Erm - All Files in One

ASSESSMENT OF LOC:
- Glasgow Coma Scale (GCS) - KNOW THIS:

o Eyes opening in response to:
§ 4. Spontaneous
§ 3. Voice
§ 2. Pain
§ 1. Not
§ (Score out of 4)
o Speech:
§ 5. Oriented
§ 4. Confused Speech
§ 3. Inappropriate Speech
§ 2. Incomprehensible/Incoherent
§ 1. None
§ (score out of 5)
o Motor
§ Can either -Obeying commands/localising painful stimulus (directly respond to painful stimulus)/
withdraws from painful stimulus/flexing (Very bad)/Extension (very very Bad)/None
§ (Score out of 6)
o (Less than GCS10 = Deeply unconscious; Less than GCS8 = Coma)
o (Max Score = 15 = Awake, Alert, Responsive = Conscious)
o (Min Score = 3 = Dead)
(*Remember 4 Eyes, Jackson 5, 6 Cylinder Engine)
- AVPU
o Conscious
§ Awake
§ responding to Voice
o Unconscious
§ Only Responsive to Pain
§ Unresponsive
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PRIMARY SURVEY (ABSOLUTELY CRITICAL IN CASES OF LOC):
- ABCDEFG:
o Airway:
§ Commonest cause of Unconsciousness is Airway Obstruction
§ Clear The Airway:
• Left Lateral Position/Suction/Guedell Airway/Jaw Thrust
§ (Generally GCS<8 require definitive airway management – Endotracheal tube/Intubation
àVentilation)
o Breathing:
§ Essential to ensure adequate ventilation
§ (without adequate ventilation, pt will suffer a secondary hypoxic brain injury)
§ Give Oxygen
§ Maintain Sats & Normocarbia
• If hypoventilation à Hypercarbia à Cerebral Vasodilation à Increases Intracranial
Pressure à Decreases Cerebral Perfusion.
o Circulation:
§ Must ensure adequate circulation (IV fluids)
§ Cerebral perfusion pressure = Blood Pressure – Intracranial Pressure
• As ICP goes up, must ensure at least a normal BP in order to maintain cerebral circulation
§ In head trauma, 5 minutes of Hypotension à 25% increase in mortality.
o Disability (Ie. Level of Consciousness):
§ Assess level of consciousness & Document it.
§ Monitor for changes
§ Assess Pupillary Size/Reactivity
o Exposure:
§ Examine the Whole Patient (Including the Back)
o DON”T EVER FORGET GLUCOSE
• CASES
o Give each of the following cases a AVPU rating and GCS.
o Case 1
§ A 16 year old female is brought into your ED by ambulance after falling from a third floor
balcony. Her eyes are closed despite painful stimulus and she’s making groaning noises. She
pulls her hands and feet away when painful stimulus applied to them.
§ AVPU………………...
§ GCS…………………..
o Case 2
§ A 24 year old man who is cheerfully intoxicated with alcohol is brought to your ED by Police.
His speech is slurred he doesn’t know what day or month it is, but is very happy to assist you
with your physical examination of him.
§ AVPU…………………..
§ GCS…………………….
o Case 3
§ A febrile 82 year old is brought into your ED by relatives. She is looking around the ED but
every time you ask a question she tells you to “@#$% off” and this response never varies.
She tries to hit you when you ask her to move her arms or legs.
§ AVPU………………....
§ GCS……………………
o Case 4
§ A six month old is brought your ED by his parents after suffering a generalised seizure. His
eyes are open but he makes no response to any stimulus.
§ AVPU………………….
§ GCS…………………. .
§ How useful do you think the AVPU and GCS scales are in this age group? Why?
PRE-HOSPITAL CARE
LEVEL OF PROVIDERS
❏ levels of providers not standard in every community
❏ first responders usually non-medical (i.e. firefighters, police)
• administer CPR, O2, first aid, assist ventilation, automatic defibrillation (firefighters)
❏ Level I Paramedic
• basic airway management (oropharyngeal airway and suction), O2 by mask or cannula, CPR,
semi-automatic external defibrillation, basic trauma care
• blood sugar kit, administer some drugs (nitro, salbutamol, epinephrine, ASA, glucagon)
❏ Level II Paramedic
• start IV, ventilation of intubated patients, interpret ECGs, manual defibrillation
❏ Level III Paramedic
• advanced airway management (intubation), cardioversion and defibrillation,
emergency drugs (IV epinephrine, naloxone, dopamine), ACLS, needle thoracostomy
❏ base hospital physicians
• provide medical control and verbal orders for Paramedics through line patch
• ultimately responsible for delegated medical act and pronouncement of death in the field
APPROACH TO COMA
Definitions
❏ Coma - a sleep-like state, unarousable to consciousness
❏ Stupor - unresponsiveness from which the patient can be aroused
❏ Lethargy - state of decreased awareness and mental status (patient may appear wakeful)
GLASGOW COMA SCALE (GCS)
❏ designed for use on trauma patients with decreased LOC; good indicator of severity of injury
❏ often used for metabolic causes as well, but less meaningful
❏ most useful if repeated
• changes in GCS with time is more relevant than the absolute number
• patient with deteriorating GCS needs immediate attention
Table 3. Glasgow Coma Scale

Eyes Open Best Verbal Response Best Motor Response
spontaneously 4 answers questions appropriately 5 obeys commands 6

to voice 3 confused, disoriented 4 localizes pain 5
to pain 2 inapproriate words 3 withdraws to pain 4
no response 1 incomprehensible sounds 2 decorticate (abnormal flexion) 3
no verbal response 1 decerebrate (abnormal extension) 2
no response 1
❏ best reported as a 3 part score: Eyes + Verbal + Motor = total

❏ provides indication of degree of injury
• 13-15 = mild injury
• 9-12 = moderate injury
• < 8 = severe injury
❏ if patient intubated, GCS score reported out of 10 + T (T= tubed, i.e. no verbal component)
Coma (GCS ≤ 8)
2/3 1/3
Toxic/Metabolic Primary CNS Disease/Trauma
M - Major organ failure

E - Electrolyte/Endocrine
T - Toxins/Temperature
A - Acid disorders Bilateral Cerebral Brainstem
B - Base disorders Hemispheres (affecting cognition) (affecting Recticular
O - decreased Oxygen level Activitating System (RAS))
L - Lactate
I - Insulin (diabetes)/Infection (sepsis) Diffuse lesion Diffuse trauma/ischemia Compression Direct
C - Cardiac/hyperCalcemia • supra/infratentorial • brainstem
tumour infarct
• sub/epidural • brainstem
Figure 2. Etiology of Coma hematoma hemorrhage
ER6 – Emergency Medicine MCCQE 2002 Review Notes
APPROACH TO COMA . . . CONT.
MANAGEMENT OF THE COMATOSE PATIENT

❏ ABC’s
❏ airway management should take into account
• probability of C-spine injury, high if:
• major trauma
• head or face trauma
• history of fall or collapse
• likelihood of aspiration
• adequacy of ventilation
• correct hypoxia and hypercarbia
• reversibility of the cause of the coma
• hypoglycemia or narcotic overdose (OD) rapidly reversible therefore ETT may not be needed
(controversial)
• need for maximizing oxygenation
• carbon monoxide (CO) poisoning
• raised ICP (usually requires ETT)
Components of Resuscitation
❏ IV access
❏ rapid blood sugar, CBC, lytes, Cr and BUN, LFT’s, glucose, serum osmolality, ABG’s
❏ ECG
❏ universal antidotes
• thiamine 100 mg IM before glucose (if cachectic, alcoholic, malnourished)
• glucose: 50 cc of 50% (D50W) if glucose < 4 mmol/L (70 mg/dL) or
rapid measurement not available
• naloxone 0.4-2.0 mg IV if narcotic toxidrome present (risk of withdrawal
reaction in chronic opiate users, therefore use naloxone 0.4 mg in known users)
❏ drug levels of specific toxins if indicated
❏ rapid assessment and correction of abnormalities essential to prevent brain injury
Secondary Survey and Definitive Care
❏ focused history (from family, friends, police, paramedics, old chart, etc.)
❏ onset and progression
• abrupt onset suggests CNS hemorrhage/ischemia or cardiac cause
• progression over hours to days suggests progressive CNS lesion or toxic/metabolic cause
❏ condition prior to coma
• confusional/delerious states suggest toxic/metabolic cause
• antecedent trauma, seizure activity, fever
• medications, alcohol, or drugs
❏ past medical history (e.g. similar episode, depression)
❏ physical examination
• vitals including temperature, cardiac, chest, abdominal exam and inspection for 5 N’s
❏ selected laboratory and imaging studies (x-ray and CT)
Inspection - The Five N’s
❏ Noggin – e.g. Raccoon eyes, Battle’s sign (appear ~8 hrs. after trauma)
❏ Neck – C-spine, neurogenic shock, nuchal rigidity
❏ eNt – otorrhea, rhinorrhea, tongue biting, odour on breath, hemotympanum
❏ Needles – track marks of IV drug abuse
❏ Neurological – full examination essential but concentrate on
• GCS - follow over time
• respirations (rate and pattern)
• apneustic or ataxic (brainstem)
• Cheyne-Stokes (cortical, brainstem or toxic/metabolic)
• posture
• decorticate: severe bilateral damage above midbrain
• decerebrate: damage in midbrain, diencephalon
• movement
• spontaneity, symmetry and seizure activity
• pupils - reactivity and symmetry (CN II, III), papilledema (increased ICP)
• reflexes
• corneal reflex (CN V, VII)
• gag reflex (CN IX, X)
• oculocephalic reflex/doll’s eye reflex (after C-spine clearance): test for brainstem integrity
• oculovestibular reflex (rule out tympanic perforation and cerumen impaction first)
• deep tendon reflexes and tone
• plantar reflex
• caloric stimulation: normal response consists of ipsilateral slow gaze (brainstem mediated) and
contralateral saccadic correction (cortically mediated); cannot be voluntarily resisted
• lumbar puncture (LP) after normal CT to rule out meningitis, subarachnoid hemorrhage (SAH)
(increasing evidence that LP can be done as primary investigation if no evidence of increased ICP)
Diagnosis
❏ findings suggesting a toxic-metabolic cause
• dysfunction at lower levels of the brainstem (e.g. caloric unresponsiveness)
• respiratory depression in association with an intact upper brainstem (e.g. reactive pupils)
• see Tables 4 and 5
MCCQE 2002 Review Notes Emergency Medicine – ER7
APPROACH TO COMA . . . CONT.
Table 4. Structural vs. Metabolic Coma
Structural Toxic-Metabolic
Pupillary asymmetric pupils equal, round, regular

Reaction or absent reaction to light (see Table 5)
Extraocular asymmetric symmetric

movements or absent or absent
Motor asymmetric symmetric

Findings or absent or absent
Table 5. Toxic - Metabolic Causes of Fixed Pupils
Cause Pupils Characteristics Treatment
Anoxia dilated antecedent history of 100% O2,

shock, cardiac expectant management
or respiratory arrest, etc.
Anticholinergic dilated tachycardia physostigmine (for Atropine)

Agents warm, dry skin sodium bicarbonate (for TCA)
(e.g. atropine, TCA’s)
Cholinergic Agents small, barely diaphoresis, vomiting, atropine

(e.g. organo- perceptible reflex incontinence, increased
phosphates) secretions
Opiates pinpoint, barely needle marks naloxone

(e.g. heroin) perceptible reflex
(exception:
meperidine)
Hypothermia normal history of exposure warm patient

or dilated temperature < 35ºC (e.g. warm IV solutions, blankets)
Barbiturates midsized history of exposure ABC’s

to dilated positive serum levels no specific antidote
confusion, drowsiness,
ataxia shallow respirations
and pulse
Methanol (rare) dilated optic neuritis ethanol ± dialysis

increased osmolal gap
metabolic acidosis
❏ it is essential to re-examine comatose patients frequently - can change rapidly

❏ diagnosis may only become apparent with the passage of time
• delayed deficit after head trauma suggestive of epidural hematoma
Disposition
❏ readily reversible coma: discharge if adequate follow-up care available
❏ enduring decreased LOC: admit to service based on tentative diagnosis
❏ transfer patient if appropriate level of care not available
Wk 1
Emergency Medicine Notes
Principles of Emergency Medicine; Triage
Small Stuff:
Key words + Definitions:
• Emergency:
o “A medical condition requiring Immediate Treatment”
• Triage:
o “The Process of Sorting Patients based on Urgency.”
• Resuscitation:
o To revive somebody from unconsciousness or apparent death
• The Primary survey – ABCDE:
o Airway
o Breathing
o Circulation
o Disability
o Expose
• Retrieval Medicine
o Pre-Hospital care performed in an emergency retrieval vehicle (Helicopter/Ambulance/Etc)
• National Triage Scale:
o The standardized triage guidelines for Australian Hospitals.
Big Stuff:
Major Concepts:
• What Constitutes an Emergency?:
o “A medical condition requiring Immediate Treatment”
o (Not necessarily life-threatening)
• Framework Dealing with an Emergency:

o 1. Triage:
§ “The Process of Sorting Patients based on Urgency.”
§ Describe the principles of triage and priorities in care:
• Triage establishes ‘Priorities of Care’ among groups of patients.
• Triage done by asking: “This patient should receive medical care from a doctor in
NO MORE THAN …?... Minutes.”
• Patient Assessment (Via the Primary Survey) is necessary to answer the above
question.
§ National Triage Scale:
• The standardized Triage Guide in Australia.
o 2. 30-Second Patient Assessment in an Emergency: “The Primary Survey” - “ABCDE”:
§ Airway (With c.spine control)
§ Breathing Achieved by: “Tell me your name”
§ Circulation “How are you today?”
§ Disability “Where does it hurt?”
§ Expose
“Tell me your name”:
§ Pt: “I’m John Smith” - You Know That:

• 1. Airway is Patent
• 2. Pt’s Breathing is Adequate.
• 3. Consciousness = Adequate Cerebral Perfusion = BP
is >Sys 80mmHg.
§ If Unresponsive:
• There is a Problem with One/More of the ABC.
“How are you today?”:
§ Pt: “Awful! This pain is dreadful”:

• You now know the Problem = Pain.
“Where does it Hurt?”:
§ Pt: “In my belly. Just here”:

• You now know the Location = Abdomen.
§ At the Same Time You are LOOKING & FEELING:

LOOKING FEELING
• APPEARANCE • PULSE
General, rash, pallor, cyanosis, jaundice Rate, rhythm, volume
• NECK • SKIN
Neck veins, thyroid Temperature, sweating
• CHEST
Respiratory distress, rate
You Now Have an Approximation of the First 3 Vital Signs:
- Respiratory Rate. (High/Normal/Low)
- Pulse (Tachy/Brady; Strong/Bounding/Thready)
- Temperature (Hot-ish/Cold-ish)
You Also Have an Idea of O2 Saturation:

- If Central Cyanosis = Low O2 Saturation.
- If No Cyanosis = O2 Sats are Ok (for now)
Other Observations:
- Normal Skin Colour = Unlikely Anaemia/Jaundice/Cyanosis/Shock.
- Normal Pulse = Cardiac Output is OK; No major Arrhythmias
- Warm, Dry Extremities = Adequate Peripheral Perfusion; Not Hypothermic
- Regular, Symmetrical Chest Movement = Unlikely Pneumothorax/Acidosis.
- Soft Neck with NO JVP = No RHF, No Goitre, No Neck Trauma.
NB: As a Problem is Identified/Arises, It is IMMEDIATELY Dealt With:
- If Blocked Airway à Clear It
- If Not Breathing à Ventilate
- If Pulse is Weak/Thready à Get IV Access
- If in Pain à Give Analgesia
o 3. Assess the Patient’s Pain Status:
§ *Analgesia should be the NEXT PRIORITY After Prolonging Life:
• Is it needed?..If So:
- What?
- Which Route?
- What Dose?
§ Pain Assessment:
• Site of Pain:
- Location
- Radiation?
• Circumstances @ Pain Onset:
- Trauma?
- Ie. What caused it.
• Character of Pain:
- Pain Description – (Sharp, throbbing, aching, dull, burning)
• Intensity of Pain:
- @ Rest
- On Movement
- Duration
- Continuous/Intermittent
- Aggravating Factors
• Somatic Pain?
- Sharp, hot or stinging
- Well localised
- Local Tenderness
• Visceral Pain?
- Dull, cramping pain
- Poorly localised
- Local Tenderness or Referred Tenderness
- Related symptoms – (Nausea, Sweating & CV Changes)
• Treatment?
- Current & Previous Meds.
§ Pain Scales – (Because Pain is a Subjective Experience):
• Eg. Categorical Scales:
- Verbal Descriptors (mild/moderate/severe/excruciating/agonising)
- Numeric (0-10)
• Eg. Visual Analogue Scale:
- 5 Emoticon faces with corresponding scores.
• NB: Different Pain Scales are used for different people:

- Eg. Deaf people are more suited to picture-based pain scale.
- Eg. Blind people are best suited to verbal/numeric scales.
- Eg. Babies/Foreigners are best suited to picture-based scales.
§ Importance of Analgesia:
• Relieves pain
• Improves Patient Communication
• Improves Patient Cooperation
• Can improve symptoms (eg. Pain-related tachycardia)
§ Advantages and Disadvantages of various Forms of Analgesia:
• Oral Analgesia (Paracetamol/Aspirin) – Cheap & Easy; But Weak
• Parenteral Analgesia (IM/IV opiates) – Strong; But More Expensive/Complicated
• Regional Blocks (LA injection around a nerve) – Only Good for Isolated Injuries
o 4. Early Management:
§ Prevention of Morbidity & Complications
§ Minimises Suffering
• Importance of Communication:
o *Communication is Critical for a Coordinated Effort & Positive Patient Outcome:
§ Between Doctors & Nurses
§ Between Doctors & Patient
§ Between Doctors & Family
• Impact of Emergencies:
o On Patients
o On Families
o On Communities
o On Health Workers
GLS Stuff:
Triage & Assessment Questions:
NTS NTS Maximum

Number Name Waiting Time Colour Code Example
1 Resuscitation 0 min Red Cardiac Arrest

Major Trauma
2 Emergency 10 min Orange Acute Severe Asthma
3 Urgent 30 min Green Acute Abdominal Pain
4 Semi Urgent 60 min Blue Sprained Ankle
5 Non Urgent 120 min White Repeat Script
- 1. Assign each of the following patients to a Triage Category:

o A) Jim is 26. He is a chef at the local pub. He has cut his forearm while filleting fish. He cannot
bend or feel most of his fingers and has a heavily blood stained bandage wrapped around his
arm. He has no other injuries and all his observations are normal.
o B) Jane is 40. She has been vomiting for 3 days and is a known diabetic. Her blood sugar level is
“HI”, pulse is 15, respiratory rate 35, blood pressure 75/40 mmHg. She is semiconscious, groaning
but does localise to pain and open her eyes.
o C) Jeffery is 52. He is a local property owner. He has tripped in a pothole and has twisted his
ankle. He is still able to walk. His observations are all normal.
o D) Jerry is 50. He has had a cough for 3 days and now seems quietly confused muttering to
himself about purple kangaroos. His respiratory rate is 40, oxygen sats 82%, pulse 120 and blood
pressure 100/65.
o E) Jenny is 48. She has suddenly collapsed in the middle of a heated debate. She has no pulse and
no spontaneous respirations. A bystander is doing CPR.
Patient 1 is a triage category 3

- 2. Assign each of the following patients to a Triage Category:
PATIENT DESCRIPTION TRIAGE REASON

CATEGORY
67 yo male
1 - VF Arrest 1 Cardiac Arrest
23 yo female
2 - Repeat script for OCP 5 Repeat Script
38 yo male
3 - Inversion injury to ankle. 4 Sprained Ankle
Swollen, sore, unable walk.
12 yo male
4 - Acute asthma. RR 40, sats 2 Acute Severe
85% on air, silent chest Asthma
26 yo female
5 - 8 weeks pregnant with lower 3 Acute Abdominal
abdominal pain and vaginal Pain
bleeding. Observations all normal.
2 yo female Febrile Convulsion
6 - Febrile convulsion. 3 implies an Active
Seizure stopped. Now awake. Infection à
?Meningitis
18 yo female
7 - MVA high speed. 1 Acute Trauma
Unconscious, P120, BP 75/40
73 yo male
8 - Rash for 2 months. 5 Not Urgent
43 yo female
9 - Vomiting and diarrhoea 2 days. 3 Needs IV
Now unable to keep fluids down.
33 yo male
10 - Recent admission with
depressive illness. Wants to ? ?
talk to someone as recurrence of
suicidal thoughts.
Has made no attempts.
INITIAL PATIENT ASSESSMENT AND MANAGEMENT
APPROACH
❏ 5 level triage (new Canadian Guidelines)
• I Resuscitation
• II Emergent
• III Urgent
• IV Less-urgent
• V Non-urgent
PRIORITIZED PLAN
1. Rapid Primary Survey (RPS)
2. Resuscitation (often occurs at same time as RPS)
3. Detailed Secondary Survey
4. Definitive Care
RAPID PRIMARY SURVEY (RPS)
Airway maintenance with C-spine control
Breathing and ventilation
Circulation (pulses, hemorrhage control)
Disability (neurologic status)
Exposure (complete) and Environment (temperature control)
❏ restart sequence from beginning if patient deteriorates
A. AIRWAY
❏ first priority is to secure airway
❏ assume a cervical (C-spine) injury in every trauma patient ––> immobilize with collar and sand bags
Causes of Airway Obstruction
❏ decreased level of consciousness (LOC)
❏ airway lumen: foreign body (FB), vomit
❏ airway wall: edema, fractures
❏ external to wall: lax muscles (tongue), direct trauma, expanding hematoma
Airway Assessment
❏ assess ability to breathe and speak
❏ signs of obstruction
• noisy breathing is obstructed breathing until proven otherwise
• respiratory distress
• failure to speak, dysphonia
• adventitous sounds
• cyanosis
• agitation, confusion, “universal choking sign”
❏ think about ability to maintain patency in future
❏ can change rapidly, ALWAYS REASSESS
Airway Management
❏ goals
• achieve a reliably patent airway
• permit adequate oxygenation and ventilation
• facilitate ongoing patient management
• give drugs via endotracheal tube (ETT) if IV not available
• NAVEL: Narcan, Atropine, Ventolin, Epinephrine, Lidocaine
❏ start with basic management techniques then progress to advanced
1. Basic Management (Temporizing Measures)
❏ protect the C-spine
❏ chin lift or jaw thrust to open the airway
❏ sweep and suction to clear mouth of foreign material
❏ nasopharyngeal airway
❏ oropharyngeal airway (not if gag present)
❏ transtracheal jet ventilation (through cricothyroid membrane)
• used as last resort, if unable to ventilate after using above techniques
2. Definitive Airway
❏ endotracheal intubation (ETT) (see Figure 1)
• orotracheal +/– Rapid Sequence Intubation (RSI)
• nasotracheal - may be better tolerated in conscious patient
• does not provide 100% protection against aspiration
❏ indications for intubation
• unable to protect airway
• inadequate spontaneous ventilation
• O2 saturation < 90% with 100% O2
• profound shock
• GCS = 8
• anticipate in trauma, overdose, congestive heart failure (CHF), asthma,
and chronic obstructive pulmonary disease (COPD)
• anticipated transfer of critically ill patients
❏ surgical airway (if unable to intubate using oral/nasal route)
• needed for chemical paralysis of agitated patients for investigations
• cricothyroidotomy
INITIAL PATIENT ASSESSMENT AND MANAGEMENT . . . CONT.
trauma requiring intubation
no immediate need immediate need
C-spine x-ray apneic breathing
positive negative* facial smash no facial smash
fiberoptic ETT oral ETT oral ETT oral ETT nasal ETT
or nasal ETT (no RSI) or RSI
or RSI
unable unable unable
cricothyroidotomy cricothyroidotomy cricothyroidotomy
* note: clearing the C-spine also requires clinical assessment (cannot rely on x-ray alone)
* ETT (endotracheal intubation), RSI (rapid sequence intubation)
Figure 1. Approach to Endotracheal Intubation in an Injured Patient
B. BREATHING
LOOK mental status (anxiety, agitation), colour, chest movement, respiratory rate/effort
FEEL flow of air, tracheal shift, chest wall for crepitus, flail segments
and sucking chest wounds, subcutaneous emphysema,
LISTEN sounds of obstruction (e.g. stridor) during exhalation, breath sounds
and symmetry of air entry, air escaping
Oxygenation and Ventilation
❏ measurement of respiratory function: rate, pulse oximetry, ABG, A-a gradient, peak flow rate
❏ treatment modalities
• nasal prongs ––> simple face mask ––> oxygen reservoir ––> CPAP/BiPAP
• Venturi mask: used to precisely control O2 delivery
• Bag-Valve mask and CPAP: to supplement ventilation
C. CIRCULATION - see Shock section
Table 1. Estimation of Degree of Shock

Class I II III IV
Blood loss < 750 cc 750 - 1500 cc 1500 - 2000 cc > 2000 cc
(<15%) (15 - 30%) (30 - 40%) (> 40%)
Pulse < 100 > 100 > 120 > 140
Blood pressure (BP) Normal Normal Decreased Decreased
Respiratory Rate (RR) 20 30 35 > 45
Capillary refill Normal Decreased Decreased Decreased
Urinary output 30 cc/hr 20 cc/hr 10 cc/hr None
CNS status Anxious Mild Confused Lethargic
Fluid replacement Crystalloid Crystalloid Crystalloid + blood Crystalloid + blood
Table 2. Estimated Systolic Blood Pressure (SBP)

Based on Position of Palpable Pulse
Radial Femoral Carotid
sBP > 80 > 70 > 60
(mmHg)
❏ stop major external bleeding

• apply direct pressure
• elevate profusely bleeding extremities if no obvious unstable fracture
• consider pressure points (brachial, axillary, femoral)
• do not remove impaled objects as they tamponade bleeding
• use tourniquet as last resort
❏ treatment
• 2 large bore peripheral IV’s for shock (14-16 gauge)
• bolus with Ringer’s lactate (RL) or normal saline (NS) (2 litres) and then blood as indicated
for hypovolemic shock
• inotropes for cardiogenic shock
• vasopressors for septic shock
D. DISABILITY
❏ assess level of consciousness by AVPU method (quick, rudimentary assessment)
A - ALERT
V - responds to VERBAL stimuli
P - responds to PAINFUL stimuli
U - UNRESPONSIVE
❏ size and reactivity of pupils
❏ movement of upper and lower extremities (UE/LE)
E. EXPOSURE / ENVIRONMENT
❏ undress patient completely
❏ essential to assess all areas for possible injury
❏ keep patient warm with a blanket +/– radiant heaters; avoid hypothermia
RESUSCITATION
❏ restoration of ABCs
❏ manage life-threatening problems as they are identified
❏ often done simultaneously with primary survey
❏ vital signs q 5-15 minutes
❏ ECG, BP and O2 monitors
❏ Foley catheter and nasogastric (NG) tube if indicated
• Foley contraindicated if blood from urethral meatus or other signs of urethral tear
(see Traumatology section)
• NG tube contraindicated if significant mid-face trauma or basal skull fracture
• may use orogastric tube
❏ order appropriate tests and investigations: may include CBC, lytes, BUN, Cr, glucose, amylase,
INR/PTT, ß-HCG, tox screen, cross + type
DETAILED SECONDARY SURVEY
❏ done after RPS problems have been corrected
❏ designed to identify major injuries or areas of concern
❏ head to toe physical exam and X-rays (C-spine, chest, pelvis - required in blunt trauma)
History
❏ “AMPLE”: Allergies, Medications, Past medical history, Last meal, Events related to injury
Head and Neck
❏ pupils
• assess equality, size, symmetry, reactivity to light
• inequality suggests local eye problem or lateralizing CNS lesion
• reactivity/level of consciousness (LOC)
• reactive pupils + decreased LOC ––> metabolic or structural cause
• non-reactive pupils + decreased LOC ––> structural cause
• extraocular movements (EOM’s) and nystagmus
• fundoscopy (papilledema, hemorrhages)
❏ palpation of facial bones, scalp
❏ tympanic membranes
Chest
❏ flail segment, contusion
❏ subcutaneous emphysema
❏ auscultate lung fields
❏ CXR
Abdomen
❏ inspection, palpation, percussion, auscultation
❏ immediate laparotomy if
• refractory shock with no other discernable cause
• obvious peritonitis
• increasingly distended abdomen
• positive diagnostic peritoneal lavage/CT scan
❏ rectal exam for gastrointestinal (GI) bleed, high riding prostate and anal tone
❏ bimanual exam in females
Musculoskeletal (MSK)
❏ examine all extremities for swelling, deformity, contusion, tenderness
❏ log rolled, palpate thoracic (T) and lumbar (L)-spines
❏ pelvis: palpate iliac crests and pubic symphysis, pelvic stability (lateral, AP, vertical)
Neurological Examination (see Neurosurgery Chapter)
❏ Glasgow Coma Scale (GCS)
❏ alterations of rate and rhythm of breathing are signs of structural or metabolic abnormalities
❏ progressive deterioration of breathing pattern implies a failing CNS
❏ full cranial nerve exam
❏ assessment of spinal cord integrity
• conscious patient: assess distal sensation and motor ability
• unconscious patient: response to painful or noxious stimulus applied to extremities
❏ signs of increased intracranial pressure (ICP)
• deteriorating LOC (hallmark of increasing ICP)
• deteriorating respiratory pattern
• Cushing reflex (high BP, slow heart rate)
• lateralizing CNS signs (e.g. cranial nerve palsies, hemiparesis)
• seizures
• papilledema (occurs late)
DEFINITIVE CARE
1. continue therapy
2. continue patient evaluations (special investigations)
3. specialty consultations including O.R.
4. disposition: home, admission, or another setting
Ethical Considerations
Adults
❏ Emergency Rule: consent not needed when patient is at imminent risk of suffering serious injury
(i.e., severe suffering, loss of limb, vital organ or life)
AND obtaining consent is either:
a) not possible (eg., patient is comatose), OR
b) would increase risk to the patient (e.g., time delay)
❏ any CAPABLE and INFORMED patient can refuse any treatment or part of treatment, even if it is life-saving
❏ in E.D. consider: is the patient truly capable? does pain, stress, psychological distress cloud their judgement?
❏ the emergency rule assumes that most people would want to be saved in an emergency
❏ EXCEPTIONS: Treatment can not be initiated if:
1. a competent patient has previously refused the same or similar treatment and there is no evidence to
suggest the patient's wishes have changed
2. an advance directive is available
3. a do not resucitate (DNR) order is available
4. refusal for help in a suicide situation is NOT an exception; care must be given
❏ when in doubt, treat
Children
❏ treat immediately if patient is at imminent risk
❏ parents / guardians have right to make treatment decisions, however
❏ if parents refuse treatment that is life-saving or will potentially alter the child's quality of life,
CAS is almost always contacted
❏ MDs cannot then treat without consent of Child Services
Jehovah's Witnesses
❏ refuse whole blood, packed red blood cells (PRBCs), platelets, plasma and WBCs even if life-saving
❏ should be questioned directly about the use of albumin, immunoglobulins, hemophillic preparations
❏ do not allow for autollogous transfusion unless there is uninterrupted extra corporeal circulation
❏ ask for the highest possible quality of care without the use of the above interventions
(e.g., crystalloids for volume expansion, attempts at bloodless surgery)
❏ may carry a signed, witnessed, dated Medical Alert card +/– bracelet specifically identifying their religious
affiliation and the procedures they will not consent to
❏ will generally sign hospital forms releasing medical staff from liability
❏ are consenting, capable adults and have the right to refuse medical treatment
❏ most legal cases involve children of Jehovah's Witnesses
❏ large centres may have policies surrounding care
❏ if life-saving treatment is refused (e.g., blood transfusion) CAS is contacted
Wk 3
Cardiovascular Emergencies & Shock
Objectives:
• To be able to describe the physiological basis for fluid resuscitation and differences between various IV
fluids
WHAT IS A CARDIOVASCULAR EMERGENCY ?

Consider these cases:
- CASE 1
o 19 year old female in an MVA
o Pale and sweaty with a distended abdomen (Indicates haemorrhage in Abdomen)
o P is 140 and BP is 65 / 40
o Was this a CVS Emergency ? YES

o Why? She’s in shock (Tachycardic & Hypotensive)
- CASE 2
o Robert is an 81 year old retired nurse
o He has presented complaining of palpitations and feeling weak and light headed
o His pulse is 20 and difficult to feel (:. Hypotensive)
o Was this a CVS Emergency? YES

o Why? Bradycardic & Probably Hypotensive à Probably a form of Heart block. Requires Pacing
- CASE 3
o Mike is a 54 year old mechanic
o He has developed a crushing pain in his central chest and left arm while walking
o The pain has lasted 2 hours and is getting worse
o He feels nauseated and breathless
o Was this a cardiovascular emergency? YES

o Why? Possible Myocardial Ischaemia &/Or Infarct.
What Constitutes CARDIOVASCULAR EMERGENCIES:

- 1. Disturbance of BP:
o Shock
o Hypertensive Crisis
- 2. Disturbance of Pulse:
o Brady Arrhythmias
o Tachy Arrhythmias
- 3. Disturbance of Function and Form
o Pump Failure
o Cardiac Tamponade
o Valve dysfunction
o Aortic Dissection
o Myocardial Ischaemia
CV EMERGENCIES: 1 – BP DISTURBANCES
(Shock / Hypertensive Crisis)
SHOCK:
- Medical Definition:
o EXAM Definition: Indequate Perfusion of Vital Organs (Heart/Brain/Kidneys)
o Other definitions:
§ “A rude unhinging of the machinery of life”
§ A state of inadequate tissue perfusion.
o NB: There are no numbers in definition. Shock is relative.
§ (Eg. A BP of 90 may indicate shock in a person with normal BP of 160)
CLINICAL EFFECTS OF SHOCK:

- Inadequate Tissue Perfusion à
o CNS Features such as impaired consciousness, Confusion, unresponsiveness, Coma;
o Renal features such as ↓Urine Output;
§ (Ie. Hypoxia of Brain & Decreased Filtration in Kidney)
- (:. CNS & Renal Function can be used to measure End Organ Perfusion.)
WHY DOES SHOCK OCCUR ?

- From failure of any of the components of the cardiovascular system à State of Decreased Flow:
o Pump
o Circuit – Loss of Vasomotor Tone
o Fluid – Eg. Hemorrhage/Fluid Loss/Dehydration.
Hypovolaemic Shock Vs. Cardiogenic Shock
TYPES OF SHOCK
- LOW CARDIAC OUTPUT SHOCKs
o CARDIOGENIC – (Pump Failure – Not pumping enough)
§ Inability of the heart to pump adequately
§ Possible Causes:
• AMI (May survive if quick treatment)
• Valvular Problems (Eg. From RHD; Probably not fit for surgery & probably die)
• Cardiomyopathy (Global myocardial weakness – the heart just cannot pump)
o Require a heart transplant/mech.heart for survival.
• Myocarditis
§ e.g. M.I., valve dysfunction, arrhythmias, myocarditis, Cardiomyopathy.
o HYPOVOLAEMIC – (Not Enough Blood volume)
§ Haemorrhagic:
• Blood Loss
• Internal/External Haemorhage
§ Fluid Loss:
• Eg. Loss of Gastrointestinal Fluids (Vom/Dia)
• Eg. Metabolic (eg. Diabetic ketoacidosis) can lose lots of fluid in their Urine.
• Eg. Large Seeping Burns
• Eg. Heat Stroke/Sweating
o DISTRIBUTIVE – increased size of circuit or capacitance due to altered vascular tone.
§ Septic Shock:
• Gram Negative Sepsis: Immune Response to liberated Endotoxin (LPS) à
Cascade of Cytokine Effects à ↑Cap. Permeability, Vasodilation à Hypotension
à Shock.
• May have Fever or be Hypothermic
• Warm & Well Perfused (can à Cold, clammy & shut down)
• Decreased Peripheral Resistance (can à ↓↓Diastolic Pressure à Compensatory
Tachycardia & ↓Myocardial perfusion à myocardial Ischaemia.)
• Causes:
o Eg. Bowel Perforation
o Eg. Meningococcus (Neisseria Meningitidis) can progress to septic shock.
o Eg. Melioidosis (A gram neg that lives in the soil)
• (incl. Increased Capillary Permeability)
• à ↓Peripheral Resistance
• à ↓Cardiac Perfusion
§ Anaphylactic Shock:
• Acute Allergic Reaction (IgE-Mediated Mast-Cell Degranulation)
o à Release of Vasoactive Mediators (incl. Histamine) à Loss of
Vasomotor Tone à Hypotension.
o Urticarial Rash
o Severe Bronchospasm
o Rapidly Aggressive Systemic Oedema (Esp. Face & Airway)
• (Mortality of up to 50%)
• 2 Allergic Syndromes:
o True Anaphylaxis:
§ Prior exposure à Cross Bridging of IgE à mast Cell
Degranulation
o Anaphylactoid (Clinically indistinguishable):
§ No Prior Exposure
o OBSTRUCTIVE – blockage to outflow
§ e.g. massive PE, cardiac tamponade, tension pneumothorax
COMPENSATORY MECHANISMS:
- All compensation relates directly or indirectly to the formula:
o (CO = SV x HR)
- (IMMEDIATE) Sympathetic Stimulation:
o Baroreceptors (in blood vessels) and CNS ischaemic response à Release of Catecholamines:
§ β1 Receptors on Heartà
• ↑HR (Chronotropic) à ↑CO
• ↑Contractility (Inotropic) à ↑SVà ↑CO
§ α1 Receptors in Vesselsà
• àArteriolar Vasoconstriction à↑Total Peripheral Resistance à↑BP.
• àVenous Constriction à↓Capacitance and ↑Venous Return à ↑CO & BP.
o (with sparing of cardiac and cerebral circulations)
- (DELAYED) Angiotensin and Vasopressin (ADH):

o Constrict Peripheral Arteries à↑Total Peripheral Resistance à↑BP
o Minimises Urine Output à ↑Circulating Fluid Volume à ↑BP
- Other
o Thirst Stimulated
o EPO Produced
o Increased salt appetite
- Frank Starling Mechanism:
o “↑Preload à ↑Stroke Volume”
§ Incomplete Chamber Emptying à↑PRELOAD à ↑Cardiac Output BY ↑SV
o (↑Preload à helps stretch myocardial fibres à Enhance cardiac function up till the point where
there is no longer any overlap between the myocardial muscle fibres.)
- The Concept of “CARDIAC RESERVE”:
o Cardiac Reserve = Maximal % that CO can Increase Above Normal.
o Normal Cardiac Reserve = 300-400%
o (The higher the Cardiac Reserve the lower the chance of shock after losing ‘x’ amount of blood)
DETERMINANTS OF CARDIAC OUTPUT

- Preload, Contractility, Afterload
HOW DO WE RECOGNISE AND ASSESS SHOCK ?

