Final Emergency Medicine for third year medical students

Emergency Medicine: A digital booklet for medical students 1

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Index:Burns Page 4Broken bones and fractures Page 6Open wounds Page 8Animal bites Page 10Hypothermia Page 12Anaphylaxis Page 14Cardiac arrest Page 18Test yourself Page 20-------------------------------------------------------------------------------------------------------How to use this booklet • The major incidents students have reported as wanting to know how to treat are divided into the above sections. • Each topic has colour coded: o Symptoms to recognise the condition o Pre hospital aid to treat in the community o Hospital treatment summary with access to equipment and drugs. • Some topics also include a brief description or break down of the types of each condition eg types of burns. • Drugs are in bold to aid fast access in emergency setting. o Drug doses are correct at time of writing, but always check local trust guidelines. • Relevant diagrams and videos are included to aid visual learners. • At the end of each topic are additional references if you need to expand your knowledge with further information.------------------------------------------------------------------------------------------------------- 3

BurnsSymptoms: Ø Blisters, pain (degree not related to severity of the burn- most serious burns can be painless), peeling skin, red skin, shock (pale and clammy skin, weak, blue lips, decreased alertness), swelling, white or charred skin.-------------------------------------------------------------------------------------------------------Pre-hospital aid: 1. Stop the burning process (water on fire/fire extinguisher/remove person from area/switch off power supply/use of non-conductive implements) 2. Remove clothes/jewellery near burnt area of skin BUT not anything that has stuck to the skin (care to be taken in chemical burning) 3. Cool burn with cool/luke warm water for 10-30 mins 4. Try and keep patient warm to prevent hypothermia 5. Cover burn with cling film. Place layers of it on the area. DO NOT wrap it all the way around (this will create a tourniquet effect) 6. If possible provide high flow O2-------------------------------------------------------------------------------------------------------When to go to hospital: • Call 999 or go straight to hospital if a baby or child has been burned • All chemical and electrical burns • Large or deep burns – any burn bigger than your hand • Burns that cause white or charred skin – any size • Burns on the face, hands, arms, feet, legs or genitals that cause blisters-------------------------------------------------------------------------------------------------------Major burn treatment in hospital: 1. Airway- Assess for and treat any obstruction (eg stridor, swelling), give O2, apply cervical collar if possible spinal injury 2. Analgesia- 2xlarge bore cannula, IV morphine, IV 50mg cyclizine 3. Fluids- 0.9% saline, at 2-4mL of crystalloid per kg body weight per % body surface area burned over first 24hrs. Give half of this volume in first 8hrs. o Urinary catheter o Check pulse, BP and RR every 10-15 min initially------------------------------------------------------------------------------------------------------- 4

Types of burns • Superficial epidermal burn – where the epidermis is damaged; skin will be erythematous, slightly swollen and painful, but not blistered • Superficial dermal burn – where the epidermis and part of the dermis are damaged; skin will be pale pink and painful, and there may be small blisters • Deep dermal or partial thickness burn – where the epidermis and the dermis are damaged: this type of burn makes the skin turn red and blotchy; skin may be dry or moist, and become swollen and blistered, and it may be very painful or painless • Full thickness burn –all three layers of skin (the epidermis, dermis and subcutaneous) are damaged; the skin is often burnt away and the tissue underneath may appear pale or blackened, while the remaining skin will be dry and white, brown or black with no blisters, and the texture of the skin may also be leathery or waxy. Burn depths classification www.dovemed.com/healthy-living/first-aid/burns/References:NHS information on burns:https://www.nhsinform.scot/illnesses-and-conditions/injuries/skin-injuries/burns-and-scaldsOxford Handbook of Emergency Medicine- Page 412 5

Broken Bones and FracturesSymptoms:Swelling, loss of motion, movement in unnatural direction, limbshorter/twisted/bent, grating noise/feeling, loss of strength, shock-------------------------------------------------------------------------------------------------------Pre-hospital aid: • If open, cover with sterile dressing and apply pressure around wound to stop bleeding • Support injured body part to stop movement-------------------------------------------------------------------------------------------------------Hospital Treatment of compound/open fractures • Arrange orthopaedics referral • Treatment life threatening injuries before limb injuries • Control haemorrhage by direct manual pressure • Start IV fluids • Analgesia- incremental IV opioids • Correct severe deformities with traction and splint • Irrigate with saline • Cover wound with steroid moist dressing (eg saline soaked pads). • Immobilise limb in a plaster of paris backslab and leave covered until surgery • Record presence/absence of distal pulses and sensation and recheck frequently • Drug administration v IV antibiotics: 1.2g co-amoxiclav or 1.5g cefuroxime o Add gentamicin or metronidazole if grossly contaminated v Tetanus toxoid if tetanus prone (heavy contamination, devitalized tissue, infection or wounds >6hrs old, puncture wounds and animal bites) o If patient fully immunized does not vaccine- can give 250- 500units IM HATI (Ig) if risk very high-------------------------------------------------------------------------------------------------------Types of fractures:Stable fracture: The broken ends of the bone line up and are barely out ofplace. 6

