailed Secondary Survey
4. Definitive Care

Question 4

Signs of airway obstruction

Answer 4

• Agitation, confusion, “universal choking sign”
• Respiratory distress
• Failure to speak, dysphonia, stridor
• Cyanosis

Question 5

Who should have a cervical collar applied

Answer 5

assume a cervical injury in every trauma patient and immobilize with collar

Question 6

What are conditions that you should think of impending airway collapse

Answer 6

Facial fractures

Edema

Burns

Question 7

When should you not conduct a head-tilt

Answer 7

suspected c spine injury

Question 8

temporizing airway measures

Answer 8

• nasopharyngeal airway (if gag reflex present i.e conscious)
• oropharyngeal airway (if gag reflex absent ie. unconscious)
• “rescue” airway devices (e.g. laryngeal mask airway, Combitube®)
• transtracheal jet ventilation through cricothyroid membrane (last resort)

Question 9

What are definitive airway management strategies

Answer 9

• ETT intubation with in-line stabilization of C-spine
■ orotracheal ± RSI preferred
■ nasotracheal may be better tolerated in conscious patient
◆ relatively contraindicated with basal skull fracture
■ does not provide 100% protection against aspiration

• surgical airway (if unable to intubate using oral/nasal route and unable to ventilate)
• cricothyroidotomy

Question 10

Contraindications to intubation

Answer 10

• supraglottic/glottic pathology that would preclude successful intubation

Question 11

Medications that can be delivered via ETT

Answer 11

NAVEL 
Naloxone (Narcan) 
Atropine 
Ventolin (salbutamol) 
Epinephrine 
Lidocaine

Question 12

Indications for intubation

Answer 12

• Unable to protect airway (e.g. GCS <8; airway trauma)
• Inadequate oxygenation with spontaneous respiration (O2 saturation <90% with 100% O2, or rising pCO2)
• Impending airway obstruction: trauma overdose, CHF, asthma, COPD, anaphylaxis, angioedema, airway burns, expanding hematoma
• Anticipated transfer of critically ill patients

Question 13

In patients with a C-spine xray that is positive and that require intubation, what type of intubation should be used

Answer 13

Fibreoptic ETT
or nasal ETT
or RSI

Question 14

Rescue techniques in intubation

Answer 14

• Bougie (used like a guidewire)
• Glidescope®
• Lighted stylet (uses light through skin to determine if ETT in correct place)
• Fiberoptic intubation – (uses fiber optic cable for indirect visualization)

Question 15

What does noisy breathing mean

Answer 15

Noisy breathing is obstructed breathing until proven otherwise

Question 16

How to evaluate breathing

Answer 16

• Look
■ mental status (anxiety, agitation, decreased LOC), colour, chest movement (bilateral vs. asymmetrical), respiratory rate/effort, nasal flaring

• Listen
■ auscultate for signs of obstruction (e.g. stridor), breath sounds, symmetry of air entry, air escaping

• Feel
■ tracheal shift, chest wall for crepitus, flail segments, sucking chest wounds, subcutaneous emphysema

Question 17

Breathing interventions in order of increasing FiO2

Answer 17

nasal prongs → simple face mask → non-rebreather mask → CPAP/BiPAP

Question 18

What breathing interventions supplement inadequate ventilation

Answer 18

Bag-Valve mask

CPAP

Question 19

Definition of shock

Answer 19

• inadequate organ and tissue perfusion with oxygenated blood (brain, kidney, extremities)

Question 20

What type of shock do you assume in a trauma patient until proven otherwise

Answer 20

hemorrhagic

Question 21

Types of shock

Answer 21

Hypovolemic

• hemorrhage (external and internal)
• Severe burns
• High output fistulas
• Dehydration (diarrhea, DKA)

Cardiogenic

• Myocardial ischemia
• Dysrhthmias
• CHF
• Cardiomyopthies
• Cardiac valve problems

Distributive (vasodilation)

• Septic
• Anaphylactic
• Neurogenic (spinal cord injury)

Obstructive

• Cardiac tamponade
• Tension pneumothorax
• PE
• Aortic stenosis
• Constrictive pericarditis

Acronym for causes of shock
SHOCKED
Septic, spinal/neurogenic
Hemorrhagic
Obstructive (e.g. tension pneumothorax, cardiac tamponade, PE)
Cardiogenic (e.g. blunt myocardial injury, dysrhythmia, MI)
anaphylactiK
Endocrine (e.g. Addison’s, myxedema, coma)
Drugs

