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Hangman vs Jefferson fracture
Jefferson - C1 burst fracture, usually from axial loading (like a diving injury)
Hangman - posterior C2 fracture, usually from hyperextension
symptoms and management of hydrofluoric acid burns?
used in glass etching, metal cleaning, and electronics manufacturing
hypocalcemia, hypomag, and hyperkalemia
treat with topical, intra-arterial, IV calcium gluconate
mild vs moderate vs severe hypothermia
definitions and treatment
mild 32-35: active external warming
moderate 28-32: +active core (bladder, gastric lavage)
severe < 28: ECMO, pleural lavage
treatment of shivering
BDZs
atropine dose
0.02mg/kg (minimum dose of 0.1mg)
What’s a normal ankle-brachial index?
> 0.9
disorder with mousy/musty odor
PKU
fishy odor
trimethylaminuria
sweaty feet smell
isovaleric acidemia
SIRS criteria
Core temp < 36 or >38.5
tachycardia or bradycardia
tachypnea
leukocytosis, lymphopenia, or 10%+ bandemia
Septic shock definition
sepsis + SIRS + continued cardiovascular dysfxn after 40ml/kg fluids
refractory septic shock definitions
fluid refractory: after 60ml/kg fluidscatecholamine refractory: after 10 mcg/kg/min of dopa, epi, or norepi
severe sepsis definition
when associated with:
ARDS
cardiovascular dysfxn
dysfxn of 2 or more organ systems
what is hydrogen sulfide
mustard gas
causes superficial skin burns, eye irritation, and resp tract irritation
What are the classifications of neutropenia
severe < 500
moderate 500-1000
mild 1000-1500
What is the discriminatory zone with HCG?
transvaginal US- 1,500 mIU/mL
transabdominal US- 6,000 mIU/mL
symptoms of carbemazepine toxicity
can cause resp compromise, altered mental status, vomiting, drowsiness, slurred speech, nystagmus, hallucinations, hypotension, coma, dystonic reactions, seizures has some anticholinergic properties false positive for TCAs on UDS
expected compensation for acute resp acidosis
increase in serum bicarb 0.1 meq for each 1 mmHg PCO2
expected compensation for acute metabolic acidosis
decrease in PCO2 1.2 mmHgfor each 1 meq of bicarb
expected compensation for acute resp alkalosis
decrease in serum bicarb 0.2 meq for each 1mmHg PCO2
expected compensation for acute metabolic alkalosis
increase in PCO2 0.6 mmHg for each 1meq of bicarb
how frequently can you repeat epi in anaphylaxis?
3-4 times every 5-15 minutes
what is the pathophys of staph scalded skin syndrome?
hematogenous spread of epidermolytic or exfoliative toxin; children are more affected that adults due to inefficient renal clearance
most common nerve injury in supracondylar fracture
median nerve
most common artery injury in supracondylar fracture
brachial artery
treatment of DUB
combo pills or progestin only pill taper
sites for IO access
proximal tibia distal tibia distal femur proximal humerus sternum in adults
MUDPILES
methanol/metabolic defects uremia DKA, alcoholic ketoacidosis, starvation paraldehyde iron and INH lactic acidosis ethylene glycol salicylates * also CO, cyanid, hydrogen sulfide, metformin, phenformin, sulfur, theophyllin, and toulene!
normal CSF opening pressure
< 20 cm H2O
LR +
= (positive test/presence of disease) / (positive test/absence of disease)
= sensitivity / (1 - specificity)
LR -
= (negative test/presence of disease) / (negative test/absence of disease)
= (1 - sensitivity) / specificity
How do you use LRs?
You have to convert the pretest probability to odds
This is pretest probability / (1 - pretest probability)
Then you multiply by the LR
Finally, you convert the odds BACK to the probability!
What are clinically significant LRs?