Open, compound fracture: The skin maybe pierced by the bone or by a blow thatbreaks the skin at the time of the fracture.The bone may or may not be visible in thewound.Transverse fracture: This type of fracture Types of bone fractureshas a horizontal fracture line. https://emedprimarycare.com/fractures/Oblique fracture: This type of fracture hasan angled pattern.Comminuted fracture: In this type of fracture, the bone shatters into three ormore pieces.------------------------------------------------------------------------------------------------------- How to make a sling: 1) Slip one end of the bandage under the arm and over the shoulder. 2) Bring the other end of the bandage over the other shoulder, cradling the arm 3) Tie the ends of the bandage behind the neck. 4) Fasten the edge of the bandage, near the elbow, with a safety pin. Sling diagramhttp://evaq8.co.uk/Triangular-Bandage-Non-WovenReferences:Oxford handbook of emergency medicine- Page 443St Johns:www.sja.org.uk/sja/first-aid-advice/bones-and-muscles/broken-bones-and-fractures.aspx 7

Open woundsPre-Hospital Treatment: • Cut/graze: rinse under water, pat dry with gauze swab and cover with sterile dressing. • If wound is covered by clothing: remove or cut clothes to gain access. • If an object is in a severe bleeding wound: do not remove, apply pressure around object, preferably with sterile cloth and secure with bandage, elevate above heart level. • If no object in severe bleeding wound: apply direct pressure on wound, preferably with sterile cloth and secure with bandage, elevate above heart level.-------------------------------------------------------------------------------------------------------Hospital Treatment: • Clean with 0.9% saline, if ingrained with dirt may require pressure saline irrigation or toothbrush scrubbing • Devitalized or grossly contaminated wound edges need to be debrided (trimmed back) except on hands or face • Close wound if required o Anaesthetise (with 25 gauge needle), then suture, steri strips • If closure not required, clean and lightly dress it and review in 3-5 days • If heavily contaminated wound or it is infected but not requiring admission review in 36hr-------------------------------------------------------------------------------------------------------Methods of closure:Steri strips: • Wound less than 5cm + no risk factors for infection/tension/wetting • Adhesive skin closing strips allow skin edges to be opposed with an equal distribution of forces- useful for pretibial lacerations, inappropriate over jointsSkin glue: • Useful in children with superficial wounds and scalp wounds. Oppose dry skin edges apply glue and hold together for 30-60secs. Don’t allow glue into wound or near joints. 8

Staples: • Quick and easy, suitable for scalp wounds. Staple removers required for removalSutures: • Most common for primary closure. • If wound 5cm or bigger, or <5cm but subjection to tension (ie flexion) or getting wet • Oppose skin with slight eversion of skin edges and suture shut with non absorbable inert monofilament with curved cutting needles Diagram of wound closure techniques https://www.fairview.org/patient-education/116841EN-------------------------------------------------------------------------------------------------------Wound closures: - Primary closure: surgical closure soon after injury - Secondary closure: No intervention- heals by granulation - Delayed primary closure: surgical closure 3-5 days after injuryReferences: 9 Nice guidelines on lacerations:https://cks.nice.org.uk/lacerations#!scenarioMore detailed info on types of lacerations:https://www.rch.org.au/clinicalguide/guideline_index/Lacerations/

Animal BitesSymptoms: Ø Initial bite: puncture marks shape of teeth, blood Ø Infected bite: pus or fluid oozing from the wound, tenderness in areas near the bite, loss of sensation around the bite, limited use of the finger or hand if the hand was bitten, red streaks near the bite, swollen lymph nodes, fever or chills, night sweats-------------------------------------------------------------------------------------------------------Pre-hospital Treatment: 1. Wash wound thoroughly with soap and water, pat dry and cover with sterile dressing 2. Go to hospital if: severe bleeding, wound is still dirty, risk of rabies, unsure if received tetanus vaccination-------------------------------------------------------------------------------------------------------Hospital Treatment: 1. Clean with normal saline or tap water 2. Refer to specialist if facial or involving tendons or joints 3. Delayed primary closure (3-5days): everywhere except face and hands (due to infection), if very deep or more than 6hr old 4. Primary closure on face or larger lacerations 5. Co-amoxiclav (or doxycycline + metronidazole if allergic) given if: o Dog bite less than 3 day old, all cat bites, dog bites involving hand, foot, face, joint, genitals, deep wound affecting tendons/nerves etc, primary wound closure and diabetic/IC/elderly.-------------------------------------------------------------------------------------------------------Jelly fish sting: 1. Rinse in sea water to remove stinging cells 2. Immerse in hot water for 30-90 minutes to reduce pain and swelling Jelly fish sting http://boxjellyfish.org/box-jellyfish-sting- facts-deadliest-sting/ 10

