Case conf Flashcards
HypoK pearls
HyperK widens QRS
HypoK prolongs QT (flattens T/ Biphasic T or U)
Give mag with it, give more than you think (100 for .3)
DC patient if QT is under 500, K 3.0 or higher, and not N/v (fix underlying) so they can swallow K replacement
top peds rashes to think about
SSSS
SJS
Kawaski
Scarlet fever
Super deep laceration repair
Close th emeat, jsut get it close and put a word catheter in and have them follow up in a week to repair again
msucle will tear- fidn the fascia
peds arrest pearls
Calcium glcuonate 100 mg/kg
calcium chlride 20 mg/kg
Bicarb 2meq/kg
blood 10 cc/kg
epi .01 mg/kg
2j/kg shock (2J showed better than 4 J)
Complete white out of 1 lung DDX and approach
- Trachea pulled toward white lung
- Atelectasis
- L/R main stem
- Pnuemonectomy - Teachea away
- HTX
- PLeural effusion
- Diaphram injury - Trachea midline
- Aspiration
- COnsilidation
- Pulem edema, ARDS, TRALI
put the good lung down with gravity UNLESS! lots of pus and blood then good lung up so no blood or pus cna drain into good lung
Ddx for SInus tach
Vitals: hypocxia SHock, fever
Chest pain: PE, Tmaponade, ACS, peri, myocard
Endocrine: Thyrotixcosis, pheo
Autonomic: Stimnulants/drugs/ withdrawal
Other: pain, anxiety
Hyperthyroid scale?
Tx?
Birch wortofsky
Steroids 300 mg IV hyrdocortisone
20 mg propanolol or esmlol (Unless they have CHF! listne to lungs)
MEthimazole
wait 1 hour then
potassium iodide
Causes: same 5 Is for DKA
When you see ST changes in lead AVL look to which lead ext?
lead 3- direct oppositie of it
Upright T waves in lead v1- good or bad?
bad
Anisoicira DDx
Brain- herniation/bleed Eye- Cn3 or gluaocma Trauma (iritis) recent surgery or iris irritation Drugs- anticholinergic or sympathomimetic (flower or cocaine snoorting or nebz arolsiolzed, scop patch)
pilocaprine challenge
Stays dilated- Rx mediated
constircts= oculomotor nerve palsy
2 of 3 tings needed ot make pancreaitits dx
lipase 3x nromla limit
tendenr belly
CT imaging
Order LDH for inpatinet or TG3
insulin drips may be needed
can send home if stable
think abuot necrosis, thrombosis, pseudocyst
Hypothermia Tx
COntinuous core temp
Abx, synthrid, steorids (adrenal insufficiency)
Bair hugger, blankets
Warm IV fluids (take awhiel and not perfect)
Heated humidifed air!!!!
ECMO or CRRT can be used too- you want to get to at least 32 degrees celsius
check for pH, K
high dose thiamine for possible wernickes
PALS one ventilation every 6 or 4 seconds in kids?
6
Valproate symptom, reaosn and tx
ataxia, AMS
Ammonia too high
L-canrintie
cold damp, hot dog fish lloking toes with painful lesions?
chillblains or pernio- Warm and maybe CCB
Define acute chest and what is TX?
Adequate and immediate pain control
●Fluid management to prevent hypovolemia
●Supplementary oxygen and incentive spirometry
●Blood transfusion
●Antibiotics
●Venous thromboembolism (VTE) prophylaxis
new radiodensity on chest radiograph accompanied by fever and/or respiratory symptoms
think about PE, ACS PNA
DEEP intverted t waves
3 causes non cardiac
5 cardiac
HypoK, ICP elevated, PE
Cardiac: ischemia, Pericaditis, myocarditis, Takosubo, HOCM
treating ethylene glycol, 5 txs?
- Fomeipozle 15 mg/kg loading dose and then 10 mg/kg q 12 hr
- 100 mg IV thiamine and B6
- correct acidosis with bicarb drip
- HD if ph <7.3, EG levels >50 or 300 after formpeizole given, AKI
- call position control
What is your STEMI criteria
1 mm in all leads
V2 and V3:
Females: 1 mm
Males >40 2.5 mm
Males <40 2.0 mm
What mneunomic do you use for Reciprocal changes?
PAILS
Remember in inferior MI your RCA supplies posterior decsning too so youget posterior MI changes
What is monteggia fx
Proximal Ulna fx, radius dislocaiton
Galezzia- distla radius fx, ulna dislocation
check for nerve invvlement- this is long arm splint and operation
Frozen shoudler
Phase 1: intial, painful, worse a tnight, stiff- months
phase 2- decreased ROM (up to 2 years)
Phase 3?
rule out fracture, dislocaiton, buritis, Rotator cuff injury, impingement, septic arthritis
NSAID, rest, possible injection, referral, PT
PCP receptpor it blocks and pulmonary menifiestatoion?
