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Emergency 3 Exam

Emergency Medicine: Trauma/Wound, Mental Status Change, Poisoning

What is important when you have a traumatic case? DO NOT HAVE TUNNEL VISION and miss something!
Most common cause of trauma death/disability Blunt trauma
energy exchange between an object and the human body, without intrusion of the object through the skin Blunt trauma
Involves disruption of skin and tissues in a focused area Penetrating trauma
What does the Trauma Score take into account? (3) First, answer what is it for? Used to determine likelihood of survival (esp head injuries). Takes following into account: 1) Glasgow Coma score 2) Respiratory rate 3) Systolic BP
What should you do when suspecting a multi-system trauma? (2) 1) Assess the entire body 2) Prioritize the Tx of injuries
T/F: Glasgow Coma Score accurately predicts survivability in patients w/ severe head injuries FALSE, this is why we have the Trauma score. GCS is simply an evaluation tool to determine LOC
T/F: Trauma score of 7-8 will almost always do well True, 7: 96.9% survival
What should you always assume in pts w/ multisystem trauma? C-Spine injury...C-collar should remain in place until pt can cooperate w/ clinical exam or C-Spine injury has been ruled out
What should every patient be assessed for upon arrival to ED? Airway, Breathing, Circulation, Disability, Exposure (ABCDEs)
T/F: Airway patency alone ensures adequate ventilation False, Necessary to inspect, palpate and auscultate, possibly getting CXR
Multiple rib fractures, paradoxical movements of the chest wall, impaired oxygen. Tx? Flail Chest. Tx: Put something firm on injury to stabilize. That way they can at least oxygenate (even though they will still retract)
Sounds like you are pushing down on rice krispies or a bag of popcorn on their chest when patients have this Subcutaneous Emphysema
What should be assumed in any hypotensive pt? Hemorrhagic shock until proven otherwise.
LOC, skin color, pulses in all 4 extremities, BP and pulse pressure Rapid assessment of hemodynamic status
If hemodynamic status unstable, what fluid do you use to rapid resuscitate initially? After that? Crystalloid, followed by blood, plasma, or colloid
LOC, pupil size and reactivity, motor function, GCS Abbreviated neuro exam to assess Disability
What is essential when assessing Exposure? COMPLETE disrobing of patient (logroll to inspect back)
When doing a secondary survey (after your ABCDEs), what pneumonic do you used to ID other injuries? DCAP-BTLS: Deformities, Contusions, Abrasions, Punctures, Burns, Tenderness, Lacerations, Swelling
Bruising behind the ear? Battle sign, skull fracture
two black eyes after trauma? Raccoon eyes, skull fracture
What does FAST stand for? Focused Assessment with Sonography in Trauma
What should you get after a FAST scan in a hemodynamically stable blunt abd trauma w/ concerning Hx? What about in a deteriorating pt? CT; Deteriorating: Straight to OR
What is the blood product ratio that is ideal? 1:1:1
Initial Tx for ED trauma? (5) 1) Warmed IVF 1 liter (change to blood if only minimal change) 2) Pain management 3) Sedation if needed 4) Tdap 5) ABX if open fracture
Trauma Triad of Death...what is the trigger? 1) Coagulopathy 2) Hypothermia 3) Metabolic acidosis; Trigger: Hemorrhage.