Weever fish sting: Weever fish https://www.glaucus.org.uk/weever2.htm 1. Remove large spines with tweezers 2. Spines near joints/tendons will require removal in A&E 3. Clean wound with soap and water and rinse in fresh water 4. Immerse in hot water for 30-90 minutes 5. Do not cover 6. If not vaccinated get tetanus cover 7. Itching: apply hydrocortisone cream 2-3x/dayReferences: 11 NHS stings:https://www.nhs.uk/conditions/jellyfish-and-other-sea-creature-stings/St Johns:http://www.sja.org.uk/sja/first-aid-advice/skin/animal-bites.aspx

HypothermiaSymptoms: Ø Apathy, amnesia, ataxia, dysarthria, coma, hypotension, arrhythmias, respiratory depression, muscular rigidity Ø Ventricular fibrillation may occur when temperature is below 28 degrees or upon limb movement/invasive procedures. Stages of hypothermia: Oxford Handbook of emergency medicine- Page 254 -------------------------------------------------------------------------------------------------------Pre-hospital Treatment: 1. If wet, change into dry clothes 2. Cover body and head with blankets 3. Protect from cold ground by lying them on a mat/pine branches/heather 4. Give hot drink/food-------------------------------------------------------------------------------------------------------Treatment in hospital 1. Treat in warm room above 21 degrees 2. Handle patient gently to reduce risk of VF 3. Remove wet clothes and dry skin 4. Monitor ECG- AF with slow ventricular response, prolong of QRS, delayed repolarization and ST-T wave abnormalities 5. Give warmed humidified O2 by mask 6. IV access 7. Correct hypoglycaemia with IV glucose 8. Hypothermic cardiac arrest can make heart unresponsive to defib, pacing and drug therapy, so avoid drugs until temp above 30 degrees 9. Defibrillation is appropriate if VF/VT occurs- if 3 shocks unsuccessful stop shocks until temp above 30 degrees • Passive rewarming: wrap in warm blankets and polythene sheets. Aim for rate of 0.5-2 degrees/hr. Suitable for mild above 32 degrees • Active rewarming: water bath at 41 degrees. Useful for immersion hypothermia but not used if injured or if CPR required. • Core rewarming: Airway warming with 40-45 degree humidified O2 can reduce risk of arrhythmia. Peritoneal lavage saline at 45 degrees run in via DPL catheter for 10-20 mins. Directly heats liver and retroperitoneal 12

organs eg IVC blood. Extracorporeal rewarming with cardiopulmonarybypass maintains brain and organ perfusion- method used in severehypothermia or cardiac arrest. Treatment options for hypothermia stageshttps://www.ausmed.com/articles/hypothermia/References: 13 Oxford Handbook of emergency medicine - Page 278NICE guidelines:https://www.nice.org.uk/guidance/cg65/chapter/Recommendations

AnaphylaxisSymptoms: Ø Respiratory: Swelling of lips, tongue, pharynx and Example of anaphylaxis in a paediatric epiglottis, dyspnoea, wheeze, chest tightness, hypoxia, patient hypercapnia https://firstaidforlife.org.uk/anaphylactic Ø Skin: Pruritis, erythema, urticarial and angioedema Ø CVS: Hypotension, shock, arrthymias, ischaemic chest -shock-acute-allergic-reaction/ pain Ø GI: nausea, vomiting, diarrhoea, abdo cramps Ø---------------------------------------------------------------------------------Pre hospital aid:1. Call 999- note substance that induced reaction2. Inject them with auto injector if they have one- eg Epipen: o hold pen in fist, pull of safety cap, inject orange end at 90 degrees at 10cm in outer mid thigh, hold for 10 seconds then remove, massage injection site for 10 seconds o Each pen can only be used once3. If no response- inject second Epipen after 5-15 mins-------------------------------------------------------------------------------------------------------Hospital treatment1. Discontinue administration of suspected factor/remove sting by carefully scraping away from skin2. Give 100% O23. Open and maintain airway- may require intubation or surgical airway4. Drug administration: Ø 0.5mg (0.5mL of 1:1000 solution) IM adrenaline o if no improvement repeat in 5 mins o If already been given Epipen the 300mcg dose usually sufficient o Give only 50% adrenaline dose to patients on tricyclic antidepressants, MAOIs or beta blockers Ø Beta 2 agonist nebulised with O2- eg 5mg salbutamol Ø 1-2L IV 0.9% saline rapid infusion if hypotension doesn’t respond to adrenaline Ø Antihistamine: H1 blocker 10-30mg slow IV chlorphenamine and H2 blocker 50mg IV ranitidine Ø 100-200mg slow IV Hydrocortisone Ø Admit/observe after initial Treatment for 4-6hrs 14

