5's Flashcards
1
Q
Approach to the Emergency Patient: “ABCDE/NGT, Opening Gambit, and FIVE vital signs”
A
“How do they look?” e.g. Sick, Not Sick, CPR in progress, etc
- Airway–is the patient alert, speaking, coughing, moving air? Stridor, hoarseness, gurgling?
- Breathing–any distress? Do you hear bilateral breath sounds?
- Circulation–do they have bilateral radial pulses? Do they look well perfused?
- Disability (Neuro)–are they alert and appropriate? ALTERED MENTAL STATUS? Think ”NGT!”
- Exposure/Environment–patient in a gown or trauma patient naked. Skin cold/hot, wet/dry?
2
Q
“The OPENING GAMBIT” for any patient who has an emergency or appears unstable
A
- O2
- O2 Sats
- IV access
- ECG monitoring
- 12-lead EKG, +/- portable CXR
3
Q
“There are FIVE vital signs” -Dr. Slovis
A
- HR
- BP
- RR
- O2 sat
- Temperature
4
Q
What is “NGT”?
A
In patients with altered mental status, think of “NGT” before moving on:
Narcan: opiate reversal. for the obtunded patient with pinpoint pupils, apnea or slow RR, stigmata of narcotic use.
0.4mg IV to reverse iatrogenic opiates
2mg IV to reverse heroin user off the street (typical dose)
10mg IV to reverse certain special overdoses (see “ROC-LAVA-X”)
Glucose: CHECK FINGER STICK ON EVERY PATIENT WITH ALTERED MENTATION, SEIZURE, TIA/CVA, OR GENERALIZED WEAKNESS! (in grams/100ccs) – with glucose 1 amp = 50 ccs
One amp D50- adult. This is 25 grams of glucose in 50cc of water. Should raise glucose by ~200 within a few minutes
D25 at 4cc/kg- child.
D10 at 10cc/kg- infant.
Thiamine: (usually 100 mg) there are 5 types of patient who need thiamine if they are altered– 1. The cachectic calorie malnourished; 2. disheveled alcoholic; 3. malabsorption syndromes (short gut, gastric bypass, etc); 4. hyperemesis gravidarum; 5. anorexia nervosa
Causes of pinpoint pupils: narcotics, cholinergic overdose, pontine bleed
Causes of big pupils: benzos, barbiturates, global CNS hypoxia, anticholinergics
5
Q
Narcan Dosing and Indications
A
opiate reversal. for the obtunded patient with pinpoint pupils, apnea or slow RR, stigmata of narcotic use.
0.4mg IV to reverse iatrogenic opiates
2mg IV to reverse heroin user off the street (typical dose)
10mg IV to reverse certain special overdoses (see “ROC-LAVA-X”)
6
Q
High-dose Narcan (10mg IV) is the antidote for…
A
"ROC-LAVA-X" Reserpine (antipsychotic); Opiates; Clonidine; Lomotil (anti-diarrheal); ACE inhibitor/ARB overdose; Valproate; Aldomet (methyldopa); Xanaflex. There are many others.
7
Q
Glucose Dosing
A
Glucose: CHECK FINGER STICK ON EVERY PATIENT WITH ALTERED MENTATION, SEIZURE, TIA/CVA, OR GENERALIZED WEAKNESS! (in grams/100ccs) – with glucose 1 amp = 50 ccs
One amp D50- adult. This is 25 grams of glucose in 50cc of water. Should raise glucose by ~200 within a few minutes
D25 at 4cc/kg- child.
D10 at 10cc/kg- infant.
8
Q
Who needs thiamine?
A
Dose: usually 100 mg
There are 5 types of patient who need thiamine if they are altered–
- The cachectic calorie malnourished;
- disheveled alcoholic;
- malabsorption syndromes (short gut, gastric bypass, etc);
- hyperemesis gravidarum;
- anorexia nervosa
9
Q
Causes of Hypoglycemia
A
Causes of Hypoglycemia “Re-ExPLAAAINeD”
Renal failure (insulin metabolism occurs in the kidneys); EXogenous insulin or oral hypoglycemics; Pituitary insufficiency; Liver disease; Adrenal failure; Alcohol ingestion (esp in children); Aspirin toxicity; Infection (esp sepsis in children); NEoplasm (insulinoma); Drugs Other hypoglycemia pearls: OCTREOTIDE can treat Sulfonylurea overdose by suppressing endogenous insulin secretion. GLUCAGON can stimulate glycogenolysis and gluconeogenesis but causes bad nausea and vomiting. Watch for POTASSIUM shifts when treating hyper and hypoglycemia!
10
Q
3 Causes of pinpoint pupils (Miosis)
A
narcotics
cholinergic overdose
pontine bleed
11
Q
4 Causes of big pupils (midriasis)
A
benzos
barbiturates
global CNS hypoxia
anticholinergics
12
Q
5 causes of altered mental status:
A
- Vital sign abnormalities–hypoxia, shock, hypertensive encephalopathy, heat stroke (Open the gambit!)
- Toxic/Metabolic–particularly Hypoglycemia, Hypo/hypernatremia, (NGT, get labs!)
- Structural lesion–mass, bleed, stroke, demyelination, edema, (Get imaging!)
- CNS infection–encephalitis/meningitis (Get cultures, give abx, do an LP!)
- Psychiatric or Non-convulsive Status Epilepticus (Get a neuro consult for EEG, possibly psych consult!)
13
Q
5 Causes of Seizure
A
- vital sign abnormalities–hypoxia, febrile sz
- toxic/metabolic–hypoglycemia, hyponatremia, alcohol withdrawal, INH toxicity, cocaine
- structural–bleed, mass
- CNS infection–herpes encephalitis
- Epilepsy
14
Q
The FIVE treatments for status seizures
A
- ABC/NGT/GAMBIT–Roll on their side to protect airway from vomit, give O2, check O2 sats, CHECK GLUCOSE!
