Critical Care - Succinct CC notes covering Australian Medical School curriculum PDF

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Succinct ENT notes covering Australian Medical School curriculum...

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Critical Care Emergency medicine 1. List life threats to the airway  Acute upper airway obstruction  Causes o Consider serious threat to airway in a patient with reduced GCS (94%  Inhaled foreign body o Complete obstruction (choking)  Perform 5 back blows between shoulder blades using heel of hand with victim laying forwards or on side  Perform 5 abdominal thrusts (Heimlich’s manoeuvre) – if still no resolution, repeat back blows and abdominal thrusts  If baby – hold with head down and deliver up to 5 back blows  If not cleared, attempt removal under direct vision with laryngoscope and Magill forceps  If all else has failed and patient in extremis – perform cricothyroidotomy o Stable airway obstruction  Summon anaesthetic and ENT help urgently  If child’s symptoms have resolved – foreign body has likely passed to lower airways – request an AP and lateral CXR only on stable child with suspect foreign body

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CXR may not show the inhaled object, but may show secondary effects (hyperinflation, collapse, consolidation) Will likely require rigid bronchoscopic removal

Epiglottitis o Life-threatening infection of supraglottic tissue, typically in child 3-7 during winter o Classically caused by H.influenzae type B, but this has declined with routine immunisation  Other causes – strep, staph, viral o Symptom onset 6-12h, and may progress rapidly to obstruction  High fever, inspiratory stridor, severe throat pain, dysphagia, drooling, muffled voice  Child is anxious, pale, toxic and leans forward with drooling open mouth o Management  Keep child calm – do NOT examine child further and absolutely do not instrument the airway  Lateral neck x-ray may show thumb-print sign, but only if diagnosis is uncertain  Call senior ED consultant, paediatric, anaesthetic and ENT teams urgently, warn ICU  Do not leave child until help arrives  Be prepared for impending obstruction needing ETT or surgical airway  Start IV ceftriaxone Croup o Viral infection (usually parainfluenza virus) of the upper airway which may affect 6m to 5 years, but typically ages 1-3  2% of preschool aged children o Causes inflammation and obstruction of upper airway o Coryza, pyrexia, harsh barking cough, hoarse voice, stridor  Worse with crying or agitation, often worse at night o Tracheal tug, subcostal/substernal/clavicular retractions, tachycardia, dyspnoea, cyanosis  Cyanosis/extreme pallor indicates need for immediate supplemental oxygen, adrenaline nebs and intubation  Both cyanosis and severe distress in b1 and almost no alpha action Pharmaceutics o Oral tab 2, 4, 8mg o Puffer 100ug MDI o Nebs 2.5 or 5mg o SC/IM 1mg in 1mL, usually 0.5mg dose Use and dose o Bronchodilation and uterine relaxation o

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Dose in asthma – refer to guidelines, but generally:  4-12 puffs of MDI repeated via spacer every 20-30min as required  Severe asthma – 12 puffs, or 5mg nebs driven via air, or oxygen if sats 45% blood loss since child/young person will maintain a BP until too late Manage circulatory collapse by:  Direct pressure over external haemorrhage  Wide bore IV access  Take blood for crossmatch  IV resuscitation (replace like with like – e.g. warmed crystalloid/colloid)  Blood  Aim for fully crossmatched blood within 1h, and type-specific within 10 min  O-neg if no typing/crossmatch and need for immediate transfusion Massive blood transfusion defined as 10 or more units of packed RBC in 24h, 4 units in 1h with ongoing need or replacement of 50% total blood in 3h  Incidence 5% of trauma Aim to prevent the triad of death: hypothermia, acidosis, coagulopathy  Severe haemorrhage  reduced oxygenation and hypothermia  consumptive coagulopathy (+ dilutional if excessive crystalloid given)  blood loss causing hypoperfusion + anaerobic metabolism  metabolic acidosis which reduces myocardial performance (further causing hypoperfusion)

Disability o Determine GCS (< 8 is coma), or rapid assessment with AVPU (Alert, responds to Voice, responds only to Pain, or Unresponsive to stimulus) o Pupils, glucose, EtOH/drugs Exposure, environment o Gain adequate exposure, log roll

