A very distressed 4yo girl is brought by her father to ...



A very distressed 4yo girl is brought by her father to your ED after she ignited her clothes with a cigarefte lighter. She has partial thickness bums to her anterior neck, chest, abdominal wall, and circumferential involvement of half her right upper limb. Describe your management.

OR

A 2 year old child presents by ambulance with 50% burns to the lower half of the body. Describe your management of this child.

ANSWER

Introductory paragraph

This child has significant bums and these will have to be dealt with on their merits. Other important issues include analgesia, airway and breathing assessment, referral to an appropriate burns service and consideration of non-accidental injury.

Treatment

This child has partial thickness burns involving 18% of body surface area. She will therefore ultimately require transfer to a paediatric burns unit.

Reassurance to father and child.

Airway

— Needs rapid assessment for risk of obstruction (history of smoke exposure,

deposits in mouth or nose, carbonaceous sputum) in view of anterior neck and

chest involvement. Consider intubation with rapid sequence induction using

suxamethonium and thiopentone if:

o Signs of imminent airway obstruction

o Hypoxia

o Oral erythema and / or blistering

o NB. Risk of leaving an involved airway is that there will probably be progressive airway obstruction.

Breathing

— high flow oxygen. Monitor breathing with resp. rate, work of breathing and looking for cyanosis (late).

— Chest full thickness esharotomy if restriction of ventilation.

— Pulse oximetry may not be helpful if CO present

Circulation

— 2 IV cannulas preferably not in burnt areas / intraosseous if needed.

— If shocked give fluid bolus of 2OmLIkg; repeat if necessary; blood transfusion if shock continues (consider other injuries if this is the case).

— Maintenance fluids plus:

— Fluid replacement: 2-4mL/kgl% area: half in first 8 hours, half in next 16 hours. Hartmans or colloid can be used.

Intravenous analgesia as soon as possible — morphine 0.1mg/kg and repeat as required. Treat any injuries noted in secondary survey

Burns

— Remove clothing

— Clean bums

— Saline soaked gauze until review by bums unit

— Uruent referral to burns / surgical unit for:

o Consideration of eseharotomy if evidence of compartment syndrome in right upper limb

— Tetanus prophylaxis +1- Ig if immunisations incomplete

— Avoid hypothermia

Other

— Advice to father about fire safety

— Consider non-accidental injury

Dis~sition

Transfer to a paediatric burns unit

NB. If ambulance transfer is necessary and there were concerns regarding the airway, the safest practice may be to intubate the child pre-transfer

A 32 year old woman is brought to your department unconscious from the scene of a house fire. She is 34 weeks pregnant.

Paramedics found that her GCS was 3, PR 110, BP 120/80. She was intubated by them without the use of drugs.

Her initial ABO results on 100% 02 are:

pH 7.05

mmHg

PO2 200 mmHg

H003 8 mmol/L

BE -15.

COHb 40%. (94%

- Full NIPM

Trt

Treat in supine position, without leg elevation to minimize risk of further cerebral artery aneurysm

A – maintain airway

B – high flow O2

- if pneumothorax – insert ICC; this is MANDATORY if patient going for

recompressive therapy

- if pneumomediastinum – supportive cares only

C – IV fluids – to maintain hydration, to prevent 2Y vascular ischaemic insults

Avoid dextrose as may exacerbate neurological injury

Arrhythmias are usually refractory to standard therapy

D – monitor GCS and neurological status closely

Mannitol only if suspect impending cerebral herniation

Lignocaine may improve outcome (48hr infusion)

E – monitor temperature, aim normothermia

Hyperbaric O2 is definitive treatment

- inform retrieval team and accepting hospital ASAP

- early treatment has better outcomes

- stabilize patient for transfer

- patient will require transport at sea level cabin pressure

A 49 year old power line technician is brought into your department by workmates who describe seeing a flash of light near him and that he then fell 3 meters from a power-pole. The incident occurred only minutes from your emergency department. He is unconscious. His BP is 75/45 and his pulse rate is 130.

Outline your

a) assessment (40%) and

b) management (60%).

a) Assessment

Differential Diagnosis:

- High voltage AC electric shock has occurred resulting in:

- Blunt trauma – fall 3m from power pole, possibility of head, chest, abdominal or spinal injuries

- Blast injury – can result in chest or GIT hollow viscera injury

- Thermal burns – likely extensive deep tissue involvement, regardless of skin appearance

- Crush injury – significant risk of rhabdomyolysis

- Cardiovascular injury – myocardial injury highly likely given high voltage AC current; with resulting arrhythmias

- Neurological injury – could be 1Y neurological insult or 2Y to hypoxic injury

Focused history:

Sx of condition: will need to be from bystanders

- Nature of current in powerline (voltage, ampage, type of current)

- Precautionary measures taken (eg. wearing hard hat, rubber gloves)

- Pathway of current – touched with hand?

- Duration of current – any witness of tetany and prolonged contact with line?

