1
Q
Approach to the Critically Ill Patient
A
- Rapid Primary Survey (RPS)
- Resuscitation (often concurrent with
RPS) - Detailed Secondary Survey
- Definitive Care
2
Q
Signs of Airway Obstruction
A
- Agitation, confusion, “universal
choking sign” - Respiratory distress
- Failure to speak, dysphonia, stridor
- Cyanosis
3
Q
ABCDE : que veut dire A
A
Airway maintenance with C-spine control
4
Q
ABCDE : que veut dire B
A
Breathing and ventilation
5
Q
ABCDE : que veut dire C
A
Circulation (pulses, hemorrhage control)
6
Q
ABCDE : que veut dire D
A
Disability (neurological status)
7
Q
ABCDE : que veut dire E
A
Exposure (complete) and Environment (temperature control)
8
Q
ABCDE : particularités E
A
■ continually reassessed during secondary survey
■ changes in hemodynamic and/or neurological status necessitates a return to the primary survey beginning with airway assessment
9
Q
- addressing the “ABCs” is the hallmark of the emergency department
■ in the setting of cardiac arrest, the approach changes to the …
A
“CABs”: chest compressions, airway, and breathing
10
Q
A. AIRWAY : first priority is to …
A
secure airway
11
Q
A. AIRWAY : assume what
A
assume a cervical injury in every trauma patient and immobilize with collar
12
Q
A. AIRWAY : assess
A
ability to breathe and speak
13
Q
A. AIRWAY : can change rapidly, therefore …
A
reassess frequently
14
Q
A. AIRWAY : assess for …
A
facial fractures/edema/burns (impending airway collapse)
15
Q
Airway Management
A
anatomic optimization to allow for oxygenation and ventilation
16
Q
Airway Management : 3 étapes
A
- Basic Airway Management
- Temporizing Measures
- Definitive Airway Management
17
Q
Airway Management : Basic Airway Management -> protect
A
C-spine
18
Q
Airway Management : Basic Airway Management -> quoi faire pour ouvrir la mâchoire
A
chin lift (if C-spine injury not suspected) or jaw thrust
19
Q
Airway Management : Basic Airway Management -> étape en lien avec la bouche
A
sweep and suction to clear mouth of foreign material
20
Q
Airway Management : Temporizing Measures -> airway if gag reflex present and conscious
A
nasopharyngeal airway
21
Q
Airway Management : Temporizing Measures -> airway if gag reflex absent et unconscious
A
oropharyngeal airway
22
Q
Airway Management : Temporizing Measures -> devices
A
“rescue” airway devices (e.g. laryngeal mask airway, Combitube®)
23
Q
Airway Management : Temporizing Measures -> last resort
A
transtracheal jet ventilation through cricothyroid membrane
24
Q
Airway Management : Definitive Airway Management -> 3 options
A
- ETT (endotracheal tube) intubation with in-line stabilization of C-spine
- surgical airway
- cricothyroidotomy
25
Airway Management : Definitive Airway Management -> ETT intubation with in-line stabilization of C-spine (2 options)
■ **orotracheal** ± RSI (rapid sequence induction) preferred
■ **nasotracheal** may be better tolerated in conscious patient
26
Medications that can be Delivered via ETT (5)
NAVEL
Naloxone (Narcan®)
Atropine
Ventolin® (salbutamol)
Epinephrine
Lidocaine
27
Indications for Intubation (4 P’s)
* Patent airway
* Protects against aspiration (e.g.