NMDA glutamate
Leaky caps in lngs for pulm edema
Non cards pulm edema ddx
Drugs- opioids, naloxone, phencyclidine, and salicylates. infection PE recent thoracentesis ARDS inhalation injury aspiration
Thrombytics dosing
Reperfusion stuff
15 mg over 2 min tpa
Accelerated idioventricular rhythm after tpa - kind of looks like v tach but negative deflecthon axis in 1/F - self resolving and normal
If inferior- get ready to pace
5 steps to VT or SV abberancy- stable
modified valsalva 12 mg Adenosine Lidoncaine 1.5 mg/kg over 15 seconds procainamide up to 500 mgs DC cardioversion
lido and procaine can go to gotehr - don’t mix with amio
5 causes agitation in trauma patients
Hypoxia HupoG Blood in head Hem shock Hyper sympathetic alike coke
Tca OD
Push 1 amp bicarb and then do a drip Shoot for 7.5-7.55 no higher you can do harm with protein binding etc!bdont pish a lot do
Blind bicarb
1 amp is 0.1 increase and 1 meq/kg get you 0.1-0.15
Qrs is marker of disease>100 is bad news
Wood FB dispo
Admit - very dirty and infected
What kills with adenosine
Dehydrated old sinus tach
Wide irregular and now uses bypass tract
Adenosine vs silt in svt
Adenosine 12 in young and need quick
Silt 2.5 mg/min for old and a littler longer takes 10-15 min. Max at about 25 min. Pee treat with 3 cc calcium glauconate(doesn’t block chronograpy and helps with negativeniontorope effect to help with hypotension.) and has 98% conversion rate vs 86% adenosine 12mg
Epi drip anaphylaxis
2mcg min
Im Epi is .3 or 300 mcg
Be careful of what you give IV - not 1 mg Epi IV!
Sine wave
Hyper K Acidosis Bb Ccb Tca
Give bicarb!
When to terminate arrests
No ROSC
unwitnessed
non shcokable rhythm
EPi and no return of pulse
no IV and asytole =dead, n ouse of ETT epi
reversible in the field- decomrpess, oxygenate and ventilate (HR <40 after epi magic number to stop)
If you bolus Esmolol after mult shocks for v fib- start smolol and wait at least 5-7 minutes
that is all
5 tx for non pregnan VB
blood
sto pcoagulaopathy (vwf?)
IV estrogen 25 mg q6 (dont do it is combined ocps) will stop in 6 hours
TXA 1 g (good data post partum bu tno downside to this)
Surgical or reboa
Wide complex tachycardia
always think about:
- HyperK
- Sodium channel blockade OD
- Dig toxicity
- and always give clacium and bicarb when thinking about this. Never give Amio/procain to this (lido is more shrot and safe)
Adensonise if you really can rule out VT. Never give in old people, irregular ryghtms but wide is controverisal in giving adenosine.
Lidocaine 1-1.5 mg/kg is the preferred drug in wide compelx tachyarrythmia (short on and off). Procaine 17 mg/kg or amio is your other choices but has side effects
if polymorphic VT: add magnesium. Overdrive pacing is what you do too (add 30 bpm over theri HR to narrow the complex)
5 things to look if VT?
Irregular then your done P waves before qrs= done Fusion Capture Concordance v1-v6 and Axis (if neg, neg then VR
Treating stable wide complex tacky
Modified valsalva
Adenosine (only if regular, kills if irregular)
Lidocaine is 20% of time
Procaine should work after 5 min- 100 mg/min 2 min, 50 3 min, then 35 for 4 min
Nec fasc
1 lab
1 score
Gas on CT?
Low sodium
lrinec
48% sensitive, 92% spec- clinical diagnosis and rapidly spreading
No access hypoG ?
1 mg IM glucagon or 3 mg intransal
Maybe IO too
IO stuff
Want meta-epilhysis junction
Medial mal kid- just above the mm
anterior med midline femur 2-3 cm above tibia
Night time pain, limp, peds - think….
Leukemia- 15% have limp
Displaced supracondylar peds with NV not intact-
Don’t reduce- can do more damage- transfer for surgery
Depressions in a retired leads and elevation in avr in SVT is…
Normal . Less normal if older
Trop leak is normal in young person if it goes in for awhile
Want to give dilt but old and slightly on hypotension side…
Give calcium gluconate with it
2.5 mg/min max 50 mg over 20 min for svt if you want dilt
Anaphylaxis updated lit pearls
5 min before a re dose epi
25 benadryl is best first line dose- but no real acute effects and MAY delay epi usage
If you need second dose of epi then start fluids, nto needed up frnt
Major change!: 3rd line is steroids and recoemmend against it bc it has no literature (cory is still giving, especially if severe anaphylaxis)
Still use 0.3 cc 1 min in 1cc IM epi
5% biphasic reactions-
if severe anaphylaxis or 2 doses at least 6 hours obs
A fob can be rate controlled and sent home
A flutter can worsen the block snd needs to be in usually
Yup
Incidence of stroke shocking a fib no AC
5%
Becarwful of things that look irrwfualr but also look like Vtach
K centra used for
Wardarin
Xarelto
Eliquis
