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Emergency Notes Flashcards

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1
Q

What is the acronym to assess breathing?

A

RATES - Rate, auscultate, trachea, effort, SpO2.

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2
Q

What Investigations do you order for trauma patient?

A

FBC, UEC< LFT< Lipase, Coags, G+H
CXR - haemothorax
FAST - Focused Assessment with sonography in Trauma - intra-abdominal blood and cardiac tamponade
Pelvic XR - Pelvic CTA

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3
Q

What is the coagulopathy of trauma?

A

A lethal triad of:
Acidosis - causes clotting factor dysfunction. Inadequate tissue perfusion in hypovolaemic shock - metabolic acidoses. Resp issues - resp acidosis
Hypothermia - platelet dysfunction, enzymatic function disrupted. Acidosis and hypothermia are synergist and when both present worsen coagulopathy more.
Haemodilution - fluid administration. Iatrogenic coagulopathy. Alterations in the coag system induced by large volumes of IV fluids or unbalanced components of blood administration.

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4
Q

How many stages of haemorrhagic shock are there?

A

4

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5
Q

What 8 factors change through the stages of haemorrhagic shock?

A

Blood loss (mL)
%Blood loss
Pulse
BP
Pulse pressure
RR
Urine output
CNS

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6
Q

Describe the first stage of haemorrhagic shock.

A

Less than 750mL blood loss (less than 15%). Pulse less than 100, BP is normal, Pulse pressure is normal or elevated, RR is 14-20, Urine output is over 30 mL/hr, CNS is slightly anxious.

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7
Q

Describe the second stage of haemorrhagic Shock

A

Blood loss 750-1500 mL, 15-30%. Pulse 100-120, N BP, decreased pulse pressure, RR 20-30, Urine output 20-30 mL/hr, Mildly anxious.

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8
Q

Describe the third stage of Haemorrhagic shock.

A

1500-2000 mL blood loss (30-40%), 120-140 PR, lowered blood pressure, lowered pulse pressure, 30-40 RR, 5-15 ml/hr of urine output, and confused.

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9
Q

Describe the fourth stage of haemorrhagic shock.

A

Over 2L blood loss, over 40%. Over 140 HR, with lowered BP and pulse pressure. Over 35 RR, Neglible urine output and confused and lethargic CNS.

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10
Q

What is a major trauma?

A

Major injury affecting more than one body system or
Injury severity score over 15.

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11
Q

What is the trauma call criteria?

A

Mechanism: Fall over 6m, high risk MVC, MBC, vehicle vs pedestrian.
Specific injuries: Flail chest, paralysis, proximal penetrating injuries or amputations, pelvic fractures, multiple long bone fractures, crushed or mangled extremity.
Physiological derangement: GCS less than 14, SBP less than 90, RR over 30 or less than 10.
Patient factors: Extremities of age, pregnant.

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12
Q

How to fill out the injury severity score?

A

Score the worst injury at each region of the body - from No injury - minor - moderate - serious - critical - unsurvivable
Total out of 75 - Head and neck, face, chest, abdo, pelvis, extremity.

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13
Q

What are the trauma bloods?

A

FBC, UEC, VBG, Group and crossmatch, Coags, Lipase, LFTs

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14
Q

Besides trauma bloods, what other investigations would you consider for major trauma?

A

ABGs, BSL, Temp, ECG, FAST US, XR, CT, diagnostic peritoneal aspirate or diagnostic laparotomy.

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15
Q

What does TBI stand for?

A

Traumatic Brain Injury

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16
Q

How do we classify TBI?

A

Primary - injury to the brain that occurs at the time of impact or insult with immediate effects, eg direct trauma to the brain, haemorrhage, contusion, axonal shearing.
Secondary - occurs as a result of insult the the brain after the initial injury, can cause worsening damage. Eg hypotension, hypoxia, anaemia, hypercapnia, electrolyte distrubance.

Or by location:
Extradural, Subdural, subarachnoid, intraparenchymal.

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17
Q

What clinical features can you get from TBI?

A

Eyes - VI nerve palsy. Ipsilateral fixed and dilated pupils, papilledema.
Cushing’s triad
Motor and sensory abnormalities
Blood or CSF from ears
Posturing

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18
Q

What is Cushing’s Triad and what does it indicate?

A

Systolic hypertension - widening pulse pressure
Bradycardia
Respiration abnormalities - decreased or irregular

Indicates transtentorial herniation.

