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Emergency 3 Exam
Emergency Medicine: Trauma/Wound, Mental Status Change, Poisoning
| Term | Definition |
|---|---|
| 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 |
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crward88
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