- An Obvious cause. (Eg. Bleeding, seeping burns)
- Signs and Symptoms of Inadequate Tissue Perfusion. (Eg. Cold, sweaty)
o Decreased Renal Perfusion à ↓Urine Output
o Decreased Cerebral Perfusion à Confusion, Anxiety, Agitation
o Decreased Myocardial Perfusion à Ischaemia, Hypotension
§ NB: Since the coronaries come off the base of the aorta, if a patient is in shock with signs
of myocardial ischaemia (Ie. ST-Depression), they are in SERIOUS TROUBLE.
- Evidence of Compensation. (Eg. Tachycardia)
- Hypotension (Despite Compensation)
STAGES OF SHOCK
- 1. Nonprogressive (Compensated) Shock:
o Beginnings of shock
o Adequately Compensated à No Hypotension or Hypoperfusion
- 2. Progressive Shock:
o No longer able to compensate à Showing signs of Hypotension & Hypoperfusion
o Still reversible with treatment
- 3. Irreversible Shock:
o No treatment is sufficient
o Pt WILL Die
o Vicious Cycle
GRADING SHOCK:
- Grade 1:
o <15% Blood Loss (750mL)
o Mild resting Tachycardia (+ Vasoconstriction)
o Normal BP Maintained
- Grade 2:
o 15-30% Blood Loss (750-1500mL)
o Moderate Resting Tachycardia (+ Vasoconstriction)
o Extended Cap.Refil time
o Normal BP Maintained
- Grade 3:
o 30-40% Blood Loss (1500-2000mL)
o Severe Resting Tachycardia (+ Vasoconstriction)
o Hypotension
o (Compensatory Mechanisms Beginning to Fail)
§ Eg. Low Urine Output
- Grade 4:
o 40-50% Blood Loss (2000-2500mL)
o Severe Hypotension
o End Organ Failure & Death
- NB: Notice how Arterial Pressure is the LAST thing to Fall following Haemorrhage?
o This is because it is maintained by Vasomotor-Constriction for a while.
o (IE. Shock can be present before any change in BP)
o (NB: Without treatment, people suffering from haemorrhagic shock will ‘bleed out’ à No CO)
- Assessment of Blood Loss: (EXAM: Memorise this Table)
Class % Volume Symptoms Signs (P,BP) Urine output Treatment
I <15% Mild Normal Normal Cup of Tea

<750 ml Biscuit
II 15-30% Anxious P 100-120 (àTachy) Decreased 2L IV fluid

< 1.5l BP normal
III 30-40% Agitated P 120 Minimal 2L IV Fluid & 2

< 2l lethargic BP 80/60 (BP Falling) Units of Blood
IV >40% Drowsy P 140 None IV Fluid

> 2l Unconscious Very low (40) Blood Surgery
Crash
- NB: The Aim of Fluid Resuscitation is to bring the patient up to Class I
- Good to know where the fluids that you give actually go:
o Eg. Average 70kg man:
§ 60% water :. Total body water (42L)
§ 2/3 Intracellular Fluid (28L)
§ 1/3 Extracellular Fluid (14L)
§ 5L blood [1/3 RBC (1.5L); 2/3 Plasma (3.5L)]
- So What happens to the Different IV Fluids?:
o Glucose is actively taken into cells
§ (volume of distribution is large, as none effectively remains in blood)
§ Therefore Glucose IS NOT suitable for pressure fluid resuscitation.
o Crystalloids (ie. Saline) – is kept in ECF by Na/K-ATPase
§ :. Volume of distribution = 14, and of that, 25% remains in circulation (3.5L)
o Colloid, kept in blood by capillary membrane (Albumin, Gelatine, etc)
§ Volume of Distribution is 3.5L, and ALL of that remains in Circulation.
o (500mL of Colloid = 2L of Crystalloid) – (NB: So long as you give the right amounts,
- Blood:
o The best fluid to replace blood loss is Blood
o But, either saline/hartmanns or colloid are still ok.
o NB: Blood has risks (immunogenic/infections/etc)
o NOT Glucose
TREATING SHOCK:
- Hypovolaemic Shock:
o Recognise severity of the loss (Ie. Estimate how much has been lost – good 1st step to treatment)
o Replace Loss (Typcially crystalloid Fluids)
o Stop ongoing Loss (May require surgery)
- Septic Shock:
o IV Fluid Resuscitation
o Appropriate Antibiotics (Broad Spectrum Initially; then Specific Therapy following blood cultures)
o Inotropic Support à Improve myocardial perfusion.
o Vasopressors (eg. Noradrenaline or Vasopressin) (to ↑PVR à ↑Diastolic Pressure à
↑Myocardial perfusion)
o May require surgery (eg. Bowel Perforation)
- Anaphylactic Shock:
o ABC Primary Assessment
o Adrenaline (+ Steroids – but too slow to be of use)
§ A:
• May need early airway management (Eg. ET Intubation)
• Nebulised Adrenaline (effective against airway oedema & Bronchospasm)
§ B:
• Nebulised Adrenaline
• Or IV Adrenaline
§ C:
• IV Fluids
• Adrenaline (IM / IV) (IV is better than IM/SC as it is absorbed faster)
- Cardiogenic Shock:
o Angioplasty/Reperfusion
o Inotropes
o ?Transplant?
- Mechanical:
o Tamponade (often due to trauma/Infection):
§ Pericardiocentesis
o Tension Pneumothorax:
§ Thoracocentesis
o Pulmonary Embolus:
§ Thrombolysis
GLS – SHOCK CASES:
Case 1 - Bart:
- He is pale and sweaty, has a distended abdomen and obvious bilateral femoral fractures. His pulse is 140
and his blood pressure is 75/40.
• What signs of shock are evident?
o Pale and Sweaty
o Tachycardic
o Hypotensive
• What Type of Shock is This?
o à Hypovolaemic (Haemorrhagic) Shock:
§ Seems to be bleeding into abdomen à Hypovolaemia à ↓CO àHypotension +
Compensatory Tachycardia
• Could Bart be shocked without a change in BP?
o Yes. Young, healthy people are able to compensate for up to 1500mL of blood loss by
Tachycardia & Vasopression, but then deteriorate rapidly afterwards.
• Is this consistent with our definition of shock ?
o No - Our definition stipulates a loss of blood pressure.
o (Clinically important - Need to remember that relying on blood pressure changes alone to
diagnose shock means that we will not recognise shock until a patient has lost 30 - 40 % of their
blood volume (class 3))
• Initial Treatment:
o Fluid Replacement – (For Hypovolaemia)
Case 2 – Homer:
- Suddenly collapsed and clutched his chest. He is pale and sweaty. His pulse is 40 and his blood pressure is
85/60. He is feeling short of breath. You note that his JVP is raised. Moe thinks that Homer has had a
heart attack.
o Pale & Sweaty
o Hypotensive
o Bradycardic à Suggests Cardiogenic Shock
o à Cardiogenic Shock:
§ Myocardial Infarction à Heart Failure (↓CO) & Bradycardiaà ↓BP.
• Homer’s ECG has shown an anterior myocardial infarction. Why might this have caused him to be
shocked ?
o Myocardial Infarction à Disrupted heart Contraction & Conduction à ↓HR (in this case), and
↓CO
• If Homer has a heart that is not pumping properly (decreased contractility) which direction will his
Starling curve move?
o His starling curve will shift Downwards (Ie. Stroke Volume & CO will be Less @ any given End-
Diastolic Volume)
o Inotropes – (For the Bradycardia)
Case 3 - Marge:
- Marge has bought a special new brand of extra strong hairspray. Begins to feel very itchy and notices
small bumps coming up on her head. She collapses. She is conscious but confused. Skin is bright red &
covered in raised lumps. Her pulse is 120 and her blood pressure is 90/60.
o Tachycardic
o Hypotensive
o à Distributive (Anaphylactic) Shock:
§ Itchy, red, bumps on skin + History of new Hairspray à Allergy (Systemic release of
Histamine & Other Vasoactive Mediators à Loss of Vasomotor Tone à ↓BP &
Compensatory Tachycardia.
• What has happened to her:
o Venous Tone? Decreased
o Venous Capacitance? Increased
o Venous Return? Decreased
o Preload? Decreased
o Stroke Volume? Decreased
o Cardiac Output? Decreased
• Why has she collapsed?
o Due to Postural Hypotension à Hypo-Perfusion of Brain à Momentary loss of consciousness.
(Regained once supine)
o Adrenaline – (For the Anaphylaxis)
Case 4 – Lisa:
- Lisa has been playing her saxophone. She collapsed gasping for breath. Her pulse is 120 and her Blood
Pressure is 65/45. Neck veins are distended. No breath sounds on the left side. Tension pneumothorax.
o Tachycardic
o Hypotensive
o à Obstructive Shock:
§ Spontaneous Tension Pneumothorax from Playing Saxophone à ↑Intra-Thoracic
Pressure à Inhibits Cardiac Filling (Seen as raised JVP) à ↓CO à Hypotension &
Compensatory Tachycardia
• How might Lisa’s tension pneumothorax cause her to be shocked?
o If pressure in the tension pneumothorax is high enough it may:
§ Compress (Decrease) Venous Return to the chest & heart à ↓CO à Shock
§ Shift the Mediastinum such that one/more of the Great vessels gets ‘kinked’ à ↓CO à
Shock
o Chest Drain – For the Pneumothorax.
Case 5 - Maggie:
- Her dummy fell in dog poo. Now very sleepy. Her skin is a mottled grey colour. Pulse of 180 and blood
pressure is 60/40. Angry inflamed area on her face which has pus in the middle of it.
o Tachycardic
o Hypotensive
o Grey, colourless skin
o à Distributive (Septic) Shock:
§ Bacterial infection from dog faeces à Endo/Exo Toxin à Systemic Cytokine Release à
Loss of Vasomotor Tone à ↓BP à Compensatory Tachycardia
• How have the following been affected ?
o Venous tone? Decreased
o Vessel Permeability? Increased
o Myocardial function? Inotropic
o Antibiotics
o (Also check Lactic Acid Level):
§ High levels can indicate severe infection
§ & Can indicate lack of Tissue Perfusion & Production of Lactica Acid by Anaerobic
Metabolic Pathways.
CV EMERGENCIES: 1 – BP DISTURBANCES
(Shock / Hypertensive Crisis)
HYPERTENSION (HT):
- = A persistently high blood pressure >140/90
- Untreated Hypertensionà↑Risk of Stroke, Coronary Artery Disease (& MI), & Aneurysm.
- 95 % = Essential (Primary) HT:
o (HT with no Direct Medical Cause)
o Usually Asymptomatic.
o Most common in Older (>30) People.
- 5 % = Secondary HT:
o (HT caused by other Conditions – eg. Affecting Kidneys/Arteries/Heart/Endocrine)
§ Eg. Cushing’s Syndrome
§ Eg. Hyperthyroidism (Thyrotoxicosis)
§ Eg. Pre-Eclampsia (HT in pregnant women)
o Most common in Young (< 30) People.
THE EMERGENCY – Hypertensive CRISIS (Malignant/Accelerated Hypertension):

- = HT Associated with Rapidly Progressive Organ Damage (renal failure, encephalopathy, retinopathy)
o “Malignant” or “Accelerated” Hypertension is rare; & can complicate HT of any Aetiology.
- Pathophysiology Not well Understood:
o Failure of normal Autoregulation and an abrupt ↑Vascular Resistance are typically initial steps.
o Common Causes:
§ Cessation of Antihypertensives (Rebound HT)
§ Autonomic Hyperactivity
§ Drug use (Cocaine/Amphetamines)
§ Glomerulonephritis
§ Head Trauma
§ Tumours
§ Pre-Eclampsia
o Is a Vicious Cycle of Homeostatic Failure à Potential Multi-Organ Involvement:
§ àCerebral Infarction
§ àPulmonary Oedema
§ àHypertensive Encephalopathy (Cerebral Oedema)
§ àCongestive Heart Failure
- Symptoms Include:
o Headache
o Drowsiness
o Confusion
o Vision disorders (Due to Papilloedema – Swelling of Optic Disc due to Cerebral Oedema)
o Nausea
o vomiting
- Management:
o Aim: To Smoothly Reduce BP over 24 to 36 hours to 150 / 90
§ (Excessive reduction may à Coronary/Cerebra/Renal Ischaemia)
CV EMERGENCIES: 2 – DISTURBANCES OF PULSE
(Tachy-Arrhythmias / Brady-Arrhythmias)
DISTURBANCE OF PULSE
- Working knowledge of ECG and Cardiac Cycle is Essential:
o What does the P wave represent ?
§ Atrial Depolarisation
o What does the QRS complex represent ?
§ Ventricular Depolarisation
o What does the T wave represent ?
§ Ventricular Repolarisation
o What rate is normal ?
§ 70bpm
o What is this called ?
§ Resting Heart Rate (Pulse)
o What rate is too fast?
§ Tachycardia
§ >100bpm
o What rate is too slow ?
§ Bradycardia
§ <60bpm
- Revision of the Cardiac Cycle:

o P-Wave?
§ Atrial Systole
o QRS-Complex?
§ Beginning of Ventricular
Systole
o T-Wave?
§ Ventricular Filling
§ Isovolumetric Relaxation
o S-Wave?
§ Isovolumetric Contraction
o First & Second Heart Sounds:
§ 1. Lubb (AV Valve Closure)
§ 2. Dupp (Semilunar Valve
Closure)
§ How do they relate to:
• The cardiac cycle
o 1) Beginning of Ventricular Systole
o 2) End of Ventricular Systole
• The ECG ?
o 1) QRS Complex
o 2) T-Wave
o When blood enters the right atrium from the vena cava, Is this diastole or systole ?
§ Atrial Diastole
§ Ventricular Diastole
o Which valves are open and closed?
§ AV Valves are Open
§ Semilunar Valves are Closed
o How does the atria help the ventricle finish filling ?
§ The atria contract following passive ventricular filling, actively pumping their contents
into the Ventricles
§ (and how is this seen on the ECG) – P-Wave.
o Once blood leaves the ventricles, is this diastole or systole?
§ Atrial Systole
§ Ventricular Systole
o Which valves are open and closed?
§ AV Valves Closed
§ Semilunar Valves Open
o how does the ventricle empty ?
§ Via Active Contraction
§ (how is this seen on the ECG) – QT-Segment
LOOKING AT ECGs:
- Check Pt ID
- Check Voltage & timing
o 25mm/sec
o 1large square = 0.2s (1/5sec)
o 1small square = 0.04s
- What is the rate?
o 300/number of large squares between QRS Complexes
§ Tachycardia
• >100bpm
§ Bradycardia
• <60bpm
- What is the Rhythm?
o Sinus? (are there P-Waves before each QRS complex)
o If Not Sinus?
§ Is it regular
§ Irregular?
§ Irregularly Irregular (AF)
§ Brady/Tachy
- Atrial Fibrillation:
o Irregularly Irregular
o P-Waves @ 300/min
- QRS:
o Is there one QRS for each Pwave?
o Long PR Interval? (1st degree heart block)
o Missed Beats? (Second degree block)
o No relationship? Complete heart block
- Look for QRS Complexes:
o How wide – should be < 3 squares
o If wide – It is most likely Ventricular
o (Sometimes atrial with aberrant conduction (LBBB/RBBB)
o IF Tachycardia, & Wide Complex à VT is most likely. (If hypotensive à Shock; if Normotensive à
IV Drugs)
- Look for TWaves:
o Upright or Inverted
- Look at ST-Segment
o Raised, depressed or inverted
o ST Distribution à Tells you which of the coronaries are blocked/damaged
§ Inferior ischaemia (II, III, AVF)
§ Lateral ischaemia (I, II, AVL, V5, V6)
§ Anterior ischaemia (V, leads 2-6)
o NB: Normal ECG Doesn’t exclude infarct.
o ST Depression à Ischaemia
o ST Elevation à Infarction
o If LBBB or Paced, you CANNOT comment on ST-Segment
GLS - ECG CASES:
ECG 1
Sinus rhythm
- P-Wave is Present
- Consistent 1:1 P-Wave:QRS-Complex Ratio
- QSR Complex is Normal
- Normal ECG (Sinus Rhythm)
- CO is Normal
- (35yr old Male Triathlete)
ECG 2
Sinus Tachycardia
- P-Wave is Present
- 1:1 P:QRS Ratio
- Sinus Tachycardia
- à ↑CO
- (Elderly Female with palpitations)
ECG 3
Ventricular fibrillation
- No Visible P-Wave
- No P:QRS Relationship
- No Recognisable QRS Complexes.
- Ventricular Fibrillation
- No Cardiac Output
- (61 yo male collapsed at the office, now unconscious with no pulse)
ECG 4
Complete heart block
- P-Wave Present
- No P:QRS Relationship
- Inverted QRS Complexes
- ST-Depression
- Complete Heart Block (Complete conduction failure between Atria & Ventricles)
- Cardiac Output will be Reduced (due to disordered contraction of Atria & Ventricles)
- (76 yo female with recurrent dizzy episodes, collapsed twice)
CV EMERGENCIES: 3 – DISTURBANCES OF FUNCTION AND FORM
(Myocardial Ischaemia/Heart Failure/Tamponade/Valve Dysfunction/Aortic Dissection)
- Often associated with changes in Cardiac Output/Rhythm.

- Knowledge of anatomy of the heart needed to understand effects and treatment
MYOCARDIAL ISCHAEMIA
- Risk factors
o Hypertension
o Hyperlipidaemia
o High cholesterol
o Smoking
o Obesity
o Diabetes
o Age
o Systemic Inflammatory State
o – However, in an ED setting, these are of little use.
- Acute ischaemia
o Pathogenesis - Atherosclerosis
o Symptoms:
§ Typically Crushing Chest Pain
§ Nausea, Vomiting
§ Dyspnoea
§ Radiating pain to Shoulders, Neck & Arm.
o Complications à Infarction à Death of muscle.

- Myocardial Infarction:
o Pathogenesis – Atherosclerosis (& Thrombosis)
o Symptoms:
§ Arrhythmias (Palpitations)
§ Syncope
§ Crushing chest pain
§ Dyspnoea (Shortness of Breath)
§ Nausea, Vomiting
§ Sweating
§ Possible shock
- Examination & Diagnosis:
o Examination:
§ Weak, Thready (Irregular) Pulse
§ Cool, Pale, sweaty skin (Peripheral Vasoconstriction)
§ Tachypnoea
§ If à Heart Failure:
• à Raised JVP (Jugular Venous Pressure)
• à Oedema (incl. Pulmonary Oedema)
o ECG:
§ Arrhythmias
§ Changes in serial ECG traces.
• Eg. ST-Elevation
• Eg. ST-Depression
• Eg. Pathological Q waves
o Imaging:
§ Obstruction on Coronary Angiogram
o Cardiac Enzymes:
§ Raised Troponin I & T Levels
§ (Also Raised Creatine Kinase-MB)
§ (NB: Rise and fall of serum cardiac biomarkers (Troponins & CKMB) indicate
cardiomyopathy – Typically Infarction)
§ Therefore, Cardiac Markers have to be measured at different times.
• 1. Immediately upon presentation
• 2. 4-6hrs after attack (This is when cardiac troponins are released if it’s an MI)
• 3. Over the next 24hrs
- Treatment:
o Nitrates (Vasodilators)
o Thrombolytics
o Surgery (Angioplasty/Stent)
HEART FAILURE
- = Where the heart cannot maintain adequate CO to perfuse the organs of the body.
o (or can only do so at expense of filling pressure à Frank Starling Law à ↑SV)
o (Frank Starlings Law = ↑Preload à ↑Contractility à ↑SV à ↑CO.)
- Body’s Response to HEART FAILURE

o àActivation of Renin Angiotensin System à
§ ↑Vasoconstriction à ↑PVR à ↑BP à ↑Organ Perfusion
§ Aldosterone Secretion à Salt & Water Retention à ↑Preload à ↑SV à ↑CO
o àActivation of Sympathetic System à
§ ↑Vasoconstriction à ↑PVR à ↑BP à ↑Organ Perfusion
§ ↑HR à ↑COà ↑Organ Perfusion
§ ↑Contractility à ↑SV à ↑CO à ↑Organ Perfusion
o Initially helps cardiac function by altering afterload or preload and h myocardial contractility
o Ultimately causes ↓CO by excess peripheral vascular resistance
TAMPONADE
- Cardiac Tamponade = “Emergency condition where Fluid Accumulates in the Pericardium”.
o AKA: “Pericardial Effusion”
o (NB: The Pericardium is Fibrous, & Doesn’t stretchàAs little as 100mL can cause tamponade)
- Effects on CV System:
o Puts pressure on the heart à Prevents proper Ventricular Filling à ↓SV, CO
o à Obstructive Shock
o à Cardiac Arrest
- Possible Causes:
o Physical trauma
o Hypothyroidism
o Pericarditis
o Iatrogenic Trauma (Eg. From surgery)
o Myocardial Rupture (Typically of an Infarcted Area following MI)
- Treatment:
o Pericardiocentesis (Chest tube to drain fluid)
VALVE DYSFUNCTION
- Eg. Aortic Valve Stenosis:
o = “Abnormal narrowing of the Aortic Valve opening.”
§ à Blood cannot be adequately pumped through the narrow orifice.
o Effects on CV System:
§ à ↑L-Ventricular Afterload à LV-Hypertrophy (Initial compensation – Maladaptive)
§ à Eventually, LV-Dilation occurs due to ↑Wall Stress à Systolic Function Deteriorates.
• à Congestive Heart Failure/Syncope/Angina
o Treatment:
§ Valve Replacement
- Eg. Mitral Regurgitation:
o = “Where the mitral valve doesn’t close properly during Systole”
§ à Regurgitation of blood from left ventricle into the left atrium.
§ AKA: Mitral Insufficiency or Mitral Incompetence
o Effects on CV System:
§ à Regurgitation of blood from left ventricle into the left atrium.
§ à↓Ejection Fraction & SV à ↓CO
§ àCongestive Heart Failure (Dyspnoea, Pul.Oedema, Dyspnoea lying down)
§ à Cardiovascular Collapse à Cardiogenic Shock
o Treatment:
§ Mitral Valve Replacement (If acute)
§ Vasodilators & Antihypertensives to ↓Afterload & ↑Ejection Fraction (If Chronic)
AORTIC DISSECTION
o = “A tear in the wall of the Aorta where Blood flows Between the Layers of the Wall”
§ à Forces the layers of the wall apart.
§ à If Aorta Ruptures – 80% Mortality Rate
§ (An Absolute Medical Emergency)
o Treatment:
§ Emergency Surgery
ASSESSMENT OF CVS EMERGENCIES
- AIMS:
o Determine Cause
o Determine Severity
- METHODS
o 1. ABC : 30 second exam
o 2. Stabilise
o 3. In Depth:
§ Appearance
§ History
§ Examination
§ Monitoring (ECG, Sats, Vitals)
§ Investigation
APPEARANCE
- Level of consciousness
- Sweating
- Agitation
- Cyanosis or Pallor
- External blood loss
- Clutching chest, obvious bleeding or other clues to cause
HISTORY
- Nature of symptoms
- Onset of symptoms
- Progression of symptoms
- Associated symptoms
- Treatment so far
- Previous episodes
- Other significant past history
EXAMINATION
- Appearance
- Pulse
- Capillary Refill Time
- Blood Pressure
- Heart Sounds
- Evidence of heart failure – JVP, oedema, creps
- Signs of chronic disease
PULSE
- Rate
- Rhythm
- Volume
- Location
CAPILLARY REFILL TIME

- Peripherally - Press down on nail bed for 5 seconds and then release.
o Watch for return of normal colour
o Normal is less than 2 seconds
o Abnormal is 2 seconds or greater
- Centrally – same thing over the sternum
- What may potentially interfere with assessment of CRT?
o (Cold ambient temperature à Peripheral Vasoconstriction to Conserve Heat)
BLOOD PRESSURE
- What is normal for the patient?
- What is low?
- What is raised?
- How and where to measure?
ASSESSMENT: MONITORING & INVESTIGATION:

- MONITORING
o Direct CVS monitor
§ BP and Pules
§ ECG
o Indirect CVS monitor
§ O2 sats
§ urine output (For kidney perfusion)
§ GCS (For brain perfusion)
- INVESTIGATION
o ECG – (Detect Rhythm Abnormalities & Diagnose other Conditions)
o Chest XR – (Detect CV Abnormalities and their effects such as Pulmonary Oedema)
o Echocardiography
o Pathology (Blood tests)
WHEN ASSESSMENT IS COMPLETE

- SHOULD HAVE AN IDEA OF CAUSE
o Simple?: Shock, HT Crisis, Arrhythmia
o Advanced?: Differential Diagnosis
- SHOULD KNOW SEVERITY OF PROBLEM AND HENCE DEGREE OF URGENCY
REMEMBER
- AS YOU IDENTIFY PROBLEMS IN THE PRIMARY SURVEY YOU NEED TO TREAT THEM
TREATMENT OF CVS EMERGENCIES:
- SUPPORTIVE TREATMENT
o AIM = To restore / maintain adequate tissue perfusion
o Examples:
§ Control of external bleeding
§ Correct circulating volume (Eg. IV fluids)
§ Help tissue oxygenation (Eg. With Supplemental O2)
§ Symptom relief (Eg. Nitroglycerin for Angina)
- DEFINITIVE TREATMENT
o AIM = Treating the underlying pathology
§ (These are :. diagnosis dependant.)
o Examples
§ Surgery to control bleeding in trauma (Eg. Ruptured Spleen)
§ Pacemaker for complete heart block (Pacing)
§ Restoration of coronary circulation in AMI (Eg. Thrombolytics/Angioplasty)
§ Long term Antihypertensives (Eg. Daily Antihypertensive Meds)
SUPPORTIVE TREATMENTS:
- INTRAVENOUS CANNULATION
o Various sizes/sites/uses
- CENTRAL VENOUS ACCESS

o Where do these go? (Subclavian, Juggular, Femoral)
o What advantages or disadvantages do they have ?
§ + Big Vessels – irritating drugs can be administered
§ - Time/Expertise required
o When would you use them?
§ Very ill patients in ICU
- OTHER ACCESS SITES

o Intraosseus (With intraosseus needle – Can give fluid & drugs like normal IVs)
o Venous Cutdowns (Cannula is inserted into surgically-exposed vein under direct vision)
o Umbilical Veins
- INTRAVENOUS FLUIDS
o Different types of fluids – what does this mean when choosing ?
§ Crystalloids (Eg. Electrolytes)
§ Colloids (Eg. Proteins)
§ Blood & Blood Products
- MEDICATIONS
o Inotropic agents
o Chronotropic agents
o Rate control (eg. In Tachyarryhthmia/eg. Pacing in Heart Block)
o Diuretics (Eg. If pulmonary oedema)
o Oxygen
BASIC LIFE SUPPORT
ADVANCED LIFE SUPPORT
Wk 5
Loss of Consciousness/ALOC (Altered Level of Consciousness)
Causes of Loss of Consciousness:

- Common Causes:
o Trauma
o Drugs
o Post-ictal
o Hypoglycaemia
o SAH (Sub-arachnoid Haemorrhage)
o Systemic
- Uncommon Causes:
o Infection
o Endocrine
o Metabolic
o Tumour
o Vascular
o Paralysis
o Hypothermia
Head Trauma à Loss of Consciousness:

o Primary Injury:
§ Concussion
§ Contusion
§ Laceration
§ Diffuse Axonal Injury
§ (NB: Primary injury determines the best possible outcome)
o Secondary Injury:
§ Hypoxia
§ Hypoglycaemia
§ Decreased cerebral perfusion
• Hypotension
• Haemorrhage
• Oedema
§ (Secondary Injury determines the Actual Outcome)
§ (All treatments are focussed on preventing secondary injury)
HEAD TRAUMA à ALOC:
- Concussion:
o No structural damage
o Usually only a brief Loss of Consciousness
o Likely to fully recover (unless secondary injury)
- Contusion:
o Bruising, swelling, bleeding of the Brain Following Trauma.
o (Often a “Contre-Coup injury” = Brain Injury on the Opposite Side of Impact – Due to Rebound of the
Brain)
§ (NB: “Coup Injuries” = Brain Injury on the Side of Impact)
o Some damage
o Expect a reasonable recovery (but decreased memory, concentration; but still retain normal
function)
- Laceration:
o An incised wound of brain tissue (Eg. Bullet/knife/etc)
o Usually SEVERE damage
o Typically a Poor Prognosis.
- Diffuse Axonal Injury:

o High Energy Injury (Grey matter of whole areas of the brain have been sheared right off)
o CT may appear normal initially (but by day 3, they have a non-functional brain)
o GCS 3
o à Brain Damage à Organ donor
VASCULAR CAUSES OF ALOC:
- Ischaemic Stroke:
o Focal Ischaemia of the Brain caused by Emboli/Bleeding.
o àMuscle weakness associated with severe headache
- Or Haemorrhage:
o (Typically cause secondary injury à Increases ICP à Pressure on the brain à Hypoxia)
o Intracranial (Extradural) Haemorrhage:
§ Caused by:
• Typically a cranial fracture which cuts an artery
• Or Blood vessel bursts spontaneously
§ Leads to:
• à Dissects the dura from the skull à ↑Intracranial Pressure
• àSudden collapse with a severe headache, vomiting and altered consciousness.
• (NB: Normal brain underneath)
§ Imaging:
• Limited by attached dura
• Clearly defined margin
§ Rapid progression (due to arterial source of blood)
§ Good prognosis with surgery (Drill a hole in the head to relieve the pressure)
• Die without surgery
o Subdural Haematoma (typically a venous bleed; happens slowly)

§ Caused by:
• Mostly Old people with Low force trauma à Slow Venous Bleed
o Because their brain is shrunken
o Brain moves significantly under mild trauma
§ Gradual onset (:. Is often Chronic)
§ Wide distribution – ie. Over the entire hemisphere
§ Presentation:
• Unsteady gait
• Other abnormalities
§ Abnormal Brain underneath (Ie. Pt. Is often demented, or alcoholic, or have severe cerebral
atrophy)
• Therefore the prognosis is worse
o Sub-Arachnoid Haemorrhage
§ Caused by:
• Often due to aneurysm of circle of willis
• (Arterial Bleed)
§ Presentation:
• Typically a fit, well person who has sudden onset, severe headache (or feel like
they’ve been hit in the head with a baseball bat)
• Loss of Consciousness.
OTHERS CAUSES OF ALOC:

Tumours:
- Rare
- Benign or Malignant
- May be metastasies
Systemic Causes of LOC:

- Hypoxia
- Hypoventilation
- Hypotension
- Sepsis
Endocrine Causes:
- Diabetes
o NB: In EVERY case of LOC, you MUST CHECK BLOOD SUGAR (despite obvious
trauma/stroke/etc.)
o Hypoglycaemia
o Hyperglycaemia/ketoacidosis
- Hypothyroidism/Thyrotoxicosis
Metabolic Causes:
- Uraemia (due to acute renal failure) à Requires renal transplant/dialysis.
- Hepatic Failure (eg. Alcoholic liver disease à Acute liver failure)
Infection:
- Meningitis – Diagnosis is ESSENTIAL
o If pt. Has altered consciousness and fever, assume meningitis
o à Give antibiotics unless proven otherwise
- Encephalitis
o If pt. Has Altered consciousness and fever, can give antivirals
- Tuberculosis
o Acute altered consciousness in immigrants.
- AIDs
o Eg. Opportunistic infections
o Or. Direct encephalitis by the HIV Virus
- Malaria
o Mostly in immigrants
o If been overseas, and come back with fever and altered consciousness à Suspect Malaria.
Drugs:
- Prescription Medication:
o (Ie. Taken in accidental overdose – Esp. Old people/suicide)
o (Or. Drug Interaction)
o Analgesics
o Sedatives
o Antidepressants
- Recreational Drugs:
o Alcohol
o Opiates
o Etc.
- Treatment:
o Treat Specific OD
o Assess Suicide Risk
o Psych Review
Paralysis (Very rare):

- Eg. Trauma/C-Spine Injury
- Eg. Snake Bite
- àPt is Unresponsive, may be Apnoeic.
ASSESSMENT OF LOC:
- Glasgow Coma Scale (GCS) - KNOW THIS:
o Eyes opening in response to:
§ 4. Spontaneous
§ 3. Voice
§ 2. Pain
§ 1. Not
§ (Score out of 4)
o Speech:
§ 5. Oriented
§ 4. Confused Speech
§ 3. Inappropriate Speech
§ 2. Incomprehensible/Incoherent
§ 1. None
§ (score out of 5)
o Motor
§ Can either -Obeying commands/localising painful stimulus (directly respond to painful
stimulus)/ withdraws from painful stimulus/flexing (Very bad)/Extension (very very
Bad)/None
§ (Score out of 6)
o (Less than GCS10 = Deeply unconscious; Less than GCS8 = Coma)
o (Max Score = 15 = Awake, Alert, Responsive = Conscious)
o (Min Score = 3 = Dead)
- AVPU
o Conscious
§ Awake
§ responding to Voice
o Unconscious
§ Only Responsive to Pain
§ Unresponsive
PRIMARY SURVEY (ABSOLUTELY CRITICAL IN CASES OF LOC):
- ABCDEFG:
o Airway:
§ Commonest cause of Unconsciousness is Airway Obstruction
§ Clear The Airway:
• Left Lateral Position/Suction/Guedell Airway/Jaw Thrust
§ (Generally GCS<8 require definitive airway management – Endotracheal tube/Intubation
àVentilation)
o Breathing:
§ Essential to ensure adequate ventilation
§ (without adequate ventilation, pt will suffer a secondary hypoxic brain injury)
§ Give Oxygen
§ Maintain Sats & Normocarbia
• If hypoventilation à Hypercarbia à Cerebral Vasodilation à Increases Intracranial
Pressure à Decreases Cerebral Perfusion.
o Circulation:
§ Must ensure adequate circulation (IV fluids)
§ Cerebral perfusion pressure = Blood Pressure – Intracranial Pressure
• As ICP goes up, must ensure at least a normal BP in order to maintain cerebral
circulation
§ In head trauma, 5 minutes of Hypotension à 25% increase in mortality.
o Disability (Ie. Level of Consciousness):
§ Assess level of consciousness & Document it.
§ Monitor for changes
§ Assess Pupillary Size/Reactivity
o Exposure:
§ Examine the Whole Patient (Including the Back)
o DON”T EVER FORGET GLUCOSE
History:
- Past history
- Medication, drug use
- Collateral History
- Trauma?
- Overseas Travel?
Examination:
- Primary Survey
- Look for Trauma
- Look for needle marks (Drug use)
- Signs of Infection (Fever, neck stiffness, focal neurology?)
- Respiratory Effort
Investigation:
- Check Glucose
- Urine & Elecrolytes
- FBC
- Head CT
Disposition:
- 2 groups of unconscious patients:
o Active management (ICU):
§ Vast majority of patients
§ Aggressive treatments
o Palliative Care:
§ à ward or back to nursing home.
Specific Treatment:
- Depends entirely on cause
- All receive Supportive Care:
o O2
o Iv fluids
o Glucose
o Antibiotics
o (All of these apply even if you don’t know what’s wrong)
- Rarely surgery
- Rarely Drugs-Antidotes:
o Eg. Naxolone/Narcan (Opioid Antagonist – Reverses Respiratory Depression)
KEYPAD SESSION:
LOSS OF CONSCIOUSNESS QUESTIONS

1. Adult female, overdose, eyes ope ot voice, withdraws from pain & swears at you. GCS?
a. 10
2. Which is an uncommon cause of altered consciousness:
a. Hypoglycaemia
b. Trauma
c. Drugs
d. Sepsis
e. Meningitis – (Usually only cases headache, nausea, vomiting, neck stiffness; but not altered
consciousness)
3. Which is a cause of primary brain injury (Cf Secondary Brain Injury):
a. Hypovolaemia
b. Hypoglycaemia
c. Seizures
d. Diffuse Axonal Injury – (Caused when the brain hits the skull)
4. A Contre-coup injury is related to which of the following?
a. Concussion
b. Contusion (Contre-Coup = A contusion opposite to the site of injury)
c. Laceration
d. Diffuse Axonal Injury
5. Subdural Haematoma – Which is true?
a. Associated with good outcome following surgery
b. Associated with arterial bleeding
c. Is often chronic
d. Mostly affects young people with severe trauma.
6. Extradural Haematoma – Which is True?
a. Associated with arterial bleeding
b. Is usually slow in onset
c. Has a poor prognosis after surger
d. Is associated with alcoholism
7. Which is true for Diffuse Axonal Injury?
a. Has a good prognosis
b. Is associated with high energy injury
c. Is usually obvious on initial CT scan
d. Is caused by shearing between the brain stem and spinal cord.
8. Which is a systemic cause of altered consciousness?
a. Septic Shock
b. Encephalitis (Local)
c. Brain Metastases (Local)
d. Hypertensive Crisis
9. Which of the following drugs typically cause respiratory depression in overdose?
a. Opiates
b. Amphetamines
c. Paracetamol
d. Beta Blockers
10. Which antidote is commonly used for unconscious patiens?
a. NAC (N Acetyl Cysteine – for Paracetammol Overdose)
b. Flumazenil (Benzo Antidote)
c. Pralidoxime (For Overdose of Organophosphate poisoning)
d. Naloxone (An opioid Antagonist)
11. Which is true for an unconscious patient presenting to ED:
a. The airway is usually patent on arrival
b. Cervical spine precautions are unnecessary unless here is a clear history of trauma
c. The glucose should always be measured immediately
d. Paralysis is never a cause of unconsciousness
12. Which of the following is true for eth Glasgow Coma Scalew:
a. The lowest score possible is zero (Lowest is 3)
b. A GCS of less than 8 roughly equates with coma
c. A GCS of more than 13 is consistent with a moderate head injury (Less than 13 is moderate head
injury)
d. Response to pain is usually tested peripherally
13. What GCS score is incoherent speech?
a. 0 (No such thing)
b. 1 (No speech)
c. 2 (Incoherent)
d. 3 (Inappropriate)
e. 4 (Confused)
f. 5 (Normal)
14. What score does a motor response of abnormal extension get?
a. 0 (No such thing)
b. 1
c. 2
d. 3
e. 4
15. What score does a motor response “Obeying commands” get?
a. 2
b. 3
c. 4
d. 5
e. 6
16. On the AVPU scale:
a. A corresponds to Agitated
b. V Equates to Veralising
c. P Equates roughly to unconscious
d. U Means Unresponsive to Voice
17. Which best applies to airway management in an unconscious patient?
a. The LMA (Laryngeal Mask) is a suitable definitive airway (A “Definitive Airway” = an inflated tube
Within the airway)
b. Head tilt, chin lift is the most effective way to clear the airway (Not as effective as a jaw thrust)
c. A Guedel Airway reliable ensures a clear airway
d. If possible, Endotracheal Intubation is the best way of ensuring a clear airway.
18. Which applies to Hypercarbia?
a. Associated with cerebral vasodilation & increased intracranial pressure
b. Associated with hyperventilation
c. Causes peripheral cvasoconstriction
d. Associated with decreased cardiac output.
19. Which is true for ventilation of an unconscious patient:
a. All unconscious patients require assisted ventilation
b. Ventilation is perforemed in order to produce hypercarbia
c. Deliberate slight hyperventilation is possibly beneficial – (Useful in short-term, not long term à
↓CO2)
d. Ventilation using an LMA is usually inadequate
20. Which is true for IV therapy in an unconscious patient?
a. Aggressive IV resuscitation should be avoided as it causes cerebral oedema
b. Even brief hypotension is associated with an increase in mortality in head trauma
c. IV glucose should always be given early (Only given if sugar is low)
d. Permissive hypotension may be beneficial in trauma
CHEST XRAY QUESTIONS:
21. Which structure contributes to the Right heart border on a CXR?
a. Right ventricle
b. Aortic knuckle
c. IVC
d. Diaphragm
22. What’s the best way to differentiate between AP and PA?
a. Look for position of the scapulae (If retracted, it’s PA)
b. Look for widening of teh mediastinum
c. Look for Kerley B Lines
d. Look for ECG leads
23. What abnormality is present on this CXR?
a. Left upper lobe pneumonia
b. Cardiomegaly
c. Right upper lobe pneumonia
d. Pulmonary embolus
24. What abnormality does this CXR show?

a. Widening of the mediastinum
b. Pneumothorax
c. Pneumoniwa
d. Pleural effusions (NB: Loss of Costophrenic Angles due to Meniscus)
25. Which suggests a technically adequate film?

a. Vertebral discs clearly through the mediastinum
b. Clearly visible costo-phrenic angles
c. Widening of the mediastinum
d. Cervical spines well centred between the medial ends o the clavicles (Ensures no rotation)
Wk 12
Envenomation
Objectives
• Understanding of basic terminology
o Poison = Ingested Toxins (Typically Chemicals)
o Venom = Injected Peptides/Proteins by an Animal from a Gland where it’s kept.
o Toxin = Either Poisons or Venoms.
o Envenomation = Being injected with a venom
o Toxinology = study of envenomation
o Toxicology = study of clinical effects of drugs (man made)
• Envenomation by Critter
o Toxin
o Signs, symptoms
o Investigation
o Management
Recognition & Assessment of Envenomation:

• Clinical Assessment
o History (when? Where? How? What? Symptoms?)
o Increased vigilence in children & with ALOC
o Examination (signs)
o Investigation - blood, urine, VDK, nematocysts
• Syndromic approach to diagnosis
• Identification of animal
o description, morphology, scale counts
o characteristics of sting site, nematocysts
Approach to the Envenomated Patient:

• First aid
• ABCDE (primary survey)
• Secondary survey
• Supportive care - analgesia, respiratory, cardiovascular, renal, metabolic.
• Definitive care – antivenoms, disposition
Marine Envenomation:
• Cnidarians
o Contain Stinging Organelles Called ‘Cnidomes’ or ‘Nematocysts’:
§ Millions of Nematocysts line the surface of the body & appendages of cnidarians
o Notables:
§ Cubozoa - Box Jellyfish

• Chironex Fleckeri – Multitentacled
o 2-30cm Diameter
o Shallow Water
o Rudimentary Senses (Vision, Balance, Vibration)
o Venom – Clinical Actions (Dose Dependent – body surface area):
§ Severe Local Pain
§ Dermatonecrotic component - scarring
§ Haemotoxin - not significant in human stings
§ Lethal factor(s) - act by increasing ionic (Na+ & Ca++) conduction
across nerve & muscle membranes- rapidly cardiotoxic
o Visual Appearance of Sting:
§ Whip Wheals
§ Frosty Appearance
§ Ladder Pattern
o Management:
§ Pre-hospital
• Vinegar – inactivates the nematocysts that haven fired.
• Anti-venom
§ Emergency
• Supportive – (Analgesia/Oxygen/Fluids/Monitoring)
• Anti-venom- (Only with evidence of envenomation – eg.
Arrhythmias/10% of Body SA)
• Analgaesia/tetanus
• Carukia Barnesi (Irukandji) – 4 Tentacles:
o Small cube shaped 1.2 - 2.5cm diameter
o 4 tentacles - 1 in each corner - retractile from 60 - 8cm, 1mm diam
o Nematocysts on both bell & tentacles
o Virtually transparent & rarely seen in the water (They may not have seen
it)
o Venom – Clinical Actions:
§ Delay to systemic Symptoms
§ Irukandji Syndrome
• Severe Generalised Pain. Comes in Waves
• Autonomic Dysfunction
o Sweating
o Hypertensive
o Tachycardic
• Cardiopulmonary decompensation
o Bite à Massive Catecholamine Release à
Cardiomyopathy à Heart Failure à Pulmonary
Oedema.
o Management:
§ Ice + vinegar
§ Supportive
§ Monitor – vitals and cardiac markers (Troponins)
§ Opiates
§ Nitrates
§ MgSO4 (magnesium)
§ (midazolam/promethazine/chlorpromazine/phentolamine)
§ hydroids (bluebottles, fireweeds)
§ hard & soft corals, anemones
§ medusoid or blubber jellyfish
• Molluscs
o poisonous shell fish
o venomous cone shells
• Venomous Fish Spines

o Stonefish
§ 13 dorsal fin spines
§ Each paired venom glands
§ Spines erect when fish trodden on and venom into wound
§ Neurotoxic, myotoxic, vascular and myocardial effects
§ Excruciating pain
§ Treatment:
• Immerse in hot water (As hot as bearable – Max 43OC)
• Opioid analgesia – ?effective
• Regional anaesthesia (Ankle Block)
• Antivenom – if evidence of envenomation.
o How much? 1 Vial/2-3 spines.
• Debride the wound – (X-Ray to see remaining spines)
• ADT
o Stingrays
• Venomous spiny starfish
• poisonous fish - tetrodotoxin
• Blue ring octopus - tetrodotoxin
• Sea snakes
Terrestrial Envenomation
• Terrestrial venomous animals:
o Hymenoptera:
§ Wasps
§ Bees
§ Ants
o Arachnida
§ Spiders:
• Redbacks (latrodectus) - single greatest cause of envenomation in Australia:
o Found throughout Australia
o Most bites in urban area’s
o Venom (latrotoxin) àUncontrolled Release of NTs ACh, NE, and GABA
o Many bites will not result in envenoming or symptoms
o 20% of bite victims require treatment
o Symptoms
§ extreme pain - locally
§ local sweating and sometimes piloerection
§ Swollen or tender regional lymph nodes
§ Malaise, nausea, vomiting
§ Chest or abdo pain
§ Headache, fever, hypertension
§ Rare – seizures, acute pul. Oedema, coma, death
o Treatment
§ Antivenom – Generalised Symptoms i.e. headache, vomiting etc
§ Analgesia and ice - Local Symptoms
§ Usually 6 hours observation
§ Give antivenom IM not IV
§ Have adrenaline ready – anaphylaxis
§ Usually need 1 vial – occasionally 2
• Funnel-webs: all have very toxic venom

• Hadronyche - widespread coastal Qld
• Mouse spiders (stocky trapdoors) - can cause significant systemic illness
especially in children
• Bird eating spiders (theraphosidae) - can cause systemic symptoms & illness
• Fiddle-back (loxosceles) - can cause systemic illness & probably the major cause
of necrotic aracnidism. Numerous spiders including huntsman, wolf, white-tailed,
black house (window), brown house (cupboard) & ‘large sac’ species can cause
painful bites &/or systemic illness &/or necrotic ulcers.
§ Scorpians
§ Ticks
o Snakes:
§ Australia has most venomous snakes in the world
§ Fatalities uncommon (1-2/year)
§ Venom injected form venom glands – modified parotid glands
§ Signs of Envenomation
• General – headache, N & V, Abdo pain
• Neurotoxins – ptosis, weakness, blurred vision, cardio – resp failure, dysarthria
• Myotoxins – Rhabdomyolysis, myoglobulinuria
• Procoagulants – Afibrinogenaemia, bleeding diathesis
• Local cytotoxins – tissue damage
§ Venom – Mechs of Action:
• Potent prothrombin activators
o àConsumptive coagulopathy
• Tiger and taipan powerful pre-synaptic neurotoxins – block NT release
o àDescending paralysis – difficult to reverse
• Death adder post synaptic neurotoxins – reversible. Block Ach receptors.
• Rhabdomyolysis – renal failure
§ 5 Main Venom Groups:
• Taipan
o Rate of envenomation - >80 %
o Venom contains:
§ myotoxins
o Clinical effects:
§ haemotoxins àConsumptive coagulopathy in mins
§ Myotoxins + Pre/post Synaptic Neurotoxins à
• Flaccid paralysis in hours
• Autonomic Dysregulation
§ Renal failure late – sec to coagulopathy
o Treatment:
§ Monovalent antivenom
• Brown:
o Envenomation rate – 20 -40 %
o Clinical effects
§ Coagulopathy common
§ Renal damage – sec to coagulopathy
§ Paralysis unusual
o Treatment:
§ Monovalent brown antivenom
• Death adder:
o Envenomation 40 – 60 %
o Clinical effects:
§ Paralysis
§ Nil coagulation effects
§ Post synaptic neurotoxins
o Treatment:
§ Reversible with antivenom
• Black:
o Envenomation 40 – 60 %
o Clinical effects:
§ Local effects at site
§ Lethality rate - < 1%
§ Minor coagulopathy only
§ Anticoagulant effect- no consumption of clotting factors
§ Aims of Treatment
• Reduce risk systemic absorption
• Eliminate clinical effects of venom
• Reduce risk death
• SPECIFIC – antivenoms
• GENERAL – 1st aid, wound care, prevent reactions to antivenom
o Pressure immobilisation bandage + Splinting the leg
o Go over site and then proximally
o Complete immobilisation
o Don’t wash site – You’ll need to swab it.
o Leave bandage in situ until antivenom or normal bloods and no clinical
signs
§ Identifying the Culprit:
• Never rely on “experts” or colour
• SVDK – venom group not species
• SVDK – cut hole in bandage
• Urine VDK – no bite site seen
o SVDK neg but clinically enven
o discard first urine
• Monovalent if VDK positive
• No blood VDK
• Specific antivenoms less hazardous than polyvalent
§ ANTIVENOMS:
• Horse serum
• Risk anaphylaxis < 1%
• 4% assoc with minor reactions
• Delayed serum sickness
• Tasmania – tiger
• Victoria – tiger and brown
• Elsewhere – everything!!
• HOW MUCH?
o Iniatially 1 amp polyvalent if clinically envenomated – await VDK
o May need several doses
o Titrate to clinical effect
o Brown snake – 4 amps
o Dilute 1:10 with crystalloid over 30 mins
o Pre medication - controversial
o Have adrenaline infusion ready
RESPIRATORY Pathology:
FLUID RESUSCITATION
FLUID REPLACEMENT THERAPY:
Crystalloid Vs. Colloid Solution:

- Crystalloids:
o = Aqueous Solutions of Mineral Salts or other water soluble molecules.
o Crystalloids have a Low Osmotic-Pressure in Blood due to Haemodilution.
- Colloids:
o = Mixtures of Larger Insoluble Molecules. (NB: Blood itself is a colloid)
o Colloids Preserve a High Colloid-Osmotic Pressure in the Blood.
Crystalloid Solutions:
- *Saline:
o The Most Commonly used Crystalloid.
o Advantage Is Isotonic Does not cause dangerous fluid shifts.
o Disadvantage If you only replace fluid, O2 Carrying Capacity goes down (Dilution Anaemia)
Al i ce i ai e E acell la Fl id i i able f P i h Hea Fail e Oede a
o Used for General Extracellular Fluid Replacement
- Dextrose:
o Saline with 5% Dextrose Used if Pt is at risk of Hypoglycaemia; or Hypernatraemia.
o NB: Becomes Hypotonic when Glucose is Metabolised Can cause fluid overload.
- Lac a ed Ringer Har mann Sol ion
o A Solution of Multiple Electrolytes:
Sodium
Chloride
Lactate
Potassium
Calcium
o Used in Pts with Haemorrhage, Trauma, Surgery or Burns.
o Also used to Buffer Acidosis
Colloid Solutions:
- Albumin:
o Albumin 40g/100ml - Used in Liver Disease, Severe Sepsis, or Extensive Surgery.
o Albumin 200g/100ml Used in Haemorrhage/Plasma loss due to Burns/Crush Injury/Peritonitis/
/Pancreatitis; or Hypoproteinaemia; or Haemodialysis
- Polygeline (Haemaccel):
o = Gelatin Cross-linked with urea.
o Used in Dehydration due to GI Upsets (Vom/Diarrhoea)
Blood Products:
- Whole Blood:
o RBCs, WBCs, Plasma, Platelets, Clotting Factors, Electrolytes (Na/K/Ca/Cl).
o Used to Replace Blood Volume & Maintain Haemoglobin Level O2-Carrying Capacity
- RBCs:
o Used to Increase Haematocrit (proportion of RBCs) O2-Carrying Capacity
- Plasma:
o Plasma (With Plasma Proteins), Clotting Factors, Fibrinogen, Electrolytes (Na/K/Ca/Cl).
o Used to restore Plasma Volume in Hypovolaemic Shock & Restore Clotting Factors.
Fluid Resuscitation Principles

- Good to know where the fluids that you give actually go:
o Eg. Average 70kg man:
60% water :. Total body water (42L)
2/3 Intracellular Fluid (28L)
1/3 Extracellular Fluid (14L)
5L blood [1/3 RBC (1.5L); 2/3 Plasma (3.5L)]
- So What happens to the Different IV Fluids?:
o Glucose is actively taken into cells
(volume of distribution is large, as none effectively remains in blood)
Therefore Glucose IS NOT suitable for pressure fluid resuscitation.
o Crystalloids (ie. Saline) is kept in ECF by Na/K-ATPase
:. Volume of distribution = 14, and of that, 25% remains in circulation (3.5L)
o Colloid, kept in blood by capillary membrane (Albumin, Gelatine, etc)
Volume of Distribution is 3.5L, and ALL of that remains in Circulation.
o (500mL of Colloid = 2L of Crystalloid) (NB: So long as you give the right amounts,
- Blood:
o The best fluid to replace blood loss is Blood
o But, either saline/hartmanns or colloid are still ok.
o NB: Blood has risks (immunogenic/infections/etc)
o NOT Glucose
Fluid Management (Surgical Context)
NBs:
- Water moves with solute (Esp. Salt & Sugar)
- Propofol PVR, Preload & Contractility BP
- Neuromuscular Blockers Venous Pooling BP
- NB: Anuria = Obstruction....NOT Hypovolaemia
Indications:
- Dehydration
- Fluid Loss
- Blood Loss
- 3rd Spacing
Fluid Replacement Goals:

- Replace Pre-Existing Deficits
- Replace Ongoing Normal Losses (Obligatory Losses)
- Replace 3rd Space Losses
- Replace Bleeding
2 Types of Fluids:
- Crystalloids (Salts/Sugars/Lactate):
o Normal Saline (0.9% NaCl)
o Dextrose (4% Dextrose + 0.5% NaCl)
o Hartmann s (Lactate)
o (Cheap, Effective, Safe)
- Colloids (4% Albumin):
o ONLY for Surgical / Renal Patients
o NOT for Resuscitation
o (Expensive, but Pulls fluid into IV Space)
- (Blood Products)
o Whole Blood
o Packed RBCs
o FFP
3 Compartments:
- 1. Intravascular (5L)
- 2. Interstitial (10L)
- 3. Intracellular (30L)
“1/3 Rule”:
- For Every 1L of Crystalloid Fluid, only 300mL ends up IV.
o :. 1L Blood Loss requires 3L of fluids.
“35-45 Rule”:
- Normal Ranges:
o Na 135-145
o K 1.35-1.45
o pH 7.35-7.45
“4-2-1 Rule of Fluid Replacement”:

- Bolus (Vol. Of Estimated Acute Losses)
- 4mL/kg/hr for the 1st 10kg
- 2mL/kg/hr for the next 10kg
- 1mL/kg/hr for remaining kgs.
- (Ie. 60mL/hr for 1st 20kg, + 1mL/kg/hr for remaining kgs)
- (Ie. 100ml/hr for 1st 60kg, + 1ml/kg/hr for remaining kgs)
OSCE Station: “Assess Fluid Balance”:
- 1. ABCDE – (Airway, Breathing, Circulation, Disability, Expose)
- 2. Specific Signs of Fluid Balance:
o Fluid Overload:
Pulmonary Oedema (Basal Crepitations/Cough/Dyspnoea)
Rx: Call for help + LMNOP:
o Lasix (Frusemide Fluid Volume)
o Morphine (Vasodilate)
o Nitrates (Vasodilate)
o Oxygen (Maximise Sats)
o Positioning (Sit up 90o)
Hypertension
JVP
Pleural Effusion
Ascites
Peripheral Oedema
Polyuria (Normal = >>500mL/day)
o Fluid Depletion:
Dry Mucous Membranes
Postural Hypotension
Tachycardia
Supine Hypotension
Loss of Skin Turgor
Lethargy/Confusion
Oliguria (Normal = >>500mL/day)
- 3. Cannulate
o Just stick the needle to the arm with tape to simulate cannulation.
- 4. Write up fluids in chart!!!
- 5. Hook up bag:
o Aseptic technique
o Prime line
o Purge line of bubbles
o Hook up to cannula
TRAUMATOLOGY . . . CONT.
SHOCK IN THE TRAUMA PATIENT (see Anesthesia Chapter)

❏ inadequate organ and tissue perfusion (brain, kidney, extremities)
❏ SHOCK IN THE TRAUMA PATIENT IS HEMORRHAGIC UNTIL PROVEN OTHERWISE
Classification
❏ hemorrhagic shock (most common) - see Table 6
❏ cardiogenic shock - e.g. blunt myocardial injury
❏ obstructive shock - e.g. tension pneumothorax, cardiac tamponade, pulmonary embolism
❏ distributive shock - e.g. spinal/neurogenic, septic and anaphylactic shock
Table 6. Classification of Hemorrhagic Shock (70kg male)

Class Blood loss (mL) BP Pulse Resp rate Urine output
I < 15% (< 750) normal <100 14-20 > 30 mL/hour
II 15-30% (750-1500) normal >100 20-30 0-30 mL/hour
III 30-40% (1500-2000) 9 >120 30-40 5-15 mL/hour
IV >40% (>2000) 99 >140 > 35 0 mL/hour
Clinical Evaluation
❏ rapidly assess for other causes of traumatic shock
❏ clinical features of acute hemorrhage
• early: tachypnea, tachycardia, narrow pulse pressure, reduced urine output (U/O),
reduced capillary refill, cool extremities and reduced central venous pressure (CVP)
• late: hypotension and altered mental status
Management of Hemorrhagic Shock
❏ secure airway and supply O2
❏ control external bleeding (prompt surgical consultation for active internal bleeding)
❏ infusion of 1-2 L of NS or RL as rapidly as possible
• replace lost blood volume at ratio of 3:1 (maintain intravascular volume)
❏ if no response, consider ongoing blood loss (e.g. chest, abdomen, pelvis, extremities)
––> operative intervention required
❏ blood transfusion
• indicated if:
1. severe hypotension on arrival, 2. shock persists following crystalloid infusion, 3. rapid bleeding
• packed RBC’s (PRBCs)
• cross-matched (ideal but takes time)
• type-specific (provided by most blood banks within 10 min.)
preferred to O-negative uncrossmatched blood if both available
• O-negative (children and women of child-bearing age)
• O-positive (everyone else) if no time for cross and match
• consider complications with massive transfusions
Unproven or Harmful Treatments
❏ Trendelenberg position
❏ steroids (used only in spinal cord injury)
❏ MAST garments - non efficacious for treatment of shock; no longer used
❏ vasopressors during hemorrhagic shock
CHEST TRAUMA
❏ trauma to the chest accounts for, or contributes to 50% of trauma deaths
❏ two types
• immediately life-threatening
• potentially life-threatening
A. IMMEDIATELY LIFE-THREATENING CHEST INJURIES
❏ identified and managed during the primary survey
• airway obstruction
• tension pneumothorax
• open pneumothorax
• massive hemothorax
• flail chest
• cardiac tamponade
❏ 80% of all chest injuries can be managed non-surgically with simple measures such as intubation,
chest tubes, and pain control
Wk 7
GI Emergencies
Principle Topics This Week:

• Difference between different types of Abdominal Pain
• GI Tract Bleeding
• Infection/Inflammation
• Hepatic Dysfunction
• Pancreatic Dysfunction
Gastrointestinal Emergencies:
• Is not (adult) gastroenterology
• Covers all ages and many disciplines
An Important distinction:
- Gastrointestinal emergency - Vs - Intra-abdominal emergency (Not the same thing)
Anatomy:
- The Abdomen
Note that the chest and abdominal boundaries aren’t mutually exclusive
Abdominal injuries can involve the chest
Chest injuries can involve the abdomen
- Abdominal Quadrants
Note that the chest and abdominal boundaries aren’t mutually exclusive
Abdominal injuries can involve the chest
Chest injuries can involve the abdomen
- Abdominal Contents – Not just the GI Tract!

o Gastrointestinal Tract:
§ Oesophagus
§ Stomach
§ Duodenum
§ Small Bowel (jejunum and ileum)
§ Appendix
§ Large Bowel/Rectum/Anus
o Other ‘Intra-Abdominal’ Contents:
§ Liver and Pancreas
§ Gallbladder
§ Spleen
§ Kidneys
§ Ureters
§ Bladder
§ Uterus and ovaries
§ Aorta and Vena Cava
§ Lymphatics, Nerves, Muscles
- Retroperitoneal Organs:
o Urinary System:
§ Adrenal Glands
§ Kidneys
§ Ureters
§ Bladder
o Cardiovascular System:
§ Aorta
§ Inferior Vena Cava
o GI Tract:
§ Oesophagus
§ Head & Neck of Pancreas
§ Rectum
Gastrointestinal Emergencies:
(Pressure mark on abdomen – suggest possible traumatic injury)
- Abdominal Pain:
o A very common reason for patients to come to the Emergency Department
o We will focus on the GIT causes of Abdominal Pain:
§ Almost endless!
§ Think of an organ then apply the ‘surgical sieve’
• Infection
• Trauma
• Neoplasia
• Haemorrhage
• Toxins/Drugs
o 3 Types of Abdominal Pain:
§ 1. Visceral (‘Colicky’) Pain:
• Pain Arising from abdominal viscera
o Typically due to Pressure
o Typically Diffuse Pain (Poorly localised – often, but not always, felt in
periumbilical region)
o Fluctuating in Intensity (Comes & Goes)
• Transmitted by autonomic nerve fibres
• Often associated with nausea and autonomic symptoms (e.g. sweating)
• Pts tend to move around a lot (Can’t get comfortable)
§ 2. Somatic/Parietal Pain:
• Pain due to Inflammation/Irritation of the Parietal Peritoneum
o Typically Very Localised
o Sharp Pain (Hurts to Move, Cough, Breathe)
o Irritated by Movement
• Usually implies involvement of the (parietal) peritoneum
• Transmitted via somatic nerves
• Well localised
§ 3. Referred Pain:
• Pain referred to one location from pathology in a different location
• Usually associated with Embryonic Dermatome Origins of the Affected Structures
• Eg. Diaphragmatic Pain felt at the Shoulder Tip
• Beware of extra-abdominal pain referred to the abdomen
o Eg. Myocardial ischaemia/Infarction:
§ Inferior Infarcts often ® Epigastric pain
o Eg. Testicular pathology
§ Eg. Testicular Torsion ® hypogastric pain
• Assessing Pain:
o Pain Qualities:
§ Poorly defined or well localised
§ What does the pain make you do?
• If Move around (can’t get comfortable) – Somatic
• If Can’t move – Visceral
§ Waxing and waning (typical of colicky pain)
• Pain comes & goes
• Usually an obstruction of something
§ Constant – sharp or dull
• Sharp implies peritoneal pain
• Dull implies Visceral Pain
§ Exacerbating or mitigating factors (e.g. movement)
• Better when you eat?
• Worse when you eat? (Eg. Gastric/duodenal ulcer)
• Worse when you move?
§ Progression from visceral to parietal as pathology progresses (e.g. appendicitis:
• Begins as Visceral
• à Irritates Peritoneum à Somatic/Parietal Pain
o What does the patient do?
§ Visceral Pain - Colic- can’t get comfortable, moves around.
• Biliary colic
• Renal colic
§ Parietal Pain - worse with movement, tend to keep still
• Bleeding or infection
o Radiation?
§ Where does the pain go?
Potential Sources of Pain in Each Abdominal Quadrant:
- GI Bleeding:
o A common problem – most people will have some form of GI bleeding during their life time!
o Can be Trivial/life-threatening
o May be painful or painless
o Underlying pathology may or may not be serious
o Terms:
§ Haematemesis
• Vomiting blood – may be fresh or denatured (dark)
• Can be VERY SERIOUS
• Usually Implies bleeding from the Stomach
• Priority = Get Large-Bore IV Access & Cross-Match Blood type (Because people
can bleed out very quickly from the stomach)
§ Haematochezia
• Rectal Bleeding
• The passage of bloody stools
• Usually implies bleeding from lower GIT
§ Melaena
• black tar-like stool (usually from upper GI bleeding)
• Usually implies bleeding from upper GIT
o Origins:
§ Can originate from anywhere in the GI tract from oropharynx to anal margin
§ Broad range of pathology e.gs:
• Inflammation/Ulceration
• Infection
• Neoplasia
• Trauma
o Occult (Hidden) GI Bleeding:
§ GI tract bleeding may result in occult blood loss (occult = hidden)
§ An important cause of Chronic Anaemia
§ Detected by testing stool for ‘faecal occult blood’
o NB: Acute GI tract bleeding may initially be concealed.
§ :. Consider GI Bleeding in any patient with signs of hypovolaemic shock
- Infection/Inflammation:
o Inflammation may or may not be caused by infection
o Think of organ then add ‘itis’ to end:
§ Gastritis
§ Hepatitis
§ Colitis
o Causes of inflammation include:
§ Infection
§ Immune response (Incl. Autoimmune)
§ Drugs/Toxins
§ Trauma
o May have local and/or systemic manifestations
§ Local:
• Pain
• Swelling
• Organ dysfunction
§ Systemic:
• feeling unwell
• fever
• sweating
• circulatory changes or compromise
- Dysfunction:
o Results from too little or too much function
o Think of the underlying organ and its function then apply the ‘too little’ or ‘too much’ concept
§ Just applied physiology!
§ Think through the ‘surgical sieve’
• Infection
• Trauma
• Neoplasia
• Haemorrhage
• Toxins/Drugs
o Liver:
§ Functions:
• Production of Coagulation Factors
• Production of Albumin
• Produces Angiotensinogen
• Production of Bile
• Detoxification of Blood/Enzymatic Conversion of Drugs
• Metabolism of Bilirubin & Biliverdin
• Carbohydrate Metabolism
o Gluconeogenesis
o Glycogenolysis
o Glycogenesis
• Cholesterol & Fat Packaging
• Amino Acid Metabolism & Synthesis
• Converts Ammonia to Urea
§ Dysfunction à:
• Easy Bruising (due to low Coagulation Factors)
• Oedema due to Low Albumin
• Unexplained Hypoglycaemia
• Jaundice (Hyperbilirubinaemia àBilirubin deposits in skin à Intense Itch)
• Pale Stools (If bilirubin/biliverdin/stercobilin isn’t excreted in bile)
• Dark Urine (if bilirubin mixes with urine)
• Abnormal Metabolism of fats
• Excessive Fatigue
§ Markers for Evaluating Liver Pathology/Dysfunction:
• Liver Function Tests
o ALT
o GGT
• INR (Coagulation Test)
• Abnormal Serum Glucose
• Albumin Levels
• NB: Inflammation à Release of AST & ALT (liver cell damage) – But doesn’t imply
dysfunction.
o Pancreas:
§ Functions:
• Endocrine:
o (Beta Islet Cells) à Insulin Secretion
o Glucagon
o Somatostatin
• Exocrine:
o (Acinus)
o Digestive Enzyme Production
§ Amylase
§ Pancreatic Lipase
§ Trypsinogen
§ Chymotrypsinogen
§ Elastase
§ Carboxypeptidase
§ Dysfunction à:
• Dysregulated Glucose Metabolism (Diabetes)
• ↓Pancreatic Lipase à ↓Fat Absorption à Fatty Stools
• ↓Other Pancreatic Enzymes à ↓Digestion/Absorption of other nutrients (eg.
poor Protein Digestion)
• à Malabsorption & Malnutrition
§ Markers for Evaluating Pancreas Pathology/Dysfunction:
• Elevated Serum Amylase
• Elevated Serum Lipase
§ Location of Pain:
• Severe Epigastric pain radiating to the back
ASSESSMENT/MANAGEMENT
- DON’T FORGET TO MAKE THE MAIN THING THE MAIN THING!
- ABC Approach:
o (Stabilise the unstable)
o Airway- OK
o Breathing- OK
o Circulation - IV access, IV analgesia, titrated opiates, IV antiemetics, IV fluids
- Analgesia
- Start correcting obvious fluid and electrolyte disturbances
o Especially in Vomiting (Hypokalaemia, etc)
- History/Examination/Investigation to define pathology
o Careful examination- Other causes? ESP AAA
o Investigations
§ Immediate- Urine FWT- Blood?
§ FAST scan- free fluid, AAA?
§ U&E’s, FBC, etc
o Imaging:
§ CT to image stone, hydronephrosis
§ X-Ray (Now obsolete to the CT for Abdominal Imaging)
• Mainly used for diagnosing Bowel Obstructions – (Can see multiple fluid levels)
- Specific Treatments if required:
o Eg. Nasogastric Tube:
§ Indications:
• Parenteral Feeding
• Parenteral Drug Administration
• Administering activated charcoal
• Treatment of Anorexia Nervosa
• Aspiration of stomachs contents
§ Procedure for Insertion:
1) measure with the tube from the tip of the patient's nose to their ear and down
to the xyphoid process
2) The tube is marked at this level to ensure that the tube has been inserted far
enough into the patient's stomach.
3) The end of a plastic tube is lubricated (local anaesthetic, such as 2% xylocaine
gel, may be used
4) The tube should be directed aiming down and back as it is moved through the
nasal cavity and down into the throat.
5) Patient may gag à Asked to swallow
6) Once the tube enters the oesophagus, it is easily inserted into the stomach
7) Ensure the tube hasn’t passed through the larynx into the trachea.
8) Inject air into the tube & auscultate for bubbles in stomach.
9) X-ray to ensure correct position
§ NB: Careful not to pass it through the larynx. – Confirmed by:
• Inject air into the tube & auscultate for bubbles in stomach.
• X-ray to ensure correct position
• Laryngoscope
- Case: Renal colic?
o 60 year old man
o Symptoms:
§ severe left loin pain,
• Diffuse
• Radiates to Groin
§ sweating
§ vomiting
§ distressed
o Vitals:
§ P 110 (Bit Tachy)
§ BP 120/90 (Normotensive)
o Assessment?
§ A- OK
§ B- OK
§ C?- Volume (Is he hypovolaemic)
• Feel periphery (if cold, probably hypovolaemic)
o Priorities:
§ IV access, IV analgesia, titrated opiates, IV antiemetics, IV fluids
o Suspicions:
§ Renal Colic
§ Abdominal Aortic Aneurysm (AAA)
o Careful Examination:
§ Most Likely Renal Colic
§ Other Causes?
§ Look at the patient (What are they doing?)
• Are they moving around/Can’t get comfortable (Typical renal colic)
o Investigations:
§ Immediate:
• Urine (is there Blood) – If so, suggests renal colic.
• Ultrasound – Check for Aneurysm
§ Quick:
• FBC
• CT
SS Questions:
Which is Retroperitoneal?
- Stomach
- Duodenum
- Transverse Colon
- Sigmoid Colon
Which is Intraperitoneal?:
- Pancreas
- Kidneys
- Adrenals
- Liver
Which typically produces pain referred to the right iliac fossa?

- Appendicitis
- MI
- Ruptured Ectopic Pregnancy
- Testicular Torsion
Which is non-abdominal cause of abdo pain?

- Appendicitis
- Ectopic Pregnancy
- Diverticular Disease
- Pneumonia
Which causes parietal pain?

- Biliary Colic
- Renal Colic
- Bowel Obstruction
Gas under diaphragm caused by:

- Bowel obstruction
- Ruptured ectopic pregnancy
- Abdominal viscus perforation
- Bowel obstruction
Which suggest liver failure?

- Raised urea
- Raised glucose
- Raised INR (↓production of coagulation factors by the liver)
- Raised AST
Which liver function test measures synthetic function:

- Bilirubin
- Albumin
- ALP
- Gamma Glutyl-Transferase
Which suggests liver inflammation?

- Raised AST
- Raised Gamma GT
- Raised INR
- Raised Immunoglobulin
Which is raised in pancreatitis?
- INR
- APPT
- Lipase
- Glucose
50yrs male presents with severe central abdo pain radiating through to the back. The most likely organ is
involved is?
- Stomach
- Liver
- Gall Bladder
- Pancreas
20yrs female presents with severe shoulder tip pain with tachycardia and hypotension. What is most likely?
- Ruptured Aortic Aneurysm
- Dissection of Thoracic Aorta
- Bleeding Gastric Ulcer
35yrs presents with left loin pain radiating to his groin. Diagnosis?
- Ruptured AAA
- Left Renal Colic
- Splenic Infarct
- Pancreatitis
70yrs presents with collapse and left sided loin pain radiating to his groin. Which is most likely?
- Ruptured AAA
- Ruptured Gastric Ulcer
- Myocardial Infarction
- Urinary Sepsis
Alcoholic presents with bright haematemesis, haemodynamically stable. What is the priority?
- 22G IV, blood tests
- Large Bore IV + Cross match
- Immediate surgery
- Immediate gastroscopy
14yr boy presents with URTI symptoms and diffuse pain in his right iliac fossae. What is the diagnosis?
- Pancreatitis
- Mesenteric Adenitis (Relates to the URTI Symptoms)
- Appendicitis
- Cholecystitis
ABDOMINAL TRAUMA
❏ two mechanisms
• blunt trauma - usually causes solid organ injury
• penetrating trauma - usually causes hollow organ injury
Blunt Trauma
❏ two types of hemorrhage
• intra-abdominal bleed
• retroperitoneal bleed
❏ high clinical suspicion in multi-system trauma
❏ physical exam unreliable in multi-system trauma
• slow blood loss not immediately apparent
• other injuries may mask symptoms
• serial examinations are required
❏ inspection: contusions, abrasions, distension, guarding
❏ palpation: tenderness, rebound tenderness, rigidity
❏ diagnostic tests are indicated in patients with
• unexplained shock
• equivocal signs of abdominal injury
• unreliable physical exam (paraplegia, head injury, substance use)
• high likelihood of injury (pelvic/lumbar fracture, etc.)
• impending periods of non-observation (e.g. surgery)
❏ diagnostic tests include
• CXR
• free air under diaphragm (if patient not supine)
• diaphragmatic herniation
• ultrasound: FAST (focused abdominal sonogram for trauma)
• to identify presence/absence of free fluid in the peritoneal cavity
• NOT used to identify specific organ injuries
• CT scan: best investigation if patient stable enough
• IVP
• diagnostic peritoneal lavage (DPL)
• tests for intra-peritoneal bleed
• cannot test for
• retroperitoneal bleed
• discerning lethal from trivial bleed
• diaphragmatic rupture
• criteria for positive lavage:
• > 10 cc gross blood
• bile, bacteria, foreign material
• RBC count > 100,000 x 106/L,
WBC > 500 x 106/L, amylase > 175 IU
❏ management
• general: fluid resuscitation and stabilization
• surgical: watchful wait vs. laparotomy
• solid organ injuries: decision based on hemodynamic stability, not the specific injuries
• hemodynamically unstable or persistently high tranfusion requirements ––> laparotomy
• all hollow organ injuries ––> laparotomy
❏ note: seatbelt injuries may have
• retroperitoneal duodenal trauma
• intraperitoneal bowel transection
• mesenteric injury
• L-spine injury
Penetrating Trauma
❏ high risk of gastrointestinal (GI) perforation and sepsis
❏ history: size of blade, calibre/distance from gun, route of entry
❏ local wound exploration with the following exceptions:
• thoracoabdominal region (may cause pneumothorax)
• back or flanks (muscles too thick)
❏ management
• gunshot wounds ––> always require laparotomy
• stab wounds - “Rule of Thirds”
• 1/3 do not penetrate peritoneal cavity
• 1/3 penetrate but are harmless
• 1/3 cause injury requiring surgery
• mandatory laparotomy if
• shock
• peritonitis
• evisceration
• free air in abdomen
• blood in NG tube, Foley catheter or on rectal exam
APPROACH TO COMMON ER PRESENTATION
ABDOMINAL PAIN
Origins of Abdominal Pain
1. GI: appendicitis, diverticulitits, bowel obstruction, perforation, hepatitis, cholecystitis, organ lasceration
2. Urinary: cystitis, pyelonephritis, ureteral calculi
3. Genital
Female: ectopic pregnancy, pelvic inflammatory disease (PID), endometriosis,
salpingitis / tubo-ovarian abscess, ovarian torsion / cyst
Male: referred from testicles
4. Vascular: AAA, bowel or splenic infact (be aware of sickle cell status)
5. Other: diabetic ketoacidosis (DKA), Herpes Zoster Virus (HZV), intra-abdominal abscess, MI, pneumonia,
lead poisoning, glaucoma
Life-Threatening Causes
❏ ectopic pregnancy
❏ ischemic bowel, aortic rupture/dissection (pain >> findings)
❏ hepatic/splenic injury
❏ perforated viscus
❏ myocardial infarction (MI)
History
❏ pain: onset, location, character, severity, aggravating and alleviating factors,
associated symptoms (nausea, vomiting, diarrhea, vaginal bleeding)
❏ past medial/surgical/gynecological history, drugs, travel history
Physical Exam
❏ general appearance (diaphoretic, jaundiced, lying very still vs. writhing in pain),
vital signs (including posturals)
❏ inspection: distention, scars, ecchymoses
❏ auscultation: bowel sounds, bruits
❏ palpation: peritoneal signs (shake, cough, rebound tenderness and guarding),
organomegaly, hernias, pelvic and testicular exams
Tests
❏ DO NOT DELAY CONSULTATION if patient unstable
❏ CBC, U/A, amylase, ß-HCG, LFTs, renal function, lytes
❏ AXR: calcifications, free air, gas pattern
❏ U/S: biliary tract, ectopic pregnancy, AAA (abdominal aortic aneurysm)
❏ CT: trauma, AAA, pancreatitis but UNSTABLE PATIENTS SHOULD NOT BE SENT FOR IMAGING
Management
❏ NPO, IV, NG tube, analgesics (communicate with consultants in advance)
❏ growing evidence that SMALL amounts of narcotic analgesics
improve diagnostic accuracy of physical exam of surgical abdomen
❏ consults: general surgery, vascular, gyne as necessary
ALCOHOLIC EMERGENCIES (see Psychiatry Chapter)
❏ EtOH LEVELS CORRELATE POORLY WITH INTOXICATION
Acute Intoxication
❏ may invalidate informed consent
❏ slurred speech, CNS depression, disinhibition, incoordination
❏ nystagmus, diplopia, dysarthria, ataxia ––> coma
❏ frank hypotension (peripheral vasodilation)
❏ obtundation - must rule out
• head trauma + intracranial hemorrhage
• associated depressant/street drugs
• synergistic ––> respiratory/cardiac depression
• hypoglycemia: must screen with bedside glucometer
• hepatic encephalopathy
• precipitating factors: GI bleed, infection, sedation, electrolyte abnormalities, protein meal
• Wernicke’s encephalopathy (“WACO”)
Ataxia
Coma
Ocular findings: nystagmus, CN VI paresis ocular findings (may be absent at time of presentation)
• give thiamine 100mg IV
• post-ictal state, basilar stroke
Seizures
❏ associated with ingestion and withdrawal
❏ withdrawal seizures
• occur 8-48 hr. after last drink
• typically brief generalized tonic-clonic seizures
• if >48 hr., think of delerium tremens (DT) (see Table 10)
Wk 10
Haematological & Renal Emergencies
RENAL STUFF
Overview:
• Renal:
o Functions of the kidney
o Renal failure – acute (and chronic)
o Urogenic Pain
o Catheterization of females and males
• Haematology:
o Coagulation
o Coagulopathies
o Blood products and transfusions
o Won’t deal with: anaemia, neutropenia, etc or leukaemic emergencies per se
Basic Anatomy:
• Kidneys:
o Approximate Size ≈ 10cm x 5cm x 3cm
o Location = The hilar of each kidney is near the transpyloric plane (T12-L1)
o Retroperitoneal. :. Rupture à Retroperitoneal Bleeding
• Ureters:
o Travel from the Kidney à Bladder
o Close association with Psoas Major Muscle
o Length ≈ 20-30cm
o Narrowest Parts (Ie. Where Renal Calculi are most likely to get Stuck):
§ Renal Pelvis
§ Where the Ureters cross the Pelvic Rim
§ Entrance to Bladder
• Urethra:
o Male – Longer (8 inches)
§ Prostatic Urethra, Membranous Urethra, Spongy Urethra
§ Kinks at the prostate
§ Exits at the end of the penis
o Female – Shorter (1.5-2 inches)
§ Obliquely downward and forward
§ Exits between the clitoris & the vagina
The Kidney
• Functions of the kidney
o Erythropoiesis
o Urine Production
o Calcium Metabolism
o Fluid/Electrolyte Balance (Na/K)
o Renin Angiotensin System (BP Regulation)
o Filters out toxins
o Urea Excretion
o Acid/Base Balance
Renal Failure:
• General Effects/Problems Encountered in Renal Failure:
o (Recall the functions of the kidney and then infer what happens when they are eliminated!)
§ Acid Base Balance (Renal Failure à Met. Acidosis)
§ Electrolyte Balance (Renal Failure à Na+ & K+ Retention)
§ Fluid Balance (Renal Failure à Fluid Overload & Hypertension)
§ ↓Erythropoiesis (Renal Failure à Anaemia)
§ Renin Angiotensin System
§ Calcium Metabolism (Renal Failure à Osteoporosis)
§ Uraemia
§ ↓Urine Output
§ ↓Toxin Excretion (Renal Failure à Accumulation of Urea & Creatinine)
• Classification Of Renal Failure:
o 1. Pre-Renal Renal Failure:
§ Before the Blood Reaches the Kidney (Ie. Impaired Glomerular Perfusion)
§ Structurally intact kidney fails because of impaired glomerular perfusion
§ Causes:
• Hypovolaemia (Eg. Blood Loss)
• Decreased cardiac output (Eg. Heart Failure)
• Renal artery obstruction (Eg. Embolism)
o 2. Intra-Renal Renal Failure
§ The kidney itself is damaged:
• Problems can occur at any location along the structures.
§ Causes
• Acute glomerular nephritis
• Tubular diseases e.g. acute tubular necrosis
• Interstitial diseases e.g. auto immune disorders such as SLE
• Vascular diseases e.g. polyarteritis nodosa
o 3. Post-Renal Renal Failure
§ Due to outflow obstruction from the kidneys
§ HAS TO BE BILATERAL - unless the patient has only one kidney(!)
§ Post-renal examples
• Cancer – esp. cervix or prostate
• Blood clot
• Calculi (Kidney stones – Bilateral)
• Accidental surgical ligation
Urogenic Pain:
- Nature of Pain may Vary:
o Colicky Pain (Comes & Goes):
§ Commonly caused by kidney stones
§ Pain comes in Waves due to Ureteric Peristalsis
o Constant Pain:
§ Caused by a constant pathological process (Eg. Pyelonephritis, Ascending UTI, etc)
- Location of Pain Varies Depending on Organ Affected:
o Kidney Pain:
§ Unilateral Flank/Back pain Radiating to Groin.
o Ureteral Pain:
§ Flank-Groin Colicky-Type (Comes & Goes) Pain
o Bladder Pain:
§ Suprapubic Pain
o Urethra Pain:
§ Localised to the Urethra.
Catheterization (Females and Males):
- Indications:
o Urinary retention
o Urine Sample
o Post-operative to assess urinary output, perfusion.
o Prostatic obstruction:
§ BPH [most likely].
§ CA of prostate.
o Other obstructions:
§ Clots.
§ Stones.
§ Bladder CA.
o Trauma.
o Paralysis.
- Peri-Urethral Structures that might Interfere with Catheterisation:
o Labia
o Foreskin
o Prostate
o Urethral Sphincters
- Different Types of Catheters:
o Foley (Brown Latex): Cheapest, Commonest
o Silastic (Clear Silicone): can leave in longer than Foley with less chance of complications
o Robinson’s: Has no balloon, is used for Short term drainage
o Coude: Angled for easier insertion around prostate
- Basic Process of Catheterisation:

o Initial Steps:
§ Gather Equipment
§ Explain Procedure and get Consent
§ Lay pt into supine position + Spread Legs
§ Prepare Sterile Field + Apply Gloves
§ Cleanse Periurethral Mucosa with Cleansing Solution
o Check Balloon for Patency
o Coat the distal 2-5cm with Lubricant
o Gently Insert Catheter into Urethra until 1-2inches beyond the point of Urine Flow.
o Inflate Balloon with 10cc of Sterile Liquid.
o Gently Pull Catheter back until Balloon is snug against bladder neck.
o Connect To Drainage System + Make sure bag is below the level of the bladder.
- Complications:
o Tissue Trauma
o Infection
o Bacteruria
o Renal Inflammation
o Pyelonephritis
- Suprapubic Catheters:
o If trans-urethral catheterization isn’t possible.
o Involves piercing the bladder (via the peritoneal cavity) with a syringe.
HAEMATOLOGICAL STUFF
Haemorrhage Control:
• Coagulation:
o We live on a knife-edge between bleeding to death and clotting to death!
§ A constant process of clot formation and clot lysis.
§ A battle between pro-coagulants and anti-coagulants
• Terms:
o Anti-coagulation is inhibition of clot formation
o Fibrinolysis is dissolution of a clot by ‘dissolving’ fibrin strands
• Haemostasis – the big picture:
o Vessel Injury à
§ Vasoconstriction
§ Platelet Activation, Aggregation
§ Blood Coagulation Cascade
• Key points:
o Vasoconstriction:
§ Important vascular reflex
§ Neural + local myogenic spasm + local humoral factors
§ More pronounced with vessel crush injury (vs. cutting)
o Platelet activation:
§ Very Central Role - The underrated hero of coagulation
§ Platelets are 2 - 4µm in diameter
§ Contain Chemical Mediators àVasoconstrict & initiate Coagulation Cascade + Repair.
• àForm Platelet Plugs
§ Platelet Deficiencies = Either ↓number and/or ↓function
o Fibrin formation:
§ Via the Coagulation Cascade
• Coagulation Cascade – THE FOCUS OF THIS WEEK:
o Intrinsic Pathway:
§ Begins in the blood itself i.e. intrinsic to the blood
§ Initiated by activation of Hageman Factor (Factor XII)
o Extrinsic Pathway:
§ Activated by damage to a vessel wall i.e. extrinsic to the blood
§ Initiated by Tissue Factor (Factor III)
o Common Pathway:
§ Both Pathways à Formation of a: ‘Prothrombin Activator Complex’ (PAC)
§ PAC then activates final common pathway leading to formation of fibrin
o Formation and stabilization of Fibrin:
§ Prothrombin à Thrombin
• Fibrinogen à Fibrin
o à Fibrin Deposition
• NB: Calcium Ions:
o Essential for the coagulation cascade to function
o Promote all reactions except the first two of the intrinsic pathway
The coagulation system is ‘irreducibly complex’