- Begin a Benzo–Ativan1-2mg IV, repeat as necessary
(What if I can’t get an IV? Ativan 2mg IM, Versed 5mg IM or 0.5mg/kg Intranasal, Valium 10mg rectal) - Consider Specific Antidotes (see below)
- Keppra 1000mg IV loading dose, or Fosphenytoin 1000mg IV over 20 min
- Barbiturates or Propofol ONLY IF you can manage the airway
15
Q
The FIVE causes of seizure that need a true ANTIDOTE
A
- Hypoxia –> oxygen
- Hypoglycemia –> D50
- Hyponatremia –> 3% hypertonic saline
- INH toxicity –> Vitamin B6
- Eclampsia –> Magnesium and delivery of fetus
16
Q
The DDX for Agitated Delirium/Hyperthermic and Altered
A
Sympathomimetic intoxication Anticholinergic toxidrome Sepsis Aspirin toxicity Heat stroke (T>40) Thyroid storm NMS (stiff) Serotonin Syndrome (clonus) Malignant Hyperthermia (stiff) Subarachnoid hemorrhage Malaria
17
Q
The Five treatments of heat stroke
A
Heat stroke dx = Temp >105 + altered mental status + appropriate context
- Wet & Windy–spray and fan. NO ice water immersion (can’t monitor, will overshoot). Slow down when temp reaches 102
- Benzos for shivering (shivering keeps core temp high)
- IV fluids but be cautious. Replace their urine output. Need 2 IVs, a foley, and a rectal probe.
- Search for COMORBID CONDITION– occult infection or HONK in the elderly; CO poisoning, hypoglycemia, or sodium imbalance in the marathon runner
- Admit to ICU for support of multisystem organ failure (ARDS, liver failure, kidney failure, DIC)
18
Q
The Five treatments of HYPOthermia
A
Only Rewarming will help the heart
1. Rewarm from the core–>out. Heating blankets, warm fluids, gut lavage, etc. NO immersion!
What is “Cold Diuresis”? When the pt gets cold, blood is shunted to the core, so renal perfusion increases and the kidneys pee off fluids that they should be holding onto. Hypothermic patients are thus usually hypovolemic.
Why not immerse in the hot tub? Lactate, potassium, and toxic metabolites are trapped in cold extremities and skin-warming will vasodilate, causing dumping of these toxins into the core causing hypotension
2. Consider NGT. Is this a malnourished drunk/drug user who passed out in the cold?
3. Consider Cx and antibiotics. Is this an elderly person who is septic and immobilized without heat?
4. Consider steroids. Is this pituitary/adrenal failure?
5. Consider synthroid. Is this hypothyroid myxedema coma?
19
Q
Hypothermia: 5 EKG findings
A
(1) J/Osborne wave—risk of re-warming arrhythmia;
(2) Sinus brady;
(3) Slow A-fib;
(4) long QT; (prolonged PR, QRS too)
(5) V-fib that doesn’t respond to drugs or shocks.
20
Q
Approach to a TIA/CVA
A
- ABC–protect airway by keeping HOB at 30 degrees, keep NPO
- NGT– CHECK FINGER STICK
- Activate stroke team
- Stat head CT without contrast to look for bleed
- Thrombolytics within 3-4.5h from sx onset)
(tPA = 30% more likely to have “minimal disability”; 5% will bleed [10-fold increase]; NO change in mortality)
21
Q
Tests to order for TIA (3-5)
A
MRI of brain;
CTA or MRA of head and neck (or carotid duplex ultrasound);
+/- TEE for atrial thrombus
22
Q
Meds to prescribe for TIA:
A
Aspirin. If on aspirin, consider plavix. If on plavix, consider heparin/coumadin.
23
Q
Risk of stroke after TIA
A
10% of TIA patients will have CVA within 3 months, half of these within the first 48 hours (5%)!Do not miss this dx!
24
Q
5 indications for intubation
A
- Failure to maintain airway—altered LOC, no gag, stridor, aspiration
- Failure to oxygenate (sats dropping) or ventilate (PCO2 rising)
- Multisystem instability—severe shock, poor physiologic reserve
- Projected Clinical Course—e.g. airway swelling after burn resuscitation, neck abscess/hematoma
- Need for transport/definitive tests—combative, harmful to self, safety in ambulance or helicopter
25
Troubleshooting Problem with ventilator
DOPES
Displacement of tube
Obstruction of tube,
PTX (also: PE, pulmonary edema, collapse),
Equipment failure
‘Stacked breaths’ (bronchospasm, ventilator settings)
26
Vignette: “Patient on a ventilator goes into PEA.” Think....
Think HYPOVOLEMIA or PNEUMOTHORAX. High intrathoracic pressure is occluding venous return.
Tx = disconnect vent, allow exhalation, bag ventilate, give bolus, consider needle decompression
27
Vignette: “Patient in status asthmaticus is getting better, then goes into PEA”: think
Think BREATH STACKING or PNEUMOTHORAX. High intrathoracic pressure is occluding venous return.
Tx = disconnect vent, allow long exhalation, give bolus, consider needle decompression.
28
The 5 reversible causes of Cardiac Tamponade
(1) Trauma
(2) Uremia
(3) Infection/TB
(4) malignant effusion—breast CA or lymphoma
(5) Rheumatic effusion—RA/SLE
29
The 5 phases of Alcohol Withdrawal:
(1) Tremulous/tachycardic/anxious in 6-8 hours
(2) Seizures in 24 hours
(3) hallucinosis in 24-48 hours
(4) Delirium Tremens = acting wild/all vitals elevated/need to be restrained in 3-5 days
(5) post-abstinence personality changes
30
Treatment of acute alcohol withdrawal (2)