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Consider environment – prevent hypothermia at the scene or in hospital (worsens mortality) o Adjunctive measures  ECG monitoring  Insert urinary catheter  DRE  Gastric decompression  ABGs, oximetry, BP, CO2  Radiology – C spine, chest, pelvis Secondary survey o Begins once primary survey is complete, involves a rapid history and thorough examination History o A.M.P.L.E.  Allergies, medications, past medical hx/pregnancy status, last meal, events/environment surrounding trauma Examination o Full top to bottom examination – head/skull, face/mouth, neck, chest, abdomen/back, rectum/vagina, neuro, msk Consider special circumstances o Elderly  Increased morbidity/mortality, concominant disease, medications and physiological changes o Children  Short trachea, large occiput, compliant chest wall, large BSA (hypothermia risk higher), mediastinal mobility, spinal cord injury without radiological abnormality o Pregnancy  Maternal and foetal considerations – treat mother to treat foetus  Increased plasma volume masks shock, IVC compession, and need to monitor both foetus and mother Damage control resuscitation o Refers to efforts aimed to control haemorrhage, maintain circulating volume and reversing the triad of death, rather than addressing definitive issues which are dealt with later o Starts in the ED, and continues through to theatre and ICU Principles of damage control surgery o Management of metabolic derangement of ongoing bleeding supersedes need for definitive surgery o Abberivated operations aimed at controlling haemorrhage and controlling spillage from alimentary or urogenital tracts o Rapid transfer to ICU for correction of acidosis, coagulopathy and hypothermia o Definitive surgery is deferred Stages o

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Recognition – pre-hospital, ED, anaesthesia, surgery, ICU, haematology Haemostatic resuscitation  Early transfusion to maintain circulating volume  Minimising crystalloid use  Reduce coagulopathy  Keep warm  Prevent acidaemia Rapid transfer to theatre  Scoop-and-run approach  Address immediate life threats in pre-hospital and emergency department  Permissive hypotension if vascular trauma pending surgical control  Avoid delay in transfer to theatre Initial surgery  Short time in theatre, with limited focused surgery aimed at haemorrhage control and decontamination  Packing, partial resection, stapling off and removing injured bowel, fibrin sealants, leave abdomen open Move to ICU  Restore physiology – correct lethal triad  Optimise ventilation  Plan re-operation Return to theatre at 24-36h  Remove packs, perform definitive surgery  Formally close abdomen  (return to ICU)

11. Discuss diagnosis and management of traumatic emergencies including approach to major trauma 12. Discuss diagnosis and management of traumatic emergencies including approach to minor trauma  Head/facial injury  Scalp o Look for laceration, haematoma, penetrating wound, foreign body

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Palpate for deformity/fracture Assess GCS and identify signs of major head injury Check integrity of airway again, bruising, swelling/deformity, parotid and facial N damage Clean and evaluate facial lacerations – will need debridement and formal closure once more serious injuries are dealt with Look for blunt/penetrating injury and specific conditions (iris prolapse, hyphaema, lens dislocation, traumatic mydriasis 31

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Assess pupils for size and reaction, examine fundi (vitreous/retinal haemorrhage, retinal detachment) Visual acuity, eye movements Blood or CSF rhinorrhoea, deformity/fractures, specifically look for septal haematoma

Mouth o Broken/missing teeth, nasopharyngeal bleeding, tongue lacerations Ear o Skin/cartilage damage, frank bleeding (EAC or TM damage) Neck injury Cervical spine o Ask about local tenderness to palpation and any noted limb weakness or sensory deficits o Palpate for areas of tenderness, swelling, deformity o Assess limb tone, power, reflexes, sensation and anal tone

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C-spine imaging  Lateral c-spine x-ray – ensure adequate view, must visualise C7/T1 junction (swimmer’s view may be necessary)  CT the C spine if abnormality on plain film, suspicious/inadequate or incomplete plain film, suspected vascular/airway/oesophageal or other soft tissue injury, or if head CT is indicated anyway C-spine management  Always apply rigid C-spine collar before clearance of C spine injury  Urgent airway control if unconscious or respiratory distress – needs skilled doctor, usually with RSI and manual in-line C spine stabilisation

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Refer all suspected or confirmed C spine injury to surgical/orthopaedic team urgently