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19
Q

Outline the treatment for TBI

A

Head CT
ABCDE + ATLS
Secure airway, intubate, C-spine precausions
Optimise ventilation, O2, EtCO2 monitoring 30-35
IVC, maintain BP, reverse anticoagulation
BSL
Look for other injuries, normothermic

Other:
Antiemetic prophylaxis - ondansetron
Seizure Prophylaxis
Sedation if combative
Increased ICP: Head elevation to 90 degrees, Mannitol, Hypertonic saline.

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20
Q

What is Serotonin Syndrome?

A

A drug related complication resulting form increased brain stem serotonin activity, usually precipitated by the use of one or more serotonergic drugs.

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21
Q

What drugs are associated with serotonin syndrome?

A

SSRI, SNRI, MAOI, TCA
Metoclopramide, Ondansetron
Amphetamines, Opioids
St John’s Wart
CNS stimulants

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22
Q

What symptoms are associated with serotonin syndrome?

A

CNS: Headache, agitation, hypomania, confusion, hallucination, coma
Autonomic: Pupil dilation, sweating, hyperthermia, tachycardia, nausea
Somatic: Akathisia, tremor, clonus, myoclonus, hyperreflexia
Severe: Seizures, metabolic acidosis, rhabdomyolysis, Renal failure, DIC, Malignant hyperthermia.

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23
Q

What criteria are used for serotonin syndrome?

A

The Hunter Serotonin Toxicity Criteria

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24
Q

What is the antidote used in serotonin syndrome?

A

Xyproheptidine, Olanzipine, Chlorpromazine. Used for mild-moderate refractory to benzos.