What is TXA? Tranexamic Acid, an ANTI-fibrinolytic....which inhibits the breakdown of clots. Large study showed mortality benefit
Tachys, metabolic acidosis, oliguria, cool/clammy skin, confused sensorium Initial signs of end organ dysfunction (in shock)
blood loss of significant magnitude to overcome normal physiologic compensatory response and compromise tissue perfusion. Tx? (3) Hemorrhagic shock. Tx: Control hemorrhage 2) rapid bolus of several liters of NS 3) If that doesn't work: transfuse
Classes of Hemorrhagic shock (4) 1) 15% loss (mildly tachycardic) 2) 15-30% loss (Pulse pressure down) 3) 30-40% loss (SBP down/MS changes) 4) >2 liter loss (obtunded/clammy)
Most important goals for Disaster Triage (3) 1) DO GREATEST GOOD for the greatest number of people 2) BE most EFFICIENT use of available resources 3) TX AS MANY AS POSSIBLE who have a chance of survival
Explain START Triage Model (not a pneumonic). What 2 Txs allowed? How long w/ each patient? etc. Txs: 1) Open/clear airway 2) Control major external hemorrhage. ~30 sec/patient, Don't second guess, let most experienced person lead
What level should a GCS of 10-13 go to? 9 or less? Level 2 trauma center; Level 1 trauma center
Where should someone w/ no airway, hemodynamically unstable, and unable to control severe hemorrhage go w/ trauma? Nearest emergency departement
1) SBP <90 in adult or <80 in child. 2) Respiratory distress (<10 or >20 in adults, <20 or >40 in child) 3) Altered mental status GCS<13 3 physiological criteria for level 1 trauma center (adult and child)
1) Flail chest 2) 2+ long bone Fx 3) penetrating injury to head, neck, torso, groin 4) amputation 5) paralysis 6) unstable Fx 7) trauma/burns combination >15% anatomical criteria for level 1 trauma center
Where should someone 14 yo or younger or pregnant go w/ trauma? Highest level of care
Epidermis only, skin red, swollen, painful. Superficial (1st degree formerly) burns (will heal spontaneously in 7 days)
Involves epidermis and dermis, painful. Can be deep or moderate. Partial-thickness burns (former 2nd degree)
Involves destruction of both layers of skin, incapable of self-regeneration, skin white, waxy, brown, leathered, charred w/ sensory nerves destroyed so no pain Full-thickness burns (former 3rd degree)
What is the Rule of Nines? Each part of the body bilaterally is 9% of the body. Trunk divided into an upper and lower anterior and posterior respectively
What is the Rule of Palms? burn equivalent to size of patient's hand= 1% body surface area (BSA)
2nd/3rd degree >10% BSA in <10 or >50 yo OR 20% in 10-50 yo, 3rd degree >5%, cosmetic or functional disability, inhalation injury Criteria for Burn Center Transfer
Type of IV fluid for burns? How is burn % calculated (in Parkland formula) in regards to fluid administered? Lactated Ringers. Burns other than superficial are counted in Burn Area %
Parkland Formula (over 24 hour period) 4mL of LR x Burn Area % (2nd degree+) x Weight (kg). 1/2 given over first 8 hours. 2nd 1/2 given over next 16 hours
Dry/sterile dressings, prevent heat loss, replace lost fluid, pain management, Tdap update, Tx underlying trauma Burn management
Emergent surgical incisions to relieve pressure of an area at risk for complete vascular compromise or constriction of chest wall Emergency Escharotomy
T/F: Adhesives > sutures? True
T/F: It matters whether you have sterile gloves or just clean non-sterile gloves False, it doesn't.
T/F: Larger the suture number, the smaller the thread True
When considering closing a laceration, what should you check for? (2) Should check to make sure there is no severed tendon or foreign body. Don't want to close those.
Difference between infection rates in wound irrigation w/ NS or tap water None
4 things timing of closure depends on? 1) Patient 2) Comorbidities 3) Location 4) Origin
Major times ABX are indicated: (5) 1) Contaminated wounds 2) Open Fx 3) Exposed vital structures 4) bites 5) immunocompromised
awareness of self and the environment consciousness
a non-pathologic decreased mental state from which one is easily aroused Sleep
a decreased level of consciousness, in which the patient is arousable but not normal. Lethargy
unresponsiveness that cannot be aroused by verbal or physical stimuli Coma
an acute transient confusional state with associated impairment of attention and cognition Delirium
chronic state, often with normal attention and wakefulness but diminished cognition and memory. Dementia
Arousal or wakefulness requires intact: Reticular Activating System (RAS) (intact mid-pons, midbrain, thalamus, cerebral hemispheres)
Initial ED approach to AMS? (3) SAME AS ALWAYS: 1) ABCDEs/IV/O2/Monitor 2) Hx 3) PE
diencephalic control of breathing, crescendo-decrescendo pattern. Breathing pattern that w/ apnea then compensation breathing) Cheyne-Stokes respiration
specific respiratory pattern due to metabolic acidosis or brain injury Hyperventilation
characterized by prolonged pause at the end of respiration (can be lesion around CN5) Apneustic breathing
irregular breathing without a pattern, a precursor of agonal respirations and death Ataxic breathing
cherry red skin carbon monoxide poisoning
What 5 items should you ask for a neuro exam? 1) remember 3 words 2) what year? 3) what month? 4) What day of the week? 5) Recall 3 words. Give 1 point to each correct response...score below 4/6 suggests impairment
What helps differentiate post-syncope shakes from seizures (2 big things) Slow return of baseline mental status, available witnesses able to confirm shaking activity, bowel/bladder incontinence are suggestive of seizure.