LR + > 10
LR - < 0.1
Amanita phalloides ingestion
white mushroom that can kill. classically:
stage I: 6-24hrs of no sxs
II: V/D 12-24hrs
III: seeming recovery
IV: 2-4d later with liver and renal failure
loss of contralateral pain and temperature
loss of ipsilateral motor
Brown Sequard syndrome
hemisection of the spinal cord
loss of motor and pain sensation
preserved temp and proprioception
Anterior cord syndrome
disruption of the anterior spinal artery
upper extremities affected more than lower extremities
central cord syndrome
Posterior cord syndrome
loss of proprioception and pain sensation
loss of proprioception and pain sensation
posterior cord syndrome
ectasy/MDMA intoxication
hyponatremia, concentrated urine, altered mental statusmay see serotonin syndrome
lab abnormality in hereditary angioedema
low C4
reasons to use VariZig
only for post-exposure ppx, but NOT once there is varicella infection
lab abnormalities in strep glomerulonephritis
low C3, nml C4. if levels are normal, consider something else
non-ketotic hypoglycemia with metabolic acidosis should make you think of…
fatty acid oxidation disorder
classic lab findings in fatty acid oxidation disorder
non-ketotic hypoglycemia
anion gap formula
AG = Na - Cl - HCO3
calculated osmolarity
= 2 x Na + glucose/18 + BUN/2.8
Multi-casualty vs mass casualty event
multi-casualty = 5+ victims
mass casualty = strains the existing EMS system
What can different levels of responders do: first responders? EMT-B? EMT-I? EMT-P?
1st responders: airway clearance, control blood loss, AED, CPR
EMT-B: assessment, spinal immobilization, BVM, defibrillation
EMT-I: pacing, cardioversion, IO, EKG, needle thoracostomy, advanced airway management
EMT-P: arrhythmias, advanced airway management, intubation, cricothyrotomy, meds, fluids
Best pressors for shock that is:
- cold
- warm
- normal BP
- epi
- norepi
- dopa
CXR findings (measurements) for RPA
prevertebral soft tissue swelling >7mm at C2 or 14mm at C6
Lab findings concerning for a pulmonary EXUDATE
WBC >10K glucose < 50% of serum protein > 50% of serum amylase > 200 LDH > 60% of serum pH < 7.0 (v. suggestive of empyema)
EKG findings in pericarditis
widespread ST elevation
PR depression
ST elevation in limb and precordial leads with concave elevations
Location for ____ nerve block at wrist:
1) ulnar
2) median
3) radial
1) ulnar - proximal ventral crease at ulnar styloid
2) median - medial tendon of flexor carpi radialis
3) radial - dorsal crease @ radial styloid
pressure readings associated with compartment syndrome
> 30 mmHg
Components of the pediatric trauma score
- size
- airway
- consciousness
- SBP
- fractures
- cutaneous
ranges from -6 to 12
lower the score, the higher the chance of mortality
How do you determine size for:
- ET tube
- ET tube depth of insertion
- NG tube size
- chest tube size
- ET tube = age/4 + 4
- ET tube depth of insertion = ETT x 3
- NG tube size = ETT x2
- chest tube size = ETT x 4
low plasma alanine levels are associated with what IEM?
ketotic hypoglycemia
what are treatments for hyperammonemia?
IV arginine
sodium benzoate
phenylacetate
hemodialysis
what disease is associated with +reducing substances in the urine, cloudy cornea, and HSM?
galactosemia
What is the BP treatment for pheochromocytoma?
phenotalamine 2nd line is CCBs
NO beta-blockers!!!
Patient with a PAINFUL Horner’s syndrome should make you think of…
carotid artery dissection
treatment for HOCM emergency?
B-blockers and CCBs
what is the treatment for lichen sclerosis?
topical steroids
treatment of prolapsed urethra
topical estrogen
treatment for tet spells
morphine (decreases pulmonary venous return, relaxes the infundibulum)
phenylephrine (increases SVR)
sodium bicarb (reduces acidosis)
beta-blockers (relaxes infundibular spasm, decreases inotropic effect)
treatment of HOCM?
what should you avoid?