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25
How do you manage serotonin syndrome?
Cessation of serotoninergic medications Supportive management - Benzodiazepines for clonus Atypical antipsychotics with serotonin antagonist activity Cyproheptadine is an antihistamine with serotonin antagonism in severe cases Hyperthermia - benzodiazepines for muscle hyperactivity and vecuronium if severe.
26
Prognosis of serotonin syndrome?
Most symptoms resolve within 24 hours. But deaths have occurred.
27
What is Neuroleptic Malignant Syndrome?
A life threatening reaction that occurs due to Neuroleptic or antipsychotic medications.
28
What drugs can cause NMS?
1. Haloperidol, droperidol, promethazine, chlorpromazine. 2. Clozapin, olanzapine, risperidone, quetiapine 3. Dopaminergic drugs: Levodopa on cessation, metoclopramide.
29
What is the pathophysiology of NMS?
Blockade of dopamine receptor D2 leading to abnormal function of the basal ganglia and muscular Sx. Atypical antipsychotics also affect serotonin, GABA and glutamate worsening the syndrome.
30
What are the symptoms of NMS?
FEVER - fever, encephalopathy, Vital instability (autonomic Sx), Elevated Enzymes (CK, rhabdomyolysis), Rigidity of muscles. Can be agitated, delirious, coma, hyperkalaemia, renal failurek, seizures. Onset within 1 week, Reaches peek in approx 3/7. Can last 8hrs - 1 month.
31
How to treat NMS?
Cessation of causative medication If hyperthermic - active cooling Symptomatic management Dantroline for severe rigidity ?Bromocyptine
32
What is anticholinergic syndrome?
The inhibition of cholinergic neurotransmitters at muscarinic receptor sites following ingestion of certain medications.
33
What are the causative agents of anticholinergic syndrome?
Anti-histamines, anti-Parkinson's, Atropine, Anti-spasmodics, Skeletal muscle relaxants.
34
What are the symptoms of anticholinergic syndrome?
Flushing, dry skin Mydriasis Altered Mental Status Fever Tachycardia and HTN Myoclonic jerking Urinary retention Dysrhythmias Seizure "Mad as a hatter, Dry as a bone, Red as a beet, Hot as a desert, Blind as a bat"
35
What is the treatment for anticholinergic syndrome?
Cessation of causative agent Supportive management Physostigmine: Reversible acetylcholinesterase inhibitor
36
Investigations for anticholinergic toxicity?
ECG Temp UEC CK Bladder scan Toxicology
37
What is the treatment for anticholinergic toxicity?
IV fluids Activated charcoal Whole bowel irrigation if severe Diazepam for agitation Avoid anticholinergic drugs Physostigmine - reversible acetylcholinesterase inhibitor, half life 4 hours. Pts get better then deteriorate. Symptomatic management.
38
What are extra-pyrimidal symptoms?
Drug induced movement disorders/symptoms that occur as a result of certain medications.
39
What drugs cause EPS?
Typical and atypical antipsychotics, Metoclopramide, Antidepressants
40
What symptoms are included in EPS?
ADAPT: Acute Dystonia, Akathisea, Parkinsonism, Tardive Dyskinesia
41
What is acute dystonia?
Sustained or repetitive muscle contractions reslting in twisting and repetitive movements or abnormal fixed postures
42
What is akathisia?
Feeling of inner restlessness and need to be in constant motion
43
What is parkinsonism?
TRAP - Tremor, rigidity, akinesia (bradykinesia), postural instability.
44
What is tardive dyskinesia?
Involuntary repetitive body movements.
45
How do you monitor for EPS?
Abnormal Involuntary movement scale Tool for monitoring antipsychotic effects
46
What is the treatment for EPS?
Dose titration or cessation of causative medicine. Anticholinergic medications Akathisia may require B-blockers or benzos.
47
What symptoms can you get if you stop antidepressants too quickly?
FINISH Flu like illness Insomnia Nausea Imbalance Sensory disturbance Hyperarousal
48
What is acute cholecystitis?
Inflammation of the gall bladder
49
What are the causes of acute cholecystitis?
Calculous 90% of the time. Acalculous can be from trauma, sepsis, blood transfusion, narcotics, ABs
50
What are the symptoms of acute cholecystitis?
Epigastric pain --> RUQ pain, worse on movement. Billiary colic Pain preceded by fatty foods or EtOH Fevers, Rigors, Chills N+V Anorexia Jaundice 10% Shock Charcot's Triad and pentad
51
What are Charcot's Triad and pentad?
Tirad: RUQ Pain, Fever, leucocytosis Pentad: Triad + Hypotension, altered consciousness.
52
What clinical features to look for acute cholecystitis?
RQU pain worse on palpation Garding Murphey's Sign Palpable gall bladder Febrile Tachycardia Peritonism
53
What investigations to do for acute cholecystitis?
FBC CRP LFTs (cholestatic picure) Increased conjugated bilirubin US - Gall bladder wall thickening or oedema (double wall sign) HIDA scan CT when US unreliable (obesity) MRI when pregnant Cholangiogram: MRCP + ERCP + PTC (Magnetic Resonance Cholangiopancreatography + Endoscopic Retrograde cholangiopancreatography + Percutaneous transhepatic Cholangiography
54
Treatment for Acute cholecystitis?
Supportive management: IV fluids, analgesia (buscapan), antiemetics IVABs Laparoscopic or open cholecystectomy. If pain settles, DC and elective. If persisten - admission and inpatient..
55
What are the causes of acute pancreatitis?
IGETSMASHED Idiopathic Gallstones Ethanol Trauma Steroids Malignancy and mumps Autoimmune Sting - bee, scorpion, spider Hyperlipidaemia, hypertriglyceridemia, hypercalcaemia, hyperthyroidism ERCP Drugs (thiazides, frusemide, azathioprine, oestrogen).
56
What are the symptoms of acute pancreatisi?
Epigastric pain, dull and stead, progressive. LUQ or RUQ pain Radiation to back N+V Fever, chills Shock
57
What clinical features are you looking for acute pancreatitis?