1. Benzos. Give Ativan or Valium. Titrate to effect, not a fixed dose.
```
2. Fluids/Lytes/Supplements. A Banana Bag is:
1L of D5NS at 200cc/hour, containing
1 amp multivitamin,
100 mg thiamine,
20-40 mEq K
2g Mg
```
31
Treatment for acute THYROTOXICOSIS: in order— (4)
(1) Dexamethasone;
(2) Propranolol;
(3) PTU;
(4) Oral potassium-iodide
32
The 5 causes of Anaphylaxis:
1. Food
2. Stings /hymenoptera
3. Drugs (sulf, NSAIDs)
4. Contrast
5. Blood Transfusion
33
The 5 treatments for Anaphylaxis
1. EPI 0.3 mg 1:1000 IM injection for adult, (0.1 for cardiac dose,
Peds dose 0.01 mg/kg)
2. Benadryl 25mg IV (as effective as 50mg, with less side effects)
3. H2 blocker of choice (20mg pepsid)
4. Solumedrol 125mg IV
5. IV Fluids 20 cc/kg
+/- epi drip (= 1mg epi in 1L NS at 240cc per hour = 4 mics/min)
Can also give albuterol and glucagon if on beta blocker (with zofran)
34
The 5 causes of Hyperkalemia; next step
1) NOT (hemolyzed)
2) CRF/renal failure;
3) Acidosis(RF made worse by...acidosis);
4) Cell Death (burns, Rhabdo, Post-Ictal, Tumor Lysis;
5) Drugs (NSAIDS, ACE-I/ARB, succ, dig, tmp/smx)
“Next step for Hyperkalemia” = EKG! And repeat the lab sample
35
The 5 EKG findings of HyperK, in order of appearance:
(1) Peaked T—5.5;
(2) prolonged PR—6.5;
(3) Flat P wave—6.5;
(4) QRS widens—7.0-8.0;
(5) Sine wave
36
The 5 causes of Sine Wave on EKG:
1) HyperK;
2) TCA overdose;
3) Beta-blocker overdose;
4) CaChannel blocker overdose;
5) Severe Acidosis
If you see a sine wave, assume hyperK, go down that pathway
37
The 5 treatments for Hyperkalemia: (K should fall about 1-1.5/hr if you do this)
3 stages:
- reverse electrical (EKG) effects: CaCl
- Drive K into cells (I+G, albuterol)
- get it out of body (Kayexelate)
1. Ca Chloride 10cc (1 amp), max 2 amps. for wide QRS, stabilizes membranes
2. Regular Insulin 10U IV + 2 amps D50
3. Albuterol or other Beta-Agonist
4. Bicarb ONLY IF acidotic
5. IV Fluids in DKA, rhabdo, tumor lysis, adrenal insufficiency
What you need to know about bicarb: 1 amp is 50mL (1mEq per mL), will raise pH acutely by 0.10. Has intrinsic pH of 8.0, tons of sodium, osmolality of 2000.
38
Treatment for Rhabdomyolysis (3)
Myoglobin dissociates into sticky ferrous/heme component and clogs renal tubules under acidic/low-flow conditions.
1. IV fluids to obtain urine output of 1.5-2 cc/kg/hr or 200cc/hr
2. NaBicarb to alkalinize urine (may use acetazolamide)
3. Mannitol, ONCE EUVOLEMIC, to increase urine output
39
The 5 EKG findings of Hypokalemia
(1) Flat T;
(2) U wave;
(3) LONG QT;
(4) Non specific ST/T Wave changes;
(5) V-tach or Torsades
40
The 5 things that drive K into a cell:
(1) Insulin
(2) beta agonist
(3) rising pH
(4) Sodium
(5) Magnesium
41
The 5 causes of HypOKALemia:
(1) Cellular shifts—Alkalosis, Albuterol, Insulin
(2) Renal—diuretics (lasix, HCTZ), hyperaldosteronism; RTA 1&2,
(4) GI—vomiting, diarrhea, fistula, pancreatic/biliary losses;
(5) Starvation state, alcoholism
(6) HypOMagnesemia (hypokalemia is a better indicator than the actual Mg level!)
42
Treating HypoK
100mEq will raise serum K by 0.3. (takes forever, so replenish until 3, and eat K rich foods)
Supplement 500mg/hr of Magnesium.
43
8 Life Threatening Causes of Chest Pain
```
ACS
Aortic Dissection
Cardiac Tamponade
Myocarditis
PE
PTX
PNA
Esophageal Rupture (Boerhaave's)
```
1. ACS—STEMI, NSTEMI/UA: Ask sharp? Pleuritic or reproducible? No heart dz? (“yes” to these three makes ACS 1% likely.) get CXR, CBC, BMP, Coags, Cardiac Enzymes, repeat ECG
2. Aortic Dissection: Ask Maximal at onset? Tearing/ripping to the back? Migratory pain source? (“no” to all three questions = low likelihood). Get both arm BP, CBC, BMP, Coags, Type+Cross, CXR, spiral CT of chest or TEE, esmolol for BP control
3. Tamponade: Muffled heart, clear lungs on CXR, JVD, hypotension. Get ECG and ECHO
4. Myocarditis: fever, positional chest pain, troponin leak, heart failure, effusion
5. Esophageal rupture/Boerhaaves: h/o scope procedure or wretching. Ask “hurts to swallow and move neck?” CBC, BMP, blood cultures, Get CXR, CT, Gastrograffin Swallow Study, antibiotics, call CT surgery
6. Pulm embolism
7. Pneumothorax
8. Pneumonia
44
Who do we get ABG's on? (5)
1. on ventilator
2. pts in shock
3. very bad asthmatic (can't tell if sleepy or hypercarbic)
4. significantly sick
5. significant lung disease (COPD, more)
45
What 5 tests are routine for eval a toxic/metab camuse of AMS?
```
Glucose
BMP
Calcium (hyper and hypo)
Urine drug screen
Alcohol
```
46
What 5 tests are routine if an overdose is suspected?
```
ECG (TCA OD shows RSR' complex in V1)
Aspirin Level
Tylenol level
Blood alcohol level
UDS
(6) pregnancy test
```
47
The 5 causes of DKA (the 5 I’s):
(1) Insulin lack;
(2) Indiscretion with sugar (eating badly)
(3) Infection;
(4) Ischemia--brain, heart, bowel;
(5) Infant on board (pregnancy)
48
The 5 treatments for DKA, and any pearls?
Glucose will drop about 100/hr.