Airway injury o May be penetrating, blunt, isolated or associated with multiple injuries – hoarse voice, pain, strior, cough, haemoptysis o Never leave patient alone, call for help immediately o Protect airway immediately – risk of obstruction is grave – perform endotracheal intubation, surgical airway, or pass an ETT directly into a gaping airway wound Vascular injury o Never attempt to probe or remove a penetrating neck wound o Needs angiography and panendoscopy with urgent surgical exploration and repair in theatre Oesophageal injury o Rare – dysphagia, drooling, localised pain, subcutaneous emphysema o Urgent surgical repair Neck sprain o Most commonly due to hyperextension (“whiplash”) but can occur with any directed force o Conservative management with NSAIDs, physio Chest Pneumothorax o May be simple or with tension (management described elsewhere) Haemothorax o Hypotension, respiratory distress, reduced chest expansion, quiet breath sounds, dull percussion – confirmed on CXR o Management  High dose O2, IV resuscitation  Insert large bore intercostal drain into 5th or 6th intercostal space, mid-axillary line  Give local, then can cut over a rib with scalpel (ensures you don’t stab patient’s lung), down to muscle layer, then use blunt dissection technique to penetrate through to pleura  Once access to pleura, maintain patency of tract (insert finger into hole), then pass the intercostal catheter in place over finger  Thoracotomy sometimes necessary if massive bleed Rib and sternal # o Due to direct trauma – causes localised pain, worse on breathing o Consider associated injury

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Flail segment may result if multiple rib # in two sites causing hypoxia mainly from underlying pulmonary contusion o Perform ECG to exclude myocardial contusion o Get CXR to identify # but also associated injury (e.g. pneumo- or haemothorax) o Manage with:  High flow O2 to maintain saturations  IV resuscitation and analgesia, insert intercostal catheters if indicated  Refer to surgical team if complicated #  d/c uncomplicated rib or sternal #, providing analgesia and recommending deep breathing exercises to prevent atelectasis Myocardial contusion o Due to deceleration injury, associated with rib or sternal # o May be asymptomatic, or cause chest pain, or transient RV dysfunction o Get IV access, check cardiac enzymes and perform ECG which shows a number of conduction abnormalities and arrhythmias o ICU or CCU referral if cardiac injury suspected Aortic rupture o High speed deceleration – always consider if deceleration >60kmh or fall >5m – only 10-15% survive to hospital o 2 x wide bore IV access, crossmatch 10 units of blood, perform CXR  Widened mediastinum  Blurred aortic outline, obliteration of aortic knuckle  Left apical cap of fluid in pleural space from haemothorax  Displaced bronchus, trachea, or NG tube within oesophagus o Get CT angiogram if suspected o Management  Fluid cautiously – take care not to overresuscitate (i.e. permissive hypotension)  Emergency referral if high risk mechanism of injury or radiographic confirmation for thoracotomy or endocascular stenting Diaphragmatic rupture o L sided lesions commoner and allow stomach/intestinal herniation into chest o 75% associated with intraabdominal injury o Causes difficulty breathing and occasional bowel sounds in chest o Perform CXR o If diagnosed, decompress with NG intubation o If associated haemothorax or pneumothorax, blunt dissection chest tube insertion only – use of trochar may penetrate bowel in chest o Surgical referral urgently Ruptured oesophagus o Blunt/penetrating trauma, instrumentation, swallowing sharp object or Boerhaave’s syndrome o

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Retrosternal pain, difficulty swallowing, haematemesis, and on examination there is SC emphysema o Wide bore IV cannula, get CXR which shows wide mediastinum, pneumomediastinum, L pneumothorax, pleural effusion, haemothorax o Get CT to better define anatomy o Management – oxygen, fluids, broad spec antibiotics, chest tube if required, surgical referral for gastrograffin swallow and/or scope +/- repair Penetrating chest injury o Pain, dyspnoea and may be haemodynamically unstable (haemothorax, tamponade, tension pneumothorax) o IV access, bloods, CXR, urgent bedside USS, especially if suspecting tamponade (e.g. hypotension, raised JVP) o Protect airway, give O2, needle thoracocentesis if required and fluid resuscitation o Most cases managed conservatively with ICC, but cardiac or great vessel injury may necessitate open thoracotomy (in theatre or in the ED) o ED thoracotomy is necessary in traumatic arrest, with optimal survival if palpable pulse at scene, 15 min since signs of life Abdomen/pelvis Blunt abdominal trauma o Suspect if MVA or fall from height, or presence of hypotension without associated overt bleeding or chest injury o Ask about localised tenderness and shoulder tip pain o Look for imprint of clothing or tyre marks as potential sites of injury o Chest, abdomen and pelvic examination including genitalia o