decreasing GCS < 8)
* Positive pressure ventilation
* Pulmonary toilet (suction)
28
Contraindications to Intubation
supraglottic/glottic pathology that would preclude successful intubation
29
Trauma requiring intubation : quoi regarder
* no immediate need
* immediate need
30
Trauma requiring intubation : no immediate need ➙ quoi faire
C-spine x-ray
31
Trauma requiring intubation : no immediate need ➙ c-spine x-ray ➙ quoi regarder
c-spine x-ray positive ou negative
32
Trauma requiring intubation : no immediate need ➙ c-spine x-ray ➙ positive ➙ quoi regarder
fiberoptic ETT or nasal ETT or RSI
33
Trauma requiring intubation : no immediate need ➙ c-spine x-ray ➙ positive ➙ fiberoptic ETT or nasal ETT or RSI ➙ quoi faire si unable
rescue devices or cricothyroidotomy
34
Trauma requiring intubation : no immediate need ➙ c-spine x-ray ➙ negative ➙ quoi faire si negative
oral ETT (± RSI)
35
Trauma requiring intubation : no immediate need ➙ c-spine x-ray ➙ negative ➙ oral ETT (± RSI) ➙ quoi faire si unable
rescue devices or cricothyroidotomy
36
Trauma requiring intubation : immediate need ➙ quoi regarder
apneic or breathing
37
Trauma requiring intubation : immediate need ➙ apneic ➙ quoi faire
oral ETT
38
Trauma requiring intubation : immediate need ➙ apneic ➙ oral ETT ➙ quoi faire si unable
rescue devices or cricothyroidotomy
39
Trauma requiring intubation : immediate need ➙ breathing ➙ quoi regarder
yes or no
40
Trauma requiring intubation : immediate need ➙ breathing ➙ yes ➙ quoi faire
oral ETT (no RSI)
41
Trauma requiring intubation : immediate need ➙ breathing ➙ no ➙ quoi faire
nasal ETT or oral ETT (± RSI)
42
Trauma requiring intubation : immediate need ➙ breathing ➙ no ➙ nasal ETT or oral ETT (± RSI) ➙ quoi faire si unable
rescue devices or cricothyroidotomy
43
B. BREATHING : Breathing Assessment
quantitative measures of respiratory function: rate, oximetry, ABG, A-a gradient
44
B. BREATHING : Breathing Assessment -> 3 étapes
* look
* listen
* feel
45
B. BREATHING : Breathing Assessment -> look
**mental status** (anxiety, agitation, decreased LOC), **chest movement** (bilateral vs. asymmetrical), **respiratory rate/effort**, nasal flaring, increased work of breathing
46
B. BREATHING : Breathing Assessment -> listen
auscultate for **signs of obstruction** (e.g. stridor), breath sounds, symmetry of air entry, **air escaping**
47
B. BREATHING : Breathing Assessment -> feel
tracheal shift, chest wall for **crepitus** (e.g. subcutaneous emphysema, rib fracture), flail segments, sucking chest wounds
48
B. BREATHING : Management of Breathing -> nommer 5 méthodes pour administrer O2
* nasal prongs
* face mask
* non-rebreather
* high-flow nasal cannula
* CPAP/BiPAP
49
B. BREATHING : Management of Breathing -> classer les méthodes d'administration d'O2
nasal prongs → simple face mask → non-rebreather mask → high-flow nasal cannula → CPAP/BiPAP (in order of increasing FiO2)
50
B. BREATHING : Management of Breathing -> qu'est-ce qui permet de supplémenter la ventilation inadéquate
Bag-Valve mask and CPAP
51
C. CIRCULATION : definition of shock
inadequate organ and tissue perfusion with oxygenated blood (brain, kidney, extremities)
52
C. CIRCULATION : Shock in a trauma patient is ____ until proven otherwise
hemorrhagic
53
C. CIRCULATION : major types of shock
* hypovolemic
* cardiogenic
* distributive
* obstructive
54
C. CIRCULATION : dire c'est associé à quel type de choc -> Hemorrhage (external and internal)
hypovolemic
55
C. CIRCULATION : dire c'est associé à quel type de choc -> severe burns
hypovolemic
56
C. CIRCULATION : dire c'est associé à quel type de choc -> high ouput fistulas
hypovolemic
57
C. CIRCULATION : dire c'est associé à quel type de choc -> dehydration (diarrhea, DKA)