Resuschittatptiso:n//wCwouwn.creils(uUsK.o) rg.uk/anaphylaxis/emergency-treatment-of-anaphylactic-reactions/ Anaphylactic reactions – Initial treatment Anaphylactic reaction? Airway, Breathing, Circulation, Disability, Exposure Diagnosis - look for: • Acute onset of illness • Life-threatening Airway and/or Breathing and/or Circulation problems 1 • And usually skin changes • Call for help • Lie patient flat • Raise patient’s legs (if breathing not impaired) Intramuscular Adrenaline 2 1 Life-threatening problems: Airway: swelling, hoarseness, stridor Breathing: rapid breathing, wheeze, fatigue, cyanosis, SpO2 < 92%, confusion Circulation: pale, clammy, low blood pressure, faintness, drowsy/coma 2 Intramuscular Adrenaline IM doses of 1:1000 adrenaline (repeat after 5 min if no better) • Adult 500 micrograms IM (0.5 mL) • Child more than 12 years: 500 micrograms IM (0.5 mL) • Child 6 -12 years: 300 micrograms IM (0.3 mL) • Child less than 6 years: 150 micrograms IM (0.15 mL) March 2008 5th Floor, Tavistock House North, Tavistock Square, London WC1H 9HR Telephone (020) 7388-4678 • Fax (020) 7383-0773 • Email [email protected] www.resus.org.uk • Registered Charity No. 286360Drug doses for anaphylaxis: Adrenaline Hydrocortisone Chlorphenamine< 6 months 150 micrograms (0.15ml 1 25 mg 250 micrograms/kg in 1,000)6 months - 6 years 150 micrograms (0.15ml 1 50 mg 2.5 mg6-12 years in 1,000)Adult and child > 300 micrograms (0.3ml 1 100 mg 5 mg12 years in 1,000) 500 micrograms (0.5ml 1 200 mg 10 mg in 1,000) https://www.resus.org.uk/anaphylaxis/emergency-treatment-of-anaphylactic-reactions/ 15

References:St Johns:http://www.sja.org.uk/sja/first-aid-advice/illnesses-and-conditions/allergic-reactions.aspxResus guidelines:https://www.resus.org.uk/anaphylaxis/emergency-treatment-of-anaphylactic-reactions/ 16

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Cardiac arrestSymptoms: Ø Unconscious, no carotid/femoral pulse (for 10secs), not breathing-------------------------------------------------------------------------------------------------------Pre hospital aid: • Check danger, assess responsiveness, call help, look/listen/feel, tell help there is cardiac arrest and get defibrillator and call 999 • Start CPR: 2 breaths for 30 compressions-------------------------------------------------------------------------------------------------------Hospital treatment: • Continue BLS- compressions and bag-valve-mask ventilation • Remove/cut clothing from upper body • Apply defibrillation pads: one to right of upper sternum below clavicle, other mid axillary line LHS, pause compressions get rhythm • Get IV access at same time • If VF/VT rhythm, remove O2, stand clear, defibrillate at 150J (if biphasic defibrillator) • Resume compressions for 2 mins then reassess rhythm. • If defibrillation not available- give single precordial thump: tightly clenched fist, deliver one direct blow from 20cm height to lower half of sternum • Drug administration v Adrenaline after 3 shocks in VF/VT every 3-5 mins, adrenaline straight away if asystole/PEA Example of VT, VT/VF and VF waves on an ECG http://slideplayer.com/slide/5687622/ 18

References:St Johns:http://www.sja.org.uk/sja/first-aid-advice/heart/heart-attack.aspxResus guidelines:www.resus.org.uk/resuscitation-guidelines/adult-basic-life-support-and-automated-external-defibrillation/ 19

Now test your knowledge! Click on the link: https://xerte.plymouth.ac.uk/xerte/play.php?template_id=827 20