1. IVF: IL bolus, then 250-500cc/hr for next 4 hours
2. Insulin: load 0.1 unit/kg IV -then- maintain 0.1 unit/kg/hr IV until gap is closed
3. Potassium 10-20mEq in each liter of fluid
4. Consider Bicarb if pH <6.9 to 7.0 (Risk of cerebral edema!)
5. Phosphate supplement
When blood glucose drops to about ~250, SLOW the insulin, ADD DEXTROSE to fluids (D10 or D5)
** NO FLUID BOLUS in CHILDREN unless hypoperfusion… (Risk of cerebral edema!)
DKA pearls:
- The killer in children is CEREBRAL EDEMA. To avoid this, avoid large fluid boluses, avoid bicarb, and don’t load with insulin—just start a gentle drip.
- Cerebral edema = obtunded. Treatment is 3% hypertonic saline
- If the gap closes but the pH and HCO3 are still low, it’s probably HYPERCHLOREMIA. Switch your fluids to half-normal saline or LR.
- The most common cause of death in DKA is arrhythmia due to iatrogenic hypOkalemia
49
What are the 5 BMP rules?
1. Check the #s (are the high/low?, check K)
2. Check the gap
3. Apply the rule of 15 (to determine additional resp process, HCO3- + 15 = what should be the pCO2, pH after decimal. If actual pCO2 higher or lower, separate resp. process)
4. apply delta 1:1 rule (Difference between AG-14 should be same diff. b/w [24 - current HCO3]. If actual HCO3 is higher, addl. met. alk. If lower, addl. met. acid.
5. Unexplained acidosis? Figure out cause by doing osmolar gap.
50
5 Red flags for Back pain
1. Age <20, >55 (less likely to be benign pain)
2. Severe systemic disease
3. Non-MSK complaints (fevers, rashes, etc.)
4. Non-MSK pain (i.e. moving around for kidney stones)
5. ANY new Neurologic symptoms (like urinary retention, new numbness, weakness)
51
5 Acid-Base Rules
1. Check the numbers; is there a low or high bicarb?
2. Check the Anion Gap, even if the bicarb is normal
3. Rule of 15: uncovers respiratory compensation
a. if there is perfect respiratory compensation for a metabolic acidosis, then:
Bicarb + 15 = expected PCO2 = expected last two digits of the pH
b. A PCO2 higher than expected means additional primary respiratory acidosis.
c. A PCO2 lower than expected means additional primary respiratory alkalosis.
d. The PCO2 bottoms out at 15—maximal hyperventilation.
A Bicarb of 5CO2 15pH 7.12; Bicarb of 2.5CO2 15pH 6.88
4. Delta Gap: compare the (gap – 14) to the (bicarb – 24). Should be equal and in opposite direction for a single metabolic disturbance. If the delta is larger than 3-4, there is an additional metabolic disturbance.
5. Check Osmolar Gap: compare estimated Osm = (Na x 2) + (BUN/2.8) + (Gluc/18) + (EtOH/4.6) to lab serum osmoles. Osmolar Gap > 10 or so suggests alcohols as cause of anion gap acidosis
a. As glucose goes up by 100, the minimum fall in sodium is 2 `
52
Vignette: ”You detect a GAP ACIDOSIS and a RESPIRATORY ALKALOSIS.” What are your two immediate RULE-OUTs and your two most common causes?
1. SEPSIS with hyperventilationrule out
2. ASA toxicityrule out
3. Bleeding from trauma and breathing hard due to pain
4. Alcohol withdrawal; a keto-acidosis with tachypnea
53
Atypical is TYPICAL with ACS in the female or elderly:
(1) Short of breath
(2) Syncope
(3) weakness
(4) abdominal complaints—epigastric pain, nausea
(5) diaphoresis
54
The 5+ things to check on the ECG to find an MI or ischemia:
Posterior wall infarct?
RV infarct?
(1) ST elevation in 2 contiguous leads;
(2) ST depressions in 2 contiguous leads;
(3) New T-wave inversions
(4) New LBBB;
(5) Tall R/deep ST depression on V2 (sign of posterior MI)
(6) Q-waves;
posterior wall infarct? Look at V1,2,3: Tall R, upright T-wave, deep ST depression (See R>S, ST depression, TWI)
“RV” infarct? With hypotension and II/III/aVF pattern. add a right-sided lead, V4R, to see it
55
Know your enzymes (3)
1. Myoglobin: Quickest peak, least specific, gone in 24 hours, not used
2. CK-MB: Rise at 4-8hrs, peak at 12-24 hrs, gone by day 2-4. Catches MI overall about 87% of the time
3. Troponin: Most sensitive, just takes a while. 50% sensitive at 3-6 hours; 100% sensitive at 10-16 hours. Lingers for a couple weeks.
56
Treatment for Cocaine-associated chest pain:
1. Aspirin
2. Ativan or Valium
3. Nitroglycerin or nitro drip
4. always obtain repeat 12-lead and enzymes
5. consider further antiplatelet/anticoagulation if also high risk for MI
57
Acid-Base rules for the ABG (3)
1. Which direction has the pH moved?
2. Has the CO2 moved opposite (primary respiratory) or same (primary metabolic) direction as pH?
3. For a pure, acute respiratory disorder, an increase in CO2 of 10 = decrease in pH of 0.08
58
The 5 causes of Hypoxia:
1. VQ mismatch (the common lung diseases): PNA, Asthma, COPD, Atalectasis, PE, pulmonary edema, ARDS. Corrects with supplemental O2.
2. Shunt: deadspace (alveoli filled with pus, fluid, or blood); or cardiac defect with RL shunt. Will NOT improve with supplemental O2.
3. Diffusion defect: interstitial lung disease or interstitial edema.
4. Hypoventilation: resp depression, CNS injury, peripheral neuromuscular dz, chest wall rigidity
5. Low Fi02: altitude, SCUBA system malfunction
(*items 1, 2, and 3 give you a large A-a gradient.)