What is in the DD if a seizing patient comes in to the ED that are REVERSIBLE (7) 1) Hypoglycemia 2) Hypoxia 3) Dysrhythmia 4) Toxic ingestion 5) Intracranial hemorrhage 6) Meningitis 7) Eclampsia
What are some drugs that can induce seizures at toxic levels? (7...this is a non-exhaustive list) Isoniazid (antimycobacterial for TB), stimulants, haldol, TCAs, carbamazepine, lead, lithium
4 complications from status epliepticus 1) Hyperthermia 2) Acidosis 3) Hyperkalemia secondary to acidosis 4) Myoglobinemia
Rule of Thirds for Status Epilepticus etiology 1/3: exacerbation of seizure disorder 1/3: first onset of seizure disorder 1/3: other cause
Pseudoseizures generally will not respond to antiseizure treatment and the majority of patients with these have psychiatric disease; Pseudoseizures=Psychiatric
Gold standard to Dx pseudoseizures? EEG
AVPU? Alert, responds to Voice, responds to Pain, Unresponsive
GCS Severe? Moderate? Mild? S: 8 or less; Mo: 9-12; Mi: 13+
What is the IV coma cocktail? D50, Thiamine, Naloxone
Treatable causes of AMS and how to remember them? AEIOU-TIPS: Alcohol, Epilepsy, Insulin, Opiates, Urea, Trauma, Infection, Psychiatric/poison, Shock/stroke/sugars
1) Rapid deterioration over a few hours 2) Confusion state w/ altered consciousness 3) No focal deficits found 4) PERRLA...what abnormality are we most suspicious for? Metabolic!
Glucose >250, pH <7.3, serum bicarb <18, moderate ketonuria or ketonemia. Elevated serum ketone levels and high anion gap DKA
Glucose >600, pH>7.3, serum bicarb >15, Minimal ketonuria/emia HHS
vestibulo-ocular reflex should be present even in a comatose patient with intact brainstem function. How do we test this? Brainstem intact? Brainstem injury? Doll's Eyes test; Intact: eyes deviate contralaterally (look away from rotation); Injury: eyes follow direction of head rotation
osmotic diuretic that reduces intracranial pressure Mannitol
Alcohol intoxication (%)? Alcohol poisoning (%)? Intox: 0.15%; Poisoning: 0.3%
Between what hours might DTs or delirium tremens occur in alcohol withdrawal? Withdrawal seizures? 48-72 hours; 24-48 hours
Acid-base disorder w/ Pulmonary embolus Respiratory alkalosis
Acid-base disorder w/ Hypotension Metabolic acidosis
Acid-base disorder w/ Vomiting Metabolic alkalosis
Acid-base disorder w/ Severe diarrhea Metabolic acidosis
Acid-base disorder w/ Cirrhosis Respiratory alkalosis
Acid-base disorder w/ Renal failure Metabolic acidosis
Acid-base disorder w/ Sepsis (2) Respiratory alkalosis, met. acidosis
Acid-base disorder w/ Pregnancy Respiratory alkalosis
Acid-base disorder w/ Diuretic use Metabolic alkalosis
Acid-base disorder w/ COPD Respiratory acidosis
Approach to acid-base disorders (4) 1) Look at pH 2) Look at pCO2 3) Calculate anion gap 4) Calculate excess anion gap
CNS depression, airway obstruction, PE Respiratory Acidosis
Diuretics, vomiting, Cushing’s syndrome Metabolic Alkalosis
Anxiety, CNS disease, ASA, sepsis, hypoxia Respiratory Alkalosis
MUDPILES pneumonic (what is it for?) Anion Gap metabolic acidosis
HARDUPS pneumonic (what is it for?) Non-anion gap metabolic acidosis
What does PCO2 tell you about alkalosis? PCO2>40 ~ metabolic; PCO2< 40 ~ respiratory
What does PCO2 tell you about acidosis? PCO2> 40 ~ respiratory; PCO2<40 ~ metabolic
How to check anion gap? What is normal? Na-Cl-HCO3 where normal is 6-12
Excess anion gap? And what does it mean? (AG-12)+HCO3; if >30, metabolic acidosis, if <30, metabolic alkalosis
a sudden and brief loss of consciousness associated with a loss of postural tone, from which recovery is spontaneous Syncope
Syncope w/ decrease in HR and BP, w/ distinctive prodrome: dizziness, nausea, diaphoresis, numbness, diminished vision and pallor. Typically caused by a stimulus. Vasovagal response: sympathetic response to a stressful or noxious stimulus
______ sinus stimulated can cause increase in vagal tone...typically in elderly. Precipitants: shaving, tight collar, suddenly turning head to side Carotid Hypersensitivity
Syncope from increase vagal tone from distinct event such as urinating, defecating, extreme coughing Situational Syncope