What does that mean? – Requires everything there for it to function. (An all or nothing process)
Abnormal Bleeding:
• May or may not involve dysfunction of coagulation system:
o Coagulation cascade dysfunction (Coagulopathy)
o Thromboycytopenia or platelet dysfunction
o Loss of vessel integrity (especially the microvasculature e.g arteritis)
• Coagulopathy - Inborn or Acquired:
o Inborn Coagulopathy:
§ Abnormal or deficient clotting factors
§ Genetic – usually hereditary
§ Eg. Haemophilia
o Aquired coagulopathy:
§ Problem with Factor Synthesis:
• Liver Disease
• Vit.K Deficiency
§ Inhibition of Coagulation:
• Coagulation Factor Antibodies
• Drug Therapy (Eg. Heparin/Warfarin)
§ Excess Consumption of Clotting Factors:
• Eg. Disseminated Intravascular Coagulation (DIC)
• Bleeding Management Principles:
o ABC
o If Obvious Exsanguinating Haemorrhage → control with Direct Pressure or Tourniquet.
o If controllable → restore BP to normal
o If not controllable → keep SBP ≤ 90mmHg until surgical control of bleeding achieved
o Correct any underlying coagulopathy
Blood Transfusion:
- Common Blood Groups & Characteristics:
Phenotype Genotype RBC Antigens Naturally occurring Frequency
antibodies
O OO None AB 40%
A AA, AO A B 30%
B BB, BO B A 25%
AB AB A&B None 5%
(Rh-D Positive) D No anti-D
(Rh-D Negative) - Anti-D
- Universal Donor:
o O-Negative
§ No A or B Antigens
§ No Rh-D Antigens
- Universal Recipient:
o AB-Positive
§ No anti-A or anti-B Antibodies
§ No anti-Rh-D Antibodies
- Group Specific Blood Vs. Cross Matched Blood:

o Group Specific = Blood of any ‘Type’ (ABO,D) that’s compatible with the Recipient. (20mins)
o Cross Matched = Complex Pre-Transfusion Testing for Compatibility across all Blood Types. (1hr)
- In Emergency Situations:
o Sometimes there isn’t time to obtain a blood group or do a full cross match, so it is best to give
O-Neg in an emergency situation.
- What infections are screened for in donated blood and how long does the screening process take?
o HIV
o Hep B/C (Not Hep A)
o HTLV1/2
o Syphilis
- What is the difference between whole blood and packed red cells?
o Whole blood = All blood components
o Packed Red Cells = RBCs only
- What is added to blood when it’s donated? Why?

o Anticoagulants
o Ca-Citrate
o Glucose
- How long can blood be stored for?

o 5-6 weeks
Cases:
- 1. Driver of Semi—trailer, lost control crossing a bridge, crashed into the creek.
o Initial Assessment:
§ Entrapped.
§ GCS 14
§ HR 150
§ BP 95/40
§ RR 40
o Problems:
§ Trapped
§ Compound # right femur – Bleeding
§ Facial Lacerations
o Potential Issues:
§ Crush Legs
§ ? Neck Injury
§ ?Chest – Heart/Lungs/Mediastinum
§ ?Liver/Spleen/Pancreas
§ ?Spine Injury
o What happened:
§ Pre-hospital blood transfusion started
§ Wife arrived at the scene.
§ Fluid Replacement
• 10L of Crystalloid
• 14 units of blood
• Fresh frozen plasma
§ Difficult extrication (trapped for 3hrs)
§ Intubated and MAST/PASG suit (An Anti-Shock “G-Suit” Trowsers) applied immediately
after extrication.
o On Arrival:
§ HR 135
§ BP Low
§ Hypothermic
§ Profuse blood loss
o Outcome:
§ Died of persistent blood loss the next day.
Week 11 Renal and Haematological Emergencies MCQ’s
1. All of the following are recognised functions of the kidney except:
a. Acid-base homeostasis
b. Fluid balance
c. Blood pressure regulation
d. Glucose homeostasis
e. Regulation of erythropoiesis
Answer: D
2. All of the following are causes of intra-renal renal failure except:
a. Acute tubular necrosis
b. Cardiogenic shock
c. Glomerular nephritis
d. Interstitial nephritis
e. Arteritis involving the vasa recta
Answer: B
3. The transpyloric plane is situated:
a. At the level of the iliac crests
b. At the level of the umbilicus
c. At a point midway between the sternal notch and the symphysis pubis
d. At the level of the xiphoid process
e. None of the above
Answer: C
4. Urogenic pain radiating from the flank to groin most likely arises from the:
a. Kidney
b. Ureter
c. Vesicoureteric junction
d. Bladder
e. Urethra
Answer: B
5. Which of the following clotting factors is not part of the intrinsic pathway?
a. XI
b. IX
c. VII
d. III
e. XII
Answer: D
6. Blood group ‘B’ is best described as:
a. Having ‘B’ RBC antigens and ‘anti-A’ antibodies
b. Having ‘B’ RBC antigens and ‘anti-B’ antibodies
c. Having ‘A’ RBC antigens and ‘anti-B’ antibodies
d. Having ‘A’ RBC antigens and ‘anti-A’ antibodies
e. Having ‘AB’ RBC antigens and ‘anti-A’ antibodies
Answer: A
7. All of the following may result in coagulopathy except:
a. Factor VIII deficiency
b. Liver disease
c. Vitamin K deficiency
d. Snake evenomation
e. Thrombocythemia
Answer: E
8. Which blood group is regarded as the ‘universal donor’?
a. O –ve
b. O +ve
c. AB –ve
d. AB +ve
Answer: A
9. Which blood group is regarded as the ‘universal recipient’?
a. O –ve
b. O +ve
c. AB –ve
d. AB +ve
Answer: D
10. Approximately how long does it take to fully cross match blood?
a. 10 minutes
b. 20 minutes
c. 30 minutes
d. 40 minutes
e. 50 minutes
Answer: E
11. Donated blood is screened for all of the following except:
a. HIV
b. Hepatitis B
c. Hepatitis C
d. Syphylis
e. CMV
Answer: E
GENITOURINARY TRACT (GU) INJURIES

❏ diagnosis based on mechanism of injury, hematuria (gross or microscopic),
and appropriate radiological studies
Renal
❏ etiology
• blunt trauma
• contusions (parenchymal ecchymosis with intact renal capsule)
• parenchymal tears
• non-communicating (hematoma)
• communicating (urine extravasation, hematuria)
• penetrating injuries
• renal pedicle injury due to acceleration/deceleration
❏ history: mechanism of injury, hematuria, flank pain
❏ physical exam: costovertebral angle (CVA) tenderness, upper quadrant mass, shock
❏ investigations
• CT scan (study of choice if hemodynamically stable)
• intravenous pyelogram (IVP) (during laparotomy)
• renal arteriography (if renal artery injury suspected)
❏ management
• 90% conservative (bedrest, analgesia, antibiotics)
• 10% surgical for
• hemodynamically unstable or continuing to bleed > 48 hours
• major urine extravasation
• renal pedicle injury
• all penetrating wounds
• major lacerations
• renal artery thrombosis
• infection
Ureter
❏ etiology
• iatrogenic (most common)
• blunt (rare) at uretero-pelvic junction
• penetrating (rare)
❏ history: mechanism of injury, hematuria
❏ physical exam: findings related to intra-abdominal injuries
❏ investigations: retrograde ureterogram
❏ management: uretero-uretostomy
Bladder
❏ etiology
• blunt trauma
• extraperitoneal rupture from pelvic fracture fragments
• intraperitoneal rupture from trauma + full bladder
• penetrating trauma
❏ history: gross hematuria, dysuria, urinary retention, abdominal pain
❏ physical exam
• extraperitoneal rupture: pelvic instability, suprapubic tenderness from mass of urine
or extravasated blood
• intraperitoneal rupture: acute abdomen
❏ investigations: urinalysis, CT scan, urethrogram, +/– retrograde cystography
❏ management
• extraperitoneal: minor rupture ––> Foley drainage, major rupture ––> surgical repair
• intraperitoneal: drain abdomen and surgical repair
Urethral
❏ etiology
• usually blunt trauma in men
• anterior (bulbous) urethra damage with straddle injuries
• posterior (bulbo-membranous) urethra with pelvic fractures
❏ history/physical
• anterior: blood at meatus, perineal/scrotal hematoma, blood and urine extending from
penile shaft and perineum to abdominal wall
• posterior: inability to void, blood at meatus, suprapubic tenderness, pelvic instability,
superior displacement of prostate, pelvic hematoma on rectal exam
❏ investigation: retrograde urethrography
❏ management
• anterior: if Foley does not pass, requires suprapubic drain
• posterior: suprapubic drainage, avoid catheterization
Contraindications to Foley Catheterization
1. blood at the urethral meatus
2. ecchymosis of the scrotum
3. “high riding” prostate on DRE of male patients
❏ if any of the above, digital rectal exam (DRE), a retrograde cystouretharogram indicated to rule out
urethral tear or ruptured bladder
Wk 1
Revision of MSK Anatomy: Relevant to Common MSK Injuries
Shoulder Region, Arm & Hand: Bones, Muscles, Nerves, Veins & Arteries.
Bones & Landmarks:

• Manubrium of Sternum (breastplate)
o Flat bone
• Clavicle
o Long bone
o Articulations:
§ Manubrium of Sternum
§ Acromion of Scapula
• Scapula
o Irregular bone
o Connects Humerus à Clavicle
o Articulations:
§ Lateral ends of Clavicle
§ Head of Humerus
• Humerus
o Long Bone
o Landmarks:
§ Head
§ Neck
§ Medial Epicondyle
§ Lateral Epicondyle
o Articulations:
§ Glenoid Process of Scapula
§ Radius
§ Ulnar
• Ulna: “Elbow”
o Major forearm bone contributing to Elbow Joint
o Landmarks:
§ Olecranon Process (Posterior Proximal)
§ Styloid Process of Ulna
§ Head of Ulna (Articulates with Wrist via Disc of Fibrocartilage)
o Articulations:
§ Trochlea of Humerus
§ Bones of Wrist
§ Radius – via Interosseous Membrane (flat, flexible ligament spanning entire length)
• Radius: “Rod”
o Major forearm bone contributing to Wrist Joint
o Landmarks:
§ Head – concave (Articulates with Capitulum of Humerus)
§ Neck
§ Styloid Process Of Radius
o Articulations:
§ Humerus
§ Bones of Wrist
§ Ulna – via Interosseous Membrane (flat, flexible ligament spanning entire length)
• ‘Hand’:
o Carpals (“Wrist”):
§ Scaphoid
§ Lunate
§ Triquetral
§ Pisiform
§ Trapezium
§ Trapezoid
§ Capitate
§ Hamate
o Metacarpals (“Palm”):
§ Metacarpals # 1-5
o Phalanges (“Fingers”):
§ Distal # 1-5
§ Middle # 1-5
§ Proximal # 1-5
NB: Some Lovers Try Positions That They Can’t Handle

Scaphoid, Lunate, Triquetrium, Pisiform, Trapezium, Trapezoid, Capitate, Hamate.
Joints & Ligaments:
• GlenoHumeral Joint:
o Features:
§ Joins Humerous & Glenoid Fossa (cavity) of Scapula
§ Synovial ball & socket
§ Glenoid Fossa = Shallow à allows huge angle of movement.
• High Mobility
• Low Stability
o Bones:
§ Head of Humerus
§ Glenoid Fossa of Scapula
• Elbow Joint
o HumeroUlnar Joint:
§ Features:
• Joins Distal Humerus to Proximal Ulna
• Synovial Hinge Joint
• Very Stable – Due to Bony Congruency
§ Bones:
• Humerus
o Medial Epicondyle
o Lateral Epicondyle
• Ulna
o Cubital Fossa
• RadioUlnar Joint:
o Proximal:
§ Features:
• Joins Radius & Ulna
• Synovial Pivot Joint
o Distal:
§ Features:
• Joins Radius & Ulna
• Synovial Pivot +
Articular Disc
• Wrist Joint:
o CarpiRadialis Joint:
§ Features:
• Joins Radius & Proximal Carpals
§ Bones:
• Radius
• Proximal Carpals
o Carpal Tunnel (Anterior Aspect):
§ Median Nerve
§ Wrist Flexor Tendons
§ Ulnar Artery
§ Ulnar Nerve
• CarpoMetacarpal Joints:
o Features:
§ Joins Carpals & Metacarpals
• Metacarpo-Phalangeal Joints (Knuckes):
o Features:
§ Joins Metacarpals & Phalanges
• InterPhalangeal Joints (Fingers):
o Features:
§ Joins adjacent Phalanges
Muscles:
Anterior View: Deep & Superficial Muscles of The Pectoral Girdle & The Glenohumeral Joint
Posterior View: Deep & Superficial Movers of The Pectoral Girdle & The Glenohumeral Joint
Upper Arm – Anterior Compartment
Upper Arm – Posterior Compartment
Lower Arm – Anterior Compartment
Lower Arm – Posterior Compartment
The Hand:
• Intrinsic Muscles of the Hand:
o Thenar Muscles:
§ “Ball” of the Thumb.
§ Median Nerve (Except *Adductor Pollicis = Ulnar Nerve)
o Hypothenar Muscles:
§ “Ball” of the Little Finger
§ Ulnar Nerve
o Lumbricals:
§ 4 worm-shaped muscles in the Palm
§ One to each finger (except thumb)
§ Median Nerve (Lateral 2) & Ulnar Nerve (Medial 2)
o Interossei:
§ Palmar Interossei: (PAD – Palmar Adduct Fingers)
• Ulnar Nerve
§ Dorsal Interossei: (DAB – Dorsal Abduct Fingers)
• Ulnar Nerve
• Extrinsic Muscles of the Hand:
o Insert via Long Tendons from the Forearm
o Anterior Flexors:
o Posterior Extensors:
Innervation (Peripheral):
• Axilla (Brachial Plexus)
o Roots (Ventral Rami)
§ C5, C6, C7, C8, T1
o Terminal Branches (Nerves)
§ Musculocutaneous
§ Median
§ Ulnar
§ Radial
§ Axillary
• Musculocutaneous Nerve:
o Runs down Anterior Arm
o Innnervates:
§ Flexors of Arm:
• Biceps Brachii
• Brachialis
• Coracobrachialis
§ Skin of Anterio-Lateral Forearm
• Axillary Nerve:
o Runs Posterior to Neck of Humerus
o Innervates:
§ Deltoid
§ Teres Minor
§ Skin & Joint Capsule of Shoulder
• Radial Nerve:
o Runs around Posterior Humerus (Radial-groove)àAnteriorly around Lateral Epicondyleà2
Branches:
§ Superficial: Follows Lateral edge of Radius à Hand
§ Deep: Runs Posteriorly to Radius
o Innervates:
§ ALL Posterior Extensor Muscles of Arm, Forearm & Hand
§ Skin of Entire Latero-Posterior Arm & Forearm & Hand (except dorsum of fingers 2 & 3)
• Median Nerve:
o Runs down Anterior Arm & Forearm
o Innervates:
§ Flexors of Anterior Forearm
§ Thenar Muscles (Intrinsic muscles of Lateral Palm)
§ Lumbricals #1 & #2
§ Skin of Lateral 2/3 of Hand, Palm Side & Dorsum of Fingers 2 & 3
• Ulnar Nerve:
o Runs down Medial ArmàBehind Medial EpicondyleàFollows Ulna down Medial ForearmàHand
o Innervates:
§ Flexors of Anterior Forearm
§ Majority of Intrinsic Muscles of Hand
• Incl. Lumricals #3 & #4
• Interossei
§ Skin of Medial 1/3 of Hand (Ant & Post).
Dermatomes of Upper Limb: (CUTANEOUS INNERVATION – NOT MYOTOMES!!)
Anterior Posterior
o Dermatomes of the Hand:
Nerve Lesions:
• Afferent: Sensory Loss
o Sensory impulses don’t reach spinal cord
o Loss of cutaneous sensation
o Loss of spinal reflexes
o Weird sensations – tingling, itching, pain, etc.
• Efferent: Paralysis
o If impulse can’t reach muscle.
o Muscle becomes flaccid – no tone.
o Complete/Incomplete
o Loss of spinal reflexes
Nerve Site of Injury Paralysis Motor Loss Sensory Loss
Axillary Axilla Deltoid Shoulder Abduction Deltoid Region
Musculocutaneous Axilla Arm Flexors Forearm Flexion Lateral Forearm
Arm Extensors Elbow Extension,

Axilla + Supinator Supination, Lateral Dorsum of
Radial Wrist Extension Hand
Cubital Fossa Arm Extensors, Supination,
Except Triceps Wrist Extension
Wrist Flexors, Weak Wrist Flexion,
Elbow Thenar Muscles, Thumb Opposition,
Lateral 2x Lumbricals Lateral 2x Finger-Flexion Lateral 3.5 Fingers
Median Thenar Muscles, Thumb Opposition,
Wrist Lateral 2x Lumbricals Lateral 2x Finger-Flexion
Wrist Flexors, Weak Wrist Flexion,
Above Elbow Hypothenar Muscles, Medial 2x Finter-Flexion Palm,
Ulnar Medial 2x Lumbricals Medial 1.5 Fingers
At Wrist Hypothenar Muscles, Medial 2x Finter-Flexion
Medial 2x Lumbricals
Arterial Blood Supply:
Venous Blood Drainage:

• Deep & Superficial
• Deep Veins run in pairs clinging to Arteries.
• Hand, Forearm & Upper Arm
• Axilla:
o Axillary Vein à
o Subclavian Vein
• Thoracic:
o Subclavian Veinà
o BrachioCephalic à
o Superior Vena Cava àHeart
The Pelvic Girdle & The Lower Limb: Bones, Joints, Muscles, Nerves & Vasculation
Bones:
• The “Bony Pelvis”:
o Sacrum:
o Coxal Bones (hip bones):

§ Landmarks:
• Acetabulum (“Wine Cup”) – Hemispherical Socket
• Pelvic Brim
• Ilium
o Iliac Crest
• Ischium
• Pubis
o Pubic symphysis
o Pubic Arch/Subpubic Angle (Wide in females)
• Femur:
o Type/Features:
§ Long bone
§ Neck of femur – prone to fracture due to lack of trabeculae.
o Landmarks:
§ Head
§ Neck
§ Greater Trochanter
§ Lesser Trochanter
§ Lateral Epicondyle
§ Medial Epicondyle
§ Lateral Condyle
§ Medial Condyle
§ Patellar Surface
o Articulations:
§ Acetabulum of the Coxal Bones of the Hip
§ Patella
§ Tibia
• Patella
o Type/Features:
§ Triangular Sesamoid Bone
§ Enclosed in Quadriceps Tendon
• Tibia
o Type/Features:
§ Long Bone
§ Weight Bearing (not fibula)
o Landmarks:
§ Condyles – Medial & Lateral
§ Tibial Plateau – (superior articular surface)
§ Tibial Tuberosity
§ Medial Malleolus
o Articulations:
§ Condyles of Femur
§ Fibula – Fibular Facet (proximally)
§ Talus Bone of the Foot.
§ Fibula – Fibular Notch (distally)
• Fibula
o Type/Features:
§ Slender Long Bone
§ No function in weight-bearing – mainly for muscle attachment
o Landmarks:
§ Head
§ Neck
§ Shaft
§ Lateral Malleolus
o Articulations:
§ Tibia Proximally & Distally
§ Trochlea of Talus Bone of Tarsals of the Foot.
• Foot:
o 7x Tarsals:
§ Talus
§ Calcaneus
§ Navicular
§ Cuboid
§ Lateral Cuneiform
§ Intermediate Cuneiform
§ Medial Cuneiform
o 5x MetaTarsals:
§ 1à5
o Phalanges:
§ 1: Proximal & Distal
§ 2 5: Proximal, Middle & Distal
à
o 2x Sesamoids:
§ “Ball” of the foot.
Joints:
• Hip Joints:
o Features:
§ Synovial, MultiAxial Ball & Socket
§ Acetabular Labrum (lip) of fibrocartilage – deepens socket – High Bony Congruency
o Bones:
§ Rounded head of Femur
§ Acetabulum of Innominate Bones.
The “Femoral Triangle”

Contents:
• Femoral Nerve
• Femoral Artery
• Femoral Vein
• Femoral Empty Space
• Inguinal Lymphatics
• Knee Joint:
o Features of The Knee Joint:
§ Synovial Modified Bicondylar Hinge Joint
§ Relatively Unstable:
• Ligaments provide the stability – not Bony Congruity.
o Bones:
§ Femur
§ Patella
§ Tibia
o Injury: The Unhappy Triad:
§ Anterior Cruciate Ligament
§ Medial Collateral Ligament
§ Medial Meniscus
The Popliteal Fossa:

• Contents:
o Popliteal Artery
o Popliteal Vein
o Tibial Nerve
o Common Fibular Nerve
• Ankle Joint (Talo-Crural):
o Ie. “Talus-Leg”
o Features:
§ Synovial Hinge Joint
§ Good bony congruity
§ Stability comes from Very Strong Ligaments
o Bones:
§ Trochlea of Talus
§ Distal end of Tibia
§ Distal end of Fibula
Muscles:
Iliac Region
Iliopsoas: Iliacus, Psoas Major, Psoas Minor
Thigh: Anterior:
(Femoral Nerve)
Thigh Medial:
(Obturator Nerve)
Thigh Posterior & Lateral:
(Sciatic Nerve)
Gluteal Region:
(Sciatic Nerve)
Lateral Rotators: Origins & Insertions: Posterior Aspect

(Obturator Nerve)
• Anterior Compartment of Leg: (Fibular Nerve)
o Tibialis Anterior:
§ Dorsiflexion
o Extensor Hallucis Longus:
§ Extension of Big Toe
o Extensor Digitorum Longus:
§ Extension of Phalanges 2à5
o Fibularis Tertius:
§ Dorsiflexion
• Lateral Compartment of Leg: (Fibular Nerve)

o Ankle Evertors:
§ Ankle Eversion
• Posterior Compartment of Leg: (Tibial Nerve)
o Triceps Surae (Calf):
§ Gastrocnemius & Soleus.
• Plantar Flexion
o & Other Plantar-Flexors:
§ Plantar Flexion
Structures Passing Medial Malleolus:

• Tom - Tibialis Posterior
• Dick - Flexor Digitorum Longus
• And - Posterior Tibial Artery
• Naughty - Tibial Nerve
• Harry - Flexor Hallucis Longus
Innervation:
• Lumbar Plexus:
o Femoral Nerve:
§ Branches off L2, L3 & L4
§ Runs between Psoas Major & Iliacus à beneath the Inguinal Ligament à Thigh.
§ Innervates:
• Hip Flexors
• Quadriceps (Knee Extensors)
• Skin of Anterio-Medial Thigh & Lower Leg + Medial Aspect of Foot
NB: Cutaneous Innervation – In blue
o Obturator Nerve:
§ Branches off L2, L3 & L4
§ Runs medial to Psoas Major, down along the inside wall of lesser pelvis à through
Obturator Canal (in obturator membrane) through Obturator Foramen à Thigh
§ Innervates:
• External Obturator
• Adductor Muscles
• Skin of medial aspect of thigh
• Sacral Plexus:
o Sciatic Nerve:
§ Branches off L4, L5, S1, S2 & S3
§ Runs from inside pelvis à through Greater Sciatic Foramen (below piriformis) à
descends along the posterior thigh to about its lower third à Divides into 2 Branches:
Tibial & Common Fibular Nerves. (some variation)
§ Innervates:
• Hamstrings (Knee Flexors)
• ½ of Adductor Magnus
• Nearly the whole of the skin of the leg.
§ Sciatic Nerve: Common Fibular (Peroneal) Nerve:

• Branches off Sciatic Nerve
• Runs through the Popliteal Fossa à Winds around neck of Fibula à divides into
Deep & Superficial Fibular (peroneal) Nerves
• Innervates:
o Dorsi-Flexors
o Ankle Evertion
o Skin of Lateral Aspect of Lower Leg
o Skin of Dorsum of Foot
§ Tibial Nerve:
• Branches off Sciatic Nerve
• Runs through Popliteal Fossa à Then follows the Tibia to the ankle à passes
into Foot (below medial malleolus) à Terminates as Medial & Lateral Plantar
Nerves
• Innervates:
o Plantar-Flexors (Calf Muscles)
o Tibialis Posterior
o Toe Flexors
Nerve Lesions:
• Most are incomplete lesions
• Can be disabling
Nerve Lesion: Functional Loss:
Femoral Nerve Lesion o Loss of Extension of Knee
o Loss of Flexion of Hip
Obturator Nerve Lesion o Loss of Adductors of Hip
o Weird Gait
Tibial Nerve Lesion o Loss of Plantar Flexion
o Loss of Movement of Toes
Fibular Nerve Lesion o Loss of Dorsiflexion à ‘foot drop’
o Loss of Extension of toes
o Loss of Eversion
Vasculation:
• Arterial Blood Supply:
o Thoracic:
§ Abdominal Aorta à
o Pelvic:
§ Common Iliac Arteries à
• Internal Iliac Artery à Pelvic & Reproductive Organs + Buttocks + Medial Thigh
• External Iliac Artery à Thigh, Leg, Foot.
o Upper Leg:
§ External Iliac Artery à
• Deep Artery of the Thigh à branches into many perforating arteries
• Femoral Artery à descends the femur, becoming more & more medial +
posterior
o Popliteal Artery à
o Lower Leg:
§ Popliteal Artery + Genicular Anastomosis à Runs down 1/3 of lower leg, then splits
into:
• Anterior Tibial Artery -
• Posterior Tibial Artery – Runs down posterior aspect of Tibia à ankle
• Fibular Artery – Runs down posterior aspect of Fibula à ankle
o Foot:
§ Anterior Tibial Artery à
• Dorsalis Pedis Artery
§ Posterior Tibial Artery à
• Lateral Plantar Artery
• Medial Plantar Artery
• Venous Blood Drainage:
o Foot:
§ Dorsal & Plantar Venous Arches
o Lower & Upper Leg:

§ Deep:
• Ant. & Post Tibial Veins à Popliteal Vein
• Fibular Vein à Popliteal Vein
§ Superficial:
• Small Saphenous Vein à Runs up calves (posteriorly), goes deep à Popliteal
Vein
• Great Saphenous Vein à All the way up the leg (medially) à Deep Femoral Vein
o POPLITEAL VEIN à Deep Femoral Vein
o Pelvic:
§ Deep Femoral Vein à External Iliac Vein
o Thoracic:
§ External iliac Vein à Inferior Vena Cava
Superficial Veins of Lower Limb:
Deep Veins of Lower Limb:
Wk 1
Musculoskeletal Injuries
Key words + Definitions:

• Fracture:
o A Break in a Bone
• Compound fracture:
o An Open Fracture where there is broken skin.
• Dislocation (or “Luxation”):
o The Displacement of Joint Surfaces such that Normal Articulation no longer occurs.
o The ligaments always become damaged as a result of a dislocation.
o A Subluxation is a partial dislocation.
• Reduction:
o Medical procedure to restore a fracture or dislocation to the correct alignment.
• Splint:
o Medical device used for immobilization of limbs or spine to prevent further injury and aid in
patient retrieval.
• Neurovascular compromise:
o Damage to either Vessels and/or Nerves as a result of an injury. Leads to functional impairments.
• Compartment syndrome:
o With any bony injury, particularly crush-injuries, bleeding may occur into the muscle
compartments. à Raises intra-compartmental pressure and compress blood vessels and nerves.
Major Concepts:
What is a Musculoskeletal Emergency and why?

- Fractures:
o Breaks in Bone.
o Emergency Because:
§ If it’s an ‘Open Fracture’ – Risk of Infection
§ Some fractures won’t heal without treatment
§ Neurovascular compromise – can pull/tear/compress/rupture surrounding
nerves/vessels.
- Dislocations:
o The Displacement of Joint Surfaces such that Normal Articulation no longer occurs.
o When forces on joint are greater than stabilizing forces of Bone, Ligament & Muscle.
o Emergency Because:
§ The longer the delay before reduction, the more difficult it becomes, as the muscles
around the joint contract.
§ Delay can also result in significant joint & ligament damage à Impairment of function.
§ Neurovascular compromise – can pull/tear/compress/rupture surrounding
nerves/vessels.
- Dismemberment:
o Loss of limb or Extreme Tissue-loss resulting in permanent functional impairment of that limb.
Factors Affecting the Degree of Urgency:
- Abnormal ABC
- Bleeding
- Major Vascular Compromise
- Open Vs. Closed Injury
- Neurological Compromise
- Pain
- Potential Loss of Function if Injury is Untreated.
The Basic Priorities of MSK Care:

- Primary Survey – “ABC” (Life before limb)
- Identify Injury
- Analgesia
- Splint
- Prevent Infection
- Reduction (Restoring Alignment)
Benefits of Reduction & Splinting:

- Splinting:
o Reduces Pain
o Reduce Bleeding
o Promote Healing
o Reduce risk of Further Compromise (Bone/Neuro/Vascular/Functional)
- Reduction:
o Reduce Pain
o Restore Function
o Reduce risk of Further Compromise (Neuro/Vascular/Functional)
(See “Wk 1 EM Notes - Revision of MSK Anatomy.doc”)
What Possible Neurovascular Compromise Can Result From:
- Common Fractures:
o Humeral #:
§ Neck:
• Axillary Nerve Damage
§ Mid-Shaft:
• Radial Nerve Damage (As it closely traverses the lateral aspect of the humerus)
§ Supracondylar:
• Median Nerve Damage
• Brachial Artery.
o Radial (Colles?) #:
§ Median Nerve (Compression)
§ Ulnar Nerve (Compression)
§ Radial Artery
o Wrist (Both Radius & Ulnar) #:
§ Median Nerve Damage
§ Ulnar Nerve Damage
§ Radial Artery Laceration
§ Ulnar Artery Laceration
o Femoral Shaft #:
§ Femoral Nerve
§ Sciatic Nerve
§ Femoral Artery
o Neck of Femur #:
§ Sciatic Nerve
§ Femoray Nerve
§ Femoral Artery
o Ankle #:
§ Post. Tibial Artery
§ Tibial Nerve
- Common Dislocations:
o Shoulder (Gleno-humoral):
§ Axillary Nerve Damage
§ Musculocutaneous Nerve Damage
§ Radial Nerve Damage
o Hip:
§ Sciatic Nerve Damage
o Knee - Usually accompanied by Severe Ligament Damage:

§ Tibial Nerve
§ Common Fibular Nerve
§ Popliteal Artery
§ Popliteal Vein
o Ankle - Usually accompanied by a Fracture:

§ Post. Tibial Artery
§ Tibial Nerve
- Laceration:
o Volar (Palmar) Aspect of Wrist – (Eg. In Attempted Suicide):
§ Median Nerve
§ Ulnar Nerve
§ Radial Artery
§ Ulnar Artery
§ Basilic Vein
§ Cephalic Vein
§ (+ Wrist Flexor Tendons)
What Functional Impairments Suggest Damage to These Nerves?:

- Upper Limb:
Axillary Nerve Axilla Deltoid Shoulder Abduction Deltoid Region
Musculocutaneous Lateral Forearm

Nerve Axilla Arm Flexors Forearm Flexion
Arm Extensors Elbow Extension, Lateral Dorsum of

Axilla + Supinator Supination, Hand, & Posterior
Radial Nerve Wrist Extension Arm.
Cubital Fossa Arm Extensors, Supination,

Except Triceps Wrist Extension
Wrist Flexors, Weak Wrist Flexion, Lateral 3.5 Fingers

Elbow Thenar Muscles, Thumb Opposition,
Lateral 2x Lumbricals Lateral 2x Finger-Flexion
Median Nerve
Wrist Thenar Muscles, Thumb Opposition,
Lateral 2x Lumbricals Lateral 2x Finger-Flexion
Wrist Flexors, Weak Wrist Flexion, Palm,

Above Elbow Hypothenar Muscles, Medial 2x Finter-Flexion Medial 1.5 Fingers
Ulnar Nerve Medial 2x Lumbricals
At Wrist Hypothenar Muscles, Medial 2x Finter-Flexion
Medial 2x Lumbricals
- Lower Limb:
Femoral Nerve Femoral Neck, Quadriceps Femori Knee Extension, Antero-Medial Leg
Shaft # Hip Flexion
Obturator Nerve Hip Hip Adductors Hip Adduction Medial Thigh
Sciatic Nerve Hip, Hamstring Function, Knee Flexion, Most of

Femur # Plantar-Flexors, Plantar-Flexion, Post.Thigh, Leg &
Dorsi-Flexors, Dorsi-Flexion, Foot
Intrinsic Foot Muscles. Ankle Eversion,
Toe Movement
Tibial Nerve Knee, Tibial #, Plantar-Flexors, Plantar-Flexion, Posterior Leg
Laceration Intrinsic Foot Muscles Toe Movement
Fibular Nerve Knee, Fibular # Dorsi-Flexors, Dorsi-Flexion, Anterio-Lateral
Laceration, Intrinsic Foot Muscles Toe Movement, Leg
Compression Ankle Eversion,
- Testing for Neurovascular Compromise:

o Presence of Vascular Compromise?
§ Bleeding/Haematoma à Probably
§ No Distal Pulses à Probably
§ Distal Pulses Presentà Probably Not
o Presence of Neurological Compromise?
§ Sensory Alterations/ Loss à Probably
§ Impaired Motor Function à Probably
§ Neither of the above à Probably Not
Major Processes:
Describe the Approach to Musculoskeletal Emergencies:

1. First, The Primary survey – ABCDE:
o Airway
o Breathing
o Circulation
o Disability
o Exposure
2. Analgesia (If Necessary):

a. Is it needed?..If So:
i. What?
ii. Which Route?
iii. What Dose?
b. Oral Analgesia (Paracetamol/Aspirin) – Cheap & Easy; But Weak
c. Parenteral Analgesia (IM/IV opiates) – Strong; But More Expensive/Complicated
d. Regional Blocks (LA injection around a nerve) – Only Good for Isolated Injuries
3. Musculoskeletal Assessment:
a. Suspicion of Injury from:
i. History
ii. Appearance
iii. Examination
iv. X-ray (Later – for Confirmatory Purposes)
b. Open Vs. Closed:
i. High Risk of Infection if Open – Requires early treatment.
c. Neurovascular Compromise?
i. Presence of Vascular Compromise?
1. Bleeding/Haematoma à Probably
2. No Distal Pulses à Probably
3. Distal Pulses Presentà Probably Not
ii. Presence of Neurological Compromise?
1. Sensory Alterations/ Loss à Probably
2. Impaired Motor Function à Probably
3. Neither of the above à Probably Not
4. Order & Examine the X-Ray:

a. X-Ray Order:
i. Include 2 Views:
1. AP (Anteroposterior)
2. Lateral
ii. Also include images of the joints Above & Below.
b. Examining the X-Ray:
i. Examine area of suspicion
ii. Examine joints Above & Below.
iii. Examine all other bones.
iv. à Confirms the clinical diagnosis & gives more info about injury severity.
5. Treatment:
a. Splinting (if permanent treatment isn’t immediately available)
b. Reduction
c. Surgery
XRays - Differentiate Normal from Abnormal and Describe an X-Ray:
• Describing an X-Ray:
o Fracture (#) or Dislocation?
o Which Bone?
o Location? (Which part of the Bone?):
§ (E) Epiphysis
§ (EP) Epiphyseal Plate
§ (M) Metaphysis
§ (D) Diaphysis (Shaft) [In ‘Thirds’]
• Eg. (1) Proximal 1/3
• Eg. (2) Diaphyseal (mid) 1/3
• Eg. (3) Distal 1/3)
(A) = Tibial Diaphysis (A) Diaphyseal Femur #

(B) = Femoral Neck (B) Distal Femur #
(C) = Greater Trochanter (C) Mid-Distal Femur #
(F) = Supracondylar # (D) Radial ‘Colles’ #
§ Epicondyle
§ Malleolus
§ Etc.
• If It’s a Fracture (#):

o Properties of Fractures:
§ Closed (Simple) or Open (Compound)?
§ Displaced? (Fracture gap) – Described as a Percentage. (Eg. 50% Displaced)
1) Aligned; 2) 50% Displaced; 3) 80% Displaced;

4) 90% Displaced; Right) 100% Displaced
§ Angulation – Expressed in Degrees relative to Each Other. (Eg. A 30o Angulation)

• 1) Fracture of the Mid 1/3 of Femur with distal fragment tilted laterally.
• 2) Midshsaft fracture of the Tibia & Fibula with Distal Fragment tilted Anteriorly.
§ Rotated – Can be hard to see on an X-Ray.
o Types of Fractures:
§ Complete: A fracture in which bone fragments separate completely.
§ Incomplete: A fracture in which the bone fragments are still partially joined.
§ Greenstick: Occurs mostly in children with non-brittle bones. (An Incomplete #)
§ Comminuted: 3 or More Pieces
§ Compacted: A fracture caused when bone fragments are driven into each other.
o What shape is the #?