59
A-a Gradient, Lower limit of PaO2
A-a Gradient = PaO2 from blood gas – [150 – (PCO2 from blood gas / 0.8)]
Lower limit of PaO2 = 96 – [age/4]
60
The 3 causes of “Saturation Gap” (SaO2 higher than ABG co-oximetry PaO2):
1. CO poisoning (headache, nausea, vomiting, abd cramps, in houseboat/trailer/ice-storm, cherry red, perfect SaO2). Takes 270 min to resolve on room air, 90 min on 100% O2, and 30 min in hyperbaric O2 chamber
2. Methemoglobinemia (PaO2 of exactly 88%, blue-grey skin, smoke inhalation?)
3. Cyanide poisoning (overdose of nitrates, smoke inhalation?) Perfect SaO2
Cyanosis occurs with absolute 3-5 grams deoxy-Hb. (i.e. cyanosis occurs EARLIER if polycythemic, or LATER if anemic)
61
The 8 deadly causes of Shortness of Breath:
1. Upper airway obstruction—Foreign body, anaphylaxis, abscess or expanding hematoma, vocal cord spasm
2. Asthma/COPD exacerbation: history. This is a dx of exclusion
3. Pulm Embolism: Virchow’s triad—smoker, OCPs, personal/family hx of clotting, surgery, stasis. CBC, BMP, D-dimer, CXR, Lower extremity duplex US, CTA of chest
4. Pulmonary edema/Heart failure: Orthopnea, DOE, PND, swelling, cough, nocturia. Get CBC/BMP, enzymes, BNP, CXR
5. Pneumothorax: sudden onset, asthmatic. Get Expiratory CXR
6. Pneumonia: CBC, BMP, Blood cultures, CXR, ask a question about TB exposure, travel, sick contacts. Give antibiotics empirically. nebs and steroids might help
7. ACS
8. Tamponade
62
The 5 causes of Wheezing:
1. Reactive Airways--asthma, COPD, allergies, inhalation pneumonitis. (Clues include hx of the disease, response to nebs, FEV1 or peak flow before and after nebs, road test)
2. CHF--check a BNP;
3. Mass effect--foreign body, tumor, pneumonia,
4. Pneumothorax;
5. Pulmonary embolism—broncho-active molecules released under ischemia, might improve with nebs, don’t be fooled
63
The 5+ treatments of Asthma Exacerbation:
1. Oxygen
2. Albuterol
3. Anticholinergics (Ipratropium)
4. IV Steroids: Solumedrol 80 or 125mg IV
5. Magnesium: 2g IV over 10 minutes
- -
6. Terbutaline, or
7. Epinephrine: 0.3mg 1:1000 subQ x 1
64
The 5 treatments of Pulmonary Edema:
1. Oxygen
2. Nitroglycerin drip, IF hypertensive. start big at 100-200mic/min
3. Albuterol only if wheezing/COPD possible (albuterol increases mortality in pure CHF)
4. IV lasix 40mg if CXR evidence of edema AND creatinine normal
5. CPAP if respiratory failure. MUST be mentating well.
(morphine and albuterol increase mortality!)
65
The 5 (made into 4) principles for catching ACS:
1. Atypical is typical, especially in the elderly
2. Repeat your ECG in 10-20 minutes
3. One set of enzymes is worthless, get a 2-hour MB and TnI “delta” or hold overnight for a rule-out
4. If a patient has angina but no ECG changes and negative enzymes, they need ONE objective test either during the admission or the next day follow up: treadmill, stress echo, nuclear, cath lab, coronary artery spiral CTA
66
Wrenn’s 5 reliable historical points for seizure
(loss of urine or stool does NOT differentiate)
1. Post-Ictal State—confusion, paralysis, sore muscles, fatigue for hours
2. Amnestic during sz—will not recall a “lightheaded” feeling
3. Duration of minutes as opposed to seconds
4. Fell so hard there was trauma—head or tongue lac, as opposed to slumping or swooning
5. History of true seizure
67
Syncope Work-up & Rules
Initially includes H+P, orthostatic vital signs (positive if SBP drops by 20, DBP drops by 5, or HR rises by 20 in one minute of standing), ECG. Consider checking for anemia, electrolytes, and blood sugar as well.
* San Francisco Syncope Rule: Sensitive for serious outcomes, should ADMIT if the patient has any of
(a) history of CHF;
(b) shortness of breath;
(c) SBP <90;
(d) abnormal ECG; and
(e) Hct < 30
68
3 categories of etiologies for syncope
(40-50% never identified)
1. Cardiovascular
MI; PE; Tamponade; Arrhythmia (bradycardia most common); Aortic Stenosis (chest pain, short of breath, syncope); HOCM (syncope following exertion!!); Hypovolemia; autonomic dysfunction; carotid sinus hypersensitivity (turning head or neck surgery); pulmonary hypertension; **Brugada syndrome
2. Neurologic
*Vertebrobasilar insufficiency/Subclavian Steal (5D’s—Drop attack, Dizzy, Dysarthria, Dysphagia, Dyplopia); increased ICP
3. Neurovascular or metabolic
Vaso-vagal syncope; Hypoglycemia
*Anterior brain circulation interruption gives focal deficit, not syncope
*Hypoxia makes you drunk, does not cause syncope per se
69
What is Brugada Syndrome?
triad of Saddle-shaped ST elevation in V1-3; RBBB; T-wave inversion. Sodium channelopathy, predisposes to V-tach, causes syncope and sudden death in middle-aged healthy men.
70
EKG: How to assess rhythm & rate
Read the rhythm:
(1) Fast or Slow;
(2) Wide or Narrow;
(3) Regular or not;
(4) P-wave connection
Rate
1. 300—max in human. Rate > 300 = artifact
2. >200 is a bypass tract (WPW)
3. >160 is usually re-entry (AVNRT/AVRT)
4. exactly 150 is A-flutter with 2:1 block
5. <140 probably sinus tach, look for underlying cause
6. <50 is junctional escape
7. <40 is ventricular escape, should be wide
71
EKG what to read after rate and rhythm? (6)
What else not to miss?