- Height of fall

- Mechanism of landing on ground (eg. head injury? Spinal injury?)

- Any history of seizure activity

- Initial assessment – initial GCS? Any bystander CPR? Initial obs on arrival of ambo?

- Pre-hospital management – rhythm strip? Any medications or interventions by ambo

Relevant PMH: known cardiac disease

Relevant DH: any cardiac medications

A

Relevant FH: cardiac disease

Relevant SH

Focused examination:

A: assess airway; assess for any evidence of facial/peri-oral/neck burns

B: assess breathing; any chest burns; any evidence of rib fractures / flail segment / pneumothorax / haemothorax / pulmonary contusions; assess RR, WOB, SaO2

C: assess circulation; re-check BP; any signs of tamponade; any evidence of exsanguinating trauma (external bleeding wounds; abdominal / chest injury, long bone / pelvic fracture)

D: assess GCS; assess neurological status; log roll for spinal injury; haemotympanum, depressed skull fracture

E: assess skin; any burns; any evidence of compartment syndrome; entry and exit wounds

Investigations

Bedside: ECG (arrhythmias, ischaemic changes), BSL

Lab: FBC, U+E (high K), CK, LFT, amy, ABG, coag, XM, urine

Radiology: CXR, CT head / chest / abdo / pelvis

b) Management

KEY ISSUES:

1) This is life threatening injury

2) Blunt trauma, blast injury, thermal burn, cardiac injury, neurological injury as above

3) Patient is tachycardic and significantly hypotensive – has a significant underlying injury

4) Decreased GCS

Practical Issues

- in resus room

- trauma call out; surgical, ICU, medical staff

Resus:

- 2x large bore IV cannulae

- High flow O2 to SaO2 >94%

- Full NIPM

Trt:

A: maintain airway – assess GCS; if GCS 2L saline required, resus with PRBC

Aim SBP >100, HR BMR of tissue before heart rewarmed to cope)

♣ Technical difficulties of Rx in bath!

Active internal

Advantage is preferential warming of central organ eg heart, decreasing irritability and normalizing CO early. Peripheral vasodilatation avoided and decreased incidence of core temperature afterdrop, rewarming acidosis, shock

• Intubation rewarming minises heat loss from lung but does little to rewarm

• Warm fluid (experiments with hot fluids awaited)

• GIT/bladder lavage. Needs airway protection at risk of aspiration

• Peritoneal lavage. Rapid rewarming can be achieved. Use K free dialysis solutions

• Pleural lavage. Left side. Use 2 tubes .Watch for tension hydrothorax

• Bypass and haemodialysis. May need heparinisation

• Mediastinal irrigation via thoracotomy

 SAQ 316

A 55-year-old electrician presents after being electrocuted whilst working on a domestic power supply. He complains of right arm pain and palpitations.

(a) Outline your assessment of this man. (70%)

(b) Outline the options for this man’s disposition. (30%)

Key Issues:

• Domestic power supply – probable 240V / 50Hz AC

• Palpitations: potential cardiac injury

• Right arm pain: ?burn, ?electrical injury to muscle etc

(a) Assessment:

History:

• Circumstances of incident:

o Time, protective equipment/clothing worn, contact point, duration of contact, path of current flow.

o Confirm power supply type

o Any associated fall, explosion, fire

o Any loss of consciousness

• Symptoms of injuries:

o Palpitations – ?compromised - any associated chest pain, pre-syncope, SOB

o Right arm – location of pain, any numbness, weakness or parasthaesia

o Any other complaints

• Past history:

o Any cardiac disease – previous arrhythmias

• Medications, allergies, tetanus status

Examination:

• Vital signs

• Assess for immediate life threats:

o Airway and breathing –

♣ Assume patent airway from question – GCS 15

♣ Assess for respiratory distress

o Circulation –

♣ HR (?regular v irregular), BP and peripheral perfusion – any compromise from palpitations

o Disability –

♣ Assume GCS 15 from question

• Systems examination:

o Right upper limb – neurovascular assessment; evidence of compartment syndrome, or fracture/dislocation (esp: shoulder – posterior dislocation); any evidence of burns

o Assess for entry and exit wounds

o Assess for other injuries and burns

Investigations:

Bedside:

• BSL

• ECG - arrhythmia especially sinus tachycardia, AF, ectopics, ST or T wave changes, myocardial ischaemia

• WTU - +ve RCC (?myoglobin)

Laboratory:

• FBC - baseline

• ELFT- esp: hyperkalaemia, baseline renal function

• CK - rhabdomyolysis

• Troponin I (if abnormal ECG) – myocardial injury

• Urinary myoglobin – if elevated CK (x3 times normal)

Radiology:

• CT head – if episode loss of consciousness / or other secondary injury suspected

• Xrays - of limbs or other as examination findings indicate.