§ Linear: A fracture that is parallel to the bone's long axis.
§ Transverse: A fracture that is at a right angle to the bone's long axis.
§ Oblique: A fracture that is diagonal to a bone's long axis.
§ Spiral: A fracture where at least one part of the bone has been twisted.
Transverse Oblique Spiral
• If Dislocation (AKA: “Luxation”):

o 1. Which Joint?
§ Shoulder (Gleno-humoral)
§ Fingers (Inter-Phalangeal)
§ Wrist - Usually accompanied by a fracture
§ Elbow - Usually accompanied by a fracture
§ Knees
§ Ankle - Usually accompanied by a fracture
o 2. What Direction?:
§ Superior/Inferior
§ Anterior/Posterior
o 3. Is there an Associated Fracture?
o 4. Any possible Neurovascular Compromises?
SPINE AND SPINAL CORD TRAUMA

❏ spinal immobilization (cervical collar, spine board) must be maintained until spinal injury has been ruled out
❏ vertebral injuries may be present without spinal cord injury, therefore normal neurologic exam
does not exclude spinal injury
❏ if a fracture is found, be suspicious, look for another fracture
❏ spine may be unstable despite normal C-spine x-ray
❏ collar everyone except those that meet ALL the following criteria
• no pain
• no tenderness
• no neurological symptoms or findings
• no significant distracting injuries
• no head injury
• no intoxication
❏ note: patients with penetrating trauma (especially gunshot and knife wounds) can also have spinal cord injury
X-Rays
❏ full spine series for trauma
• AP, lateral, odontoid
❏ lateral C-Spine
• must be obtained on all blunt trauma patients (except those meeting above criteria)
• must visualize C7-T1 junction (Swimmer’s view or CT scan often required)
❏ thoracolumbar
• AP and lateral views
• indicated in
• patients with C-spine injury
• unconscious patients
• patients with symptoms or neurological findings
• patients with deformities that are palpable when patient log-rolled
Management of Cord Injury
❏ immobilize the entire spine with the patient in the supine position (collar, sand bags, padded board, straps)
❏ if patient must be moved, use a “log roll” technique with assistance
❏ if cervical cord lesion, watch for respiratory insufficiency
• low cervical transection (C5-T1) produces abdominal breathing (phrenic innervation of
diaphragm still intact)
• high cervical cord injury ––> no breathing ––> intubation
❏ hypotension (neurogenic shock)
• treatment: warm blanket, Trendelenberg position (occasionally), volume infusion,
consider vasopressors
APPROACH TO SUSPECTED C-SPINE INJURY
Clearing the C-Spine
❏ cervical collar must stay on at all times until C-spine is cleared (see Figure 3)
Suspected C-spine Injury

* based on mechanism of injury (e.g. MVC, fall, sports)
History: midline neck pain, numbness or parasthesia, presence of distracting pain, patient head-injured,
patient intoxicated, loss of consciousness or past history of spinal mobility disorder
Physical exam: posterior neck spasm, tenderness or crepitus, any neurologic deficit or autonomic
dysfunction, altered mental state
NO YES
C-spine cleared 1. Plain x-rays, 3 views

2. CT scan if:
• inadequate plain film survey
• suspicious plain film findings
C-spine cleared • to better delineate injuries seen on plain films
• any clinical suspicion of atlanto-axial dislocation
• high clinical suspicion of injury despite normal x-ray
Normal • to include C1-C3 when head CT is indicated in head
trauma cases
Flexion/
extension Neck pain
films
Normal films Abnormal films
Abnormal
Abnormal
Remain immobilized, neurological
consult spine service exam Remain immobilized, consult spine service
Abnormal
MRI
C-spine cleared Normal
Figure 3. Approach to C-spine Clearing
C-Spine X-Rays
❏ 3-view C-spine series is the screening modality of choice
• AP
• lateral C1-T1 (± swimmer’s view) - T2 not involved with neck movements
• odontoid (open mouth or oblique submental view)
Odontoid View (see Figure 5)
❏ examine the dens for fractures
• beware of artifact (horizontal or vertical) caused by the radiologic shadow of the teeth overlying
the dens. Repeat view if unable to rule out fracture. If still unable to rule out fracture consider CT or
plain film tomography.
❏ examine lateral aspects of C1
• odontoid should be centred between C1 lateral masses
• lateral masses of C1 and C2 should be perfectly aligned laterally. If not, suspect a fracture of C1
• lateral masses should be symmetrical (equal size)
Anteroposterior View
❏ alignment of spinous processes in the midline
❏ spacing of spinous processes should be equal
❏ check vertebral bodies
Supine Oblique Views
❏ detects some injuries not visible on the usual three views
❏ better visualization of posterior element fractures (lamina, pedicle, facet joint)
❏ can be used to visualize the cervicothoracic junction
1. Dens
2 1 2 2. C1 Lateral Mass
3. C2
1. anterior vertebral line
2. posterior vertebral line
(anterior margin of spinal canal)
3. posterior border of facets
4. laminar fusion line
3
(posterior margin of spinal canal)
5. posterior spinous line
(along tips of spinous processes)
5 To clear the x-ray ensure that:
4 3 A) the dens is centred between the lateral massess of C1
2 1 B) C1 and C2 are aligned laterally
C) the lateral masses of C1 are symmetrical in size
Figure 4. Lines of Contour on a
Lateral C-Spine X-Ray Figure 5. Odontoid of C-Spine X-Ray
Illustrated by Kim Auchinachie Illustrated by Eddy Xuan
Lateral View: The ABCS

A - Alignment and Adequacy
❏ must see C1 to C7-T1 junction - if not - downward traction of shoulders, swimmer’s view, bilateral supine
obliques, or CT scan
❏ lines of contour (see Figure 4) (in children < 8 years of age: physiologic subluxation of C2 on C3, and C3
on C4, but the spinolaminal line is maintained)
❏ widening of interspinous space (fanning of spinous processes) suggests posterior ligamentous disruption
❏ widening of facet joints
❏ check atlanto-occipital joint:
• line extended inferiorly from clivus should transect odontoid
❏ atlanto-axial articulation - widening of predental space (> 3 mm in adults, > 5 mm in children)
indicates injury of C1 or C2
B - Bones
❏ height, width and shape of each vertebral body
❏ pedicles, facets, and laminae should appear as one - doubling suggests rotation
C - Cartilages
❏ intervetebral disc spaces - widening anteriorly or posteriorly suggests vertebral compression
S - Soft Tissues
❏ widening of retropharyngeal (> 7 mm at C1-4, may be wide in children less than 2 yrs. on expiration)
or retrotracheal spaces (> 22 mm at C6-T1, > 14 mm in children < 15 years of age)
❏ prevertebral soft tissue swelling: only 49% sensitive for injury
Management Considerations
❏ immobilize C-spine with collar and sand bags (collar alone is not enough)
❏ injuries above C4 may need ventilation
❏ continually reassess high cord injuries - edema can travel up cord
❏ beware of neurogenic shock
❏ administer methylprednisolone within 8 hours of C-spine injury
❏ before O.R. ensure thoracic and lumbar x-rays are normal, since 20% of patients with C-spine fractures have
other spinal fractures
❏ early referral to spine service
Sequelae of C-spine Fracture
❏ decreased descending sympathetic tone (neurogenic / spinal shock) responsible for most sequelae
❏ cardiac
• no autoregulation, falling BP, decreasing HR, vasodilation
• GIVE IV FLUIDS ± pressors
❏ respiratory
• no cough reflex (risk of aspiration pneumonia)
• no intercostal muscles +/– diaphragm
• intubate and maintain vital capacity
❏ gastrointestinal
• ileus, vasodilation, bile and pancreatic secretion continues (> 1L/day), risk of aspiration, GI stress ulcers
• NG tube may be required for suctioning, feeding, etc.
❏ renal
• hypoperfusion ––> IV fluids
• kidney still producing urine (bladder can rupture if patient not urinating)
• Foley catheter may be required (measure urine output)
❏ skin
• vasodilation, heat loss, no thermoregulation, atrophy (risk of skin ulcers)
❏ muscle
• flaccidity, atrophy, decreased venous return
❏ penis
• priapism
ORTHOPEDIC INJURIES (see Orthopedics Chapter)

❏ role of E.D.: identify injuries, restore anatomy (reduce and immobilize), administer antibiotics and
tetanus prophylaxis
Physical Exam
❏ look: deformity, swelling, bleeding, bruising, spasm, colour
❏ feel: pulse, warmth, tenderness, crepitation, sensation, capillary refill
❏ move: range of motion (ROM) assessed actively (beware passive ROM testing)
Describing Orthopedic Injuries
❏ open vs. closed
❏ neurovascular status
❏ location of fracture
❏ type of fracture
❏ alignment: displacement, angulation
General Approach
❏ fractures
• immobilize/traction/ice/analgesia
❏ open wounds
• remove gross contamination, irrigate
• cover with sterile dressing
• definitive care within 6-8 hours
• control bleeding with pressure (no clamping)
• splint fracture
• antibiotics - cefazolin (+/– gentamycin, metronidazole/penicillin in dirty injury)
• tetanus prophylaxis (if none in last 10 yrs)
❏ joint injuries
• orthopedic consultation
• reduce dislocations after x-ray
• immobilize
A. LIFE AND LIMB THREATENING INJURIES
❏ usually because of blood loss
• pelvic fractures (up to 3.0L blood loss)
• femur fractures (up to 1.5L blood loss per femur)
• open fractures (double blood loss of a closed fracture)
❏ neurovascular compromise
❏ open fractures
❏ extensive soft tissue injuries
❏ amputations
❏ compartment syndrome
Life Threatening Injuries
❏ major pelvic fractures
❏ traumatic amputations
❏ massive long bone injuries
❏ vascular injuries proximal to knee/elbow
Limb Threatening Injuries
❏ fracture/dislocaton of ankle
❏ crush injuries
❏ compartment syndrome
❏ dislocations of knee/hip
❏ fractures with vascular/nerve injuries
❏ open fractures
❏ fractures above the knee or elbow
Assessment of Neurovascular Injury
❏ assess pulses before and after reduction
❏ diminished pulses should not be attributed to “spasm”
❏ angiography is definitive if diagnosis in doubt
Vascular Injuries Suggested by 6 P’s
Pulse discrepancies
Pallor
Paresthesia/hypoesthesia
Paresis
Pain (especially when refractory to usual doses of analgesics)
Polar (cold)
Treatment of Vascular Compromise

❏ realign limb/apply traction
❏ recheck pulses (Dopplers)
❏ surgical consult
❏ consider measuring compartment pressures
❏ angiography
Compartment Syndrome (see Orthopedics Chapter)
❏ rise in interstitial pressure above that of capillary bed (30-40 mmHg)
❏ usually in leg or forearm
❏ often associated with crush injuries (extensive soft tissue damage)
❏ clinical diagnosis
❏ suspect when you find
• excessive pain; worse with passive stretching of involved muscles
• decreased sensation of nerves in that compartment
• tense swelling
• weakness, paralysis
• pulse may still be present until very late
❏ hallmark: pain refractory to treatment with “usual” dose of analgesic agent
❏ management
• compartment syndrome
• remove constrictive dressings/casts
• prompt fasciotomy
B. UPPER EXTREMITY INJURIES

❏ anterior shoulder dislocation
• axillary nerve at risk
• shown on lateral view: humeral head anterior to glenoid
• reduce, immobilize, re-X ray, out-patient appointment with ortho
❏ Colle’s fracture
• from fall on the outstretched hand (FOOSH)
• AP film: shortening, radial deviation, radial displacement
• lateral film: dorsal displacement, volar angulation
• reduce, immoblize with volar slab, out-patient with ortho (consider presentation)
• if involvement of articular surface, emergent ortho referral
❏ scaphoid fracture
• tender in snuff box, pain on scaphoid tubercle and pain on pressure on thumb (axial loading)
• negative X -ray: thumb spica splint, re-X-ray in 1 week +/– bone scan
• positive x-ray: thumb spica splint x 6-8 weeks
• risk of avascular necrosis (AVN) of scaphoid if not immobilized
C. LOWER EXTREMITY INJURIES

❏ ankle and foot fractures
• see Ottawa ankle rules (Figure 6)
❏ knee injuries
• see Ottawa knee rules (Figure 7)
❏ avulsion of the base of 5th metatarsal
• occurs with inversion injury
• supportive tensor, below knee walking cast for 3 weeks
❏ calcaneal fracture
• associated with fall from height
• associated injuries may involve ankles, knees, hips, pelvis, lumbar spine
An ankle radiographic series is only required if

there is any pain in malleolar zone and any of these findings:
1. bone tenderness at A
or
2. bone tenderness at B
or
3. inability to bear weight both
immediately and in emergency department
A foot radiographic series is only required if

there is any pain in midfoot zone and any of these findings:
1. bone tenderness at C
or
2. bone tenderness at D
or
3. inability to bear weight both
Figure 6. Ottawa Ankle Rules immediately and in emergency department
Reprinted with permission from Stiell et. al. JAMA 271:827-832,1994.
A knee x-ray examination is only required for acute injury patients with one or more of:
• age 55 years or older
• tenderness at head of fibula
• isolated tenderness of patella*
• inability to flex to 90º
• inability to bear weight both immediately and in the emergency department (four steps)**
*no bone tenderness of knee other than patella
**unable to transfer weight twice onto each lower limb regardless of limping
Figure 7. Ottawa Knee Rules

Reprinted with permission from Stiell et. al. JAMA 271:8, 611-615, 1995.
SOFT TISSUE INJURIES

Bruises
❏ tender swelling (hematoma) following blunt trauma
❏ is patient on anticoagulants? coagulopathy?
❏ acute treatment: “RICE”
Rest
Ice
Compression
Elevation
Tetanus Prophylaxis
❏ the following table provides guidance for tetanus prophylaxis in the E.D.
Table 8. Tetanus Prophylaxis
Immunization History Non Tetanus Prone Wounds Tetanus Prone Wounds1
Td2 TIG3 Td TIG
Uncertain or < 3 doses Yes No Yes Yes
3 or more, none for > 10 years Yes No Yes No
3 or more, > 5 but < 10 years ago No No Yes No
3 or more, < 4 years ago No No No No
1 wounds > 6 hours old, > 1 cm deep, puncture wounds, avulsions, wounds resulting from missiles, crush wounds, burns, frostbite, wounds
contaminated with dirt, feces, soil or saliva
2 tetanus and diptheria toxoids (Td), absorbed 3 tetanus immune globulin (TIG) - 250 units
Source: MMWr 2001; 50(20); 418, 427. MMWr 1991; 40(RR12); 1-52.
Abrasions
❏ partial to full thickness break in skin
❏ management
• clean thoroughly (under local anesthetic if necessary) with brush to prevent foreign body impregnation
(tattooing)
• antiseptic ointment (Polysporin) or Vaseline for 7 days for facial and complex abrasions
• tetanus prophylaxis are per above table
Lacerations
❏ always consider every structure deep to a laceration severed until proven otherwise
❏ in hand injury patient, include following in history: handedness, occupation, mechanism of injury, previous
history of injury
❏ physical exam
• think about underlying anatomy
• examine tendon function and neurovascular status distally
• x-ray wounds if a foreign body is suspected (e.g. shattered glass) and not found when exploring wound
• clean and explore under local anesthetic
❏ management
• irrigate copiously with normal saline
• evacuate hematomas, debride non-viable tissue, and remove foreign bodies
• secure hemostasis
• suture (Steristrip, glue, or staple for selected wounds) unless delayed presentation, a puncture wound,
or animal bite
• in general, facial sutures are removed in 5 days, those over joints in 10 days, and everywhere else in
7 days; removal is delayed in patients on steroid therapy
• in children, topical anesthetics such as LET (Lidocaine, Epinephrine and Tetracain) and in selected
cases a short-acting benzodiazepine (midazolam) for sedation and amnesia are useful
• DO NOT use local anesthetic with epinephrine on fingers, toes, penis, ears, nose
• maximum dose of lidocaine
• 7 mg/kg with epinephrine
• 5 mg/kg without epinephrine
Wk 6
Neurological Emergencies
What is a Neurological Emergency?

• Involves all or part of the CNS or PNS. (We’ll focus on CNS)
• Acute
• Serious or Potentially serious
• Requires urgent or emergent investigation and/or treatment
Classification of Neurological Emergencies:

- No Particular Method.
- Not Very Important
- (Usually Pathology/Symptom Based)
- Pathology based classification:
o Infection
o Trauma
o Neoplasia
o Haemorrhage
o Toxins/Drugs
- Symptom-sign based Classification:
o Based on anatomic/physiologic dysfunction:
§ Loss of motor function
§ Loss of sensory function
§ Visual disturbance
§ Headache or other pain
WEEK OVERVIEW - Symptoms:

• Altered level of Consciousness (Covered Last Week)
• Headache
• Acute neurological deficit
• CNS infection
• Traumatic Brain Injury (TBI) and spine trauma
• Seizures
ALTERED LEVEL OF CONSCIOUSNESS (COVERED LAST WEEK):
• Two Possibilities:
o Global Impairment of Cerebral Cortices:
§ Possible Causes (Surgical Sieve):
• Infection
• Trauma
• Neoplasia
• Haemorrhage (Vascular)
• Toxins/Drugs
• Idiopathic
• Endocrine
o Impairment of Reticular Activating System (The bit that allows consciousness) in Brainstem:
§ Possible Causes (Surgical Sieve):
• Infection
• Trauma
• Neoplasia
• Haemorrhage (Vascular)
• Toxins/Drugs
• Idiopathic
• Endocrine
• Assessment:
o Glasgow Coma Scale:
§ Grades eye opening, verbal and motor response to stimuli and is more precise than the
AVPU system.
§ (Minimum Score = 3)
§ (Comatose = < 8; Remember Airway Management)
o AVPU Scale:
§ This is the most simple and categories the patient into one of four states.
• Alert = awake but may be confused
• Verbal = responding to verbal stimulus
• Pain = responding only to painful stimulus
• Unresponsive = no response to any stimulus
• CASES
o Give each of the following cases a AVPU rating and GCS.
o Case 1
§ A 16 year old female is brought into your ED by ambulance after falling from a third floor
balcony. Her eyes are closed despite painful stimulus and she’s making groaning noises.
She pulls her hands and feet away when painful stimulus applied to them.
§ AVPU………………...
§ GCS…………………..
o Case 2
§ A 24 year old man who is cheerfully intoxicated with alcohol is brought to your ED by
Police. His speech is slurred he doesn’t know what day or month it is, but is very happy
to assist you with your physical examination of him.
§ AVPU…………………..
§ GCS…………………….
o Case 3
§ A febrile 82 year old is brought into your ED by relatives. She is looking around the ED
but every time you ask a question she tells you to “@#$% off” and this response never
varies. She tries to hit you when you ask her to move her arms or legs.
§ AVPU………………....
§ GCS……………………
o Case 4
§ A six month old is brought your ED by his parents after suffering a generalised seizure.
His eyes are open but he makes no response to any stimulus.
§ AVPU………………….
§ GCS…………………. .
§ How useful do you think the AVPU and GCS scales are in this age group? Why?
HEADACHE:
• (One of the most common presentations in ED)
• Range of Causes:
• Most are Benign
• But Some are Life Threatening
• (NB: Headache ≠ ‘Brain Ache’)-(Many extra-cranial pathologies can cause headache)
• Broad differential diagnosis
• Need to understand pathophysiology
• Classification:
• Primary (Typically Benign):
• Migraine
• Cluster Headache
• Tension Headache
• Secondary (Due to Specific Pathology):
• Eg. Meningitis
• Eg. Brain Tumour
• Eg. Bleed/Haemorrhage
• NB: IF it’s the worst headache they’ve ever had, It’s quite often a Sub-Arachnoid
Haemorhage à Investigate.
• If there’s a Neurological Deficit + Headache à Investigate
• Some Haemorrhages can cause Unexplained Headache in Healthy People:

o Subdural Haematoma (SDH):
§ Haematoma is beneath the dura
§ Caused by:
§ Presentation:
• Unsteady gait
§ Prognosis:
• Abnormal Brain underneath (Ie. Pt. Is often demented, or alcoholic, or have
severe cerebral atrophy)
o Subarachnoid Haemorrhage (SAH):
§ Caused by:
• Often due to Aneurysm of circle of willis
• Hypertension is a Contributing Factor
§ Presentation:
o Intracranial Haemorrhage (ICH) (“Haemorrhagic Stroke”/CVA):

§ Caused by:
• Non penetrating and penetrating cranial trauma.
• àHaemorrhage directly into Brain Parenchyma à Stroke
§ Presentation:
• Headache
• Various Neurological Deficits
• Loss of Consciousness
• Vomiting
§ Prognosis:
• 75% of Survivors are Disabled
ACUTE NEUROLOGICAL DEFICIT:
• (An Enormous & Complex Topic)
• *EXAM* Understand the Cerebra Circulation & Deficits Result from Ischaemia of Certain Brain Regions:
• Anterior Cerebral Arteries:
• Fed by the Internal Carotids
• Legs & Arms Affected by Compromise
• Middle Cerebral Arteries:
• Fed by the Internal Carotids
• Hands, Fingers & Face Affected by Compromise
• Posterior Cerebral Circulation:
• Fed by the Basilar Artery
• Vision Affected by Compromise
• Spinal Cord Tracts:

• Main Spinal Cord Tracts and their Functions:
• Dorsal Column Medial Lemniscal Tract (Afferent):
• Ascends in the Dorsal Aspect of the Spinal Cord
• Functions:
• Fine/Descriminitive Touch
• Proprioception
• Decussates in the Medial Lemniscal Tract in the Medulla
• Sensory Deficits will be Ipsilateral to the Spinal Lesion
• Spinothalamic (Afferent):
• Ascends in the Lateral Aspects of the Spinal Cord
• Functions:
• Touch
• Pain
• Temperature
• Decussates @ The Level of the Spinal Cord
• Sensory Deficits will be Contralateral to the Spinal Lesion
• Corticospinal (Efferent):
• Descends from the Motor Cortex through the Lateral Aspects of the Spinal Cord
• Function:
• Voluntary Movement
• Decussates in the Pyramidal Tracts (In the Brain)
• Motor Deficits will be Ipsilateral to the Lesion
• Changes in Motor Reflexes with Spinal Cord Injury:
• Immediate Consequences:
• Reflexes are conserved since they aren’t mediated by the brain.
• (NB: Reflexes are only lost if the lesion is @ the level of that reflex)
• Consequences Over Time:
• Muscle movement diminishes over a period of time
• Due to Progressive Muscle Atrophy (not Nerve Atrophy)
• Different Spinal Cord Lesions (Pathways Affected & Clinical Consequences):

• ‘Brown-Sequard’ Syndrome:
• (seen if someone is stabbed in the back with a knife or shot with a handgun
causing a hemi-transection of the spinal cord)
• Pathways Affected & Clinical Consequences:
• Dorsal Column Medial Lemniscal Pathway
• Loss of Discriminative Touch & Proprioception
• (Ipsilateral to & below the level of the lesion)
• Spinothalamic Tract
• Loss of somatosensation (Touch, Pain, Temperature)
• (Contralateral to & below the level of the lesion)
• Lateral Corticospinal:
• Loss of voluntary movements
• (Ipsilateral to the side of the lesion. Because it decussates in the
pyramidal tracts)
• Anterior Spinal Artery Syndrome:

• (Due to Lesion of the Anterior Spinal Artery. Eg. Diving injury)
• Doesn’t affect the Dorsal Column Medial Lemniscal pathway.
• No loss of Discriminitive Touch & Proprioception
• Doesn’t Affect the Corticospinal Tract
• Conserves Motor Function)
• Affects Spinothalamic Tract
• Loss of Somaosensation Contralateral to & below the level of the
lesion.
• Central Cord Syndrome:
• (Usually secondary to spinal trauma and, affects the centre of the spinal cord.)
• Mainly Corticospinal Tracts
• à Motor Impairment (Mostly in Upper Extremities)
• (Why? Motor Fibres supplying Upper limbs tend to be more
Central than those supplying the lower limbs)
• Dorsal Column & Spinothalamic Tracts:
• Variable sensory losses below the Lesion.
• Dorsal Column Syndrome:

• (Very Unusual)
• Dorsal Column Medial Lemniscal Tracts:
• Ipsilateral Loss of Discriminitive Touch & Proprioception Below
the Lesion
• Doesn’t Affect Spinothalamic Tract:
• Somatosensation (Touch, Pain, Temperature) Unaffected.
• Doesn’t Affect Corticospinal Tract:
• Motor Functions Conserved
• Central/Peripheral:
• Central:
• Due to Need to a lesion into cerebral cortex, brain stem and spinal cord
• Need to be able to localize the lesion
• Peripheral:
• (Mostly due to Trauma)
• – Not dealt with this week. (See Week 1 – MSK Emergencies)
SEIZURES:
• Classification of Seizure Disorders:
• NB: Old-School Nomenclature:
• Grand Mal (“Big Bad”) Seizure:
• Eg. Full ‘Tonic Clonic’ seizures.
• Petit Mal (“Little Bad”) Seizure:
• Eg. Absence seizure
• NB: Some old doctors regard Petit Mal seizures as any seizure that is not Grand
Mal.
• Currently: “International Classification of Epileptic Seizures” (ICES):
• Pathophysiology of Seizure Activity:

• **Neurons are Hyperexcitable**; 3 Possibilities:
• 1.**Resting Membrane Potential has been Altered in a Subset of Neurons**:
• Pushes Neurons Closer to Threshold à Spontaneous Activity
• 2.**Ion-Channelopathy à Decrease in Threshold of Voltage-Gated Channels**:
• Eg. Mutation in Amino Acid sequence in Voltage-Gated Channels à Channel
Responds to Lower Voltage (Ie. More Negative Potentials) à Hence, are More
Easily Activated.
• 3.**Neurotransmitter Imbalance**:
• Inappropriate Activity of the Epileptic Focus can be due to Excess of Glutamate
Activity or a Deficit of GABA Activity:
• ↑Excitatory (Glutamate= Primary Excitatory Neurotransmitter):
• Or ↓Inhibitory (GABA= Primary Inhibitory Neurotransmitter):
• Types of Seizures:
• “Simple Partial Seizure”:
• Ie. Conscious & Localised Seizure.
• Symptoms Depend on Cortical Region Affected:
• Typically – Small, Rapid Muscle Movements
• Duration:
• Very Short Duration (Less than 1min)
• NB: Preservation of Consciousness & Memory is Key.
• “Complex Partial Seizure”:

• Ie. Impaired Consciousness & Localised Seizure.
• NB: ‘Impaired Consciousness’ = Dazed / Vague / Dream-like / Inability to Respond
/ Amnesia.
• Symptoms Often Associated with Purposeless Movements:
• Hand-Wring
• Pill-Rolling
• Face-Washing
• Fidgeting
• Mumbling
• Duration:
• Less than 2 min
• NB: Impaired Consciousness à Little/No Memory of Seizure.
• “Partial with 2o Complex Generalised Seizure” (“Tonic-Clonic”/“Grand-Mal”):

• Ie. Simple or Complex Partial Seizure, Progressing to Complex (Unconscious) Widespread
(Generalised) Seizure.
• 4 Phases:
• 1. Pre-Seizure Period:
• Often involving Aura
• 2. Tonic Phase:
• Sustained Tonic Contraction (‘Rigid Extension’) of all Muscles of
the Body.
• 3. Clonic Phase:
• Repetitive Synchronous Jerks (‘Clonic’) of all Muscles of the
Body.
• 4. Post-Ictal Coma:
• Patients may not regain consciousness for a while.
• Duration:
• 1-2mins
• “Myoclonic”:
• Brief, Marked Contraction of Muscles (Ie. A “Shock-Like Jerk” or a “Startle”)
• Contraction may be restricted to a Specific Muscle Group or a number of Muscle
Groups.
• Typically Upper Body Muscles.
• Generally Bilateral
• Duration:
• Typically 1-5sec
• “Temporal Lobe Epilepsy”:
• Unique type of Seizure.
• Typically Manifests as some type of Behavioural Alteration or Complex Activity.
• Symptoms:
• - Automatic Activity but Without Conscious Awareness:
• - Sexually Inappropriate Behaviour:
• - Aggression:
• - Relived Experiences:
• Treating Temporal Lobe Epilepsy - Carbamazepine (AKA: Tegretol)is 1st Line:
• “Absence Seizures” (The Classic “Petit Mal”):

• Ie. Abrupt Onset of Impaired Consciousness
• Duration:
• Up to 30sec
• NB: Impaired Consciousness à Little/No Memory of Seizure.
• Treating Absence Seizures – Ethosuximide.
• “Status Epilepticus” – The Epileptic Emergency:

• A term that describes An Episode of Seizures of Any Type that have 1 of 2 Properties:
• 1. Seizures Don’t Stop Spontaneously.
• 2. Seizures Occur in Rapid Succession Without Recovery.
§ A Status Epilepticus Seizure = Absolute Neurological Emergency:
• High Risk of Cerebral Hypoxia
• High Risk of Permanent Brain Damage
• Often Results in Permanent Loss of Neurons due to Excito-Toxicity.
§ Treating Status Epilepticus:
• Benzodiazepines are the 1st Line Drugs:
o The Drugs:
§ *Diazepam – (Generally #1; But Short Acting)
§ Lorazepam – (Some argue that it’s #1 due to Higher Seizure-
Termination Rate)
§ Midazolam
o Mechanism of Action:
§ ↑Frequency of GABA-Channel Opening (Agonist-Like but NOT an
Agonist)
§ à Increased General Inhibition.
§ à Inhibits spread of Signals from Epileptic Focus
• Anti-Epileptic Drugs:
• VG-Na+ Channel Blockers:
• Phenytoin:
• (Use Dependent VG-Na+ Channel Blockers)
• (à ↑Time of Recovery of Voltage-Gated Na+ Channels from Inactive to
Resting States)
• All Seizures EXCEPT Absence Seizures
• An Adjunct to Benzodiazepines in Status Epilepticus.
• Carbamazepine (Tegretol):
Resting States)
• Lamotrigine (Lamictal):
Resting States)
• VG-T-Ca+ Channel Blockers:

• Ethosuximide:
• Blocks VG-T-Ca+ Channels in the Thalamus à Prevents Propagation of Seizure
Activity through the Thalamus.
• Used ONLY in Absence Seizures
• GABA Channel Modulators:

• Barbiturates (Primidone, Phenobarbitone):
• à Prolongs Opening of GABA Channel (But Not Frequency) à ↑Cl- Influx.
• (Like a chemical stent à Potentiates Channel Activationà ↑Cl- Influx.)
• Ie. ↑Cl- Influx à Hyperpolarisation àStabilises Membranes of Neurons.
• An Adjunct to Benzodiazepines in Status Epilepticus.
• Benzodiazepines (Diazepam/Lorazepam):
• àAgonist-Like Effects à Causes Conformational Change in GABA Channel
• à↑Frequency of GABA-Channel Opening:
• Ie. ↑Cl- Influx à Hyperpolarisation àStabilises Membranes of Neurons.
ST
• 1 LINE FOR STATUS EPILEPTICUS
• GABA Analogues:
• Gabapentin (Neurontin):
• A GABA-Analogue (But NOT a Receptor Agonist)
• à General Neuronal Inhibition of the Brain.
• Used for Partial Seizures
• Na+ Channels, Ca+ Channels & GABAA Receptors:

• Valproate:
• 3 Mechanisms of Action:
• 1. Delays Recovery Time of Na+ Channels
• à ↓Repetitive Firing of Neurons.
• 2. Inhibits Thalamic Ca+ Channels
• à Prevents Spread of Signals from Epileptic Focus.
• 3. ↑GABA Production & ↓ Breakdownà ↑ GABA (Inhibitory) Signalling.
• à General Neuronal Inhibition of the Brain.
• Effective Against ALL Seizure Types
CNS INFECTION:
• Meningitis = Inflammation of the Meninges
• Presentation:
• Meningism:
• Headache
• Photophobia
• Neck Stiffness (Due to Inflammation of the Meninges; Bending Stretches
Meninges à Pain à Neck Stiffness)
• Nausea/Vomiting.
• May eventually have loss of consciousness. (Rare)
• Typical Organisms:
• Adults: Nesseria Meningiditis.
• Neonates: E.Coli
• Immunocompromised: M.Tuberculosis, Toxoplasmosis
• Can also be Viral: Typically Herpes Virus (Treatable by Aciclovir)
• Diagnosis:
• Treat on Suspicion
• Don’t wait for lab results!
• Lumbar puncture for Definitive Diagnosis:
• Performed @ L3-L4 (or L4-L5):
• Because the spinal cord Terminates at this level
• à Becomes the Cauda Equina below the level of L3.
• Anatomical Landmarks:
• Draw a line visually between the Superior Iliac Crests
• This line intersects @ the L4 Spinous Process.
• Flex the Spine as Much as Possible:
• To Maximise the space between the Spinous Processes à Provides a
space to insert the Needle.
• Structures Between Skin & CSF (Focus on Ligaments):
• Skin
• Subcutaneous Tissue
• Supraspinous Ligament
• Interspinous Ligament (Between the Spinous Processes)
• Ligamentum Flavum
• Epidural Space (Including the Internal Vertebral Venous Plexus, Dura, and
Arachnoid)
• Subarachnoid Space (CSF should flow once this has been entered)
• NB: DON’T do a Lumbar Puncture if Intracranial Pressure is High:
• If ICP is high, and you drain CSF à Can cause “Cerebral Herniation” (Aka:
Cistern Obliteration)
• à Brain can herniated through the foramen magnum à Puts extreme
pressure on parts of the brain and thereby cuts off their blood supply.
• Is often Fatal
• Signs of Raised Intracranial Pressure:
• Cushings Response/Reflex (Cushing’s Triad):
• Hypertension
• Bradycardia
• Irregular Breathing
• Also Presents with:
• Abnormal Posturing
• Altered level of Consciousness (GCS 3-5)
• Pupils may be Dilated & Fail to Constrict in response to light.
• Vomiting
• Good prognosis with Aggressive Treatment.
• Treatment on Suspicion:
• Empirical Antibiotics (or Antivirals).
• Role of the ‘blood brain barrier’ to CNS infection and its implication for treatment:
• NB: Most antibiotics aren’t lipid soluble à don’t cross the bbb.
• However, in inflammation, the BBB permeability is increased.
• Encephalitis = Inflammation of the Brain Parenchyma

• Always Viral
• Typical Presentation:
• Altered Mental State. (Or other neurological deficit)
• Seizures
• Fever
• Treatment on Suspicion:
• Empirical Antivirals.
• Poor prognosis:
• Once symptomatic, rapid inflammation & necrosis à Brain-Death or Neurological Deficit
• Meningo-encephalitis = Inflammation of Both

• Brain abscess = Abscess in Brain
• Typically following Otitis Media
• Diagnostic Distinctions Between the 3 CNS Infections:

Normal Bacterial Viral Meningitis Encephalitis
Meningitis (Usually Herpes (typically viral)
Virus)
CSF Pressure Normal Normal-Raised Normal-Raised Markedly Raised
White Cell Count Normal Raised Raised Raised
(Polymorphs) (Lymphocytes) (Lymphocytes)
Glucose Same as Serum Lower than Normal Normal
Serum (Hungry
Bacteria)
Protein Normal Raised (produced Raised (produced Raised
by the organisms) by the organisms)
Gram Stain None Presence of Nothing (“Aseptic Nothing
Bacteria Meningitis”)
TRAUMATIC BRAIN INJURY (TBI) AND SPINE TRAUMA:
• (NB: Spinal trauma may or may not involve spinal cord injury)
• Mild = GCS 14 or 15
• Likelihood of +ve CT scan = 10% and 1% will require neurosurgery
• Moderate = GCS 9-13
• Likelihood of +ve CT scan = 40% and 8% will require neurosurgery
• Severe = GCS < 9
• Mortality around 40%!
• HAEMORRHAGES: Understand the Differences: YOU COULD GET A CT PICTURE OF ONE IN AN EXAM:
o Extradural Haematoma (EDH):
§ Caused by:
• Impact/Cranial Fracture à Arterial Laceration àSeparation of Dura from the
Skull à Haematoma in this seperated region = EDH
• Or Blood vessel bursts spontaneously
§ Leads to:
• à Dissects the dura from the skull à ↑Intracranial Pressure
• àSudden collapse with a severe headache, vomiting and altered consciousness.
• (NB: Normal brain underneath)
§ Rapid progression (due to arterial source of blood)
§ Prognosis:
• If not treated à↑ICP àCerebral Herniation (Coning), brainstem compression
àCerebral Infarct/Death
• Treatable Via Craniotomy to Relieve the ↑ICP à Good Prognosis
o Subdural Haematoma (SDH):

§ Haematoma is beneath the dura
§ Caused by:
§ Presentation:
• Unsteady gait
§ Prognosis:
• Abnormal Brain underneath (Ie. Pt. Is often demented, or alcoholic, or have
severe cerebral atrophy)
o Subarachnoid Haemorrhage (SAH):
§ Caused by:
• Often due to Aneurysm of circle of willis
• Hypertension is a Contributing Factor
§ Presentation:
o Intracranial Haemorrhage (ICH) (“Haemorrhagic Stroke”/CVA):