Read the rest: (1) Axis; (2) Intervals; (3) Ischemic patterns; (4) BBB; (5) Hypertrophy; (6) other—
**Don’t miss: hyperK, S1Q3T3 (PE), PR depression (pericarditis), Delta Waves (WPS), flutter waves
72
Common (5) and deadly (5) causes of Sinus Tachycardia
```
Pain
anxiety
fever
anemia
drugs (stimulants)
```
Deadly causes
1. Hypoxia
2. Shock
3. Pulmonary Embolism
4. Pericarditis/Myocarditis
5. Thyrotoxicosis
73
6 causes of TWI
1. Ischemia/infarct
2. LVH
3. Digoxin (“hockey stick”)
4. Hypokalemia (think lasix), HypoCa (think pancreatitis)
5. increased ICP (“roller-coaster T-waves”)
6. Respiratory alkalosis
74
The 8 NON-ischemic causes of ST elevation
1. Pericarditis
2. Early Repolarization
3. LBBB
4. LVH
5. LV Ventricular Aneurysm (with Deep Q-S waves, don’t give lytics!!)
6. Hyperkalemia (V1-2)
7. Brugada syndrome
8. WPW or bypass tract
75
The 5 reasons for Low Voltage:
(1) Pericardial effusion;
(2) Infiltration of amyloid, sarcoid, hemochromatosis, glycogen storage;
(3) COPD or PTX;
(4) Myxedema coma;
(5) obesity/anasarca/edema
76
The 5 causes of Long QT:
1. Drugs—Benadryl, anti-psychotics, levofloxacin/moxifloxacin, quinine
2. Hypo’s—K/Mg/Ca
3. Hypo’s—thermia or –thyroid
4. Increased ICP
5. Genetic—Ramano Ward/Jervell-Lange-Neilson
77
The 5 causes of PVCs and Ventricular Ectopy:
1. Hypoxia; know the O2 sat, consider CO poisoning with false 100% sats
2. Ischemia; get some enzymes and another 12-lead
3. Electrolytes; K, Mg; Look at QT interval! Check the BMP, supplement
4. Sympathetic tone; increased ICP!!, pressors, cocaine, alcohol withdrawal (is Ativan your antiarrhythmic?),
5. Severe pH issue; check an ABG on the ventilated or the sick-as-shit patient
Dr. Lown predicts increasing risk of V-fib in pts with ACS based on frequency (>5/min) and complexity of PVCs
78
5 heart blocks and their causes (think ischemia first)
1. 1st degree: Degenerative—B-blocker, CaChannel-blocker, lupus, ARF, Lyme disease
2. 2nd degree I—Post MI! Digoxin, B-blocker, CaChannel-blocker, Lyme disease
3. 2nd degree II—Anterior infarct!bad, try to open the artery and need to pace (will progress)
4. 3rd degree—Ischemia, RCA lesion! sick sinus
5. Left Bundle Branch Block—must rule out MI!
79
How to identify a bundle branch block
A wide QRS that reliably follows a P-wave. Look at “terminal force vector”— whether the end of the QRS is negative (RBBB) or positive (LBBB) in lead I. You should expect to see ST changes that are discordant with the terminal force vector (ST elevation in RBBB and ST depression in LBBB).
80
What to think when you see frequent PACs
Atrial distension from high end-diastolic pressure Occult heart failure!
81
Sgarbossa Criteria - what is it and how to use?
Read through a LBBB to find an infarct. Specific but not sensitive; therefore go to PCI or lytics in any patient with Sgarbossa score of >3 or new LBBB
1. CONcordant ST elevation > 1mm (5pts)
2. DIScordant ST elevation > 5mm (2pt)
3. ST depression > 1mm in V1,2,3 (3pts)
82
Scenarios when atropine will not work
Atropine will not work for bradycardia 2/2
1) Hypoxia;
2) High ICP,
3) Hypothermia,
4) wide complex
83
The 5 types of SVT and their causes and treatments
1. Sinus tachycardia—regular, <140, true p wave. Look for underlying cause—pain, fever, thyroid, shock, PE, cocaine, anemia (occult blood in stool?)
2. AVRT/AVNRT—regular, >160. Vagal maneuvers, adenosine, synchronized shock. Adenosine failure usually from the IV being too far from heart or identifying wrong rhythm.
3. A-flutter—regular, 150, flutter wave. Fairly stable. Use diltiazem for rate control.
4. A-fib with RVR—irregular, narrow, fast, no P wave. Goals of treatment are rate control and anti-coagulation. Avoid converting in the ED unless absolutely sure onset <24-48 hours ago. *Diltiazem and Lovanox, then refer to cardiology. No difference in mortality between converting or just rate control+anticoag. Consider admission for TEE to evaluate for mural thrombus.
a. HTN (most common cause)
b. Alcohol (most common cause under 45 years old)
c. Ischemic/CAD (15% post-MI get this)
d. Sympathomimetics, cocaine, caffeine
e. Thyrotoxicosis
f. Embolic—PE
g. Pericarditis
h. Rheumatic fever with mitral stenosis
5. Multi-focal Atrial Tachycardia—irregular, P waves vary in morphology. This is a rhythm of chronic hypoxia and COPD. Mortality is 25%. Fairly stable, but if rate is too fast or patient has symptoms—first line therapy is magnesium 2 grams IV over 10 minutes (!! can’t give B-blocker or CaChannel blocker because of COPD). Also get a theophylline level.
