emergency medicine

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emergency medicine
2014-02-22 22:10:54

chapter 14
Show Answers:

  1. what are the four essential components of effective trauma management?
    • recognition
    • assessment
    • action
    • reassessment
  2. what need to be done for the survival of the patient
    • triage by the technician
    • team takes over-act immediately and treat problems in order of priority
    • hospital need to be well equipped and well trained
  3. anticipate the worst
    • on the initial evaluation you are more likely to recognize injuries like airway, breathing and circulation (ABC's) and limb fracture from fall-pneumothorax
    • while monitoring you are more likely to recognize/prevent complications like pneumonia, delayed healing and systemic inflammatory response syndrome (SIRS)
  4. what is the ready area and what are the necessary equipment available in it
    • where all patients requiring immediate care are brought for exam and treatment
    • where in hospital emergencies are treated
    • near the operating room for rapid procedures
    • good lighting-overhead and direct
    • all necessary equipment available-crash cart is oxygen/airway, vascular access, fluids, suction, monitoring equipment, bandaging, sterile surgical supplies
  5. balanced buffered crystalloids fluids
    • LRS
    • normosol  R
    • plasmalyte A
  6. synthetic colloids fluids
    • hetastarch
    • dextran 70
  7. biologic colloids fluids
    • whole blood
    • packed red cells
    • FFP
  8. autotransfusion
    • blood in body cavity collected sterilely then re-infused into the patient
    • commercial units are costly
    • enteral feeding bag
    • IV fluid bag with slit
    • lines and bags sterilized together
    • filtered ideally but not essential in ECC
  9. diagnostic imaging-radiology
    • 300-500 mA and automatic processor/digital
    • accurate technique charts
    • horizontal beam
    • contrast materials and techniques ready
    • through the board
  10. diagnostic imaging-ultrasound
    • assessment of internal hemorrhage
    • liver, spleen, kidneys, bladder
    • fetal heart, other uterine disease
  11. laboratory basics
    • centrifuge
    • refractometer
    • basic chemistries
    • hematology
    • ACT tubes/block
    • blood gasses/acid base
    • electrolytes
    • lactate
    • colloid osmotic pressure
  12. surgery
    • often needed for resuscitation
    • anesthesia at the ready
    • operating room set up-major pack and gowns, suction unit, electrocautery, headlamps
    • warming equipment
  13. warmth
    • hypothermia interferes with metabolism
    • warm the core  first-vasodilation can worsen shock and temp
    • NEVER let the warming device contact-even the safest method can burn
    • devices-water blanket, blanket warmer, incubators/isolettes, warming bags, bubble wrap, IV fluids, heat lamps
  14. protocols
    • in humans, implementing protocols has decreased morbidity and mortality
    • drug doses for CPCR
    • resuscitation algorithms posted
  15. first aid and safety
    • give to owner when they first call
    • calm the owner down-calm owner will follow instructions better
    • may only be able to box/board the pet
  16. basic safety
    • ensure that the scene is safe-watch out for additional hazards
    • ensure the safety of the owner and staff while handling the animal-blood contact minimized human or animal, appropriate restraint, muzzles (open, tie/belt, blanket or jacket over the head)
  17. basic first aid
    • minimize patient movement- non-ambulatory (board or box) ambulatory (restricted movement)
    • direct pressure on wounds-proximal pressure, no tourniquets
    • splints-newspaper, sticks
  18. triage
    • sorting of patients according to the severity of their injury or illness to ensure that the most critical are treated first
    • usually done by tech
    • animals involved in severe accidents should be immediately triaged to the ready area
  19. arrival in the ready area
    • gloves worn
    • muzzled
    • minimal movement
    • survey quickly- RR and effort, abnormal body or limb posture, presence of blood or other materials, any gross abnormals
  20. basic rule of thumb
    if you find a vital abnormality during any phase of the assessment process, stop and treat at that point
  21. when should primary surveys be completed?
    in 60 seconds
  22. primary survey-assess level of consciousness (LOC)
    • use a scoring system like AVPU
    • a-alert
    • v-verbally responsive
    • p-responds to painful stimulus
    • u-unresponsive
    • if unresponsive, keep head and neck extended to maintain an open airway
  23. how are airways assessed
    by looking, listening, and feeling-increase effort, paradoxical chest wall movement, abdominal wall movement with respiration, nasal flare, open mouth, orthopnea and cyanosis are all evidence of respiratory distress
  24. how is breathing assessed
    • by watching chest wall motion and ausculting trachea and lungs
    • bilateral
    • listen to the lungs before the heart
    • thoracic  and abdominal percussion
  25. how is circulation assessed
    by checking MM/CRT, ausculting heart and pulses
  26. what systems need rapid assessment and palpation
    • abdominal
    • flank
    • pelvis
    • spine
    • limbs
  27. vital signs
    • taken after primary survey
    • includes- HR, pulse and strength, RR, MM/CRT (cyanosis hard to assess with severe hemorrhage, fluorescent lights hamper assessment also), temperature (take temp last due to vagal stimulation, consider using axillary or aural)
  28. peripheral pressure-blood pressure
    • important in assessment
    • high HR, high BP=pain
    • high HR, low BP=shock
  29. peripheral pressure- jugular veins
    • distended when sternal or standing=pneumo- or pericardial effusion
    • flat vein or slow fill (>4s)=hypotension
    • slow to relax (>2s)=right heart overload
  30. peripheral pressures-peripheral veins
    change in limb position causing flattening=rough assessment of pressure increase with fluids
  31. additional information
    • after primary survey and vitals
    • leads 2 ECG
    • lab data-usually labs determined after resuscitation underway-complete labs CBC, panel, U/A, ABG and coags
  32. completion of the primary survey
    • resuscitation started
    • analgesics-start after respiratory and circulatory resuscitation
    • control of hemorrhage- direct pressure on digital or pressure wraps, pressure points on digital or BP cuffs, limited external counterpressure- shock trousers-towels and duct tape, left in place until stable, unwrap slowly
  33. the male too box
    • duct tape-apply to things that are moving but are not suppose to be
    • WD40-apply to things that are not moving but are suppose to be
  34. secondary survey
    • performed after primary survey, vital and an initial database have been collected
    • this is a complete physical examination of the patient in a systemic manner
  35. history
    • in the unstable patient, it may not be taken until after the secondary survey-patient information sheet
    • in the stable patient a capsule history can be taken (AMPLE)allergies, medication, past history, lasts (meal, BM, urine, meds), events including details such as: elapsed time since accident, cause of trauma/speed of vehicle, loss of consciousness/blood, changes in patients conditions
  36. additional test-radiograph
    • survey films of chest, abdomen, and spine
    • laterals initially until stability of patient and spine achieved
    • limbs last
  37. additional test-ultrasounds
    • evaluation of hemorrhage/fluid leakage
    • guided centesis to avoid false negatives
  38. additional test-DPL- diagnostic peritoneal lavage
    fluid analyzed for PVC/TS, potassium, creatinine, and cytology
  39. goals of resuscitation-reverse the sign of shock
    increase RR and effort, tachycardia, weak or bounding pulses, pale or muddy MM, slow CRT, low body temp
  40. goal of resuscitation- provide oxygen delivery to the cells
    • oxygen gets into alveoli
    • adequate HB to carry from lungs
    • adequate preload and contractility to circulate