Question 22

Shock clinical evaluation

Answer 22

Early - tachypnea, tachycardia, narrow pulse pressure, reduced capillary refill, cool extremities and reduced central venous pressure

late - hypotension, altered mental status, reduced urine output

Question 23

Estimation of degree of hemorrhagic shock

Answer 23

Class I 
<750 cc 
<15% blood volume 
pulse <100 
BP normal 
resp rate 20 
cap refill normal 
urinary output 30 cc/h 
fluid replacement crystalloid 

Class II 
750-1500 cc 
15-30% blood volume 
pulse >100 ***
BP normal 
resp rate 30 
cap refill decreased ***
urinary output 20 cc/h 
fluid replacement crystalloid 

Class III 
1500-2000 cc 
30-40% blood volume 
pulse >120 ***
BP decreased ***
resp rate 35
cap refill decreased 
urinary output 10 cc/h 
fluid replacement crystalloid + blood 

Class IV 
>2000 cc 
>40% blood volume 
pulse >140***
BP decreased ***
resp rate >45
cap refill decreased  
urinary output none ***
fluid replacement crystalloid + blood

Question 24

Estimated systolic blood pressure based on position of most distal palpable pulse

Answer 24

Radial >80 mm Hg
Femoral >70 mm Hg
Carotid > 60 mm Hg

Question 25

Management of hemorrhagic shock

Answer 25

* clear airway and breathing either first or simultaneously * apply direct pressure on external wounds while elevating ex remities. Do not remove impaled objects in the emergency room setting as they may tamponade bleeds * start TWO LARGE BORE (14-16G) IVs in the brachial/cephalic vein of each arm * run 1-2 L bolus of IV Normal Saline/Ringer’s Lactate (warmed, if possible) * if continual bleeding or no response to crystalloids, consider pRBC transfusion, ideally crossmatched. If crossmatched blood is unavailable, consider O- for women of childbearing age and O+ for men. Use FFP, platelets or tranexamic acid in early bleeding * consider common sites of internal bleeding (abdomen, chest, pelvis, long bones) where surgical intervention may be necessary

Question 26

3:1 rule

Answer 26

Since only 30% of infused isotonic crystalloids remains in intravascular space, you must give 3x estimated blood loss

Question 27

How to assess LOC

Answer 27

GCS

Question 28

What do inequal/sluggish pupils suggest

Answer 28

local eye problem or lateralizing CNS lesion

Question 29

What does a relative afferent pupillary defect (swinging light test) indicate

Answer 29

optic nerve damage

Question 30

What etiologies of decreased LOC should be considered if pupils are reactive

Answer 30

metabolic or structural

Question 31

What etiologies of decreased LOC should be considered if pupils are not reactive

Answer 31

structural cause (especially if asymmetric)

Question 32

GCS use and components

Answer 32

* for use in trauma patients with decreased LOC; good indicator of severity of injury and neurosurgical prognosis * most useful if repeated; change in GCS with time is more relevant than the absolute number * less meaningful for metabolic coma * patient with deteriorating GCS needs immediate attention * prognosis based on best post-resuscitation GCS * reported as a 3 part score: Eyes + Verbal + Motor = Total * if patient intubated, GCS score reported out of 10 + T (T = tubed, i.e. no verbal component)