84
All waves negative in lead I
Limb lead reversal
85
5 Options for STABLE v-tach: (Do I have 30 minutes to dick around? If yes, then consider pt stable.)
1. Lidocaine. Only works in 10% of cases, but will work in 1 minute, so you can move on quickly.
2. Amiodarone. Only works in 30% of cases, takes 10 minutes.
3. Procainamide. Watch out for QT prolongation and Hypotension
4. Magnesium
5. Cardioversion
86
The 5 symptoms of Acute Glaucoma (“lady in movie theater with acute onset unilateral painful/red eye”)
(1) eye pain;
(2) blurred vision;
(3) unilateral headache;
(4) Nausea and vomiting;
(5) Abdominal pain
87
3 Bell’s Palsy tx:
(1) Prednisone;
(2) Valtrex;
(3) eye lube and tape shut at night, protect in wind
88
5 causes of unilateral leg swelling:
(1) Cellulitis;
(2) trauma;
(3) DVT;
(4) ruptured Baker’s cyst;
(5) lymphatic obstruction by tumor or parasite
89
The 7 deadly causes of sore throat:
1. Peritonsillar abscess—teens already treated for strep throat, bulging tonsil, uvula pushed away
2. Retropharyngeal abscess—spontaneous in kindergarten age kid
3. Epiglottitis—now in adults, no stridor or drooling, fat red uvula, pain out of proportion. Directly visualize the epiglottis, get lateral neck soft tissue XR (85% sensitive)
4. Diptheria—immigrants and old women
5. Ludwig’s Angina—anaerobes, brawny/tense edema of anterior neck
6. Vincent’s Angina—ulcerating gingivitis, anaerobic tooth infection, fistulas into great vessels
7. Lemiere’s syndrome—Septic thrombophlebitis of the internal jugular vein from fistula
90
Strep Throat diagnosis criteria and treatment
“Centor criteria”, one point each—(1) lack of rhinitis or cough; (2) anterior cervical LAD; (3) any exudates; (4) fever, even subjective.
- Score of 0-1 means <5% chance of strep. No test, no treatment
- Score of 2 means unsure, 5-50% chance of strep. Rapid strep test, treat if positive
- Score of 3-4 means >50% chance of strep. No test, just treat (reduce duration and prevent transmission)
1.2 million U of benzathine in butt, 2 days of PO PenVK, 2 days of prednisone, new toothbrush
Tx does not prevent glomerulonephritis or peritonsillar abscess. NNT to prevent rheumatism is 1000
91
5 headache discriminating features that are worrisome
1. WHOML, first migraine, sudden onset or syncopeSAH until proven otherwise
2. Coagulopathy— (1) heparin/coumadin/plavix; (2) dialysis (cyclical brain swelling/shrinking); (3) uremic (bad platelets); (4) liver dz (low Factor VII); (5) hemophiliac
3. Cancer or HIV—mass lesion
4. Trauma, even a few weeks ago—chronic SDH in elderly fall patient; older than 50
5. Fever, stiff neck, altered mental status, focal neuro complaints/deficits
92
To do an LP without a CT first, must have 4 things:
(1) non-focal exam;
(2) normal mental status;
(3) normal eyes including DISCs;
(4) young and otherwise healthy.
This never happens, and meningitis patients need antibiotics in 30 minutes: Blood Cx first (50% will tell you the bug)Antibiotics (won’t change cell counts, protein/glucose, or even gram stain within 4 hours) then CT then LP
93
The 4 treatments of Post-LP Headache
Low pressure HA, increases with standing
(1) Caffeine 250 mg IV over 30 min;
(2) IV fluids;
(3) Caffeinated soda, 2 liters per day;
(4) Blood patch
94
The 5 treatments of Migraine:
(1) Compazine 10mg (or Reglan, Phenergan, Thorazine, Droperidol—longQT!);
(2) Benadryl 25mg;
(3) DHErgotamine-45 (not in old or pregnant);
(4) Morphine
(5) Home on high dose Motrin
95
The 5 treatments of Cluster HA:
(1) 100% O2;
(2) Intranasal Lidocaine 4% on soaked gauze;
(3) Proparicaine in affected eye;
(4) Migraine remedies;
(5) Home on 2 weeks Prednisone 40-60mg with taper
96
Hyponatremia without edema? (5)
```
SIADH
Water intoxication
Psychogenic polydipsia
Beer potomania
Hypothyroid
```
97
5 vital signs of the eye
```
Visual acuity
IOP
EO motility
Pupil
Visual Fields
```
98
DDx of SOB (5)
```
cardiac
CNS
blood
lung
MSK
```
99
Labs for suspected PE (7) and imaging (2)
CBC
BMP
```
istat
lactate
trop
BNP
PT/PTT
```
Imaging: CT PE protocol, b/l LE U/Sigr
100
Painful vision loss differential (5)
```
Glaucoma
Optic neuritis
Trauma
Temporal arteritis
Migraine
```
101
Where do people bleed out? (6)
Chest, abdomen, retroperitoneum, pelvis, thigh, scene
102
DDX for Acute monocular vision loss
“Go-cart MTV”
```
Glaucoma (pain)
Optic Neuritis (pain)
CRAO/CRVO (painless. This is a stroke!)
Amaurosis Fugax (painless. This is a TIA!)
Retinal detachment/hemorrhage (painless)
Trauma--open globe, traumatic mydriasis, hyphema
Migraine
Temporal arteritis
Vitreous hemorrhage (painless)
```
103
Treatment's for HTN Emergency (for 9 etiologies)
1. In general, Labetolol 10mg IVP (alpha and beta blocking, non-selective, bad in asthma/COPD)
2. ACS: Nitroglycerin drip, GENTLE 5-10mic/min.
3. Pulmonary Edema: Nitroglycerin, AGGRESSIVE sublingual then drip 100mic/min
4. Hemorrhagic Stroke/Subarachnoid Hemorrhage: Nicardipine
5. Eclampsia: MgSO4
6. Aortic Dissection: Esmolol drip to heart rate of 55 –PLUS- nitroglycerin drip
7. Alcohol withdrawal or cocaine intoxication: Ativan, titrate to drowsiness
8. Heroin withdrawal or rebound HTN: Clonidine
9. Pheochromocytoma or Autonomic Dysreflexia (the paraplegic who can’t feel anything but has increased sympathetic tone due to fecal or urinary retention): Phentolamine (alpha-blockade)
In general, Nitroprusside is DANGEROUS. Can INCrease ICP! Builds up thiocyanate in renal failure—acts like lidocaine toxicity! Adverse events reported in ACS!
In general, Hydralazine DOESN’T WORK
IV Diliazem, Esmolol, Metoprolol are much better RATE CONTROL agents than antihypertensives
104
HTN Urgency vs Emergency
“Urgency” = the number is too high, there are no symptoms besides perhaps a dull headache. This patient can be sent home on PO meds with follow up. Lower the BP over 24 hours.