(b) Disposition:

• Majority of domestic power (240v) electrocutions can go home with analgesia and planned follow up of minor injuries or burns.

o Need to have symptoms resolve

o Normal ECG in sinus rhythm

o No significant burns or soft tissue injury

• Will require admission to hospital for cardiac monitoring if:

o Abnormal ECG (+/- elevated troponin) - arrhythmia, ECG otherwise abnormal (as above) until normalises.

• Will otherwise require admission if has:

o Neurovascular deficits to right upper limb

o Suspicion or evidence of compartment syndrome to right arm

o Significant burns (large or deep or to special area ie: hand) or other significant injuries requiring inpatient management or iv analgaesia

o Evidence of rhabdomyolysis

SAQ 034

A previously healthy 35 year old man arrives in your ED after collapsing during a marathon. He is having a generalised clonic convulsion. His vital signs are:

P 140

BP 100/70

Temp 42'C

Outline your management.

Diagnosis of probable exertional heat stroke (classically >40'C, anhydrosis, CNS dysfunction). Sweating may be present. Differential still contains sepsis, intracranial bleed etc

A Secure airway.O2

B

C Hydration with isotonic

D Stop the fit. Use benzo

E Insert thermometer

Ix to ID endorgan failure FBE, ELFT, COAG, Ca, Mg, Urine (for myoglobin), toxicology screen

CXR, ECG

CT head, LP

Rx

Cooling technique

Evaporation is rapid and non-invasive (spray pt with water and use fans)~0.3 - 0.03C/min cooling Complication are shivering and problems keeping electrodes on body.

Strategic ice pack cooling (alone 0.028C/min, or with evaporation 0.034C/min) Ice packs are placed in the axillae and groin

Immersion cooling (0.27-0.14C/min) complication are detachment of leads, shivering, inability to defibrillate or do resus

Cooling should be stopped when temp 96%. If ventilated aim PaCo2 ~40mmHg

• NGT if intubated

• Continue fluid resuscitation with 0.9% saline 20ml/kg boluses – aim for BP>100 and restore circulatory function / peripheral perfusion

• IDC with temperature probe – q1hr measures. Monitor response to fluid resuscitation. Aim 1ml/kg/hr

• Continue active external cooling until core temp is 38 degrees

• If further seizure activity despite midazolam and cooling – load with iv phenytoin 20mg/kg. Will require intubation and ventilation (if not already) if uncontrolled seizures

• If intubated – avoid long acting muscle relaxants to monitor for further seizures. However if temperature not falling and shivering becomes problematic – paralyse and monitor EEG

• Largactil iv 12.5mg titrated to effect also useful to settle shivering

Further specific treatment:

Identify and treat complications of hyperthermia:

• Rhabdomyolysis

o Aggressive fluid resuscitation as previous

o Aim UO >2ml/kg/hr

o If CVS stable – 0.5g/kg iv mannitol to assist diuresis and act as free radical scavenger

• Coagulopathy

o Correct abnormal coagulation profile with FFP

• Electrolyte abnormalities

o Hyperkalaemia – 10mmol Ca Gluconate if cardioprotective effect required; otherwise 10u insulin / 50ml 50% dextrose; 1mmol/kg 8.4% NaHCO3; resonium 15g retention enema

• Acute renal failure

o Observe for anuric ARF – will require haemodialysis

Disposition:

• Will depend on condition and response to initial resuscitation

• ICU – if intubated; or ongoing CVS instability / severe rhabdomyolysis, coagulopathy, electrolyte disturbance

• Otherwise general medical ward with close observation

SAQ 040

A 50 year old man presents to your small Emergency Department after flying home from a scuba diving holiday, complaining of back pain and weakness/paraesthesia in both legs. There is no history of trauma or of previous similar problems.

• What is the most likely diagnosis ?

• What are the risk factors for this condition ?

• List the differential diagnosis

• Discuss any important principles governing the transfer of this man to a tertiary referral centre 300 km. away.

Predisposing factors

Advanced age (decreased tissue perfusion)

Obesity (decreased absorption of inert gas)

Dehydration

Drunk and dehydrated

Cold water

Exertion (increased gas uptake)

Local physical injury

Multi-dives (gas build up)

Ascent to altitude ( including flight)

Dive related DCI

Not related to dive

Spine related

Musculoskeletal (muscle sprain)

Disc pathology

Non spine related

AAA

Renal pathology

Respiratory (pneumothorax)

Pancreatitis

Needs air transport pressurized to 1 atm ( or non pressurized 100mmHg

• Antiemetics – metoclopramide 10mg IV

• Analgesia – morphine 0.1mg/kg IV (titrate to pain relief/anxiolysis)

• Supportive treatment

o Maintenance fluids - IV saline 0.9% 125ml/hr – titrate to achieve urine output 0.5ml/kg/hr, HR100

♣ Consider inotropic support for refractory hypotension

o Correct any electrolyte disturbances

o Maintain normothermia

o Treat any other conditions

♣ Trauma

♣ Other toxic exposures

• Disposal

o Admission to intensive care facility

o Monitor lymphocyte count

♣ ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download