hypovolemic
58
C. CIRCULATION : dire c'est associé à quel type de choc -> myocardial ischaemia
cardiogenic
59
C. CIRCULATION : dire c'est associé à quel type de choc -> Dysrhythmias
cardiogenic
60
C. CIRCULATION : dire c'est associé à quel type de choc -> CHF
cardiogenic
61
C. CIRCULATION : dire c'est associé à quel type de choc -> Cardiomyopathies
cardiogenic
62
C. CIRCULATION : dire c'est associé à quel type de choc -> Cardiac valve problems
cardiogenic
63
C. CIRCULATION : dire c'est associé à quel type de choc -> septic
distributive
64
C. CIRCULATION : dire c'est associé à quel type de choc -> anaphylactic
distributive
65
C. CIRCULATION : dire c'est associé à quel type de choc -> neurogenic (spinal cord injury)
distributive
66
C. CIRCULATION : dire c'est associé à quel type de choc -> Cardiac tamponade
obstructive
67
C. CIRCULATION : dire c'est associé à quel type de choc -> Tension pneumothorax
obstructive
68
C. CIRCULATION : dire c'est associé à quel type de choc -> PE
obstructive
69
C. CIRCULATION : dire c'est associé à quel type de choc -> aortic stenosis
obstructive
70
C. CIRCULATION : dire c'est associé à quel type de choc -> constrictive pericarditis
obstructive
71
C. CIRCULATION : clinical evaluation -> early
tachypnea, tachycardia, narrow pulse pressure, **reduced capillary refill**, **cool extremities**, and reduced central venous pressure
72
C. CIRCULATION : clinical evaluation -> late
hypotension, altered mental status, reduced urine output
73
C. CIRCULATION : Estimation of Degree of Hemorrhagic Shock -> blood loss et % blood volume classe 1
< 750 cc
< 15%
74
C. CIRCULATION : Estimation of Degree of Hemorrhagic Shock -> blood loss et % blood volume classe 2
750-1500 cc
15-30%
75
C. CIRCULATION : Estimation of Degree of Hemorrhagic Shock -> blood loss et % blood volume classe 3
1500 cc - 2000 cc
30-40%
76
C. CIRCULATION : Estimation of Degree of Hemorrhagic Shock -> blood loss et % blood volume classe 4
> 2000 cc
> 40%
77
C. CIRCULATION : Estimation of Degree of Hemorrhagic Shock -> à partir de quand la TA diminue
classe 3 et 4
78
C. CIRCULATION : Estimation of Degree of Hemorrhagic Shock -> à partir de quand le refill capillaire est allongé
classe 2
79
C. CIRCULATION : Estimation of Degree of Hemorrhagic Shock -> fluid replacement classe 1
crystalloid
80
C. CIRCULATION : Estimation of Degree of Hemorrhagic Shock -> fluid replacement classe 2
crystalloid
81
C. CIRCULATION : Estimation of Degree of Hemorrhagic Shock -> fluid replacement classe 3
crystalloid + blood
82
C. CIRCULATION : Estimation of Degree of Hemorrhagic Shock -> fluid replacement classe 4
crystalloid + blood
83
Causes of Shock
SHOCKED
**S**eptic, **s**pinal/neurogenic
**H**emorrhagic
**O**bstructive (e.g. tension pneumothorax, cardiac tamponade, PE)
**C**ardiogenic (e.g. blunt myocardial
injury, dysrhythmia, MI)
anaphylacti**K**
**E**ndocrine (e.g. Addison’s, myxedema, coma)
**D**rugs
84
Management of Hemorrhagic Shock
* **clear airway** and **assess breathing** either first or simultaneously
* **apply direct pressure** on external wounds while elevating extremities. Do not remove impaled objects in the emergency room setting as they may tamponade bleeds
85
Management of Hemorrhagic Shock : fluides IV
* start two large bore (14-16G) IVs in the brachial/cephalic vein of each arm
* run 1-2 L bolus of IV Normal Saline/Ringer’s Lactate (warmed, if possible)
86
Management of Hemorrhagic Shock : if continual bleeding or no response to crystalloids, consider ...
pRBC transfusion, ideally crossmatched
87
Management of Hemorrhagic Shock : consider pRBC transfusion, ideally crossmatched. If crossmatched blood is unavailable, consider ...