§ Caused by:
• Non penetrating and penetrating cranial trauma.
• àHaemorrhage directly into Brain Parenchyma à Stroke
§ Presentation:
• Headache
• Various Neurological Deficits
• Loss of Consciousness
• Vomiting
§ Prognosis:
• 75% of Survivors are Disabled
ASSESSMENT OF NEUROLOGICAL EMERGENCIES:
• Clinical:
• Try to determine nature and location of lesion (Which bit of the brain is affected)
• Laboratory investigation:
• Haematology (WBC count)
• Biochemistry
• Blood Culture (If suspect infection)
• CSF (Via Lumbar Puncture)
• Radiology:
• CT
• MRI
• THE EMERGENCY-DEPARTMENT APPROACH:

o Primary Assessment:
§ Airway + Cervical Spine
§ Breathing
§ Circulation (Haemorrhage Control) & BP (Hypertensive Crisis or Shock)
§ **Check Glucose (exclude hypoglycaemia)
o Management Principles:
§ Objective:
• Primary injury has already happened :. prevent secondary injury.
§ Ensure adequate:
• Oxygenation
• cerebral perfusion
§ C-Spine Precautions (If Trauma)
CSF, CEREBRAL BLOOD FLOW, THE BLOOD BRAIN BARRIER AND INTRACRANIAL PRESSURE:
• CerebroSpinal Fluid:
• Functions Of CSF:
• Provides Buoyancy (Suspends the brain & displaces most of its mass)
• Protection (Protects the brain tissue from injury when jolted or hit.)
• Chemical Stability (In addition to the BBB) à Homeostasis of Neuro-Endocrine Factors.
• Formation Of CSF And Its Passage Within The Brain:
• Site of CSF Formation:
• Produced by modified Ependymal Cells in the Choroid Plexus.
• Site of CSF Absorption:
• It is reabsorbed into venous sinus blood via Arachnoid Granulations.
• What happens if CSF Production Exceeds Absorption?
• àHydrocephalus
• à Increased Intracranial pressure
• Path of CSF passage between those two points:
• Produced in Choroid Plexus
• àCirculates from the Lateral Ventricles
• àThrough the Interventricular Foramen
• àThird Ventricle
• àThrough the Cerebral Aqueduct
• à Fourth Ventricle
• à Through the Median Aperture under the Cerebellum
• à Into the Subarachnoid Space over the Brain & Spinal Cord.
• Point(s) of Potential Obstruction to CSF Flow à Resulting in Hydrocephalus?
• (Hydrocephals = abnormal accumulation of CSF in the Ventricles)
• Due to blockage of CSF outflow in the ventricles or the Subarachnoid Space over
the brain.
• @ The Interventricular Foramen
• @ The Cerebral Aqueduct (Between the Third & Fourth Ventricle)
• @ The Median Aperture (Between the Fourth Ventricle & the
Subarachnoid Space)
• The Blood Brain Barrier:
• What is it?
• Separation of the Circulating Blood & CSF in the CNS.
• Tight Junctions between Endothelial Cells in CNS Capillaries.
• Where is it?
• It occurs along all the capillaries in the CNS.
• Functions?
• Restricts Diffusion of Microscopic Objects (eg. Bacteria) and Large &/or Hydrophillic
molecules into the CSF.
• Allows Diffusion of Small, Hydrophobic (lipophilic) Molecules (Oxygen, Hormones, CO2).
• NB: Metabolic products (Eg. Glucose) are actively transported by the Endothelial Cells.
• Implications in terms of Drug Treatment of CNS Pathology (e.g. treatment of meningitis)?
• Only Lipophilic Drugs can diffuse through the BBB.
• NB: Most antibiotics aren’t lipid soluble à don’t cross the bbb.
• However, in inflammation (Eg. Meningitis), the BBB permeability is increased anyway.
• Cerebral Blood Flow And Intracranial Pressure:

• Cerebral blood flow is carefully regulated under normal conditions.
• Cerebral Blood Flow:
• What percentage of cardiac output goes to the cerebral circulation at rest?
• 750ml/min (15% of cardiac output)
• Relationship Between Cerebral Blood Flow & Arterial Pressure:
• Autoregulation of Cerebral Blood Flow:
• What effect does a high PCO2 have on cerebral blood flow?
• Hypercarbia à Vasodilation à ↑Cerebral Blood Flow.
• What effect does a very low and very high PO2 on cerebral blood flow?
• Very High O2 à Vasoconstriction
• Very Low O2 à Vasodilation
• What implication does this have for the management of a patient with an acute head
injury/cerebral oedema?
• You want to prevent any hypercapnia because any vasodilation will à Takes up
more room à ↑Intracranial Pressure.
• You want to maintain PO2
• Kelly-Monroe Doctrine:
• States that the Cranial Compartment is Incompressible, and the Volume is Fixed.
• The Cranial Constituents (Blood, CSF, and Brain Matter) create a state of Volume
Equilibrium:
• Any increase in Volume of one of the constituents must be compensated by a
decrease in volume of another.
• Volume Buffers:
• Both CSF and, to a lesser extent, Blood Volume.
• (Eg. In Extradural Haematoma à CSF & Venous Blood Volumes are Decreased)
• à Maintain normal ICP
• Buffer Capacity ≈ 100-120mL
• Intracranial Pressure:
• What is Normal ICP?:
• 10mmHg
• When ICP is Rapidly Increased, what happens to the following:
• Cerebral Venous Pressure?
• Remains same or slight Increase.
• Cerebral blood flow?
• Decrease (Due to reduced perfusion pressure)
• (Perfusion Pressure = Sys.BP – Intracranial Pressure)
• (NB: Perfusion only occurs when Perfusion Pressure is Positive)
• What Happens when ICP = Arterial Pressure?
• If Arterial Pressure = ICP…then Perfusion Pressure = 0.
• Nil Perfusion
• Signs of Raised Intracranial Pressure:
• Cushings Response/Reflex (Cushing’s Triad):
• Hypertension
• Bradycardia
• Irregular Breathing
• Also Presents with:
• Abnormal Posturing
• Altered level of Consciousness (GCS 3-5)
• Pupils may be Dilated & Fail to Constrict in response to light.
• Vomiting
• Treating Raised ICP:
• Osmotic Diuretics (Eg. Mannitol) à ↑Plasma Osmolarity à Extracts Water from
Brain Tissue.
• Hyperventilation à Hypocapnia à Vasoconstriction of Cerebral Vessels
• Continuous CSF Drainage/Surgical CSF Shunt
• NB: DON’T do a Lumbar Puncture if Intracranial Pressure is High:
• If ICP is high, and you drain CSF à Can cause “Coning”:
• Aka. “Cerebral Herniation” (Aka: Cistern Obliteration)
• à Brain can herniated through the foramen magnum à Puts extreme
pressure on parts of the brain and thereby cuts off their blood supply.
• Is often Fatal
• Can cause 3rd Nerve (Oculomotor) Palsy:
• Ptosis = Unable to Open Eyelid (Levator Palpebrae Superioris)
• Pupil Unresponsive to Light
• Eye faces Downwards & Outwards
Wk 8
Paediatric and Obstetric Emergencies
Overview:
• What is normal and what is not?
• What is sick and what is not?
Exam Questions:
• Physiological differences:
o Pregnancy
o Childs Vs Adult (Airway, Breathing, Circulation)
o Childs Vs Adult ECG
• Given a case, Find abnormal parameters:
o Sick child
o Pregnancy
o Umbilical height
• NB: The care of a pregnant female is a priority because there are 2 lives at stake.
OBSTETRICS: CHANGES IN PREGNANCY:

• (For Each of the systems):
o 2 things up
o 1 thing down
o And something else
• Airway
o ↑Breasts
o ↑Abdomen
o ↓Airway Patency
o Reflux
o Facial Oedema
• Respiratory:
o ↑ Tidal Volume
o ↑ Respiratory Rate
o ↓ Residual Volume
o Alkalosis (Respiratory alkalosis due to Hyperventilation)
o Dyspnoea
o Foetal haemoglobin has a higher affinity for O2 Than Mum’s.
§ (Why? Foetal O2 is @ 30mmHg from the Placenta)
• Cardiovascular:
o ↑ HR + SV
o ↑ CO
o ↓ Blood pressure
o ECG – Left Axis Deviation (Due to Mechanical presence of baby à pushing heart out of the way)
• Haematological:
o ↑ Blood volume by 40% (But ↓in BP)
o ↑ RBC Count
o ↓ Hb (Dilutional Anaemia due to ↑Volume)
o WBC (Marginal Increase)
• GIT:
o ↑ Weight gain
o ↑ Metabolic rate
o ↓ Gut Tone & Motility (à Constipation)
§ ↓Gastric Emptying + Abdominal Pressureà Reflux
o Diaphragm Raised
o GI Contents Displaced Upward (Including Appendix)
• Renal:
o ↑ Renal blood flow
o ↑ Frequency of Urination (Due to Pressure on the Bladder)
o ↓ Decreased Ureteric motility & peristalsis
o Bladder displaced by uterus (NB: @ 20wks, the Uterus is at the Level of the Umbilicus)
• Musculoskeletal:
o ↑Width of Pubis Symphysis & Flexibility of Sacroliliac Joints (Due to Relaxin)
o ↑ Increased Foot Size (Due to Relaxin)
o ↓ Ligament Tension (Due to Relaxin)
o Unstable Gait
Relevance of Changes of Pregnancy:

• Airway & Breathing:
o Breathing:
§ ↑Tidal Volume….↑Resp.Rate…..↓Residual Volume…..
§ àBurns oxygen MUCH faster because the Baby is breathing too
§ :. Very little time for Intubation. (Maternal O2 Sats drop RAPIDLY during apnoea)
o Airway:
§ Facial changes
§ Large breasts and abdomen
§ Reflux
§ à Makes Intubation Difficult & ↑Risk of Aspiration
o MANAGEMENT:
§ Intubation is Difficult
§ Give High [Oxygen]
§ Avoid Maternal Hypoxia (Avoid Foetal Hypoxia)
§ Early & RAPID Intubation
§ Full gut
• Circulation:
o They have More to lose (↑Blood Volume):
§ :. By the time they’re Tachycardic with Signs of Shock, they’ve lost a LOT (30%) of Blood.
§ Signs to look for include Urine Output, Capillary Return, Skin Colour/Temperature.
• NB: Uteroplacental circulation Shuts down first (To Protect the Mother)
o May have Supine hypotension syndrome:
§ = When they lie down, the weight of the baby blocks off the IVC.
• à Poor venous return from the legs à Hypotension.
§ Prevented by Elevating the RIGHT Hip.
o Shock:
§ Shock is very bad
§ à Utero-Placental Circulation Shuts Down à85% foetal mortality
§ Treated by:
• AGGRESSIVE Fluids (Hartman’s Solution) and/or Blood
PAEDIATRICS:
• Definitions:
o Neonate = birth to 4wks
o Infant = 4wks to 1yr
o Child = Over 1yr to adolescence
• What’s Important?
o Weight:
§ Determines everything:
• Drug Dos
• Selection of Equipment
• Fluid Resuscitation
§ Methods of Estimating Weight:
• Broselow Tape Method (A plastic strip with different sized-colour-codes)
• Formula (Based on Average Weights @ Age)
• Guess
• Disadvantages of Methods:
o Access – do you have a Broselow Tape?
o Reliability – can you do maths when stressed ? (or remember the
formula)
o Accuracy – some are rough measures only
o Accuracy across cultural groups – are methods always reliable e.g.
malnourished child in Sudan vs a well nourished child in Australia
o Child’s Airway Vs Adult’s Airway:

§ Head (Much Bigger & Lolls about)
§ Neck (Relatively Short)
§ Nose (Children are Nasal Breathers :. Give O2 through nose rather than mouth)
§ Teeth (Always Loose – Easy to knock out with Laryngoscope)
§ Tongue (Relatively big – Makes intubation harder)
§ Tonsils (Huge, Often Inflamed/Infected)
§ Epiglottis (Long, Floppy & hangs out the front)
• (:. You have to lift the whole epiglottis with the laryngoscope when intubating)
§ Larynx (More Anterior)
§ Cricoid (The Narowest part of a Child’s Airway)(Good MCQ question)
§ Trachea (Quite Short)(:. Don’t feed the laryngoscope in too far)
o Child’s Breathing Vs Adult’s Breathing:
§ Lower Respiratory Surface Area
§ Have a Flat Diaphragm and can’t increase their tidal volume.
§ If Hypoxic, What can they increase?
• Can ONLY increase their Resp. Rate
• :. If Resp Rate is High – Give them Oxygen!!!
o Child’s Circulation Vs. Adult’s Circulation:
§ Larger circulating volume/kg
§ Lower Stroke Volume :. Require Higher Heart Rate to maintain CO.
§ CO=SV x HR
§ If ↓CO, What can they increase?
• They can ONLY increase Heart Rate.
• :. If they’re tachycardic, give them fluids!!!
• Primary Paediatric Assessment (ABC):
o Observe from a Distance.
o Remain Calm
o Get Parents Help.
o Fix A before B before C!!
§ Give O2 before IV access.
o Airway
§ Observe
§ Speech = Patent Airway
§ Look for Chest Movements
§ Listen for Chest Sounds
§ Feel for Breath
o Breathing
§ Normal Resp Rate decreases by 10 each 2yrs of life until 8 yrs.
•
§ Look for:
• Recession and accessory muscles
• Abnormal Respiratory rate
• Inspiratory/Expiratory Noises (Stridor)
• Grunting and sitting
• Nasal flare
• chest expansion
• HR (Tachy)/skin colour(Blue)/mental state(Agitated/Drowsy)
• Oxygen Sats
o Circulation:
§ Focus on Heart Rate (Goes down 20 every 2yrs of life)
•
• BP isn’t really relevant in young kids
§ If Abnormal:
• Needs IV access
• ?Dehydration
o Tachycardic
o Dry mouth
o ↓Urine Output
• àGive Bolus amounts of fluid (10mls/kg)
• Secondary Paediatric Assessment:
o Focused history, exam, investigation
o Glucose
o Close monitoring
o Is the child ill or not
o Take parents concerns seriously
o Play, Observe, Respect
• Paediatric Radiology:
o (1) ribs more horizontal
o (2) thymus enlarged in childhood so may have bigger mediastinum
o (3) more likely to have prominent gas bubble under diaphragm
o (4) bigger right ventricle (compared to adult) means different heart silhoutte
• Paediatric ECG:
o NB: The Right Ventricle is Dominant in Utero, but the Left Ventricle is Dominant in Adults.
§ :. Babies initially have a larger Right-Heart à Causes an apparent Axis Shift (Right Axis
Deviation) in Early Childhood.
o ↑Heart Rate
o T-Wave Inversion
• Practice MCQ Questions:
1. Infants differ from adults in that they:
a. have a relatively smaller tongue
b. the ribs contribute more to chest expansion.
c. have a higher proportion of HbA
d. have a higher circulating volume per kilogram.
2. Upper airways obstruction:
a. is less likely in the small child because of the large cross sectional area
b. can be assessed by the intensity of the stridor
c. is usually due to foreign body inhalation
d. may be due to epiglottitis
3. Cardiac arrest in children:
a. is usually due to primary myocardial disease
b. usually presents in ventricular fibrillation
c. can be due to shock
d. has a very good prognosis
4. Treatment of shock in children involves all the following except:
a. High flow oxygen by face mask
b. Correction of metabolic abnormalities
c. Reduction of low body temperature
d. Optimisation of intravascular volume
1. The tidal volume in pregnant women
a. increases by 20%
b. increases by 40%
c. increases particularly in women with asthma
d. increases proportionally to the women’s weight
2. The cardiac output of the average size healthy woman in pregnancy is
a. increases to 8L/min
b. *increases to 6L/min
c. increases to 4.5L/min
d. increases to 4l/min
3. The haemoglobin of the average healthy woman in pregnancy is
a. 16 g/dL
b. *13g/dL
c. 9g/dL
d. resistant to hypoxia
4. Foetal oxygen from the placenta is
a. 90mmHg
b. 70mmHg
c. 50mmHg
d. *30mmHg
5. All the following are true except
a. Pulmonary embolus is more common in pregnancy
b. Hyperemesis gravidarum is more common in twin pregnancies
c. *Acute appendicitis is more common in pregnancy
d. Urinary tract infections are more common in pregnancy
6. The most common causes of death in childhood in western countries are
a. congenital
b. infections
c. cancers
d. *trauma
7. The following are true of children’s airways except
a. They have short necks
b. Their epiglottis is more anterior
c. Their larynx is higher
d. *They are narrowest at the vocal chords
8. Flow is inversely proportional to
a. r
b. r2
c. r3
d. *radius4
9. Normal capillary refill is
a. less than 1 second
b. *less than 2 seconds
c. less than 4 seconds
d. less than 5 seconds
10. Children with inadequate circulation should initially be given
a. 20ml/kg 5% glucose
b. 10ml/kg 5% glucose
c. *20ml/kg normal saline
d. 10ml/kg normal saline
11. A woman comes into the emergency department who is 32 weeks pregnant. She has been involved in a
motor vehicle collision. She was wearing her seatbelt. Her pulse is 100 bpm. Her blood pressure is
110/75. All the following are true except:
a. She should have high flow oxygen applied.
b. She should have a large bore cannula inserted.
c. She should have cardiotochographic monitoring for 4 hours.
d. *She should have an urgent foetal ultrasound.
A pregnant woman has respiratory acidosis – T/F?

- F
Differences between child & adult:
- Child has more horizontal ribs
- Child has flatter diaphragm
- Bigger heart
- Short trachea
At how many weeks is the uterus palpable during pregnancy?
- 12 weeks
Children have a relatively small head compared to the body – T/F?
- False
By the 3rd trimester, blood volume has increased by:
- 750mls
- 1L
- 1.5L
The narrowest part of the child’s airway is:
- The Cricoid Cartilage
Residual Volume in a pregnant female increases/decreases?
- Decreases
In a 2 yr old, a resp rate of what amount would worry you?
- 40
Maternal ruptured appendicitis has a foetal death rate of?
- 35%
2 ways of estimating weight?
- Broselow
- 2x Height + 8
Being pregnant is an independent risk factor of domestic violence – T/F?
- T
A HR of 120 in a 1yr old is normal/abnormal?
- Normal
3 Reasons for difficulty intubating a heavily pregnant female?
- Large Breasts
- Facial Oedema
- Aspiration from reflux
- Quick Hypoxia
List 5 differences between adult’s and child’s airway?
- Child’s Airway is:
o Larger tonsils
o Nasal Breathers
o Epiglottis is floppy and more anterior
o Trachea is shorter
o Big Tongue
An ECG of a pregnant female @ 36weeks shows R/L Axis Deviation?
- L
How much should a 4yr old weigh?
- 16kg
You should put a block under which hip of a supine pregnant woman?
- Right
3 clinical features of a dehydrated child:
- Tachycardia
- Dry mouth
- Loss of skin elasticity
- Slow cap return
- Tachypnoea
- Concentrated Urine
What is the appropriate bolus amount of fluid resus for a dehydrated child?
- 20mls/kg
PEDIATRIC TRAUMA
❏ priorities remain the same
Airway
❏ “sniffing position”
❏ short trachea (5 cm in infants, 7.5 cm at 18 months)
❏ orotracheal tube diameter = age/4 + 4
❏ uncuffed ETT under age 8
❏ surgical cricothyroidotomy NOT indicated
❏ needle cricothyroidectomy with jet ventilation if unable to intubate
Breathing
❏ stethoscope not as useful for diagnosing problems - noting tachypnea is important
Circulation
❏ normal blood volume = 80 ml/kg
❏ fluid resuscitation
• bolus crystalloid 20 ml/kg
• repeat x 1 if necessary
• blood replacement if no response to 2nd bolus of crystalloid
❏ venous access
• intraosseous infusion if unable to establish IV access in < 30 seconds
• venous cutdown (medial cephalic, external jugular, great saphenous)
Thermoregulation
❏ children prone to hypothermia
❏ blankets/external warming/cover scalp
Table 9. Normal Vitals in Pediatric Patients

HR sBP RR
Infant < 160 80 40

Preschool < 140 90 30
Adolescent < 120 100 20
TRAUMA IN PREGNANCY
❏ treatment priorities the same
❏ the best treatment for the fetus is to treat the mother
Hemodynamic Considerations
❏ near term, inferior vena caval compression in the supine position can decrease cardiac output by 30-40%
• use left lateral decubitus (LLD) positioning to alleviate compression and increase blood return
❏ BP drops 5-15 mmHg systolic in 2nd trimester, increases to normal by term
❏ HR increases 15-20 beats by 3rd trimester
Blood Considerations
❏ physiologic macrocytic anemia of pregnancy (Hb 100-120)
❏ WBC increases to high of 20,000
Shock
❏ pregnant patients may lose 35% of blood volume without usual signs of shock (tachycardia, hypotension)
❏ however, the fetus may be in “shock” due to contraction of the uteroplacental circulation
Management Differences
❏ place bolster under right hip to stop inferior vena cava compression
❏ fetal monitoring (Doppler)
❏ early obstetrical involvement
❏ x-rays as needed (C-spine, CXR, pelvis)
❏ consider need for RhoGAM if mother Rh–
Post Op Complications
Early – (In Recovery):

- Nausea/Vomiting:
o <20% of All Patients
o Risk Factors = Young, Female, Motion Sickness
o Causes = Nitrous Oxide & Opioids.
o Rx: Antiemetics (Odansetron/Metaclopromide)
- Respiratory:
o Resp. Depression (Opioids/Residual Neuromuscular Block)
o Aspiration (Gastric Contents/Loss of Cough Reflex)
o Airway Obstruction (Laryngospasm/Foreign Bodies/Clot)
o (Atelectasis/Pneumothorax/PE)
- CVS:
o Hypotension (Hypovolaemia/Haemorrhage/3rd Space) (LV Failure/IHD) (ACE-Is)
o Hypertension (Pain/Stress/Hypoxia/Overhydration) (Pre-Eclampsia/↑Thyroid/↑ICP)
o Arrhythmias (Electrolytes/Drugs)
- Pain:
o Rx. Opioids
- Hypothermia:
o Rx. Warming, Oxygen, IV Pethidine.
Late – (In Ward/Post Discharge):

- Wound Complications:
o Haematoma (Poor Haemostasis) (Predisposes to Infection) (BAD in the Neck!!)
o Infection [Day 5-10] (Diabetic/Steroids/Smoker, etc) Cellulitis. Rx. Fluclox/Gent/Vanc
o Dehiscence (Infection/Poor Closure/Suture #) Hernias
- Respiratory:
o Atelectasis [Day 2] (Elderly/Obese/Smokers) Fever, Tachypnoea, Tachycardia. Rx: Spiro
o Pneumonia (Atelectasis/Aspiration) 30% Mortality. Rx. O2 + Cefalexin
- Vascular:
o DVT (Stasis + Vascular Injury + ↑Coagulation) (Age/Ca./Surgery/OCP/HRT/CVD)
Pain & Oedema. Ix. Doppler US. Rx. Heparin + Warfarin.
o PE (DVT Pulmonary Arteries) RVF Dyspnoea/CP/Tachy/↓BP. Ix. CTPA
Rx. Thrombolysis + Heparin. Or Pulmonary Embolectomy
- CVS:
o MI (Vascular Surg/↓BP/Hypoxia) Usually Silent + ST-Dep. Ix. Tn-I. Rx. O2 +
Morphine + GTN + Aspirin.
- Abdo:
o Ileus (Physical Bowel Handling/Opioids/AAA Surg). Rx. NBM +/- NG-Tube
- CNS:
o Confusion (Elderly) (Hypoxia/Drugs/Alcohol Withdrawl/Sepsis/UTI/Full Bladder/↓BSL)
- Fever:
o See “Post-Op Fever +/- Infections”
Post Op Fever +/- Infections
The W
- Day 1: Wind (Post-op Atelectasis/Pneumonia)
- Day 2: Water (UTIs from catheters)
- Day 3: Walking (DVT – can Fever/PE)
- Day 4: Wounds (Wound Infections)
- Day 5: Wonder Drugs ??
Pe e i f he W
1. Wind:
a. Early Ambulation (Atelectasis)
b. Spirometry (Atelectasis)
c. Antibiotics (Pneumonia)
2. Water:
a. IDCs out ASAP
3. Walking:
a. DVT Prophylaxis
i. Heparin/LMWH
ii. Graduated Compression Stockings
b. Early Ambulation
4. Wounds:
a. Antibiotic Prophylaxis (Typically Cefalexin / Gentamicin / Metronidazole)
i. Or Triple Therapy: Ampicillin + Gentamicin + Metronidazole
b. Dressings/IDC/IVC/Drain Surveillance (Keep Clean & Dry)
5. Wonder Drugs:
a. Analgesia
b. NB: Some drugs can cause fever
**NB: Low-Grade Fevers are common Post-Op...Why?

- Atelectasis
- Tissue Damage/Necrosis
- Blood Transfusions
- DVT
- Or Infection...
Infection Screening:
- Common Sites of Infection:
o Abdo Peritonism
o Chest Cough/ Sats/Crackles
o UTI Dysuria/Frequency/Urgency/Pelvic Pain
o Wound/Cannula/Drain Site
o Meningism Headache/Photophobia/Neck Stiffness
o Endocarditis Splinters/Janeways/Oslers
- Phys Examination:
o Vital Signs (Fever, Tachycardia, Hypotension)
o Listen to Chest (Crepitations, Wheezes)
o IDC/IVC/Drains (Erythema, Pain, Pus, Heat, Oedema)
NB: Superficial Cellulitis
NB: Deep Fluctuant Abscess
o Wounds (Erythema, Pain, Pus, Heat, Oedema)
o Drug Chart
- Investigations:
o FBC (WBC count)
o Cultures (Blood/Wound/Sputum)
o Urine MCS
o CXR (Consolidation/Collapse)
Treatment:
Egs: Effective Antibiotics:
G Posi i es -cocci Enterococcus Spp. Penicillins (Benz-Pen-G, Amoxicillin, Ampicillin, Flucloxacillin)
(Skin / Throat) Staphylococcus Spp. - (NB: Augmentin for β-lactamase resistant bacteria = Amoxil
Streptococcus Spp. + Clavulonate)
Cephalosporins (Ceftriaxione3, Cefipime4, Cepfalexin4)
[Vancomycin (For resistant G-Pos/ if Penicillin Allergy)]
G. Negatives E. Coli Aminoglycosides (Gentamicin, Tobramycin, Streptomycin)
(GI / UTI) Neisseria Spp. - (NB: Used with Penicillins/Cephs for Synergy)
Pseudomonas Tetracyclines (Tetracycline, Doxycycline)
Haemophilus Spp. Macrolides (Erythromycin, Azithromycin)
Klebsiella Spp. Quinolones (Ciprofloxacin, Norfloxacin)
Enterobacter Spp. Cephalosporins (Ceftriaxione3, Cefipime4, Cefalexin4)
[Benz-Pen-G (For Neisseria Gono/Mening)]
Anaerobes Bacteroides Spp. [Metronidazole (For Bacteroides)]
Clostridium Spp. [Vancomycin (For C.Diff)]
Atypicals Mycoplasma Tetracyclines (Tetracycline, Doxycycline)
Legionella Macrolides (Erythromycin, Azithromycin)
Specific Infections & Rx:

- Cellulitis/Wound Infections:
o G-Pos s (GABH-Strep/Staph. Aureus)
Rx: Penicillin (Flucloxacillin; Gentamicin if Penicillin Allergic)
(Rx: Vancomycin if MRSA)
- Abdominal Infections:
o G-Negs (E.Coli, Klebsiella, Enterobacter)
Rx: Gentamicin / Doxycycline
o Anaerobes (Bacteroides, Clostridium)
Rx: Metronidazole (For Bacteroides)
Rx: Vancomycin (For C.Diff)
o G-Pos (Enterococci)
Rx: Ampicillin
- UTIs:
o G-Negs (E.Coli, Klebsiella, Enterobacter, Pseudomonas)
Rx: Ciprofloxacin
- Bone (Osteomyelitis/Septic Arthritis):
o G-Pos (Staph. Aureus/Strep)
Rx: Penicillin (Flucloxacillin; Gentamicin if Penicillin Allergic)
(Rx: Vancomycin if MRSA)
NB: Triple Therapy: Ampicillin, Gentamicin, Metronidazole = 'Broad Cover'. (Remember by AGM – Annual General
Meeting...If you want to be around next year, take these 3)
Wk 11
Psychiatric Emergencies
Overview of Psychiatry in Emergency Medicine:

• Presentation
• Initial assessment
• Implications, to individuals and community, of:
– mental illness
– suicide
– violence
• ‘‘Medical Clearance’’
– Organic vs non-organic mental health illness
• Mental Health Act
– Deprivation of liberty vs. protection/safety of Community
Definition of Mental Illness:

• “A condition characterised by a clinically significant disturbance of thought, mood, perception or
memory”
• Emergency: indicates that assessment and intervention are required within a short timeframe
Illness Detection:
- Physical/ “Organic”:
o Hx, Physical Exam, Investigations
- Mental:
o Interpret speech and behavior to establish abnormal thought paterns
o (In addition to the above)
Possible Presenting Symptoms:

- Behaviours:
o Self Harm
o Aggression
o Bizzare Actions
- Emotions:
o Distress
o Anger
o Worry
- Thoughts:
o Suicidal Ideation
o Delusions
- Physical:
o Agitation
o Overactivity
Multi-Axial (DSM) Assessment of Psychiatric Illness:

- Axis 1:
o Clinical Disorders (Other conditions that may be a focus of clinical attention)
- Axis 2
o Personality disorders
o Mental retardation
- Axis 3
o General medical conditions
- Axis 4
o Psychosocial and environmental
- Axis 5
o Global assessment of functioning state
Mental Health Assessment has 4 parts:
1. History and Corroborative History
2. Mental State Examination (MSE)
3. Physical Examination
4. Investigations
Safety:
- Can I safely interview this patient on my own, or do I need backup?
- Where is the most appropriate place to interview the patient given their level of arousal/agitation?
- Is the Patient going to be safe.
- Take away sharp objects
- Metal detectors
- Can they be left alone safely?
- What degree of observation do they need?
Mental State Examination:

- Appearance & Behaviour:
o Clothing – Appropriate, Clean, Torn?
o Grooming – Unkempt, well groomed, Smelly?
o Posture – Slumped, Rigid, Upright?
o Eye Contact – Good, Avoiding, Limited?
o Facial Expression – Sad, Animated, Anxious?
o Motor Activity – Decreased, Increased, Lethargic?
o Reaction to Interviewer – Hostile, withdrawn, operative, guarded, uncommunicative?
- Speech:
o Rate – Normal, fast, slowed, pressured
o Volume/Tone – Quiet, loud, Whispered
o Quantity – Poverty of speech, Monosyllabic, excessive
o Continuity – Can they maintain normal progression from 1 stream of thought to the next?
- Mood & Affect:
o Mood (Patient Reported) – Depressed, Euphoric, Suspicious, Elated, Angry, Anxious, Perplexed
o Affect (Clinician Assessed) – Restricted, Flattened, Inappropriate, Blunted, Anxious
o NB: Does Mood Match Affect?
- Thought Form:
o Continuity of Ideas
o Disturbance in language or meaning
o Goal-directed
o Flight of ideas
o Thought blocking
o Preoccupied
- Thought Content:
o Delusions
o Overvalued Ideas
o Pre-Occupations
o Phobias
o Suicidal Ideas
- Perception:
o Hallucinations (Auditory/Visual)
o Derealisation
o Depersonalisation
o Illusions
- Insight & Judgement:
o Partial Insight – Aware they have a problem, but believe someone else is responsible
o No insight
o Judgement – person’s ability to measure the consequences of their actions and how their
behavior may affect themselves/others.
- Components of Cognition:
o Mental Status Questionnaire (MSQ)
§ Orientation
§ Score out of 10 (8-10 = normal)
o Folstein’s Mini-Mental State Exam:
§ Orientation
§ Registration
§ Attention & Calculation
§ Recall
§ Language
§ Score out of 30 (27-30 = Normal)
Interaction of Organic Disease & Mental Illness:

- Organic diseases can cause apparent Mental Illness
- Examples of Organic causes of Mental “Illness”:
o Hypoxia
o Hypoglycaemia
o Trauma
o Sepsis
o Metabolic/Endocrine Disorders
o CNS Infection/Trauma/CVA
o Intoxication/Withdrawal
o Medications (Side Effects/Toxicity)
TYPES OF EMERGENCIES:
Suicide & Self-Harm:
- Number of factors have increased risk of suicide:
o Eg. Feelings of hopelessness, worthlessness, isolation
o Impulsiveness
o Psychodymanics/Psychological Vulnerability
o Life Stressors
o Access to Weapons
- Who is At Risk?
o Male
o Youth
o Rural
o Aboriginal
o Depressed
o Shizophrenics
o Other Mental Illness
o Substance Abusers
o Personality Disorders
- Males Vs Females:
o More males than females
o ≈20/100,000 population
- Assessment of Suicide/Self-Harm Assessment:
o “Sadperson’s Scale”:
§ Number Scoring System
§ Higher Score = Higher Risk.
§ Pneumonic:
• Sex
• Age
• Depression
• Psychiatric Care
• Excessive Drug Usage
• Rational Thinking Loss
• Separated/Single
• Organised Attempt
• No life Supports
• Stated Future Intent
o Psychiatric Examination:
§ Risk level Assessment: (Risk Factors Vs. Protective Factors)
• Low/Med/High
§ Specific Suicide Inquiry
Violence:
- Many Causes (not just Psychiatric):
o Medical
o Situational
o Criminal
- Affects All:
o Patients,
o Families,
o Health Workers
- Why are ED’s at High Risk?
o Open 24hrs
o Easy access
o Patients in crisis situations
o Long waiting times
o Overcrowding
o Inadequate security
- Management:
o Staff must Anticipate potential violence.
o Staff must act in defensive manner prior to the violence.
o Patient Placed in Quiet/Secure area
o Verbal Intervention
o Use of Restraints (Eg. Verbal/Oral Sedatives/Physical Restraints) if:
§ Imminent harm to Patient or others
§ To allow evaluation/Investigation/treatment of patient
§ At patient’s request
§ To prevent harm to the environment of the ED
§ Legal Considerations:
• Adult Guradianship laws
• Pt/Staff/Visitor Protection Vs. Pt Freedom and Autonomy.
IMPACT OF MENTAL HEALTH EMERGENCIES:

On Individuals:
- Stigma/Discrimination
- Affects Employment
- Relationships (Family/friends)
- Finances
- Self-Esteem
- Lifestyle (eg. Drug Use)
On Families:
- Time off work
- Grief
- Loss of income
- Role of Carer
- Stigma of mental illness
On Healthcare Workers:
- Burnout
- Suicide
- Stressors
GLS – Grief & Loss:
- Grief:
o Determined by Culture, Age, Gender, Physical & mental Health
o Everyone Grieves differently.
- Dimensions & Manifestations of Grief:
o Physical:
§ Pains
§ Sleep disturbance
§ Changes in eating patterns + Weight-Loss/Gain.
§ Stomach aches/headaches
§ Extreme fatigue
§ Chest pains
§ Breathlessness
o Emotional:
§ Self-blame, Guilt
§ Sadness, Numbness
§ Loneliness, Yearning
§ Fear, Crying
§ Anxiety
§ Numbness
§ Ager
§ Helpless/hopelessness
§ Sometimes Relief (if the loss has been a long time coming – Eg. Terminal Illness)
o Cognitive:
§ Nightmares/dreams
§ Memory loss
§ Decreased attention span
§ Disbelief and confusion
§ Preoccupation with the event
§ Magical thinking
§ Wishing to die
o Behavioural:
§ Regressive/Aggressive
§ Withdrawal
§ Overactivity
§ Self-destructive behaciours
§ Obsessive Acitivity
o Spiritural:
§ Utilization of spiritural beliefs
§ Abandonment of spiritual beliefs
- Secondary Sources of Loss/Stress:

o Financial problems
o Legal issues
o Single parent
o Loss of role (I’ve been a husband for 10yrs. Who am I now?).
- Models of Understanding Grief:
o (Attempt to explain the complex process experienced after significant loss & change.)
o Eg. Sigmund Freud
o Currently: “The Dual Process Model (DPM):
§ Acknowledges importance of Grief Work
§ - A Stressor-Specific Model of Coping that focuses on 2 Types of Stressors:
• 1. Loss Orientation
• 2. Restoration Orientation
Loss Orientated (Early Phase) Restoration Oriented (Late Phase)
Grief work Attending to Life Changes
Intrusion of Grief Doing New Things
Denial/Avoidance of Restoration Changes Distraction from Grief
- Adjustment:
o Adjustment to loss is a natural & normal process.
o Generally, people rely on Informal Resources for Support (Family, Friends, Colleagues, etc)
o Generally, they do Not require Formal Supports (Counselling & Medication)
- Resilience:
o The most Common Trajectory
o Multiple Pathways to resilient outcome
§ Some Suffer chronic grief symptoms after the 1st year
§ Recovery trajectory
§ Very rare to have no symptoms at all
§ Doesn’t seem to be delayed grief reactions.
o Pragmatic Coping:
§ Resilient people tend to express less negative emotion while discussing loss compared to
others.
§ Capacity to minimize the expression of grief-related emotions may help to minimize
grief.
o Protective Factors:
§ Large Social Network
§ Positive Emotion
- When To Seek Support:
o YOU feel you need it
o NB: Just because they’re sad, doesn’t mean they need a social worker.
o Maladaptive coping strategies (eg. Alcohol/drugs/compulsivity/etc)
o Thoughts of suicide or self destruction
o Feeling alone/helpless
- What does a Bereaved Person need from you?
o Generally, all you need to do is listen to how much it hurts.
o Sometimes, just your presence is enough
APPROACH TO COMMON ER PRESENTATIONS . . . CONT.
SYNCOPE
❏ sudden, transient loss of consciousness and postural tone with spontaneous recovery
Etiology
❏ usually caused by generalized cerebral hypoperfusion
❏ cardiogenic: arrhythmia, outflow obstruction, MI
• non-cardiogenic: peripheral vascular (hypovolemia), vaso-vagal, cerebrovascular disorders,
seizure disorders
History
❏ gather details from witnesses
❏ distinguish between syncope and seizure (see Neurology Chapter)
• signs and symptoms of precyncope, syncope and postsyncope
• past medical history, drugs
Physical
❏ BP and pulses in both arms, posturals
❏ cardiovascular exam and neuro exam
Investigations
❏ ECG
❏ CBC, lytes, BUN, creatinine, glucose, ABG’s, Troponin, CKMB, Mg, Ca
Disposition
❏ cardiogenic syncope: admit to medicine/cardiology
❏ non-cardiogenic syncope: discharge with follow-up of Holter or echo study
SEXUAL ASSAULT AND DOMESTIC VIOLENCE