Question 33

GCS scoring

Answer 33

``` Eyes open - 4 spontaneously 3 to voice 2 to pain 1 no response ``` ``` best verbal response 5 answers questions appropriately 4 confused disoriented 3 inappropriate words 2 incomprehensible sounds 1 no verbal response ``` ``` best motor response 6 obeys commands 5 localizes to pain 4 withdraws from pain 3 decorticate (flexion) 2 decerebrate (extension) 1 no response ``` 13-15 mild injury 9-12 moderate 0-8 severe

Question 34

Fluid resuscitation method and rate in shock

Answer 34

• Give bolus until HR decreases, urine output increases, and patient stabilizes * Maintenance: 4:2:1 rule • 0-10 kg: 4 cc/kg/h * 10-20 kg: 2 cc/kg/h * Remaining weight: 1 cc/kg/h • Replace ongoing losses and deficits (assume 10% of body weight)

Question 35

exposure/environment component of primary survey

Answer 35

* expose patient completely and assess entire body for injury; log roll to examine back * DRE * keep patient warm with a blanket ± radiant heaters; avoid hypothermia * warm IV fluids/blood • keep providers safe (contamination, combative patient)

Question 36

Unilateral, dilated, non-reactive pupil differential

Answer 36

* Focal mass lesion * Epidural hematoma * Subdural hematoma

Question 37

resuscitation components

Answer 37

* done concurrently with primary survey * attend to ABCs * manage life-threatening problems as they are identified * vital signs q5-15 min * ECG, BP, and O2 monitors * Foley catheter and NG tube if indicated * tests and investigations: CBC, electrolytes, BUN, Cr, glucose, amylase, INR/PTT, β-hCG, toxicology screen, cross and type

Question 38

contraindications to foley insertion

Answer 38

* Blood at urethral meatus * Scrotal hematoma * High-riding prostate on DRE

Question 39

NG tube contraindications

Answer 39

* Significant mid-face trauma | * Basal skull fracture

Question 40

Secondary survey timing, purpose and components

Answer 40

* done after primary survey once patient is hemodynamically and neurologically stabilized * identifies major injuries or areas of concern * full physical exam and x-rays (C-spine, chest, and pelvis – required in blunt trauma, consider T-spine and L-spine f indicated)

Question 41

Type of history to take in secondary survey

Answer 41

"SAMPLE”: Signs and symptoms, Allergies, Medications, Past medical history, Last meal, Events related to injury

Question 42

Four areas of a FAST

Answer 42

1. Subxiphoid pericardial window 2. Perisplenic 3. Hepatorenal (Morrison's Pouch) 4. Pelvic/retrovesical (pouch of Douglas)

Question 43

Physical exam in secondary survey

Answer 43

Head and Neck • palpation of facial bones, scalp Chest • inspect for: 1. midline trachea and 2. flail segment: ≥2 rib fractures in ≥2 places; if present look for associated hemothorax, pneumothorax, and contusions • auscultate lung fields • palpate for subcutaneous emphysema Abdomen • assess for peritonitis, abdominal distention, and evidence of intra-abdominal bleeding • DRE for GI bleed, high riding prostate, and anal tone Musculoskeletal • examine all extremities for swelling, deformity, contusions, tenderness, ROM • check for pulses (using Doppler probe) and sensation in all injured limbs • log roll and palpate thoracic and lumbar spines • palpate iliac crests and pubic symphysis and assess pelvic stability (lateral, AP, vertical) Neurological • GCS • full cranial nerve exam • alterations of rate and rhythm of breathing are signs of structural or metabolic abnormalities with progressive deterioration in breathing indicating a failing CNS • assess spinal cord integrity • conscious patient: assess distal sensation and motor function • unconscious patient: response to painful or noxious stimulus applied to extremities

Question 44

Secondary survey initial imaging

Answer 44

* non-contrast CT head/face/C-spine (rule out fractures and bleeds) * chest x-ray * FAST (see Figure 2) or CT abdomen/pelvis (if stable) * pelvis x-ray

Question 45

Signs of increased ICP

Answer 45

* Deteriorating LOC (hallmark) * Deteriorating respiratory pattern * Cushing reflex (high BP, low heart rate, irregular respirations) * Lateralizing CNS signs (e.g. cranial nerve palsies, hemiparesis) Seizures * Papilledema (occurs late) * N/V and headache

Question 46

What is the best imaging modality for intracranial injury

Answer 46

Non-contrast head CT

Question 47

Ethical emergency rule

Answer 47

consent is not needed when a patient is at imminent risk from a serious injury AND obtaining consent is either: a) not possible, OR b) would increase risk to the patient ■ assumes that most people would want to be saved in an emergency • any capable and informed patient can refuse treatment or part of treatment, even if it is life-saving

Question 48

Exceptions to the emergency rule

Answer 48

• exceptions to the Emergency Rule – treatment cannot be initiated if ■ a competent patient has previously refused the same or similar treatment and there is no evidence to suggest the patient’s wishes have changed ■ an advanced directive is available (e.g. do not resuscitate order) ■ NOTE: refusal of help in a suicide situation is NOT an exception; care must be given * if in doubt, initiate treatment * care can be withdrawn if necessary at a later time or if wishes are clarified by family

Question 49

Consent to treatment for children

Answer 49

* treat immediately if patient is at imminent risk * parents/guardians have the right to make treatment decisions * if parents refuse treatment that is life-saving or wll potentially alter the child’s quality of life, CAS must be contacted – consent of CAS is needed to treat

Question 50

Other issues of consent - HIV testing, administration of blood products

Answer 50

* need consent for HIV testing, as well as for administration of blood products * however, if delay in substitute consent for blood transfusions puts patient at risk, transfusions can be given

Question 51

Duty to report

Answer 51

• law may vary depending on province and/or state • examples: gunshot wounds, suspected child abuse, various communicable diseases, medical unsuitability to drive, risk of substantial harm to others