O- for women of childbearing age and O+ for men
88
Management of Hemorrhagic Shock : use what in early bleeding
Use FFP, platelets or tranexamic acid
89
décrire règle 3:1 pour fluides IV
Since only 30% of infused isotonic crystalloids remains in intravascular space, you must give 3x estimated blood loss
90
5 common sites of bleeding
* External (e.g. scalp)
* Chest
* Abdomen (peritoneum, retroperitoneum)
* Pelvis
* Long bones
91
D. DISABILITY : assess ...
LOC using GCS
92
D. DISABILITY : quoi regarder
pupils
■ assess equality, size, symmetry, reactivity to light
93
D. DISABILITY : unequal or sluggish suggests ...
local eye problem or lateralizing CNS lesion
94
D. DISABILITY : non-reactive pupils + decreased LOC =
structural cause (especially if asymmetric)
95
D. DISABILITY : Glasgow coma scale (GCS) is for use in ...
trauma patients with decreased LOC; good indicator of severity of injury and neurosurgical prognosis
96
D. DISABILITY : Glasgow coma scale (GCS) is most useful if
repeated
change in GCS with time is more relevant than the absolute number
97
D. DISABILITY : Glasgow coma scale (GCS) less meaningful for
metabolic coma
98
D. DISABILITY : patient with deteriorating GCS needs ...
immediate attention
99
D. DISABILITY : Glasgow Coma Scale -> prognosis based on ...
best post-resuscitation GCS
100
D. DISABILITY : if patient intubated, GCS score reported out of
10 + T (T = tubed, i.e. no verbal component)
101
D. DISABILITY : GCS -> mild injury
13-15
102
D. DISABILITY : GCS -> moderate injury
9-12
103
D. DISABILITY : GCS -> severe injury
<=8
104
Unilateral, Dilated, Non-Reactive Pupil, Think ...
* Focal mass lesion
* Epidural hematoma
* Subdural hematoma
105
E. EXPOSURE/ENVIRONMENT
* **expose patient completely** and assess **entire body** for injury; log roll to examine back
* **Digital rectal exam** for trauma patients
* keep patient **warm** with a blanket ± radiant heaters; avoid hypothermia
* **warm IV fluids/blood**
* keep providers safe (contamination, combative patient)
106
Resuscitation : done concurrently with
primary survey
107
Resuscitation : attend to
ABCs
108
Resuscitation : manage
manage life-threatening problems as they are identified
109
Resuscitation : vital signs q
q5-15 min
110
Resuscitation : quels paramètres regarder
ECG, BP, and O2 monitors
111
Resuscitation : quoi installer
Foley catheter and NG tube if indicated
112
Resuscitation : tests and investigations
CBC, electrolytes, BUN, Cr, glucose, amylase, INR/PTT, β-hCG, toxicology screen, cross and type
113
Resuscitation : CPR -> airway
Head tilt-chin lift; ; jaw thrust without head extension if concern for spinal injury
114
Resuscitation : CPR -> breaths
2 breaths at 1 s/breath – stop once see chest rise
115
Resuscitation : CPR -> compression -> compression landmarks
In the centre of the chest, lower half of the sternum
< 1 yr : just below nipple lines
116
Resuscitation : CPR -> compression -> compression method for adults
push hard and fast, and allow for complete recoil
2 hands : heel of 1 hand with heel of second hand on top
117
Resuscitation : CPR -> compression -> compression method for children
2 hands : heel of 1 hand with second on top, or 1 hand : heel of 1 hand only
118
Resuscitation : CPR -> compression -> compression method for < 1 year
2 fingers or thumbs
119
Resuscitation : CPR -> compression -> compression depth
adults : 2-2.4 inches
children : About ¹/3 to ¹/2 the depth of the chest
120
Resuscitation : CPR -> compression -> compression rate
100-120/min with complete chest wall recoil between compressions
121
Resuscitation : CPR -> compression -> compression-ventilation ratio
30 compressions to 2 ventilations
122
Resuscitation : CPR -> compression -> compression-only CPR
**Hands-only CPR** is preferred if the bystander is not trained or does not feel confident in their ability to provide conventional CPR or if the bystander is trained but chooses to use compressions only
123