❏ involve local/regional sexual assault team
❏ 1 in 4 women and 1 in 10 men will be sexually assaulted in their lifetime
General Management Principles
❏ ABC’s
❏ ensure patient is not left alone and ongoing emotional support provided
❏ set aside adequate time for exam (usually 1 1/2 hours)
❏ obtain consent for medical exam and treatment, collection of evidence,
disclosure to police (notify police as soon as consent obtained)
❏ Sexual Assault Kit (document injuries, collect evidence)
❏ samples ––> labeled immediately ––> passed directly to police
❏ offer community crisis resources (e.g. shelter, hotline)
❏ do not report unless victim requests (legally required if <16 years)
History
❏ who? how many? when? where did penetration occur? what happened ? any weapons or physical assault?
❏ post-assault activities (urination, defecation, change of clothes, shower, douche, etc.)
❏ gynecologic history
• gravity, parity, last menstrual period (LMP)
• contraception
• last voluntary intercourse (sperm motile 6-12 hours in vagina, 5 days in cervix)
Physical Exam
❏ evidence collection is always secondary to treatment of serious injuries
❏ never retraumatize a patient with the examination
❏ general examination
• mental status
• sexual maturity
• patient should remove clothes and place in paper bag
• document abrasions, bruises, lacerations, torn frenulum/broken teeth (indicates oral penetration)
❏ pelvic exam and specimen collection
• ideally before urination or defecation
• examine for seminal stains, hymen, signs of trauma
• collect moistened swabs of dried seminal stains
• pubic hair combings and cuttings
• speculum exam
• lubricate with water only
• vaginal lacerations, foreign bodies
• Pap smear
• oral/cervical/rectal culture for gonorrhea and chlamydia
• posterior fornix secretions if present or aspiration of saline irrigation
• immediate wet smear for motile sperm
• air-dried slides for immotile sperm, acid phosphatase, ABO group
❏ others
• fingernail scrapings
• saliva sample from victim
• VDRL - repeat in 3 months if negative
• serum ß-HCG
• blood for ABO group, Rh type, baseline serology (e.g. hepatitis, HIV)
Treatment
❏ medical
• suture lacerations
• tetanus prophylaxis
• gynecology consult for foreign body, complex lacerations
• assumed positive for gonorrhea and chlamydia
• azithromycin 1g PO x 1 dose or cefixime 400 mg PO x 1 dose +
doxycycline 100 mg BID PO x 7 days
• may start prophylaxis for hepatitis B and HIV
• pre and post counselling for HIV testing
• pregnancy prophylaxis offered
• Ovral 2 tabs STAT and 2 tabs in 12 hrs (within 72 hrs post-coital) with Gravol 50mg
❏ psychological
• high incidence of psychological sequelae
• have victim change and shower after exam completed
• follow-up with MD in rape crisis centre within 24 hours
• best if patient does not leave E.D. alone
Domestic Violence
❏ IDENTIFY THE PROBLEM (need high index of suspicion)
• suggestive injuries
• somatic symptoms (chronic and vague complaints)
• psychosocial symptoms
❏ if disclosed, be supportive and assess danger
❏ management
• treat injuries
• ask about sexual assault and children at home
• document findings
• plan safety
❏ FOLLOW-UP: family doctor/social worker
VIOLENT PATIENT
❏ SAFETY FIRST - yourself, patient, staff, other patients
❏ always consider and rule out organic causes (as they can be fatal)
❏ leading organic causes are EtOH, drugs, and head injuries
Differential Diagnosis
❏ organic
• drugs/toxins/withdrawal
• metabolic (electrolyte abnormalities, hypoglycemia, hypoxia)
• infections (sepsis, encephalitis, brain abscess, etc.)
• endocrine (Cushing’s, thyrotoxicosis)
• CNS (head injuries, tumour, seizure, delirium and dementia)
❏ functional/psychiatric
• situational crisis
• schizophrenia, bipolar disorder (manic), personality disorder
Prevention
❏ be aware and look for prodromal signs of violence
• prior history of violence or criminal behaviour
• anxiety, restlessness, defensiveness, verbal attacks
❏ try to de-escalate the situation early
• address the patient’s anger
• empathize
Restraints
❏ physical
• present option to patient in firm but non-hostile manner
• demonstrate sufficient people to carry it out
• restrain supine or on side
• suction and airway support available in case of vomiting
❏ pharmacologic
• often necessary - may mask clinical findings and impair exam
• Haldol 5-10 mg IM (be prepared for dystonic reactions, especially with multiple doses of neuroleptics
over a short period) + lorazepam 2 mg IM/IV
• look for signs of anticholinergic OD first (see Toxicology section)
❏ once restrained, search person/clothing for drugs and weapons
History
❏ antecedent and precipitating events and locale
❏ drugs: prescription, over the counter (OTC) (antihistamines, anticholinergics, stimulants),
recreation/abuse/steroids, withdrawal reaction
❏ past medical history (especially DM)
❏ past psychiatric history and past legal history
❏ patient’s insight
❏ speak to family/friends
Wk 9
Toxicology
& Endocrine Emergencies
Toxicological Emergencies
Overview:
- ABCs for Toxicology
- Red Flags:
o NB: 2 Tablets can kill a 10kg child
o Be aware of the meds that are toxic
o “Nice” or “Nasty”
- Know where to get help:
o Poisons Information Centre
Causes of Toxic Syndromes:

- Accidental:
o Household Drugs/Toxins (Typically little children)
o Occupational Exposure – (Acute/Chronic)
- Intentional Self-Poisoning:
o Recreational
o Parasuicidal Gesture (Call for attention)
o Suicide Attempt
- Inappropriate use of Medication
- Envenomation
Toxidromes:
- Paracetamol Overdose:
o No “Toxidrome” & Mostly Asymptomatic
o à Secondary Metabolite is Highly Hepatotoxic
o Antidote: N-Acetyl Cystiene (*A Precursor to Glutathione – A Conjugator for Paracetamol)
§ Give if the Blood-Paracetamol Level is Above the ‘Toxicity Line’ @ 4hrs.
§ (Small risk of Anaphylaxis)
- Cholinergic (Eg. Organophosphates – ACh-Esterase Inhibitors) – “SLUDGE”

o Salivation, Lacrimation, Urination, Defecation, GI Upset, Emesis
o Antidotes: Atropine (An Anti-Muscarinic) & Pralidoxime (An Ach-I-Inhibitor)
§ NB: Atropine can à VF/SVT/VT
- Anticholinergic Syndrome (Eg. TCA’s, Antihistamines, Atropine) – “Anti-SLUDGE”:

o Dry Mouth, Dry Eyes, Urinary Retention, Constipation, ….
o TCA Overdose à Widening QRS + Right-Axis Deviation.
o Antidote: Sodium Bicarbonate:
§ Works by preventing the combination of acid with the ionic form of TCA to form the TCA
molecule (which is absorbed by cells).
§ Also prevents the positive feedback loop of acidosis (which increases the level of TCA
Molecules)
- Extrapyramidal (Eg. Antipsychotics) - “TROD”

o Tremor, Rigidity, Opisthotonos (Abnormal Posture), Dysphagia (Difficulty Swallowing)
- Opioid:
o Triad: Coma, Respiratory Depression, Miosis (Pinpoint Pupils)
o Antidote: Naloxone (An Opioid Receptor Antagonist)
§ Given ASAP after overdose
§ NB: Naloxone is often shorter-acting than the Opioids taken :. Require constant infusion.
• Wears off after 45mins
- Sedative/Hypnotic (Eg. Benzodiazepines):
o Triad: Coma, Respiratory Depression, Impaired Airway
o Antidote: Flumazenil (Rarely Used)
§ NB: If Pt. is a Benzo Addict, Flumazenil can à Acute Withdrawal. :. Titrate Dose.
- Sympathomimetic (Eg. Amphetamines, Cocaine):

o Paranoid Schizophrenia, Very Excited, Tachycardia, Hypertension
- Serotonergic (Eg. SSRI Antidepressants):

o Agitation, Confusion, Diarrhea, Fever, Shivering, Tremor
- Withdrawal Syndromes (Eg. Alcohol/Sedatives (Benzos)/Narcotics):

o Restlessness, Irritability, Chills, Hallucinations, Confusion, Sympathetic Overactivity (Sweating,
Tachycardia, Hypertension), Seizures
Approach to the Poisoned Patient:

1) Primary Survey:
a. ABCD:
i. Airway (eg. Vomiting/Aspiration/Allergic Reaction à Swelling/Altered Consciousness à
Loss of Ability to maintain Airway)
ii. Breathing (Eg. Too Much/Too Little)
iii. Circulation (Eg. Tachy/Brady/Hypertension/Hypotension) – (Monitor with ECG & BP)
iv. Disability (Conscious State)/Danger (What did they take/When/How Much)
b. Drug Manipulation (Decontamination &/Or Decrease Absorption/Specific Antidotes):
i. Ipecac (Induce Vomiting) - Minimal Use in ED
ii. Gastric Lavarge (Useful within the 1st hour) – Now de-emphasized in ED
iii. Activated Charcoal
1. (Binds free drug in lumen of gut à ↓drug concentration à ↓Absorption)
2. Only effective for things that will bind. (won’t bind small ionic compounds, heavy
metals, or alcohols)
3. Very Time Dependent
iv. Whole Bowel Irrigation (Eg. Polyethylene Glycol – Golytley: An osmotic agent à Flushes
out bowel)
v. Skin Decontamination (eg. Organophosphate Poisoning)
vi. Left Lateral Position à Delays Gastric Emptying.
vii. Cathartics (flush things through)
viii. Urine pH Alteration
ix. Dialysis
x. Chelation
c. Differential Diagnosis:
i. Impaired Conscious State (SMASHED):
1. S Substrate/Sepsis
2. M Meningitis/Mental Illness
3. A Alcohol/Accident (CVA/SAH/Subdural/CHI)
4. S Seizures/Stimulants
5. H Hypo/Hyper- (Thyroidism/Thermia/Glycaemia/Tension/Carbia)
6. E Electrolytes/Encephalopathy/Envenomation
7. D Drugs
ii. Don’t Forget Blood Sugar
iii. ECG:
1. Screening for Lethal Toxicologies.
2) Emergency Antidotes:
a. Paracetamol N-Acetyl Cysteine
b. Opiates Naloxone
c. Benzos Flumazenil
d. Ca Antagonists Insulin & Glucose
3) Secondary Survey:
a. Examination & History:
i. Directed History:
1. Who
2. What
3. Where
4. When
5. Why
6. How
ii. Systematic Examination:
1. Identify Problems
2. Recognition of Toxic Syndromes
iii. Focused Investigations:
1. BSL
2. ECG
3. Electrolytes
4. LFTs (liver function tests)
5. EtOH
6. ABG
7. FBE
8. Paracetamol Level
9. Toxic Screen
b. Education:
i. To Prevent Accidental Poisonings (eg. In kids)
ii. Put drugs in childproof containers
c. Funny Behaviour:
i. Underlying Psychodynamics:
1. Intent? – What did you think would happen?
2. Suicidal? – Do a “SAD PERSONS” score.
3. Predisposing Psychiatric Illness (Eg. Psychosis, Depression)
4) Definitive Care:
a. Serious or Potentially Serious à ICU
b. Mild à Observe in ED
c. Self harm à Psychiatric Evaluation
Endocrine Emergencies:
Focus on Diabetic Emergencies
Diabetic Emergencies:
• Diabetic Ketoacidosis:
o Acute life threatening
o Pathology – Combination of:
§ Insulin Deficiency
• Cell unable to absorb & metaoblis glucose
§ Excess Counter-Regulatory Hormones (Eg. Glucagon/Adrenaline)
• Glycogen Breakdown
• Lipolysis à Ketogenesis
• Protein Catabolism
§ Resultant Hyperglycaemia
• Osmotic dieresis à Dehydration
o Presentation:
§ – of Underlying Diabetes:
• Polyuria
• Polydipsia
• Weight loss
§ – of Hyperglycaemia:
• Glycosuria/Osmotic dieresis
• Salt & Water Depletion
§ – of Hyperketonaemia à Metabolic Acidosis:
• Acetone Breath
• Hyperventilation (Respiratory Compensation)
• Peripheral Vasodilation à Hypotension
• K+ Depletion
o Treatment:
§ Supportive (ABCs)
§ Rehydration
• Replace ½ fluid deficit in 1st 12 hrs
§ Insulin infusion
§ Close monitoring of Electrolytes
- Hyperosmolar Non-Ketotic Coma:
o Pathophysiology:
§ Relative Insulin Deficiency
§ Enough to Prevent Lipolysis;
• à NO Ketosis
§ But Not enough to Prevent Hyperglycaemia
• à Hyperglycaemia
o Presentation:
§ Confusion/Coma
§ Marked Dehydration
o Treatment:
§ Supportive ABCs
§ Rehydration
§ Insulin Infusion
- Hypoglycaemia:
o Don’t Ever Forget Glucose:
§ Because severe or prolonged hypoglycaemia can cause Brain damage/death.
o Causes:
§ **Diabetic:
• Insulin Overdose (Accidental/Suicide Attempt)
• Missed Meal
• Exercise
• Alcohol
§ Alcohol Excess
§ Sepsis
o Symptoms:
§ CNS Glucose Deficiency
• Confunsion/Coma/Seiure
• Drowsiness
• Incoordination
§ Autonomic
• Anxiety
• Sweating
• Tremors
• Palpitation
§ Non Specifics
• Nausea
• Headache
• Fatigue
o Diagnosis:
§ Hypoglycaemia
§ Clinical Symptoms
§ Response to Glucose Administration
o Treatment:
§ Supportive:
• ABCs
§ Suspect the Diagnosis:
• Don’t ever forget glucose
§ Correct serum Glucose:
• Glucose Oral/IV
• Glucagon (if IV Glucose isn’t possible)
§ Disposition
• Oral Hypoglycaemics (Admit to all patients)
Other Endocrine Emergencies:
- Alcoholic Ketoacidosis:
o Cause:
§ Alcoholic with recent decreased food intake
o Presentation:
§ Abdo pain, nausea & vomiting
§ Metabolic Acidosis & Possible Ketoneuria
o Treatment:
§ Supportive ABCs
§ Rehydration
- Thyroid:
o Hyperthyroidism:
§ Cause:
• High free T4 & low TSH
o Eg. Graves Disease: goitre, exopthalmos, pretibial myxoedema
§ Presentation:
• àNervousness, irritability, mental disturbance, tachycardia,
• àpalpitations, heat intolerance, weight loss, goiter
§ Treatment:
• Supportive ABCs
• Block Effects of T4 (Thyroid Blocking Drugs)
o Hypothyroidism:
§ Cause:
• Low free T4 & high TSH
§ Presentation:
• àFatigue, weakness, constipation, cold intolerance & depression
• à Goitre, menstrual irregularities
§ Treatment:
• Supportive ABCs
• T4 Replacement (Thyroxine)
- Adrenocortical Insufficiency:
o Causes:
§ Primary:
• Adrenal Failure
§ Secondary:
• Pituitary Failure
• Adrenopituitary Suppression by Steroids
o Presentation:
§ àHypotension, abdominal pain, confusion, weakness, & pigmentation
§ àHyponatraemia
§ àHyperkalaemia
o Treatment:
§ Corticosteroid Replacement (Hydrocortisone)
Physical Exam
❏ vitals
• temperature often increased in delirium or toxic psychosis
• hypothermia may have altered mental status
❏ signs of trauma - especially head and neck
❏ neurologic exam, including brief mental status
❏ signs of drug toxicity and needle marks
❏ signs of hypoglycemia
Investigations
❏ screening bloodwork: CBC, lytes, glucose, creatinine, BUN, osmolality
❏ selective drug and toxin screen (see Toxicology section)
❏ CT head if necessary
TOXICOLOGY
APPROACH TO THE OVERDOSE PATIENT
History Taking
1. How much? How long ago? What method? (ingestion, inhalation, dermal, occular, environmental, IV ?)
2. accidental vs non-accidental exposure
Physical Exam
1. focus on: BP, HR, pupils, LOC, airway
Principles of Toxicology
❏ “All substances are poisons ... The right dose separates a poison from a remedy”
❏ 5 principles to consider with all ingestions
1. resuscitation (ABCs)
2. screening (toxidrome? clinical clues?)
3. decrease absorption of drug
4. increase elimination of drug
5. is an antidote available?
❏ suspect overdose when:
• altered level of consciousness/coma
• young patient with life-threatening arrhythmia
• trauma patient
• bizarre or puzzling clinical presentation
ABCs OF TOXICOLOGY
❏ basic axiom of care is symptomatic and supportive treatment
❏ can only address underlying problem once patient is stable
A Airway (consider stabilizing the C-spine)
B Breathing
C Circulation
D1 Drugs
• ACLS as necessary to resuscitate the patient
• universal antidotes
D2 Draw bloods
D3 Decontamination (decreased absorption, increased elimination)
E Expose (look for specific toxidromes)/Examine the Patient
F Full vitals, ECG monitor, Foley, x-rays, etc.
G Give specific antidotes, treatments
Go back and reassess.
CALL POISON CONTROL CENTRE
OBTAIN CORROBORATIVE HISTORY FROM FAMILY/FRIENDS IF PRESENT
D1 - UNIVERSAL ANTIDOTES
❏ treatments which will never hurt any patient and which may be essential
Oxygen
❏ do not deprive a hypoxic patient of oxygen no matter what the
antecedent medical history (i.e. even COPD and CO2 retention)
❏ if depression of hypoxic drive, intubate and ventilate
❏ only exception: paraquat or diquat (herbicides) inhalation or ingestion
TOXICOLOGY . . . CONT.
Thiamine (Vitamin B1)

❏ 100 mg IV/IM to all patients prior to IV/PO glucose
❏ a necessary cofactor for glucose metabolism, but do not delay glucose if thiamine unavailable
❏ to prevent Wernicke-Korsakoff syndrome WACO
• Wernicke’s encephalopathy - Ataxia, Confusion, Ophthalmoplegia)
• untreated, may progress to Korsakoff’s psychosis (disorder in learning and
processing of new information)
• treatment: high dose thiamine (1000 mg/day x 3 days)
• most features usually irreversible
❏ populations at risk for thiamine deficiency
• alcoholics
• anorexics
• hyperemesis of pregnancy
• malnutrition states
❏ in E.D., must assume all undifferentiated comatose patients are at risk
Glucose
❏ give to any patient presenting with altered LOC
❏ do dextrostix prior to glucose administration
❏ adults: 0.5-1.0 g/kg (1-2 mL/kg) IV of D50W
❏ children: 0.25 g/kg (2 mL/kg) IV of D25W
Naloxone
❏ antidote for opioids: diagnostic and therapeutic (1 min onset of action)
❏ used in the setting of the undifferentiated comatose patient
❏ loading dose
• adults
• 2 mg initial bolus IV/IM/SL/SC or via ETT
• if no response after 2-3 minutes, progressively double dose until a response or
total dose of 10 mg given
• known chronic user, suspicious history, or evidence of tracks 0.01 mg/kg
(to prevent acute withdrawal)
• child
• 0.01 mg/kg initial bolus IV/IO/ETT
• 0.1 mg/kg if no response and narcotic suspected
❏ maintenance dose
• may be required because half-life of naloxone much shorter
than many narcotics (half-life of naloxone is 30-80 minutes)
• hourly infusion rate at 2/3 of initial dose that produced patient arousal
D2 - DRAW BLOODS
❏ essential bloods
• CBC, electrolytes, urea, creatinine
• glucose (and dextrostix), INR, PTT
• ABGs, measured O2 sat
• osmolality
• acetylsalicylic acid (ASA), acetaminophen alcohol levels
❏ potentially useful bloods
• drug levels
• Ca2+, Mg2+, PO43–
• protein, albumin, lactate, ketones and liver tests
Serum Drug Levels
❏ treat the patient, not the drug level
❏ negative toxicology screen only signifies that the specific drugs tested were not detectable in the particular
specimen at the time it was obtained (i.e. does not rule out a toxic ingestion)
❏ generally available on serum screens (differs by institution)
(screen is different from drug levels - screen is very limited)
• acetaminophen*
• ASA*
• barbituates and other sedative/hypnotics
• benzodiazepines (qualitative only)
• ethanol
• ethylene glycol*
• methanol*
• tricyclic antidepressant (TCA) (qualitative only)
* significant if in "toxic" range
❏ urine screens also available (qualitative only)
Toxic Gaps (see Nephrology Chapter)
Anion gap (AG) = Na+ – (Cl– + HCO3–) Plasma osmolal gap (POG) = (measured - calculated) osmoles
• normal range 10-14 mmol/L • normally POG < 10 mOsm/L
• unmeasured cations: Mg2+, Ca2+ • calculated osmolality = 2 Na+ + BUN + blood glucose (mmol/L)
• unmeasured anions: proteins, organic acids, PO43–, sulfate
Metabolic acidosis Plasma Osmolal Gaps
Increased AG: differential of causes (*toxic) Increased osmolal gap: “MAE DIE”
“MUDPILES CAT" Methanol
Methanol* Acetone
Uremia Ethanol
Diabetic ketoacidosis/Alcoholic ketoacidosis
Diuretics (glycerol, mannitol, sorbitol)
Phenformin*/Paraldehyde*
Isoniazid*/Iron* Isopropanol
Lactate (anything that causes seizures or shock) Ethylene glycol
Ethylene glycol*
Salicylates* Oxygen saturation gap: (measured – calculated) O2 saturation
(1) measured by absorption spectrophotometry (pulse oximetry)
Cyanide* (2) calculated from Hb/O2 saturation curve
Arsenic*
Toluene* Increased O2 saturation gap
(3) carboxyhemoglobin
Decreased AG
1. error (4) methemoglobin
2. electrolyte imbalance (increased Na+/K+/Mg2+) (5) sulfhemoglobin
3. hypoalbuminemia (50% fall in albumin
~ 5.5 mmol/L decrease in the AG)
4. Li, Br elevation
5. paraproteins (multiple myeloma)
Normal AG
(1)K+: pyelonephritis, obstructive nephropathy, renal tubular acidosi (RTA), IV, TPN
(2)K+: small bowel losses, acetazolamide, RTA I, II
Table 13. Use of the Clinical Laboratory in the Initial Diagnosis of Poisoning
TEST FINDING SELECTED CAUSES
ABGs • hypoventilation (8 Pco2) • CNS depressants (opioids, sedative-hypnotic

agents, phenothiazines, and EtOH)
• hyperventilation • salicylates, CO, other asphyxiants
Electrolytes • anion-gap metabolic acidosis • “MUDPILES CAT”

• hyperkalemia • digitalis glycosides, fluoride, K+
• hypokalemia • theophylline, caffeine, ß-adrenergic agents,
soluble barium salts, diuretics
Glucose • hypoglycemia • oral hypoglycemic agents, insulin, EtOH
Osmolality • elevated osmolar gap • “MAE DIE”

and Methanol, Acetone, Ethanol, Diuretics,
Osmolar Gap Isopyropyl alcohol, Ethylene glycol
ECG • wide QRS complex • TCAs, quinidine, other class Ia and Ic

antiarrhythmic agents
• prolongation of QT interval • quinidine and related antiarrhythmics,
terfenadine, astemizole
• atrioventricular block • Ca2+ antagonists, digitalis glycosides,
phenylpropanolamine
Abdominal • radiopaque pills or objects • “CHIPES”

x-ray Calcium, Chloral hydrate, CCl4, Heavy metals,
Iron, Potassium, Enteric coated Salicylates,
and some foreign bodies
Serum • elevated level (> 140 mg/l • acetaminophen (may be the only clue to a recent
Acetaminophen 4 hours after ingestion) ingestion)
D3 - DECONTAMINATION
❏ PROTECT YOURSELF FIRST
❏ CALL POISON CONTROL CENTRE IF ANY UNCERTAINTY
Ocular Decontamination
❏ saline irrigation to neutral pH
❏ alkali exposure requires ophthalmology consult
Dermal Decontamination (wear protective gear)
❏ remove clothing
❏ brush off toxic agents
❏ irrigate all external surfaces
Gastrointestinal Decontamination
❏ activated charcoal (AC)
• indications
• single dose will prevent significant absorption of many drugs and toxins
• contraindications
• acids, alkalis, cyanides, alcohols, Fe, Li
• dose = 1 g/kg body weight or 10 g/g drug ingested
• odourless, tasteless, prepared as slurry with H2O
• cathartics rarely used (risk electrolyte imbalance)
❏ multi-dose activated charcoal (MDAC)
• absorption of drug/toxin to charcoal prevents availability and promotes fecal elimination
• without charcoal, gut continuously absorbs toxins; MDAC (multidose activated charcoal) interrupts the
enterohepatic circulation of some toxins and binds toxin diffusing back into enteral membrane from the
circulation
• MDAC can increase drug elimination (potentially useful for phenobarbitol, carbamazepine,
theophylline, digitoxin, others)
• dose
• various regimes
• continue until nontoxic or charcoal stool
❏ whole bowel irrigation
• flushes out bowel
• 500 mL (child) to 2000 mL (adult) of balanced electrolyte solution/hour by mouth until clear
effluent per rectum
• indications
• awake, alert patient who can be nursed upright
• delayed release product
• drug/toxin not bound to charcoal
• drug packages - if any evidence of breakage ––> emergency surgery
• recent toxin ingestion (up to 4-6 hours)
• evidence of ileus, perforation, or obstruction
❏ surgical removal
• indicated for drugs
• that are toxic
• that form concretions
• that are not removed by conventional means
E - EXAMINE THE PATIENT

❏ vital signs (including temperature), skin (needle tracks, colour), mucous membranes, odours and CNS
❏ head-to-toe survey
• C-spine
• signs of trauma
• signs of seizures (incontinence, “tongue biting”, etc.)
• signs of infection (meningismus)
• signs of chronic alcohol abuse
• signs of drug abuse (track marks, nasal septum erosion)
• mental status
SPECIFIC TOXIDROMES
Narcotics, Sedatives/Hypnotics, Alcohol Overdose
❏ signs and symptoms
• hypothermia
• bradycardia
• hypotension
• respiratory depression
• dilated/constricted pupils
• CNS depression
Drug / Substance Withdrawal

❏ withdrawal state generally opposite to the physiological effect of the drug
❏ signs and symptoms of sedative withdrawal
• increased temperature • agitation
• tachycardia • tremor
• hypertension • hallucinations
• dilated pupils • seizures
• diaphoresis
❏ drugs
• alcohol
• benzodiazepines
• barbituates
• antihypertensives
• opioids
Drug Class Overdose Signs and Symptoms Examples of Drugs
Anticholinergics • hyperthermia “Hot as a Hare” Anticholinergic drugs

• dilated pupils "Blind as a Bat” antidepressants
• dry skin “Dry as a Bone” Flexeril
• vasodilatation “Red as a Beet” Tegretol
• agitation/hallucinations “Mad as a Hatter” antihistamines (e.g. Gravol, diphenhydramine)
• ileus “The bowel and bladder antiparkinsonians
• urinary retention lose their tone and the antipsychotics
• tachycardia heart goes on alone” antispasmotics
belladonna alkaloids (e.g. atropine, scopolamine)
Cholinergics “DUMBELS” cholinergics

Diaphoresis, Diarrhea, Decreased blood pressure (nicotine, mushrooms)
Urination anticholinesterases
Miosis (physostigmine, organophosphate insecticides)
Bronchorrhea, Bronchospasm, Bradycardia
EEmesis, Excitation of skeletal muscle
Lacrimation
Salivation, Seizures
Extrapyramidal dysphonia major tranquilizers

rigidity and tremor
dysphagia
torticollis
laryngospasm
trismus (deviation of eyes in all directions)
oculogyric crisis
Hemoglobin Derangements increased respiratory rate carbon monoxide poisoning (carboxyhemoglobin)

decreased level of consciousness
seizures
cyanosis (unresponsive to O2) drug ingestion (methemoglobin, sulfhemoglobin)
lactic acidosis
Metal Fume Fever abrupt onset of fever, chills, myalgias fumes from heavy metals (welding, brazing, etc.)
metallic taste in mouth amphetamines
nausea and vomiting • caffeine
headache • cocaine
fatigue (delayed respiratory distress) • ephedrine (and other decongestants)
• LSD
Sympathomimetics increased temperature • PCP

CNS excitation (including seizures) • theophylline
tachycardia
nausea and vomiting • thyroid hormone
hypertension •ASA toxicity looks like sympathomimetic
diaphoresis overdose
dilated pupils • sedative/hypnotic withdrawal
(including alcohol) also similar
G - GIVE SPECIFIC ANTIDOTES AND TREATMENTS

❏ note: hemodialysis can be considered for all drugs
Table 14. Toxins and Antidotes
Toxin Antidote/Treatment
Acetaminophen N-acetylcysteine (Mucomyst)
Anticholinergics *Physostigmine
Benzodiazepines flumazenil (Romazicon/Anexate)
ß-blockers atropine, isoprotenerol, glucagon
Calcium channel blockers calcium chloride or gluconate
Carbon Monoxide 100% oxygen, hyperbaric O2
Cyanide Lilly kit (amyl nitrite, then sodium nitrite): Na thiosulfate
Digoxin stop dig, use FAB fragments (Digibind), restore K+
Heparin protamine sulfate
Insulin glucose/glucagon
Iron deferoxamine
Methanol/Ethylene glycol ethanol or fomepizole, leucovorin (for methanol), thiamine and pyrudoxine for EG
Nitrites methylene blue
Opioids naloxone (Narcan)
Organophosphates atropine, pralidoxime
Salicylates alkalinize urine, restore K+
TCA’s sodium bicarbonate bolus
Warfarin vitamin K; (FFP if necessary)
* available through special access programme only
SPECIFIC TREATMENTS
Acetaminophen Overdose
acetaminophen = paracetamol = APAP
❏ acute acetaminophen OD ––> metabolized by Cytochrome P450 ––> saturation of pathway ––>
toxic metabolite (NAPQI) scavenged by glutathione (an antioxidant) (in non-overdose situations)
• in OD: exhaustion of glutathione stores ––> NAPQI accumulates ––>
binds hepatocytes and hepatic necrosis
❏ toxic dose of acetaminophen > 150 mg/kg (~7.0 g)
❏ increased risk of toxicity if chronic EtOH and/or anti-convulsant drugs
❏ clinical: no symptoms
• serum acetaminophen level
• evidence of liver/renal damage (delayed > 24 hours)
• increased AST, INR
• decreased glucose, metabolic acidosis, encephalopathy (indicate poor prognosis)
❏ management
• decontamination
• serum acetaminophen level 4 hours post ingestion
• measure liver enzymes and INR, PTT
• use the Rumack-Matthew Nomogram for acetaminophen hepatotoxicity
• N-acetylcysteine (Mucomyst)
• substitutes for glutathione as anti-oxidant to prevent liver damage
• use according to dosing nomogram
• best effect if started within 8 hrs post-ingestion, but therapy should be initiated regardless
ASA Overdose
❏ acute and chronic (elderly with renal insufficiency)
❏ clinical
• hyperventilation (central stimulation of respiratory drive)
• increased AG metabolic acidosis (increased lactate)
• tinnitus, confusion, lethargy
• coma, seizures, hyperthermia, non-cardiogenic pulmonary edema, circulatory collapse
❏ ABG’s possible: 1. respiratory alkalosis
2. metabolic acidosis
3. respiratory acidosis
❏ management
• decontamination
• 10:1 charcoal:drug ratio
• whole bowel irrigation (useful if enteric-coated ASA)
• close observation of serum level, serum pH
• alkalinization of urine as in Table 14 to enhance elimination and to protect the brain
(want serum pH 7.45-7.55)
• may require K+ supplements for adequate alkalinization
• consider hemodialysis when
• severe metabolic acidosis (intractable)
• increased levels
• end organ damage (unable to diurese)
Table 15. Urine Alkalinization in ASA Overdose

Plasma pH Urine pH Treatment
alkaline alkaline D5W with 20 mEq KCl/L +
2 amps HCO3/L at 2-3 cc/kg/hr
alkaline acid D5W with 40 mEq KCl/L +
acid acid D5W with 40 mEq KCl/L + 4 amps HCO3/L
Anticholinergic Overdose (e.g. antihistamines)

❏ physostigmine salicylate: reversible acetylcholinesterase inhibitor
❏ supportive therapy
Benzodiazepine (BZ) Overdose
❏ flumazenil (Anexate): specific benzodiazepine antagonist
❏ indications
• iatrogenic BZ oversedation
• to reverse BZ anesthesia
❏ contraindications
• known seizure disorder
• mixed OD (especially if tricyclic antidepressant (TCA) suspected)
• BZ dependence or chronic use
❏ dose
• adult: 0.3 mg IV (q5mins to maximum 1.0 g)
• child: 10 µg/kg (as above, maximum 0.3 mg)
❏ CAUTION - most BZ have prolonged half life compared to flumazenil
• if re-sedation occurs, repeat doses or IV infusion may be indicated
Beta Blockers
❏ symptoms within 2 hours of ingestion
❏ atropine or isoprotenerol if severe
❏ glucagon
• works as non-ß-adrenergic receptor agonist to increase production of cAMP, thereby
increasing contractility
❏ glucagon 50-100 µg/kg (5-10 mg for adults) slow IV push, then IV at 70 µg/kg/hour
Calcium Channel Blockers
❏ order ECG, lytes (Ca2+, Na+, Mg2+, K+ especially)
❏ calcium chloride 1-4 g of 10% solution IV if hypotension
❏ glucagon
❏ inotrope/aggressive supportive therapy
CO Poisoning
❏ 100% O2 therapy by face mask critical for CO poisoning
❏ hyperbaric O2 disputed benefits; no evidence for therapy in mild-moderate
cerebral dysfunction (may prevent neurological sequelae)
❏ coma is an undisputed indication for hyperbaric O2 therapy (still the standard of care)
❏ hyperbaric O2 (efficacy unclear) suggested for pregnant patients
Digoxin Overdose
❏ Digibind = digoxin-specific antibody fragments (Fab)
❏ use in combination with activated charcoal
❏ indications
• life threatening arrhythmias unresponsive to conventional therapy (ventricular fibrillation,
ventricular tachycardia, conduction block)
• 6 hr serum digoxin >19 nmol/L (> 15 ng/mL)
• initial serum K+ > 5 mmol/L
• history of ingestion > 10 mg for adult, > 4 mg for child
❏ dose
• 1 vial = 40 mg Digibind neutralizes 0.6 mg digoxin
• cost of one vial = $200
• empirically: 20 vials if acute ingestion 5-10 vials if chronic ingestion (90-95% of cases)
• onset of action 20-90 minutes
• renal elimination half life 20-30 hours
Acute Dystonic Reaction
❏ benztropine (Cogentin), antihistamines, benzodiazepines effective
❏ benztropine has euphoric effect and potential for abuse
❏ for acute dystonic reaction
• 1-2 mg IM/IV benztropine then 2mg PO bid x 3 days
OR
diphenhydramine 1-2 mg/kg IM/IV then 25 mg PO qid x 3 days
Hydrogen Fluoride Burns

❏ Ca2+ gluconate gel topical or intradermal or both
❏ intravenous calcium chloride for systemic hypocalcemia, hyperkalemia
Insulin/Oral Hypoglycemic Overdose
❏ glucose can be given IV, PO or via NG
❏ glucagon (if no access to glucose)
• 1-2 mg IM
Ethanol Overdose
❏ very common in children
❏ mouthwash > 70% EtOH, perfumes/colognes 40 – 60% EtOH
❏ dehydrogenase pathway is less active in children
❏ presentation: flushed face, dilated pupils, sweating, GI distress, hypothermia, hypoventilation, hypotension
❏ order: serum EtOH level, glucose
❏ manage: airway, circulation, glucose levels
❏ folate up to 50 mg q4h IV
❏ gastric decontamination if ingestion < 1hr ago
❏ hemodialysis if serum EtOH > 500 mg/dL
Methanol or Ethylene Glycol Overdose
❏ ethanol PO/IV used to block metabolism of methanol and ethylene glycol preventing toxicity
❏ Fomepizole (4-methylpyrazole) 15 mg/kg initial dose, a competitive inhibitor of alcohol dehydrogenase,
available for ethylene glycol intoxication (~$2000 a day); recent evidence for use in methanol intoxication
❏ folic acid (Leucovorin) 50 mg IV q4h for several days to potentiate folate-dependent metabolism of formic
acid in methanol poisoning
❏ dialysis if ethanol treatment unsuccessful, visual impairment (MetOH), renal failure (ethylene glycol)
or uncorrectable metabolic acidosis
❏ thiamine 100 mg IV q6h plus pyridoxine 100 mg IV q6h to enhance alternative metabolism to
non-toxic products in ethylene glycol poisoning
Organophosphates/Cholinergic Overdose
❏ atropine
• anticholinergic / antimuscarinic
• for anticholinesterase poisonings and cholinergic poisonings with muscarinic symptoms
• 0.03 mg/kg to max 2 mg/dose (may repeat q 10-15 min until secretions dry)
(may need hundreds of milligrams)
❏ pralidoxime (Protopam, 2-PAM)
• reactivates acetylcholinesterase, reverses nicotinic effects
• organophosphate poisonings only
• most beneficial if given within 24-36 hours
• 25-50 mg/kg over 5 min IV q6h, up to 1-2 g for adults
Tricyclic Antidepressants (TCAs) Overdose
❏ cardiac monitoring mandatory because of cardiac toxicity
❏ QRS complex width predicts outcome
• > 100 ms: increased risk of seizures
• > 160 ms: increased risk of arrythmias
❏ evidence unavailable regarding when to give bicarbonate (HCO3–)
❏ dose: 1-2 mEq/kg q 10-15 min bolus (2-4 amps)
Warfarin/Rat Poison Overdose
❏ Vitamin K (see Table 16)
Table 16. Protocol for Warfarin Overdose
INR Management
< 5.0 • reduce maintenance dose +/– hold dose x 1
5.0-9.0 • if no risk factors for bleeding, hold Coumadin x 1-2 days and reduce maintenance dose
OR
• if rapid reversal required, Vit K 2-4 mg PO, repeat INR in 24 h
• additional Vit K 1-2mg PO if INR still high (onset 4-6 h)
9.0-20.0 • Vit K 3-5 mg PO, INR in 24h and additional Vit K if necessary
> 20.0 • fresh frozen plasma (FFP) 10-20 mL/kg

• Vit K 10 mg IV over 10 min (IV Vit K only if life-threatening hemorrhage); onset ~ 2 h
• increased Vit K dosing (q4h)
• phenobarbital (little evidence)
pH ALTERATION – see Table 14

❏ if toxin has potential for ion-trapping at physiologically achievable pH
❏ urine alkalinization
• urine pH 7.5-8.0
• potentially useful for salicylates, phenobarbital
• evidence for phenobarbital is equivocal
EXTRA-CORPOREAL DRUG REMOVAL (ECDR)
Criteria for Hemodialysis
❏ toxins that have
• water solubility
• low protein binding
• low molecular weight
• adequate concentration gradient
• small volume of distribution (Vd) or rapid plasma equilibration
❏ removal of toxin will cause clinical improvement
❏ advantage is shown over other modes of therapy
❏ greater morbidity from prolonged supportive care
❏ predicted that drug or metabolite will have toxic effects
❏ impairment of normal routes of elimination (cardiac, renal, or hepatic)
❏ clinical deterioration despite maximal medical support
❏ useful for toxins at the following blood levels:
• alcohols
• methanol: > 15.6 mmol/L (> 25-50 mg/dL)
• ethylene glycol: > 8 mmol/L (> 50 mg/dL)
• salicylates
• acute (within 6 h): > 7.2-8.7 mmol/L (> 100 mg/dL)
• chronic: > 4.3-4.8 mmol/L (> 60 mg/dL)
• lithium
• acute (within 6 h): > 4.0 mmol/L
• chronic: > 2.5-4.0 mmol/L
• bromine: > 15 mmol/L
• phenobarbital: 430-650 mmol/L
• chloral hydrate (––> trichloroethanol): > 200 mg/kg
Criteria for Hemoperfusion
❏ as for hemodialysis
❏ absorbent has greater drug binding capacity than protein or tissue
❏ useful for
• theophylline: > 330 mmol/L (chronic), > 550 mmol/L (acute)
• short acting barbiturates (secobarbital)
• non-barbiturate sedative-hypnotics
• (phenytoin, carbemazepine, disopyramide, paraquat, methotrexate, Amanita phalloides)
DISPOSITION FROM THE EMERGENCY DEPARTMENT (E.D.)
❏ discharge home vs. prolonged E.D. observation vs. admission
❏ methanol, ethylene glycol
• delayed onset
• admit and watch clinical and biochemical markers
❏ TCA’s
• prolonged/delayed cardiotoxicity warrants admission to monitored (ICU) bed
• if asymptomatic and no clinical signs of intoxication: 6 hour E.D. observation
adequate with proper decontamination
• sinus tachycardia alone (most common finding) with history of OD warrants observation in E.D.
❏ hydrocarbons/smoke inhalation
• pneumonitis may lag 6-8 hours
• consider observation for repeated clinical and radiographic examination
❏ ASA, acetaminophen
• if borderline level, get second level 2-4 hours after first
❏ oral hypoglycemics
• admit all patients for minimum 24 hours if hypoglycemic
Psychiatric Consultation (see Psychiatry Chapter)
❏ once patient medically cleared, arrange psychiatric intervention if required
❏ beware - suicidal ideation may not be expressed
REFERENCES
Roberts JR and Hedges JR. (ed). 1998. Clinical procedures in emergency medicine. 3rd ed. WB Saunders Co.
Tintinalli JE and Kelen GE. (ed). 1999. Emergency medicine: A comprehensive study guide. 5th ed. McGraw-Hill Professional Publishing.
Wk 9
Toxicology
& Endocrine Emergencies
Toxicological Emergencies
Overview:
- ABCs for Toxicology
- Red Flags:
o NB: 2 Tablets can kill a 10kg child
o Be aware of the meds that are toxic
o “Nice” or “Nasty”
- Know where to get help:
o Poisons Information Centre
Causes of Toxic Syndromes:

- Accidental:
o Household Drugs/Toxins (Typically little children)
o Occupational Exposure – (Acute/Chronic)
- Intentional Self-Poisoning:
o Recreational
o Parasuicidal Gesture (Call for attention)
o Suicide Attempt
- Inappropriate use of Medication
- Envenomation
Toxidromes:
- Paracetamol Overdose:
o No “Toxidrome” & Mostly Asymptomatic
o à Secondary Metabolite is Highly Hepatotoxic
o Antidote: N-Acetyl Cystiene (*A Precursor to Glutathione – A Conjugator for Paracetamol)
§ Give if the Blood-Paracetamol Level is Above the ‘Toxicity Line’ @ 4hrs.
§ (Small risk of Anaphylaxis)
- Cholinergic (Eg. Organophosphates – ACh-Esterase Inhibitors) – “SLUDGE”

o Salivation, Lacrimation, Urination, Defecation, GI Upset, Emesis
o Antidotes: Atropine (An Anti-Muscarinic) & Pralidoxime (An Ach-I-Inhibitor)
§ NB: Atropine can à VF/SVT/VT
- Anticholinergic Syndrome (Eg. TCA’s, Antihistamines, Atropine) – “Anti-SLUDGE”:

o Dry Mouth, Dry Eyes, Urinary Retention, Constipation, ….
o TCA Overdose à Widening QRS + Right-Axis Deviation.
o Antidote: Sodium Bicarbonate:
§ Works by preventing the combination of acid with the ionic form of TCA to form the TCA
molecule (which is absorbed by cells).
§ Also prevents the positive feedback loop of acidosis (which increases the level of TCA
Molecules)
- Extrapyramidal (Eg. Antipsychotics) - “TROD”

o Tremor, Rigidity, Opisthotonos (Abnormal Posture), Dysphagia (Difficulty Swallowing)
- Opioid:
o Triad: Coma, Respiratory Depression, Miosis (Pinpoint Pupils)
o Antidote: Naloxone (An Opioid Receptor Antagonist)
§ Given ASAP after overdose
§ NB: Naloxone is often shorter-acting than the Opioids taken :. Require constant infusion.
• Wears off after 45mins
- Sedative/Hypnotic (Eg. Benzodiazepines):
o Triad: Coma, Respiratory Depression, Impaired Airway
o Antidote: Flumazenil (Rarely Used)
§ NB: If Pt. is a Benzo Addict, Flumazenil can à Acute Withdrawal. :. Titrate Dose.
- Sympathomimetic (Eg. Amphetamines, Cocaine):

o Paranoid Schizophrenia, Very Excited, Tachycardia, Hypertension
- Serotonergic (Eg. SSRI Antidepressants):

o Agitation, Confusion, Diarrhea, Fever, Shivering, Tremor
- Withdrawal Syndromes (Eg. Alcohol/Sedatives (Benzos)/Narcotics):

o Restlessness, Irritability, Chills, Hallucinations, Confusion, Sympathetic Overactivity (Sweating,
Tachycardia, Hypertension), Seizures
Approach to the Poisoned Patient:

1) Primary Survey:
a. ABCD:
i. Airway (eg. Vomiting/Aspiration/Allergic Reaction à Swelling/Altered Consciousness à
Loss of Ability to maintain Airway)
ii. Breathing (Eg. Too Much/Too Little)
iii. Circulation (Eg. Tachy/Brady/Hypertension/Hypotension) – (Monitor with ECG & BP)
iv. Disability (Conscious State)/Danger (What did they take/When/How Much)
b. Drug Manipulation (Decontamination &/Or Decrease Absorption/Specific Antidotes):
i. Ipecac (Induce Vomiting) - Minimal Use in ED
ii. Gastric Lavarge (Useful within the 1st hour) – Now de-emphasized in ED
iii. Activated Charcoal
1. (Binds free drug in lumen of gut à ↓drug concentration à ↓Absorption)
2. Only effective for things that will bind. (won’t bind small ionic compounds, heavy
metals, or alcohols)
3. Very Time Dependent
iv. Whole Bowel Irrigation (Eg. Polyethylene Glycol – Golytley: An osmotic agent à Flushes
out bowel)
v. Skin Decontamination (eg. Organophosphate Poisoning)
vi. Left Lateral Position à Delays Gastric Emptying.
vii. Cathartics (flush things through)
viii. Urine pH Alteration
ix. Dialysis
x. Chelation
c. Differential Diagnosis:
i. Impaired Conscious State (SMASHED):
1. S Substrate/Sepsis
2. M Meningitis/Mental Illness
3. A Alcohol/Accident (CVA/SAH/Subdural/CHI)
4. S Seizures/Stimulants
5. H Hypo/Hyper- (Thyroidism/Thermia/Glycaemia/Tension/Carbia)
6. E Electrolytes/Encephalopathy/Envenomation
7. D Drugs
ii. Don’t Forget Blood Sugar
iii. ECG:
1. Screening for Lethal Toxicologies.
2) Emergency Antidotes:
a. Paracetamol N-Acetyl Cysteine
b. Opiates Naloxone
c. Benzos Flumazenil
d. Ca Antagonists Insulin & Glucose
3) Secondary Survey:
a. Examination & History:
i. Directed History:
1. Who
2. What
3. Where
4. When
5. Why
6. How
ii. Systematic Examination:
1. Identify Problems
2. Recognition of Toxic Syndromes
iii. Focused Investigations:
1. BSL
2. ECG
3. Electrolytes
4. LFTs (liver function tests)
5. EtOH
6. ABG
7. FBE
8. Paracetamol Level
9. Toxic Screen
b. Education:
i. To Prevent Accidental Poisonings (eg. In kids)
ii. Put drugs in childproof containers
c. Funny Behaviour:
i. Underlying Psychodynamics:
1. Intent? – What did you think would happen?
2. Suicidal? – Do a “SAD PERSONS” score.
3. Predisposing Psychiatric Illness (Eg. Psychosis, Depression)
4) Definitive Care:
a. Serious or Potentially Serious à ICU
b. Mild à Observe in ED
c. Self harm à Psychiatric Evaluation
Endocrine Emergencies:
Focus on Diabetic Emergencies
Diabetic Emergencies:
• Diabetic Ketoacidosis:
o Acute life threatening
o Pathology – Combination of:
§ Insulin Deficiency
• Cell unable to absorb & metaoblis glucose
§ Excess Counter-Regulatory Hormones (Eg. Glucagon/Adrenaline)
• Glycogen Breakdown
• Lipolysis à Ketogenesis
• Protein Catabolism
§ Resultant Hyperglycaemia
• Osmotic dieresis à Dehydration
o Presentation:
§ – of Underlying Diabetes:
• Polyuria
• Polydipsia
• Weight loss
§ – of Hyperglycaemia:
• Glycosuria/Osmotic dieresis
• Salt & Water Depletion
§ – of Hyperketonaemia à Metabolic Acidosis:
• Acetone Breath
• Hyperventilation (Respiratory Compensation)
• Peripheral Vasodilation à Hypotension
• K+ Depletion
o Treatment:
§ Supportive (ABCs)
§ Rehydration
• Replace ½ fluid deficit in 1st 12 hrs
§ Insulin infusion
§ Close monitoring of Electrolytes
- Hyperosmolar Non-Ketotic Coma:
o Pathophysiology:
§ Relative Insulin Deficiency
§ Enough to Prevent Lipolysis;
• à NO Ketosis
§ But Not enough to Prevent Hyperglycaemia
• à Hyperglycaemia
o Presentation:
§ Confusion/Coma
§ Marked Dehydration
o Treatment:
§ Supportive ABCs
§ Rehydration
§ Insulin Infusion
- Hypoglycaemia:
o Don’t Ever Forget Glucose:
§ Because severe or prolonged hypoglycaemia can cause Brain damage/death.
o Causes:
§ **Diabetic:
• Insulin Overdose (Accidental/Suicide Attempt)
• Missed Meal
• Exercise
• Alcohol
§ Alcohol Excess
§ Sepsis
o Symptoms:
§ CNS Glucose Deficiency
• Confunsion/Coma/Seiure
• Drowsiness
• Incoordination
§ Autonomic
• Anxiety
• Sweating
• Tremors
• Palpitation
§ Non Specifics
• Nausea
• Headache
• Fatigue
o Diagnosis:
§ Hypoglycaemia
§ Clinical Symptoms
§ Response to Glucose Administration
o Treatment:
§ Supportive:
• ABCs
§ Suspect the Diagnosis:
• Don’t ever forget glucose
§ Correct serum Glucose:
• Glucose Oral/IV
• Glucagon (if IV Glucose isn’t possible)
§ Disposition
• Oral Hypoglycaemics (Admit to all patients)
Other Endocrine Emergencies:
- Alcoholic Ketoacidosis:
o Cause:
§ Alcoholic with recent decreased food intake
o Presentation:
§ Abdo pain, nausea & vomiting
§ Metabolic Acidosis & Possible Ketoneuria
o Treatment:
§ Supportive ABCs
§ Rehydration
- Thyroid:
o Hyperthyroidism:
§ Cause:
• High free T4 & low TSH
o Eg. Graves Disease: goitre, exopthalmos, pretibial myxoedema
§ Presentation:
• àNervousness, irritability, mental disturbance, tachycardia,
• àpalpitations, heat intolerance, weight loss, goiter
§ Treatment:
• Supportive ABCs
• Block Effects of T4 (Thyroid Blocking Drugs)
o Hypothyroidism:
§ Cause:
• Low free T4 & high TSH
§ Presentation:
• àFatigue, weakness, constipation, cold intolerance & depression
• à Goitre, menstrual irregularities
§ Treatment:
• Supportive ABCs
• T4 Replacement (Thyroxine)
- Adrenocortical Insufficiency:
o Causes:
§ Primary:
• Adrenal Failure
§ Secondary:
• Pituitary Failure
• Adrenopituitary Suppression by Steroids
o Presentation:
§ àHypotension, abdominal pain, confusion, weakness, & pigmentation
§ àHyponatraemia
§ àHyperkalaemia
o Treatment:
§ Corticosteroid Replacement (Hydrocortisone)
Physical Exam
❏ vitals
• temperature often increased in delirium or toxic psychosis
• hypothermia may have altered mental status
❏ signs of trauma - especially head and neck
❏ neurologic exam, including brief mental status
❏ signs of drug toxicity and needle marks
❏ signs of hypoglycemia
Investigations
❏ screening bloodwork: CBC, lytes, glucose, creatinine, BUN, osmolality
❏ selective drug and toxin screen (see Toxicology section)
❏ CT head if necessary
TOXICOLOGY
APPROACH TO THE OVERDOSE PATIENT
History Taking
1. How much? How long ago? What method? (ingestion, inhalation, dermal, occular, environmental, IV ?)
2. accidental vs non-accidental exposure
Physical Exam
1. focus on: BP, HR, pupils, LOC, airway
Principles of Toxicology
❏ “All substances are poisons ... The right dose separates a poison from a remedy”
❏ 5 principles to consider with all ingestions
1. resuscitation (ABCs)
2. screening (toxidrome? clinical clues?)
3. decrease absorption of drug
4. increase elimination of drug
5. is an antidote available?
❏ suspect overdose when:
• altered level of consciousness/coma
• young patient with life-threatening arrhythmia
• trauma patient
• bizarre or puzzling clinical presentation
ABCs OF TOXICOLOGY
❏ basic axiom of care is symptomatic and supportive treatment
❏ can only address underlying problem once patient is stable
A Airway (consider stabilizing the C-spine)
B Breathing
C Circulation
D1 Drugs
• ACLS as necessary to resuscitate the patient
• universal antidotes
D2 Draw bloods
D3 Decontamination (decreased absorption, increased elimination)
E Expose (look for specific toxidromes)/Examine the Patient
F Full vitals, ECG monitor, Foley, x-rays, etc.
G Give specific antidotes, treatments
Go back and reassess.
CALL POISON CONTROL CENTRE
OBTAIN CORROBORATIVE HISTORY FROM FAMILY/FRIENDS IF PRESENT
D1 - UNIVERSAL ANTIDOTES
❏ treatments which will never hurt any patient and which may be essential
Oxygen
❏ do not deprive a hypoxic patient of oxygen no matter what the
antecedent medical history (i.e. even COPD and CO2 retention)
❏ if depression of hypoxic drive, intubate and ventilate
❏ only exception: paraquat or diquat (herbicides) inhalation or ingestion
Thiamine (Vitamin B1)

❏ 100 mg IV/IM to all patients prior to IV/PO glucose
❏ a necessary cofactor for glucose metabolism, but do not delay glucose if thiamine unavailable
❏ to prevent Wernicke-Korsakoff syndrome WACO
• Wernicke’s encephalopathy - Ataxia, Confusion, Ophthalmoplegia)
• untreated, may progress to Korsakoff’s psychosis (disorder in learning and
processing of new information)
• treatment: high dose thiamine (1000 mg/day x 3 days)
• most features usually irreversible
❏ populations at risk for thiamine deficiency
• alcoholics
• anorexics
• hyperemesis of pregnancy
• malnutrition states
❏ in E.D., must assume all undifferentiated comatose patients are at risk
Glucose
❏ give to any patient presenting with altered LOC
❏ do dextrostix prior to glucose administration
❏ adults: 0.5-1.0 g/kg (1-2 mL/kg) IV of D50W
❏ children: 0.25 g/kg (2 mL/kg) IV of D25W
Naloxone
❏ antidote for opioids: diagnostic and therapeutic (1 min onset of action)
❏ used in the setting of the undifferentiated comatose patient
❏ loading dose
• adults
• 2 mg initial bolus IV/IM/SL/SC or via ETT
• if no response after 2-3 minutes, progressively double dose until a response or
total dose of 10 mg given
• known chronic user, suspicious history, or evidence of tracks 0.01 mg/kg
(to prevent acute withdrawal)
• child
• 0.01 mg/kg initial bolus IV/IO/ETT
• 0.1 mg/kg if no response and narcotic suspected
❏ maintenance dose
• may be required because half-life of naloxone much shorter
than many narcotics (half-life of naloxone is 30-80 minutes)
• hourly infusion rate at 2/3 of initial dose that produced patient arousal
D2 - DRAW BLOODS
❏ essential bloods
• CBC, electrolytes, urea, creatinine
• glucose (and dextrostix), INR, PTT
• ABGs, measured O2 sat
• osmolality
• acetylsalicylic acid (ASA), acetaminophen alcohol levels
❏ potentially useful bloods
• drug levels
• Ca2+, Mg2+, PO43–
• protein, albumin, lactate, ketones and liver tests
Serum Drug Levels
❏ treat the patient, not the drug level
❏ negative toxicology screen only signifies that the specific drugs tested were not detectable in the particular
specimen at the time it was obtained (i.e. does not rule out a toxic ingestion)
❏ generally available on serum screens (differs by institution)
(screen is different from drug levels - screen is very limited)
• acetaminophen*
• ASA*
• barbituates and other sedative/hypnotics
• benzodiazepines (qualitative only)
• ethanol
• ethylene glycol*
• methanol*
• tricyclic antidepressant (TCA) (qualitative only)
* significant if in "toxic" range
❏ urine screens also available (qualitative only)
Toxic Gaps (see Nephrology Chapter)
Anion gap (AG) = Na+ – (Cl– + HCO3–) Plasma osmolal gap (POG) = (measured - calculated) osmoles
• normal range 10-14 mmol/L • normally POG < 10 mOsm/L
• unmeasured cations: Mg2+, Ca2+ • calculated osmolality = 2 Na+ + BUN + blood glucose (mmol/L)
• unmeasured anions: proteins, organic acids, PO43–, sulfate
Metabolic acidosis Plasma Osmolal Gaps
Increased AG: differential of causes (*toxic) Increased osmolal gap: “MAE DIE”
“MUDPILES CAT" Methanol
Methanol* Acetone
Uremia Ethanol
Diabetic ketoacidosis/Alcoholic ketoacidosis
Diuretics (glycerol, mannitol, sorbitol)
Phenformin*/Paraldehyde*
Isoniazid*/Iron* Isopropanol
Lactate (anything that causes seizures or shock) Ethylene glycol
Ethylene glycol*
Salicylates* Oxygen saturation gap: (measured – calculated) O2 saturation
(1) measured by absorption spectrophotometry (pulse oximetry)
Cyanide* (2) calculated from Hb/O2 saturation curve
Arsenic*
Toluene* Increased O2 saturation gap
(3) carboxyhemoglobin
Decreased AG
1. error (4) methemoglobin
2. electrolyte imbalance (increased Na+/K+/Mg2+) (5) sulfhemoglobin
3. hypoalbuminemia (50% fall in albumin
~ 5.5 mmol/L decrease in the AG)
4. Li, Br elevation
5. paraproteins (multiple myeloma)
Normal AG
(1)K+: pyelonephritis, obstructive nephropathy, renal tubular acidosi (RTA), IV, TPN
(2)K+: small bowel losses, acetazolamide, RTA I, II
Table 13. Use of the Clinical Laboratory in the Initial Diagnosis of Poisoning
TEST FINDING SELECTED CAUSES
ABGs • hypoventilation (8 Pco2) • CNS depressants (opioids, sedative-hypnotic

agents, phenothiazines, and EtOH)
• hyperventilation • salicylates, CO, other asphyxiants
Electrolytes • anion-gap metabolic acidosis • “MUDPILES CAT”

• hyperkalemia • digitalis glycosides, fluoride, K+
• hypokalemia • theophylline, caffeine, ß-adrenergic agents,
soluble barium salts, diuretics
Glucose • hypoglycemia • oral hypoglycemic agents, insulin, EtOH
Osmolality • elevated osmolar gap • “MAE DIE”

and Methanol, Acetone, Ethanol, Diuretics,
Osmolar Gap Isopyropyl alcohol, Ethylene glycol
ECG • wide QRS complex • TCAs, quinidine, other class Ia and Ic

antiarrhythmic agents
• prolongation of QT interval • quinidine and related antiarrhythmics,
terfenadine, astemizole
• atrioventricular block • Ca2+ antagonists, digitalis glycosides,
phenylpropanolamine
Abdominal • radiopaque pills or objects • “CHIPES”

x-ray Calcium, Chloral hydrate, CCl4, Heavy metals,
Iron, Potassium, Enteric coated Salicylates,
and some foreign bodies
Serum • elevated level (> 140 mg/l • acetaminophen (may be the only clue to a recent
Acetaminophen 4 hours after ingestion) ingestion)
D3 - DECONTAMINATION
❏ PROTECT YOURSELF FIRST
❏ CALL POISON CONTROL CENTRE IF ANY UNCERTAINTY
Ocular Decontamination
❏ saline irrigation to neutral pH
❏ alkali exposure requires ophthalmology consult
Dermal Decontamination (wear protective gear)
❏ remove clothing
❏ brush off toxic agents
❏ irrigate all external surfaces
Gastrointestinal Decontamination
❏ activated charcoal (AC)
• indications
• single dose will prevent significant absorption of many drugs and toxins
• acids, alkalis, cyanides, alcohols, Fe, Li
• dose = 1 g/kg body weight or 10 g/g drug ingested
• odourless, tasteless, prepared as slurry with H2O
• cathartics rarely used (risk electrolyte imbalance)
❏ multi-dose activated charcoal (MDAC)
• absorption of drug/toxin to charcoal prevents availability and promotes fecal elimination
• without charcoal, gut continuously absorbs toxins; MDAC (multidose activated charcoal) interrupts the
enterohepatic circulation of some toxins and binds toxin diffusing back into enteral membrane from the
circulation
• MDAC can increase drug elimination (potentially useful for phenobarbitol, carbamazepine,
theophylline, digitoxin, others)
• dose
• various regimes
• continue until nontoxic or charcoal stool
❏ whole bowel irrigation
• flushes out bowel
• 500 mL (child) to 2000 mL (adult) of balanced electrolyte solution/hour by mouth until clear
effluent per rectum
• indications
• awake, alert patient who can be nursed upright
• delayed release product
• drug/toxin not bound to charcoal
• drug packages - if any evidence of breakage ––> emergency surgery
• recent toxin ingestion (up to 4-6 hours)
• evidence of ileus, perforation, or obstruction
❏ surgical removal
• indicated for drugs
• that are toxic
• that form concretions
• that are not removed by conventional means
E - EXAMINE THE PATIENT

❏ vital signs (including temperature), skin (needle tracks, colour), mucous membranes, odours and CNS
❏ head-to-toe survey
• C-spine
• signs of trauma
• signs of seizures (incontinence, “tongue biting”, etc.)
• signs of infection (meningismus)
• signs of chronic alcohol abuse
• signs of drug abuse (track marks, nasal septum erosion)
• mental status
SPECIFIC TOXIDROMES
Narcotics, Sedatives/Hypnotics, Alcohol Overdose
❏ signs and symptoms
• hypothermia
• bradycardia
• hypotension
• respiratory depression
• dilated/constricted pupils
• CNS depression
Drug / Substance Withdrawal

❏ withdrawal state generally opposite to the physiological effect of the drug
❏ signs and symptoms of sedative withdrawal
• increased temperature • agitation
• tachycardia • tremor
• hypertension • hallucinations
• dilated pupils • seizures
• diaphoresis
❏ drugs
• alcohol
• benzodiazepines
• barbituates
• antihypertensives
• opioids
Drug Class Overdose Signs and Symptoms Examples of Drugs
Anticholinergics • hyperthermia “Hot as a Hare” Anticholinergic drugs

• dilated pupils "Blind as a Bat” antidepressants
• dry skin “Dry as a Bone” Flexeril
• vasodilatation “Red as a Beet” Tegretol
• agitation/hallucinations “Mad as a Hatter” antihistamines (e.g. Gravol, diphenhydramine)
• ileus “The bowel and bladder antiparkinsonians
• urinary retention lose their tone and the antipsychotics
• tachycardia heart goes on alone” antispasmotics
belladonna alkaloids (e.g. atropine, scopolamine)
Cholinergics “DUMBELS” cholinergics

Diaphoresis, Diarrhea, Decreased blood pressure (nicotine, mushrooms)
Urination anticholinesterases
Miosis (physostigmine, organophosphate insecticides)
Bronchorrhea, Bronchospasm, Bradycardia
EEmesis, Excitation of skeletal muscle
Lacrimation
Salivation, Seizures
Extrapyramidal dysphonia major tranquilizers

rigidity and tremor
dysphagia
torticollis
laryngospasm
trismus (deviation of eyes in all directions)
oculogyric crisis
Hemoglobin Derangements increased respiratory rate carbon monoxide poisoning (carboxyhemoglobin)

decreased level of consciousness
seizures
cyanosis (unresponsive to O2) drug ingestion (methemoglobin, sulfhemoglobin)
lactic acidosis
Metal Fume Fever abrupt onset of fever, chills, myalgias fumes from heavy metals (welding, brazing, etc.)
metallic taste in mouth amphetamines
nausea and vomiting • caffeine
headache • cocaine
fatigue (delayed respiratory distress) • ephedrine (and other decongestants)
• LSD
Sympathomimetics increased temperature • PCP

CNS excitation (including seizures) • theophylline
tachycardia
nausea and vomiting • thyroid hormone
hypertension •ASA toxicity looks like sympathomimetic
diaphoresis overdose
dilated pupils • sedative/hypnotic withdrawal
(including alcohol) also similar
G - GIVE SPECIFIC ANTIDOTES AND TREATMENTS

❏ note: hemodialysis can be considered for all drugs
Table 14. Toxins and Antidotes
Toxin Antidote/Treatment
Acetaminophen N-acetylcysteine (Mucomyst)
Anticholinergics *Physostigmine
Benzodiazepines flumazenil (Romazicon/Anexate)
ß-blockers atropine, isoprotenerol, glucagon
Calcium channel blockers calcium chloride or gluconate
Carbon Monoxide 100% oxygen, hyperbaric O2
Cyanide Lilly kit (amyl nitrite, then sodium nitrite): Na thiosulfate
Digoxin stop dig, use FAB fragments (Digibind), restore K+
Heparin protamine sulfate
Insulin glucose/glucagon
Iron deferoxamine
Methanol/Ethylene glycol ethanol or fomepizole, leucovorin (for methanol), thiamine and pyrudoxine for EG
Nitrites methylene blue
Opioids naloxone (Narcan)
Organophosphates atropine, pralidoxime
Salicylates alkalinize urine, restore K+
TCA’s sodium bicarbonate bolus
Warfarin vitamin K; (FFP if necessary)
* available through special access programme only
SPECIFIC TREATMENTS
Acetaminophen Overdose
acetaminophen = paracetamol = APAP
❏ acute acetaminophen OD ––> metabolized by Cytochrome P450 ––> saturation of pathway ––>
toxic metabolite (NAPQI) scavenged by glutathione (an antioxidant) (in non-overdose situations)
• in OD: exhaustion of glutathione stores ––> NAPQI accumulates ––>
binds hepatocytes and hepatic necrosis
❏ toxic dose of acetaminophen > 150 mg/kg (~7.0 g)
❏ increased risk of toxicity if chronic EtOH and/or anti-convulsant drugs
❏ clinical: no symptoms
• serum acetaminophen level
• evidence of liver/renal damage (delayed > 24 hours)
• increased AST, INR
• decreased glucose, metabolic acidosis, encephalopathy (indicate poor prognosis)
❏ management
• decontamination
• serum acetaminophen level 4 hours post ingestion
• measure liver enzymes and INR, PTT
• use the Rumack-Matthew Nomogram for acetaminophen hepatotoxicity
• N-acetylcysteine (Mucomyst)
• substitutes for glutathione as anti-oxidant to prevent liver damage
• use according to dosing nomogram
• best effect if started within 8 hrs post-ingestion, but therapy should be initiated regardless
ASA Overdose
❏ acute and chronic (elderly with renal insufficiency)
❏ clinical
• hyperventilation (central stimulation of respiratory drive)
• increased AG metabolic acidosis (increased lactate)
• tinnitus, confusion, lethargy
• coma, seizures, hyperthermia, non-cardiogenic pulmonary edema, circulatory collapse
❏ ABG’s possible: 1. respiratory alkalosis
2. metabolic acidosis
3. respiratory acidosis
❏ management
• decontamination
• 10:1 charcoal:drug ratio
• whole bowel irrigation (useful if enteric-coated ASA)
• close observation of serum level, serum pH
• alkalinization of urine as in Table 14 to enhance elimination and to protect the brain
(want serum pH 7.45-7.55)
• may require K+ supplements for adequate alkalinization
• consider hemodialysis when
• severe metabolic acidosis (intractable)
• increased levels
• end organ damage (unable to diurese)
Table 15. Urine Alkalinization in ASA Overdose

Plasma pH Urine pH Treatment
alkaline alkaline D5W with 20 mEq KCl/L +
alkaline acid D5W with 40 mEq KCl/L +
acid acid D5W with 40 mEq KCl/L + 4 amps HCO3/L
Anticholinergic Overdose (e.g. antihistamines)

❏ physostigmine salicylate: reversible acetylcholinesterase inhibitor
❏ supportive therapy
Benzodiazepine (BZ) Overdose
❏ flumazenil (Anexate): specific benzodiazepine antagonist
❏ indications
• iatrogenic BZ oversedation
• to reverse BZ anesthesia
❏ contraindications
• known seizure disorder
• mixed OD (especially if tricyclic antidepressant (TCA) suspected)
• BZ dependence or chronic use
❏ dose
• adult: 0.3 mg IV (q5mins to maximum 1.0 g)
• child: 10 µg/kg (as above, maximum 0.3 mg)
❏ CAUTION - most BZ have prolonged half life compared to flumazenil
• if re-sedation occurs, repeat doses or IV infusion may be indicated
Beta Blockers
❏ symptoms within 2 hours of ingestion
❏ glucagon
• works as non-ß-adrenergic receptor agonist to increase production of cAMP, thereby
increasing contractility
❏ glucagon 50-100 µg/kg (5-10 mg for adults) slow IV push, then IV at 70 µg/kg/hour
Calcium Channel Blockers
❏ order ECG, lytes (Ca2+, Na+, Mg2+, K+ especially)
❏ calcium chloride 1-4 g of 10% solution IV if hypotension
❏ glucagon
❏ inotrope/aggressive supportive therapy
CO Poisoning
❏ 100% O2 therapy by face mask critical for CO poisoning
❏ hyperbaric O2 disputed benefits; no evidence for therapy in mild-moderate
cerebral dysfunction (may prevent neurological sequelae)
❏ coma is an undisputed indication for hyperbaric O2 therapy (still the standard of care)
❏ hyperbaric O2 (efficacy unclear) suggested for pregnant patients
Digoxin Overdose
❏ Digibind = digoxin-specific antibody fragments (Fab)
❏ use in combination with activated charcoal
❏ indications
• life threatening arrhythmias unresponsive to conventional therapy (ventricular fibrillation,
ventricular tachycardia, conduction block)
• 6 hr serum digoxin >19 nmol/L (> 15 ng/mL)
• initial serum K+ > 5 mmol/L
• history of ingestion > 10 mg for adult, > 4 mg for child
❏ dose
• 1 vial = 40 mg Digibind neutralizes 0.6 mg digoxin
• cost of one vial = $200
• empirically: 20 vials if acute ingestion 5-10 vials if chronic ingestion (90-95% of cases)
• onset of action 20-90 minutes
• renal elimination half life 20-30 hours
Acute Dystonic Reaction
❏ benztropine (Cogentin), antihistamines, benzodiazepines effective
❏ benztropine has euphoric effect and potential for abuse
❏ for acute dystonic reaction
• 1-2 mg IM/IV benztropine then 2mg PO bid x 3 days
OR
diphenhydramine 1-2 mg/kg IM/IV then 25 mg PO qid x 3 days
Hydrogen Fluoride Burns

❏ Ca2+ gluconate gel topical or intradermal or both
❏ intravenous calcium chloride for systemic hypocalcemia, hyperkalemia
Insulin/Oral Hypoglycemic Overdose
❏ glucose can be given IV, PO or via NG
❏ glucagon (if no access to glucose)
• 1-2 mg IM
Ethanol Overdose
❏ very common in children
❏ mouthwash > 70% EtOH, perfumes/colognes 40 – 60% EtOH
❏ dehydrogenase pathway is less active in children
❏ presentation: flushed face, dilated pupils, sweating, GI distress, hypothermia, hypoventilation, hypotension
❏ order: serum EtOH level, glucose
❏ manage: airway, circulation, glucose levels
❏ folate up to 50 mg q4h IV
❏ gastric decontamination if ingestion < 1hr ago
❏ hemodialysis if serum EtOH > 500 mg/dL
Methanol or Ethylene Glycol Overdose
❏ ethanol PO/IV used to block metabolism of methanol and ethylene glycol preventing toxicity
❏ Fomepizole (4-methylpyrazole) 15 mg/kg initial dose, a competitive inhibitor of alcohol dehydrogenase,
available for ethylene glycol intoxication (~$2000 a day); recent evidence for use in methanol intoxication
❏ folic acid (Leucovorin) 50 mg IV q4h for several days to potentiate folate-dependent metabolism of formic
acid in methanol poisoning
❏ dialysis if ethanol treatment unsuccessful, visual impairment (MetOH), renal failure (ethylene glycol)
or uncorrectable metabolic acidosis
❏ thiamine 100 mg IV q6h plus pyridoxine 100 mg IV q6h to enhance alternative metabolism to
non-toxic products in ethylene glycol poisoning
Organophosphates/Cholinergic Overdose
❏ atropine
• anticholinergic / antimuscarinic
• for anticholinesterase poisonings and cholinergic poisonings with muscarinic symptoms
• 0.03 mg/kg to max 2 mg/dose (may repeat q 10-15 min until secretions dry)
(may need hundreds of milligrams)
❏ pralidoxime (Protopam, 2-PAM)
• reactivates acetylcholinesterase, reverses nicotinic effects
• organophosphate poisonings only
• most beneficial if given within 24-36 hours
• 25-50 mg/kg over 5 min IV q6h, up to 1-2 g for adults
Tricyclic Antidepressants (TCAs) Overdose
❏ cardiac monitoring mandatory because of cardiac toxicity
❏ QRS complex width predicts outcome
• > 100 ms: increased risk of seizures
• > 160 ms: increased risk of arrythmias
❏ evidence unavailable regarding when to give bicarbonate (HCO3–)
❏ dose: 1-2 mEq/kg q 10-15 min bolus (2-4 amps)
Warfarin/Rat Poison Overdose
❏ Vitamin K (see Table 16)
Table 16. Protocol for Warfarin Overdose
INR Management
< 5.0 • reduce maintenance dose +/– hold dose x 1
5.0-9.0 • if no risk factors for bleeding, hold Coumadin x 1-2 days and reduce maintenance dose
OR
• if rapid reversal required, Vit K 2-4 mg PO, repeat INR in 24 h
• additional Vit K 1-2mg PO if INR still high (onset 4-6 h)
9.0-20.0 • Vit K 3-5 mg PO, INR in 24h and additional Vit K if necessary
> 20.0 • fresh frozen plasma (FFP) 10-20 mL/kg

• Vit K 10 mg IV over 10 min (IV Vit K only if life-threatening hemorrhage); onset ~ 2 h
• increased Vit K dosing (q4h)
• phenobarbital (little evidence)
pH ALTERATION – see Table 14

❏ if toxin has potential for ion-trapping at physiologically achievable pH
❏ urine alkalinization
• urine pH 7.5-8.0
• potentially useful for salicylates, phenobarbital
• evidence for phenobarbital is equivocal
EXTRA-CORPOREAL DRUG REMOVAL (ECDR)
Criteria for Hemodialysis
❏ toxins that have
• water solubility
• low protein binding
• low molecular weight
• adequate concentration gradient
• small volume of distribution (Vd) or rapid plasma equilibration
❏ removal of toxin will cause clinical improvement
❏ advantage is shown over other modes of therapy
❏ greater morbidity from prolonged supportive care
❏ predicted that drug or metabolite will have toxic effects
❏ impairment of normal routes of elimination (cardiac, renal, or hepatic)
❏ clinical deterioration despite maximal medical support
❏ useful for toxins at the following blood levels:
• alcohols
• methanol: > 15.6 mmol/L (> 25-50 mg/dL)
• ethylene glycol: > 8 mmol/L (> 50 mg/dL)
• salicylates
• acute (within 6 h): > 7.2-8.7 mmol/L (> 100 mg/dL)
• chronic: > 4.3-4.8 mmol/L (> 60 mg/dL)
• lithium
• acute (within 6 h): > 4.0 mmol/L
• chronic: > 2.5-4.0 mmol/L
• bromine: > 15 mmol/L
• phenobarbital: 430-650 mmol/L
• chloral hydrate (––> trichloroethanol): > 200 mg/kg
Criteria for Hemoperfusion
❏ as for hemodialysis
❏ absorbent has greater drug binding capacity than protein or tissue
❏ useful for
• theophylline: > 330 mmol/L (chronic), > 550 mmol/L (acute)
• short acting barbiturates (secobarbital)
• non-barbiturate sedative-hypnotics
• (phenytoin, carbemazepine, disopyramide, paraquat, methotrexate, Amanita phalloides)
DISPOSITION FROM THE EMERGENCY DEPARTMENT (E.D.)
❏ discharge home vs. prolonged E.D. observation vs. admission
❏ methanol, ethylene glycol
• delayed onset
• admit and watch clinical and biochemical markers
❏ TCA’s
• prolonged/delayed cardiotoxicity warrants admission to monitored (ICU) bed
• if asymptomatic and no clinical signs of intoxication: 6 hour E.D. observation
adequate with proper decontamination
• sinus tachycardia alone (most common finding) with history of OD warrants observation in E.D.
❏ hydrocarbons/smoke inhalation
• pneumonitis may lag 6-8 hours
• consider observation for repeated clinical and radiographic examination
❏ ASA, acetaminophen
• if borderline level, get second level 2-4 hours after first
❏ oral hypoglycemics
• admit all patients for minimum 24 hours if hypoglycemic
Psychiatric Consultation (see Psychiatry Chapter)
❏ once patient medically cleared, arrange psychiatric intervention if required
❏ beware - suicidal ideation may not be expressed
REFERENCES
Roberts JR and Hedges JR. (ed). 1998. Clinical procedures in emergency medicine. 3rd ed. WB Saunders Co.
Tintinalli JE and Kelen GE. (ed). 1999. Emergency medicine: A comprehensive study guide. 5th ed. McGraw-Hill Professional Publishing.

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ASSESSMENT OF LOC:

- Glasgow Coma Scale (GCS) - KNOW THIS:

(*Remember 4 Eyes, Jackson 5, 6 Cylinder Engine)

Table 3. Glasgow Coma Scale

spontaneously 4 answers questions appropriately 5 obeys commands 6

❏ best reported as a 3 part score: Eyes + Verbal + Motor = total

Toxic/Metabolic Primary CNS Disease/Trauma

M - Major organ failure

MANAGEMENT OF THE COMATOSE PATIENT

MCCQE 2002 Review Notes Emergency Medicine – ER7

Table 4. Structural vs. Metabolic Coma

Pupillary asymmetric pupils equal, round, regular

Extraocular asymmetric symmetric

Motor asymmetric symmetric

Table 5. Toxic - Metabolic Causes of Fixed Pupils

Cause Pupils Characteristics Treatment

Anoxia dilated antecedent history of 100% O2,

Anticholinergic dilated tachycardia physostigmine (for Atropine)

Cholinergic Agents small, barely diaphoresis, vomiting, atropine

Opiates pinpoint, barely needle marks naloxone

Hypothermia normal history of exposure warm patient

Barbiturates midsized history of exposure ABC’s

Methanol (rare) dilated optic neuritis ethanol ± dialysis

❏ it is essential to re-examine comatose patients frequently - can change rapidly

ER8 – Emergency Medicine MCCQE 2002 Review Notes

• Framework Dealing with an Emergency:

“Tell me your name”:

§ Pt: “I’m John Smith” - You Know That:

“How are you today?”:

§ Pt: “Awful! This pain is dreadful”:

“Where does it Hurt?”:

§ Pt: “In my belly. Just here”:

§ At the Same Time You are LOOKING & FEELING:

You Also Have an Idea of O2 Saturation:

• NB: Different Pain Scales are used for different people:

Triage & Assessment Questions:

NTS NTS Maximum

1 Resuscitation 0 min Red Cardiac Arrest

3 Urgent 30 min Green Acute Abdominal Pain

4 Semi Urgent 60 min Blue Sprained Ankle

5 Non Urgent 120 min White Repeat Script

- 1. Assign each of the following patients to a Triage Category:

Patient 1 is a triage category 3

PATIENT DESCRIPTION TRIAGE REASON

trauma requiring intubation

no immediate need immediate need

C-spine x-ray apneic breathing

positive negative* facial smash no facial smash

unable unable unable

cricothyroidotomy cricothyroidotomy cricothyroidotomy

Figure 1. Approach to Endotracheal Intubation in an Injured Patient

C. CIRCULATION - see Shock section

Table 1. Estimation of Degree of Shock

Table 2. Estimated Systolic Blood Pressure (SBP)

MCCQE 2002 Review Notes Emergency Medicine – ER3

❏ stop major external bleeding

MCCQE 2002 Review Notes Emergency Medicine – ER5

WHAT IS A CARDIOVASCULAR EMERGENCY ?

o Was this a CVS Emergency ? YES

o Was this a CVS Emergency? YES