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Log roll and examine spine, perform DRE Get 2 wide bore IV cannulae, send FBC/UEC/LFT/BGL/lipase/crossmatch 4 units Get initial chest, pelvic and thoracolumbar spine x-ray, an abdo x-ray is rarely indicated  Erect CXR may help identify thoracic injury, as well as free gas  Pelvic x-ray may show fractured pelvis, often associated with major intraabdominal or retroperitoneal injuy o Management  Oxygen, fluids  Urethral catheter to monitor urine output and look for haematuria, but do not do this if blood at meatus, scrotal haematoma or high riding prostate which implies urethral rupture  Call surgeon and warn theate for impending laparotomy if persistent shock, rigid/silent abdomen, radiological evidence of ruptured viscus  If immediate laparotomy not indicated, perform besdies FAST scan (useful if unstable to go to CT), or CT if stable Penetrating abdominal trauma o Entry wound may be obvious, or difficult to find o o o

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Most important signs to look for are hypotensive shock Abdominal examination often unremarkable, but may show local rigidity and guarding with reduced bowel sounds o Associated chest injury is possible with any wound above umbilicus o Get wide bore access, send FBC/UEC/lipase and crossmatch o Get CXR and AXR o Management  Cover any exposed bowel with saline soaked pads  Oxygen, fluid resuscitation, morphine, broad spectrum antibiotics  Urgent surgical referral – all GSWs and the vast majority of stab wounds need laparotomy Pelvic injury o The major complication of fractured pelvis is massive blood loss, up to 3L which may continue despite resuscitation o Result from high-energy blunt trauma o Localised pain, tenderness and bruising o PR examination is mandatory to identify rectal or urethral injury o Get wide bore access, send bloods, crossmatch 6 units minimum o Get pelvic xray in all multi-trauma patients, get CT contrast if patient stable and fracture identified on plain radiograph o Greatest risk of haemorrhage if:  Quadripartite butterfly fracture (all 4 pubic rami)  Open book fracture with diastasis of pubis symphysis >2.5cm  Vertical shear fractures with hemipelvic disruption o Management  High flow oxygen, fluids, blood transfusion as necessary  Do no attempt to catheterise if urethral injury is a potential  Apply pelvic compression with a sheet secured tightly around front of pelvis, or a commercially available sling  Exclude intraperitoneal bleed with FAST scan, if too unstable for CT  Immediately contact surgeons, orthopaedic team and/or radiology team – haemorrhage control is the priority which may require internal fixation, laparotomy and/or arterial embolization Blunt renal injury o Causes haematuria, loin pain, tenderness +/- hypotension from haemorrhage o Large bore access, send bloods, crossmatch 4-6 units o X-rays to exclude bony trauma o o

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Contrast CT (largely replaced IVP) if high risk or suspected renal injury Management – resuscitate, FAST scan, surgical referral (85% settle with analgesia and bed rest only) Bladder/urethral injury o Bladder rupture – may be intra or extraperitoneal o o

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Intraperitoneal – shock, peritonism, while extraperitoneal – urine extravasation, local bruising  95% have macroscopic haematuria o Urethral rupture  Membranous or bulbous part  Difficulty voiding, ureathreal bleeding, high riding prostate (membranous rupture) o Management  Do not catheterise (unless senior experienced ED doctor or urologist)  Fluids, analgesia, antibiotics  Requires ascending urethrogram or cystogram – refer to urological surgeons Other orthopaedic injuries in multi-trauma Thoracic and lumbosacral spine injury o Maintain spinal precautions and careful log-roll – look for bruising, deformity, penetrating injury and palpate for swelling or localised tenderness o Perform careful neurological examination – sensory deficits, perianal sensation, motor/reflex loss o Get thoracolumbar spine x-ray if high risk for injury – get a CT if significant or potentially unstable fracture identified on XR o Management – maintain spinal precautions, manage other more life threatening emergencies, refer injuries to specialised spinal unit Limb injury o Management  Restore deformity to normal anatomical alignment to reduce risk of neurovascular compromise  Cover compound fractures with sterile saline-soaked dressing and give antibiotics  Immobilise with POP or specialised traction splint (e.g. femoral shaft #)  Orthopaedic or vascular surgical help if vascular compromise or severe injury Head injury Conscious head injury o History – nature/speed of impact, LOC, drowsiness, vomiting, seizures, length of post-traumatic amnesia (>10min significant), associated drug/EtOH, comorbidities, medications (?warfarinised) o Examination  Vitals, GCS, pupil size/reactions, eye movement, cranial nerves and limbs for lateralising signs  Examine local site for lacerations, haematomas, fractures etc.  Exclude other injuries o Radiological imaging  Clear the C spine radiologically if any risk  CT head is the investigation of choice for clinically serious brain injury – indications in the context of GCS 15 head injury include:  Drug/EtOH intoxication at time of evaluation

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 Headache or repeated vomiting  Age >60  Risk of haemorrhage (warfarin etc)  Dangerous mech...