Resuscitation : CPR -> defibrillation
**Immediate defibrillation** for all rescuers responding to a sudden witnessed collapse
**Compressions (5 cycles/2 min) before AED is considered if unwitnessed arrest**
Manual defibrillators are preferred for children and infants but can use adult dose AED if a manual defibrillator is not available
124
Secondary Survey
done after primary survey once patient is hemodynamically and neurologically stabilized
125
Secondary Survey : identifies
major injuries or areas of concern
126
Secondary Survey : quoi faire
full physical exam and x-rays (C-spine, chest, and pelvis – required in blunt trauma, consider T-spine and L-spine if indicated)
127
Secondary Survey : history
SAMPLE
Signs and symptoms, Allergies, Medications, Past medical history, Last meal, Events related to injury
128
Secondary Survey : four areas of a FAST
1. Subxiphoid Pericardial Window
2. Perisplenic
3. Hepatorenal (Morrison’s Pouch)
4. Pelvic/Retrovesical (Pouch of Douglas)
129
Secondary Survey : physical exam
* head and neck
* chest
* abdomen
* musculoskeletal
* neurological
130
Secondary Survey : physical exam -> head and neck
palpation of facial bones, scalp
131
Secondary Survey : physical exam -> chest
* inspect for **midline trachea** and flail segment: **≥2 rib fractures in ≥2 places**; if present look for associated **hemothorax**, **pneumothorax**, and **contusions**
* **auscultate lung** fields
* **palpate** for subcutaneous emphysema
132
Secondary Survey : physical exam -> abdomen
* assess for **peritonitis**, abdominal **distention,** and evidence of **intra-abdominal bleeding**
* **DRE** for GI bleed, high-riding prostate, and anal tone
133
Secondary Survey : physical exam -> musculoskeletal
* examine **all extremities** for swelling, deformity, contusions, tenderness, ROM
* check for **pulses** (using Doppler probe) and **sensation** in all injured limbs
* log roll and palpate **thoracic and lumbar spines**
* palpate iliac crests and pubic symphysis and assess **pelvic stability** (lateral, AP, vertical)
134
Secondary Survey : physical exam -> neurological
* GCS
* full cranial nerve exam
* assess spinal cord integrity
135
Secondary Survey : physical exam -> neurological -> alterations of rate and rhythm of breathing are signs of
structural or metabolic abnormalities with progressive deterioration in breathing indicating a failing CNS
136
Secondary Survey : physical exam -> neurological -> conscious patient
assess distal sensation and motor function
137
Secondary Survey : physical exam -> neurological -> unconscious patient
response to painful or noxious stimulus applied to extremities
138
Signs of Increased ICP (7)
* Deteriorating **LOC** (hallmark)
* Deteriorating **respiratory pattern**
* **Cushing reflex** (high BP, low HR,
irregular respirations)
* **Lateralizing CNS signs** (e.g. cranial nerve palsies, hemiparesis)
* **Seizures**
* **Papilledema** (occurs late)
* **N/V and headache**
139
what is the best imaging modality for intracranial injury
non-contrast head CT
140
secondary survey : initial imaging
* non-contrast CT head/face/C-spine (rule out fractures and bleeds)
* CXR
* FAST or CT abdomen/pelvis (if stable)
* pelvis x-ray
0Révision
flashcards
Decks in class (27)
# Cards
-
Souffles16
-
Épidémio96
-
Développement ped - cours90
-
Exanthèmes viraux122
-
électrolytes75
-
éruptions et purpuras43
-
Développement ped70
-
obstétrique201
-
psychiatrie - toronto notes96
-
substance-related and addictive disorders1
-
démence42
-
OMA et infections respi INESSS173
-
Cellulite, infection urinaire INESSS110
-
Antipsychotiques Toronto notes113
-
ITSS et vulvo-vaginites INESSS182
-
Antibiotiques86
-
Neuro32
-
ECG Dr Crête93
-
Bactéries - stage infectio91
-
Antidépresseurs Toronto Notes166
-
Mood stabilizers / anxiolytics Toronto Notes78
-
Neuro exam155
-
neuro variété97
-
ABCDE toronto notes140
-
trauma toronto notes, dermatomes + nerfs DC62
-
oreilles53
-
glasgow20