beta-blockers
CCBs
avoid - diuretics and digoxin
Criteria for Acute Rheumatic Fever
JONES (major) PEACE (minor) Joints - arthritis O - heart - pancarditis Nodules (subcutaneous Eythema marginatum Sydenham chorea
PR prolonged ESR elevated Arthralgias (rather than arthritis) CRP/WBC elevated Elevated temp >39C (previous rheumatic fever too)
*Polyarthritis is the most frequently found major criteria
*Dx if 2 major or 1 major + 2 minor
Tx: PCN
med to rapidly inhibit release of thyroid hormone in pediatrics
potassium iodide (PTU is contraindicated in kids; methimazole doesn’t work acutely)
Symptoms of autonomic dysfxn syndrome
tachycardia, tachypnea, diffuse diaphoresis, hyperthermia, hypertension, mydriasis, and dystonia
Treatment of autonomic dysfxn/sympathetic storm
bromocriptine, dantrolene, benzodiazepines, clonidine, and narcotics
What are the components of Cushing’s triad?
What is the earliest and most sensitive indicator?
bradycardia, hypertension, irregular respirations
most sensitive/earliest: bradycardia
What are the impt landmarks for IJ venous access?
The medial approach uses the apex of the triangle formed by the sternal and clavicular heads of the SCM.
Best localized with mild hyperextension of the neck.
Location for a distal ulnar nerve block?
just proximal to the ulnar styloid process
Location for a distal median nerve block?
between the palmaris longus and flexor carpi radialis tendons
Nerve block achieved at: between the palmaris longus and flexor carpi radialis tendons
median nerve block
Reasons to refer a patient to a burn center (4)
1) partial thickness depth >10% if 20% BSA > 11 years)
2) full thickness depth > 2% BSA
3) high risk for disability or poor cosmetic outcome (e.g., hands, feet, face, circumferential burns and those overlying joints)
4) associated inhalation injury or trauma
Parkland Formula
4 x BSA x wt (kg) Give half in first 8 hours Give second half in subsequent 16 hours Does NOT account for maintenance fluids Should only include partial and full thickness burns in BSA calculation Only apply if 15% BSA is involved
Max dose of bupivicaine
2mg/kg without epi
3mg/kg with epi
1% lidocaine is how many mg/ml
0.25% bupivicaine is…
10mg/ml
2.5mg/ml
Things that can cause false positive guaiac stools
Horseradish
Turnips
Cherries
Tomatoes
Things that can cause red stool that isn’t bloody
cefdinir/omnicef red food dye licorice blueberries spinach beets bismuth iron preparations
Most common reason for child to have hypoglycemia?What’s low/wrong?
ketotic hypoglycemia
low alanine stores in muscles
Distinction between organic acidemias and urea cycles defects?
OA: elevated ammonia and acidotic
UC: VERY high ammonia (1000s) and usually NOT acidotic; low BUN, nml lactate, encephalopathy
IEM mimic of child abuse with macrocephaly, chronic subdural effusions?
How to diagnose?
glutaric acidemia type I
dx with urine organic acidsdx usually made during crises (intercurrent illnesses) with metabolic acidosis, hyperammonemia and encephalopathy.
Lab that is usually diagnostic for CAH
17-hydroxyprogesterone (17-OHP)
IEM associated with reducing substances in urine?
galactosemia
Management of Kawasaki when acute?
When convalescent?
Acute: IVIG, high dose ASA
Conv: low dose ASA (3-5mg/kg/day)
Management of dry gangrene in scleroderma
tx with systemic or topical nitro; or CCBs
How do you calculate sodium deficit?
Figure out the volume deficitNa/1000 x 0.6 x volume deficit
Labs in RTA type IV
hyperkalemic, hyperchloremic, metabolic acidosis with normal AG
Winter’s Formula
PCO2 = 1.5 x HCO3 + 8 +/- 2
explains what the appropriate CO2 response should be to metabolic acidosis
Symptoms of scorpion sting
local pain, restlessness, hyperactivity, roving eye movements, and respiratory distress. More severe signs include seizures, drooling, wheezing, hyperthermia, cyanosis, GI hemorrhage, respiratory distress and death from shock or respiratory paralysis
Envenomation associated with metallic taste
rattlesnake
systemic symptoms of brown recluse spider bite
fever, chills, malaise, weakness, nausea, vomiting, joint pain, petechial morbilliform rash, intravascular hemolysis, hematuria, and renal failure