Author Archive

A&E Checklist For Students

Posted: November 8, 2010 by smarinz7 in A & E

LIST OF COMMON DISEASES (Selected)

1. Cardiovascular• Acute coronary syndrome• Hypertensive crisis• MI• Cardiogenic shock

2. Gastrointestinal• Cholecystitis,biliary colic

3. Neurology• Meningitis• Coma• Intracranial hypertension

4. Endocrinology• Addisonian crisis,DKA.

5. Pulmonology•Bronchial Asthma. ARDS• Pulmonary edema and congestive heart failure

6. Toxicology• General poisoning

7. Nephrology• Acute renal failure

8. Others• Pain management.Chest Pain

LIST OF PRACTICAL SKILLS

1. Arrest of bleeding

2. Transport immobilisation

3. Airway. Breathing and circulation (ABC)

a. Cardiopulmonary resuscitation (CPR)

b. Intubation

Note: This is not the only practical skills fornecessary to manage in A&E dept.

For other necessary skills, pls refer to the listof Medicine and Surgery Department.

LIST OF RECOMMENDED BOOKS:

OHCM

1. Oxford Handbook of Clinical Medicine(7th edition) – Emergency section

2. Tarascon Adult EmergencyPocketbook(Steven Rothrock)

Tarascon

3. Sarawak Handbook of MedicalEmergencies (2nd edition)

Sarawak handbook of medical emergencies

4. Singapore Handbook of Emergency

Visit also:For CPG update: http://www.acadmed.org.myCardiac care & CPR: http://www.circulationaha.org

Chest Pain

Posted: November 7, 2010 by smarinz7 in A & E

Chest Pain

  • Usually we send this pt to RED ZONE

Etiology

a)      Life threatening

  • Thoracic aortic dissection
  • Esophageal rupture
  • Tension pneumothorax
  • ACS(e.g. MI,UA)
  • Pulmonary embolism

b)      Most common

  • GI: GERD,PUD
  • CVD
  • Pulmonary
  • Musculoskeletal
  • Psychological

Things to ask:

O – Onset: “When did the pain starts?”

P – Provocation: “during cough, stress, after food and RECENT SPORT that might lead to overuse of chest muscle.

Q – Quality: “describe your pain; dull, sharp”

R – Radiation: to the head, scapula, left hand.

S – Severity:“I give u the scale from 1-10,10 is the most painful…which number is your severity?”

  • PMH: HT, DM, cerebrovasc dss, PE.
  • Medications? – drugs can trigger coronary artery spasm(e.g. cocaine, NSAID)

*If possible, ask the pt to hand the drugs to you.

  • What position relieves the pain?
  • Palpate and check skin of chest – trauma, abrasion, bruises, subcutaneous emphysema(crackles sound when palpate)

Dx

*Main Aim: TRO Life threatening causes!!

  • Pulse oximetry
  • ECG within 10min
  • CXR
  • Look for cardiac markers: TRO ACS etiology(e.g. troponin,CK-MB)

*If STEMI à start PCI or thrombolytic therapy within 90 min standard.( refer STEMI)

Suspect PE if

  • Leg swell
  • HR > 100
  • >3days immobilization
  • History of surgery within the last 4 weeks
  • Hemoptysis

Thoracic Aortic Dissection

  • Blood penetrates the tunica intima and the pressure tears the tunica media of the blood vessels.
  • 2 type

1)      Type A – in ascending aorta (typically chest pain)

2)      Type B – in descending aorta (usually abdominal pain)

  • History of HT,blunt trauma to chest.
  • Dx: TEE(transesophageal echochardiography)and MRI-gold standard, CT scan.
  • Within 2 weeks(80% mortality).
  • Tx : surgery or HT tx

Cardiac tamponade

  • a minimum of 100ml fluid in pericardium is enough to cause this.
  • Beck’s triad:

1)      Low arterial BP – bcos low stroke volume.

2)      Jugular vein distension – in non-supine position due to diastolic filling of RV.

3)      Muffled heart sound (decrease heart sound)– effects of passing thru fluid in pericardium.

  • Etio: pericarditis,myocardial rupture, blunt trauma.
  • Dx: ECG – low voltage QRS complex
  • Signs n symptom of shock(tachycardia, apnea, decrease level of consciousness .
  • Tx: pericardiocentesis at 5th intercostals space.

Tension Pneumothorax

  • chest pain is sharp and pleuritic,dyspnoe,cyanosis,tracheal deviation,jugular venous distension
  • do CXR to confirm
  • Tx: insert largest cannula into the 2nd intercostal space in the midclavicular line at the site with the absent or reduced breath sounds.
  • If air rushes out,leave the cannula in place until a chest drain is inserted.

Tips:

Auscultation of abdominal aorta : at the back of the patient lower a bit from interscapular region,slightly left from the vertebra.

Acute Pulmonary Oedema(APO)

Posted: November 7, 2010 by smarinz7 in A & E

Def: acute,severe LV failure with pulmonary venous hypertension and alveolar flooding; usually as a secondary to other dss.

*suspected in pt had history of CVD.

Sx

  • Extreme dyspnea
  • Cough producing blood tinged sputum (pink color)
  • Diaphoresis(profuse sweating)
  • Cyanosis,pallor.
  • Paroxysmal nocturnal dyspnea (PND): pt need to use pillow to sleep.
  • Crackles heard all the time.

*In pneumonia,crackles heard at the peak of inspiration.

Pathogenesis

LV failure—heart fail to pump—blood pooling in pulmonary circ—plasma moves frm pulmonary capillaries into interstitial spaces n alveoli—APO

Etio:

  • CHF
  • Kidney failure
  • ACS
  • HT
  • Valvular disorder.

Dx

  • CXR – increase fluid in lung
  • ECG – to find the etiology
  • Serum BNP(brain natriuteric peptide)

–          BNP is secreted by heart ventricle in response to excessive stretching of cardiomyocytes.

–          >100picogram per ml indicates CHF.

  • ABG

Tx

  • O2  100% – nonrebreather mask,upright position.
  • Furosemide 1mg/kg IV
  • Nitroglycerin 0.4mg SL(5min) followed by IV drop 10-20µg/min
  • Morphine 1-5mg IV

Additional(etiological tx)

  • PCI
  • Digoxin

Emergency measures:

  • A – airway

–          Max 3L/hr nasal prong(s/e: septal damage)

–          Max 5L/hr mask

–          Max HFM 8L/hr

–          In peads,max 2L /hr

  • B – breathing in upright position
  • C- circulation (BP checking TRO shock)