“Emergency” = the number is too high AND there are symptoms of end organ damage. Lower the BP by no more than 25% so as not to drop off the back of the auto-regulation curve
1. Brain—focal signs or altered mental status
2. Eye—papilledema, flame hemorrhages
3. Lungs—flash pulm edema with shortness of breath. Get CXR
4. Heart—chest paincheck pulses and BP in BOTH arms for right-to-left drop indicative of Aortic Dissection, get EKG
5. Kidney—microscopic hematuriado a UA on HTN pts.
105
Empiric tx of bacterial meningitis:
+/- Steroids before antibiotics,
Vancomycin and Ceftriaxone, plus
Ampicillin if very young or old (Listeria coverage)
106
PULM EMBOLISM information and work up
Pre-test Probability directs the work-up—use Well’s or PERC criteria. If you’re dealing with the low-probability Well’s-- D-dimer and stop; the patient meeting all PERC criteria (less than 2% chance of PE)-- maybe no tests
Get TWO tests if not low probability (CTA, D-dimer, BLE Doppler)
LMWH is bad in (1) Renal Failure and (2) Morbid obesity. Can still see HITT.
Most common ECG finding is sinus tachycardia. S1Q3T3 is rare.
Most common CXR finding is normal or atalectasis.
Hampton’s hump and Westermark sign are rare.
107
PNEUMONIA information and work up
Is this community acquired (Levaquin, Azithro+Ceftriax, Doxy), health-care associated (add Zosyn or Cefipime for pseudomonas and Vanc for MRSA), or HIV/immunosuppressed (add bactrim and steroids for PCP, isolate in case of TB)?
There are no clinical or CXR findings that reliably tell you what bug you’re treating, but: “XR worse than patient” or bullous myringitis = mycoplasm; “patient worse than XR” might = PCP, get HIV test (LDH is worthless)
108
Digitalis toxicity
*Digitalis toxicity: Blocks NaKATPase, increases intracellular calcium. Pt feels sick, sees yellow-green halos, gets confused. Most common EKG finding is frequent PVCs. Treat with Magnesium and 5 vials of Digibind. Do not give calcium. (Pathognomonic EKG finding is Bidirectional V-tach or PAT with block)
109
VIGNETTE: “The hemophiliac patient presents with bad headache”
FIRST give them factor replacement before the CT scan. The hemophiliac with life-threatening bleed (head, gut, epistaxis) needs 100% factor replacement.
Give Factor VIII at 50units/kg because 1 unit/kg raises factor by 2%. (“8-1-2”)
Give Factor IX at 100units/kg because 1 unit/kg raises factor by 1%. (“9-1-1”)
110
The DELTA wave
= Bypass tract; think WPW. If symptoms of ACS, call cardiology
111
“Tall, positive, late R-wave in aVR (where all waves should be negative)”
TCA overdose
112
New 3rd-degree AV block may be a sign of...
may be sign of RCA blockage—AV node is 90% supplied by RCA
113
“Elderly, non-athlete with HR<50, but still narrow”:
Sick Sinus Syndrome
114
A Biphasic T-wave in anterior leads or the isolated ST elevation in aVR
“Wellen’s Warning.” Sign of high-grade LAD lesion that is not amenable to medical therapy.
115
“A psych overdose patient takes a B-blocker, CaChannel blocker, and TCA’s. BP is 60/palp with wide QRS on the monitor”:
Give NaBicarb, since wide QRS means the Na channel has been poisoned
116
The otherwise healthy patient who is ACUTELY hypOnatremic and showing HARD neuro signs,
(i.e. seizure, altered mental status, paralysis):
Raise Na by 2-3mEq acutely. (Then, no more than 0.5mEq per hour or 12mEq per day)
3% hypertonic saline 100cc IV over 10 minutes, then
3% hypertonic saline 100cc IV over next hour
117
How to make an epi drip for anaphylaxis or asthma
1 mg epid in 1 liter = 1000 mcg/1000 ml
1 mcg/cc → start at 1 cc/min, then ↑ dose to 2-7 cc/min.
118
5 ECG findings of PE
1. Most common: sinus tachycardia
2. nonspecific ST segment and T wave changes
3. R sided findings (complete/incomplete RBBB, RV strain, RAD, dominant R wave in V1, RA enlargement)
4. rarely S1Q3T3 (20%)
5. atrial tachyarrhythmias
119
6 complications of status asthmaticus
```
PTX
pneumomediastinum
hypoK
hypophos
PEA
arrhythmias
```
120
5 things to figure out cause of hyper K
```
The patient
ECG
Prior K levels
History
Vital Signs
```
121
Describe the 2 types of calcium
Ca gluconate
bigger molecule! 3x the size, but only ⅓ the amount of Ca. If giving slowly, give this one! USe this one for kids, chronic hyperK, slow infusion.
Ca chloride
what we use in hyperK emergencies in adults, 3x the amount of calcium, more potent, more sclerosing. ALWAYS FLUSH THE LINE! (just like amiodarone)
122
What the real danger of hypoKalemia?
The danger of hypoK is the prolongation of QT, because it prolongs the RELATIVE refractory period. Puts pt at high risk for PVCs, VT, VF, torsades. Danger of prolonged QT → sudden death!
Any QT >500, be careful!!!
123
Giving Mg - for what and how much?
Replenishing low Mg -
Magnesium sulfate - Loading dose: 1-2g IV / 0-60 minutes, Maintenance 500 mg/hour
EMERGENCIES
Torsades 2g IV push
Eclampsia 5-6 g/hour
124
5 Major Causes of HyperCalcemia
```
Hyperparathyroidism
Cancer
Thiazides
Milk Alkali
Granulomatous diseases (ie. sarcoid, TB)
```
125
Normal phosphate level
>1.5
126
What to take note of if you have low albumin?
Ca goes down by 0.8 for every 1g albumin down.
127
Hypocalcemia EKG changes
HypoCa - prolonged QT
128
Study name that acidosis on phone!
Got it?