Sudden change in posture results in decrease in blood flow to brain (by how much?). Often due to autonomic dysfunction like advanced age, peripheral neuropathy, spinal cord injury, Shy-Drager's syndrome. Can be due to hypovolemia or medications as well Orthostatic Hypotension (20mmHg)
Short prodrome, tachydysrhythmias, bradydysrhythmias causing syncope Cardiac Dysrhythmias
Most common cardiac structural abnormalities in elderly? Young? E: Aortic stenosis Y: hypertrophic cardiomyopathy
Acute neurologic signs, CP, SOB, Age>70, serious arrhythmia, major trauma High risk syncope pts
Recurrent syncope, age >40-45, abnormal EKG w/o prior infarction, mild trauma, unexplained orthostatic hypotension Intermediate risk syncope pts
Age <40/45, 1st episode, normal EKG, no suspicion of heart disease Low risk syncope pts
exposure to a substance adversely affects the function of any system within an organism Poisoning
Approach to poisoned patient? (2) ABCDEs, secondary survey (EVERY DAMN TIME)
When is the ONLY time administration of antidote take precedence over completing primary survey? Cyanide
T/F: Rebound sedation w/ opiate overdose possible despite Narcan (naloxone) administration True, may need to give another dose of Narcan
What is required with physical exam of a poisoning? COMPLETELY undress pt. Thorough exam to ensure no substances hidden. Note smells
Most frequent type of decontamination we run into in the ED GI decontamination
Surface decontamination is achieved by completely undressing the patient and thoroughly washing them with copious amounts of water Gross decontamination
Ocular exposures are treated with copious irrigation with normal saline or LR Eye decontamination
3 methods of GI decontamination 1) Gastric emptying 2) Binding toxin inside gut lumen 3) Enhancement of Bowel Transit
Works on stomach and chemotactic trigger zone to induce vomiting Ipecac syrup
4 CONTRAs to gastric emptying 1) AMS 2) Active vomiting 3) caustic ingestion 4) seizures
Most often used to decontaminate GI after toxic ingestion. MOA? Benefits? Activated Charcoal (AC); MOA: adsorbing substances to gut lumen, making it less available for absorption, until it is eliminated by defecation. B: Not invasive, rapidly administered, high safety profile.
Simple definition of adsorb (Hint: the word is not absorb) bind to the surface of something
What is administered w/ AC? Osmotic cathartic: 70% sorbitol and 10% magnesium citrate solution
What is reserved for potentially life-threatening or amenable to removal by this method? Benefits: removes toxins already absorbed in gut or those that don't adhere to AC Hemodialysis
HR and BP up, RR up, Temp up, pupils dilated, bowel sounds increased, diaphoresis. Toxidrome and examples? Tx? (1) Sympathomimetic (cocaine, epinephrine, amphetamines). Tx: Benzodiazepines
HR and BP down, RR down, temp down, bowel sounds down, no change in pupils, diaphoresis down. Toxidrome and examples? Tx? (2) Sedative-Hypnotic (antihistamines, benzos and barbs). Tx: Supportive or Flumazenil (reverses benzos)
HR and BP up, Temp up, pupils dilated, bowel sounds down, diaphoresis down. Toxidrome and examples? Tx? (2) Anti-choliergic (low potency anti-psychotics, atropine, antihistamines). Tx: Tx hyperthermia, supportive
Pupils pinpoint, bowel sounds increased, diaphoresis increased. Garlic-like odor. Toxidrome and examples? Pneumonic? Tx? (2) Cholinergic (donezepil, insecticides [carbamates and organophosphates]); SLUDGE: Salivation, Lacrimation, Urination, Defecation, GI pain, Emesis.. Tx: antidotes before aging: atropine and 2-PAM
HR and BP down, RR down, Temp down, pupils pinpoint, bowel sounds decreased, diaphoresis decreased Opioid (morphine, heroin, hydromorphine, vicodin, percoset)
Pharmacology of cocaine blockade of presynaptic reuptake of norepinephrine, dopamine and serotonin
What kind of pathology does sympathomimetic toxidrome have similar to? 60 year olds w/ CAD (atherogenesis)
Typical of central anticholinergic syndrome? Mad as a hatter
Typical of peripheral anticholinergic syndrome? (5) Blind as a bat, dry as a bone, hot as a hare, red as a beet, stuffed as a pipe