Abdominal tenderness Guarding Abdominal distension Reduced bowel sounds Peritonitis Hypotension and SIRS Sx Grey-Turner's Sign - haemorrhagic discolouration of Flanks - retroperitoneal Cullen's Sign - haemorrhagic discolouration of umbilicus Hypocalcaemia
58
What criteria do you use for acute pancreatitis?
Atlanta Criteria: 2/3 Classic abdominal pain Lipase 3x upper limit normal Imaging suggestive of pancreatitis
59
Investigations for acute pancreatitis:
Bloods: FBC, CRP, Lipase, LFTs, Electrolytes, UECs, urine output. Imagine: US, CT, MRI, ?CXR to exclude other pathology.
60
How to treat acute pancreatitis?
Fluid Resus Analgesia, NPO, Antiemetics Electrolyte monitoring and replacement ABs (Tazocin) Surgical intervention when severe or due to gallstones
61
What are the complications of acute pancreatitis?
Peripancreatic fluid collection, pseudocyst, pancreatic abscess Intra-abdominal infection Infected necrosis Splanchnic thrombosis Abdominal compartment syndrome Pleural effusion Shock
62
What is appendicitis?
Inflammation of the veriform appendix usually due to appendiceal luminal obstruction.
63
What symptoms can you get for appendicitis?
Epigastric pain, severe, intermittent, dull. Moves to the RLQ, sharp pain, increasing in severity, constant. N, V, A Fever, malaise Constipation is late.
64
What clinical features do you look for in appendicitis?
Peritonism, guarding, rigidity, rebound tenderness, diminished bowel sounds on the right, shock. McBurney's Point - Pain on palpation - worse 3.8-5cm along line ASIS to umbilicus Rovsing's Sign - RLQ pain with palpation of LLQ Psoas Sign: Pt lies on left and passive attempt to extend R hip, painful is positive Obturator sign: Internal rotation of thigh causes pain Markle sign: Pain in abdominal cavity when dropping from toes to heels.
65
What score do we use for appendicitis?
MANTRELS score: Migration of pain to RLQ Anorexia N+V Tenderness in RLQ (2) Rebound tenderness Elevated Temp Leucocytosis (2) Shift of WBC to left
66
What investigations to do for appendicitis?
FBC Inflammatory markers UA Pregnancy test US CT Diagnostic laparoscopy
67
Treatment for appendicitis?
Analgesia Fluid resus NPO IVABs (gm-ve and anaerobic coverage) Lap appendectomy
68
What are the types of acute infectious diarrhoea?
Actue: 3 days to 14 days Chronic: Over 14 days loose stools
69
What are the symptoms of gastroenteritis?
Diarrhoea, N+V, Fever, Generally unwell, crampy abdominal pain, dehydration
70
What are the causes of gastroenteritis?
Viral: Norovirus, Rotavirus, Adenovirus Parasitic: Giardia lamblia, entamoeba histolitica Bacterial: E Coli, Campylobacter Jejuni, Salmonella, Shigella, Clostridium Difficile
71
What is the treatment for gastroenteritis?
Fluid and electrolyte replacement Bacterial: ABs.
72
Causes of small bowel obstruction?
HAVIT: Hernia, Adhesions, Volvulus, Intussusception, Tumour
73
What is a TIA?
Sudden onset focal neurological Sx caused by transient decreased blod flow, lasting for less than 24 hours resolving with no permanent neurological symptoms.
74
Describe the pathophysiology of a TIA.
TIAs are characterised by a temporary reduction or cessation of cerebral blood flow in a psecific neurovascular distribution as a result of partial or total occlusion - typically from an acute thromboembolic event or stenosis of a small penetrating vessel that resolves spontaneously with no remaining neurological deficit.
75
What are the causes of TIA?
Atherosclerosis Embolic source - AF, valvular disease, mural thrombus, paradoxial embolism Arterial dissection Hypercoagulable states Unknown
76
What are some risk factors for TIAs?
AF hypercoagulability valvular disease carotid stenosis CCF HTN DM EtOH Smoking Age
77
What score can be used for TIA?
ABCD2 score - risk stratification for CVA post TIA. 6-7 = 8% risk of CVA within 2 days. Age over 60 BP over 140/90 Clinical features: Unilateral weakness (2) Speech impairment without unilateral weakness Duration over 60mins, (2) 10-59 mins (1) Diabetes
78
What investigations for TIA?
FBC, UEC, Coags, Head CT - non-con, CT angiogram, MRI, ECG - cardioembolic cause
79
How to treat for TIA?
Treat as a stroke until proven otherwise. Antiplatelet - aspirin 100 mg or clopidogrel 75 mg Anticoagulant: NOACs Mx of risk factors / causes
80
What is an ischaemic stroke?
Sudden loss of blood circulating in an area of arterial blockage causing ischaemia, cell death and corresponding loss of neurological function. Acute neurological deficit lasts over 24 hours.
81
What are the causes of ischaemic stroke?
Thrombus Embolic - clot, cholesterol, fat, air, placenta, septic, malignant Cardioembolic Vasculitis Hypercoagulability Dissection Moyamoya disease
82
What are the DDx for stroke?
TIA, hypoglycaemia, seizure, Bell's palsy, infection, brain neoplasm, migraine
83
What is an extradural haemorrhage?
Bleeding between the inner surface of the skull and outer dura mata.
84
What is an extradural haemorrhage associated with?
Commonly with trauma. Frequently associated with a skull # of the temporal bone 75% Tearing to the middle meningeal artery 75% Can occur due to torn venous sinus and overlying #
85
What symptoms are common with extradural haemorrhage?
Hx of head trauma LOC Lucid interval Headache N+V Seizure Decreased level of consciousness
86
What clinical features are common with extradural haemorrhage?
skull contusion, laceration, bleeding Decreased level of Consciousness Cushing's triad Hemiplegia Postruing Sluggish pupils CNIII palsy - oculomotor. Dilated ipsilateral pupil, can progress to bilateral. CNVI Palsy - long course. Failure of lateral gaze Fixed dilated pupil - ipsilateral or bilateral
87
What investigations to do for Extradural haemorrhage?
Trauma bloods Non-con Head CT

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