History for accidental ingestion
- Age, past medical problems, medications, allergies
- Ingestion: what was taken? How much? How long ago?
- Current condition of patient: consciousness? Vomiting?
CXR signs of PE
- Hampton’s hump (wedge shaped infiltrate- lung infarct)
- Oligemic area/ westermark sign (dec perfusion distal to embolus)
- Unilateral effusion
- Elevated hemidiaphragm
- Normal CXR
Management of accidental ingestion over the phone
- Have child drink 2-3 glasses of milk
- Do not induce vomiting, have child lie on side in case vomit
- If unknown amount for significant amount- needs to come in
- Come in by ambulance
Lab investigations for accidental Ingestions
CBC
Lytes, creat, urea, serum osmolarity, serum ketones
ABG
CXR
Toxicology screen
Consult with toxicology for advice for management
Investigations for chest pain
CBC, lytes, glucose, INR/PTT Serial troponin ABG CXR ECG
Management of chest pain
First steps: raise head of bed, oxygen, monitor SpO2
MONA
Morphine (1 mg IV)- if BP ok
Oxygen
Nitroglycerin- if BP ok, and no med interactions (0.3mg SL q5minx3)
ASA 325 mg PO chewable
Trops Q8H
History for fall from 6 feet from ladder
- Sequence of events
- Symptoms prior to fall from ladder: loss of consciousness, seizure, dizziness, faint
- Symptoms post event: post-itcal drowsiness? Pain?
- Patient history:similar episodes in past, PMHx, PMSx, meds, allergies, smoking, alcohol, drugs
History for laceration on arm
- ID: name, age, occupation, handedness
- History of laceration: sequence of events/context environment (metal?), any other injuries?
- Symptoms: pain, loss of power, loss of sensation?
- ROS
- PMHx, meds, allergies, smoking/alcohol/drugs, vaccination status for tetanus
Choice of suture material
- face
- extremities
- face: 6.0 prolene (remove in 5 days)
- extremities: 3.0 prolene or ethylon (monofilament non-absorbable)- remove in 10 days
Suture technique
- Sterile technique
- Cleanse and irrigate the wound
- Drape
- anesthetize with lidcaine +/- epi
- start in middle of wound
- Counsel patient
- suture removal in 5 days for face, 10 days or elsewhere
- return to ER is fever, red/pain, pustular discharge from wound
- tylenol for pain control
Tetanus immunization after cut -usual tetanus immunization schedule if last tetanus immunization was: -0-5 years ago: -5-10 years ago: ->10 years ago: -unknown:
-usual tetanus immunization schedule: DTP 2,4,6,18 months, 4-6 years old, Td at 14-16 years old, then Q10 years if last tetanus immunization was: -0-5 years ago: none -5-10 years ago: Td booster ->10 years ago: booster + Ig -unknown: booster + Ig
Differential for Alcoholic with hematemasis
Esophagitis Mallory Weiss tear Esophageal varices Gastritis Duodenal ulcer Peptic ulcer Esophageal cancer Gastric cancer Lung tumor
Differential for Alcoholic with hematemasis
Esophagitis
Mallory Weiss tear
History for syncope
- events leading up to the event
- cardiac: chest pain, palpitations, shortness of breath
- neuro: tonic-clonic movements, post-itcal
- orthostatic: associated with change in position, dehydration, medication
- vasovagal: nausea, vomiting before
PMHx: cardiac disease, arrythmia, diabetes
Meds:
Habits: drug use, alcohol, smoking
Family history
Differential for syncope
- medication induced: digoxin, between blockers
- cardiac: arrythmia, valvular disease, subclavian steal,
- metabolic: hypoglycemia
- autonomic: orthostatic hypotension, vasovagal
Symptoms of digoxin poison
Anorexia, N/V, abdo pain, diarrhea, visual effects (yellow, green, white halo around objects)
ECG: junctional tachycardia, PVC, AV block
Physical exam for digoxin poisoning
Vitals Orthostatic BP Signs of dehydration: HR, urine output, thirst, mucous membranes, skin turf or BP cardio, resp Neuro exam MMSE
Labs for Digoxin poisoning
Digoxin level CBC, lytes, BUN, creat, INR/PTT, glucose ECG, Holter, echo EEG CT head Carotid Doppler
Physician in peripheral hospital, wishes to transfer unstable patient in MVC. CXR shows opacification of R lung.
- Dx?
- Management?
-physician’s name, name of centre, pt’s name, age
-injuries
-vitals, GCS
-investigations done, lab values
-is patient intubated
-can not transfer patient until: good BP, good sats, bleeding controlled, blood products given
-ETA
-physician accompanied?
-CXR: hemothorax
-need to put in chest tube in ER, connect to pleur-evac
(thoracic sx consult)