Psychedelic properties w/ unique effects on mood and intimacy; euphoria, inner peace, sociability, heightened sexual interest. Bruxism. 5 aspects of toxicity? Tx? (2) MDMA; 1) Hyperthermia 2) Seizures 3) DIC 4) Rhabdomyolysis 5) Renal failure. Tx: Benzos, aggressive IVF therapy
Nystagmus and HTN, rhabdomyolysis common. Tx? (3) PCP; Tx: Benzos, sedation, aggressive hydration
Recommended daily doses of APAP (Acetominophen) in children and adults? How is it Metabolized? (3) 4 grams for adults and 75 mg/kg in children; Met: Sulfation, glucuronidation, direct renal elimination
What does an overdose of APAP deplete? Intracellular glutathione
APAP stage: Patients often have minimal and nonspecific symptoms of toxicity Stage 1
APAP stage: Stage I symptoms often improve but clinical hepatotoxicity Stage 2
APAP stage: Progress to fulminant hepatic failure Stage 3
APAP stage: Those patients that suffer the complications of fulminant hepatic failure will recover over the next 2 weeks Stage 4
Toxic exposure of APAP? 10 grams in 24 hours or >6 grams per 24 hours over 2 consecutive days
Antidote for APAP overdose? NAC, best w/in 8 hours but if taken before 24 hours, limited hepatic necrosis
Tinnitus; Respiratory alkalosis and metabolic acidosis mixed. Tx for serious toxicity? Regular Tx? (2) Salicilyate overdose; Hemodialysis for serious toxicity; Tx: gastric lavage and supportive
Definition of hypothermia <35 degrees C or <95 degrees F
transfer of heat by direct contact down a temperature gradient Conduction
transfer of heat by the actual movement of heated material Convection
Heat may be lost into the environment Radiation
Occurs over a wide range of ambient temperatures Evaporation
What should always happen w/ hypothermia. Further management? Best combo of rewarming? Removal of wet clothing; Tx: warm IVF and IV thiamine. Best: inhalation rewarming and warm IVF
inflammatory lesions of the skin caused by long-term intermittent exposure to damp, nonfreezing ambient temperatures Chilblains
Occurs when temperatures are less than -20C (-4F) Frostbite (typically skin temp is <0C or 32F
Cold Injuries: Most severe, usually distal, damage is irreversible Zone of Coagulation
Cold Injuries: Middle ground, severe but reversible damage. Treatment is usually effective in this zone Zone of Stasis
Cold Injuries: Most superficial, usually proximal, will improve without treatment in <10 days Zone of Hyperemia
Injury characterized by partial skin freezing, erythema, desquamation, mild edema. Prognosis? Frostnip/1st degree; Excellent prognosis
Full-thickness skin freezing. Prognosis? Second degree injury? Prognosis is good
Cold damage extending into subdermal plexus. Prognosis? Third degree injury; Prognosis is poor
Cold damage extending into subcu tissues, muscle, bone, tendon. Prognosis? Forth degree injury; Prognosis EXTREMELY poor (say bye bye)
Txs for cold injury blisters? (3) Blisters: aloe vera, digits should be separated, possible prophylactic ABX
Transfer of heat by electromagnetic waves from a warmer object to a colder object Radiation
Heat exchange between two surfaces in direct contact Conduction
Heat transfer by air or liquid moving across the surface of an object Convection
Heat loss by vaporization of water (sweat) Evaporation
T/F: Patients w/ heat exhaustion develop CNS derangement FALSE, they most certainly do not
T/F: Heat stroke is an acute life-threatening emergency. Cardinal features? (2) TRUE: altered mental status and hyperthermia (>104F)
Early finding of heat stroke? Tx? (2) Ataxia; Tx: Immediate cooling, support organ function
Cooling method of choice? Evaporation: clothing removed, cool water is sprayed on most of pt body surface; TX HEAT EMERGENCIES AGGRESSIVELY, do what you have to do to cool them down.
Tx of Acute Mountain Sickness? (4) What are Sx similar to? Tx: Do not proceed, descend, Tx Sx (Oxygen helps but is generally unavailable), ACETAZOLAMIDE. Sx similar to alcohol hangover
Progressive neurologic deterioration in patients with AMS or High-Altitude Pulmonary Edema (AMS, ataxia, stupor, progression to coma); Tx? (3) High-Altitude Cerebral Edema (HACE); Tx: Oxygen supplementation, descent, steroid therapy
Most lethal of altitude illnesses. Tx? (2) High-Altitude Pulmonary Edema (HAPE); Tx: EASILY reversible w/ descent and oxygen
Created by: crward88