Case files EM 2 Flashcards
1
Q
What is the first lab to draw in any patient with AMS?
A
Blood glucose
2
Q
What is the definition of stupor?
A
Level of decreased responsiveness where an individual requires aggressive or unpleasant stimulation
3
Q
What is the defintion of obtunded?
A
Level of diminished arousal or awareness frequently from extraneous causes (infection, intoxication, metabolic states)
4
Q
Compare delirium vs dementia in terms of: onset
A
Delirium = abrupt Dementia = progressive
5
Q
Compare delirium vs dementia in terms of: timing of disorientation
A
Delirium = early Dementia = late
6
Q
Compare delirium vs dementia in terms of: variability in mental status
A
Delirium = very variable Dementia = stable
7
Q
Compare delirium vs dementia in terms of: level of consciousness
A
Delirium = AMS Dementia = Normal
8
Q
Compare delirium vs dementia in terms of: attention span
A
Delirium = short attention span Dementia = reduced slightly
9
Q
What are the four levels of eye opening in the glasgow coma scale?
A
4 = spontaneous eye opening 3 = opens to verbal commands 2 = opens to painful stimuli 1 = no response
10
Q
What are the five levels of verbal response in the glasgow coma scale?
A
5 = oriented 4 = disoriented 3 = inappropriate words 2= incomprehensible sounds 1 = no response
11
Q
What are the six levels of motor response in the glasgow coma scale?
A
6 = obeys commands 5 = localizes to pain 4 = withdraws to pain 3 = abnormal flexion 2 = abnormal extension 1 = no response
12
Q
What is the treatment for AMS caused by hyponatremia?
A
3% NS
13
Q
What is the treatment for AMS caused by hypernatremia?
A
Rehydrate
14
Q
What is the treatment for AMS caused by hypo and hypercalcemia respectively?
A
Hypo = Ca replacement Hyper = IVFs
15
Q
What pharmacologic therapy can help reduce brain swelling 2/2 tumor or edema?
A
Steroids
16
Q
What is the classic history of transient synovitis?
A
recent URI, with resultant arthralgias of a joint
17
Q
What is the most common organism that causes septic arthritis?
A
Staph aureus
18
Q
What is a slipped capital femoral epiphysis (SCFE)? What are the classic s/sx (3)? Treatment?
A
Fracture through the growth plate, resulting in slippage of the overlying end of the femur.
- Groin pain
- painful passive ROM of the hip
- waddling gait
Ortho pinning
19
Q
What is Legg-calve-perthes disease?
A
Childhood hip disorder resulting from idiopathic disruption of the blood supply to the femoral head, resulting in osteonecrosis
20
Q
True or false: pts with septic arthritis almost always have a fever
A
False–many do not
21
Q
What is the role of US in the workup of septic arthritis?
A
If no effusion is seen, very unlikely to be septic arthritis
22
Q
What is the treatment for legg-calve-perthes disease?
A
keep femoral head within the acetabulum to allow healing to occur (bace. cast)
23
Q
What is a Toddler’s fracture?
A
Nondisplaced fracture of the distal tibial shaft that occurs when a toddler is learning to walk
24
Q
What is Osgood-schlatter syndrome?
A
an inflammation of the patellar ligament at the tibial tuberosity, resulting in fragmentation of the tibial tubercle. Usually the result of stress fracture.
25
Who is usually affected with a SCFE? What is their classic gait?
Obese children
| Trendelenburg gait
26
What is the definition for a simple febrile seizure (age, presentation, s/sx)?
The definition for a simple febrile seizure is very specific: age between 6 months and 60 months, generalized tonic-clonic convulsions, spontaneous cessation of convulsion within 15 minutes, return to alert mental status after convulsion, documentation of fever (< 38.0 ° C), one convulsion with a 24-hour period, and absence of neurologic abnormality on examination.
27
True or false: simple febrile seizures require no further work up, just observation for a short period of time
True, if truly a simple febrile seizure
28
For AOM, children under what age should be treated with abx? Why?
2 years
| Risk for intracrainial extension
29
What fraction of children with febrile seizures will have another by age 6? What is their chance of developing epilepsy?
1/3 will have another, but only 1% go on to develop epilepsy
30
What is the effect of antipyretics on the occurrence of simple febrile seizures?
Does not decrease rate
31
What is the age range that is concerning for low back pain?
age ∉ [18, 50]
32
What is the relative sensitivity and specificity of the SLR and crossed SLR?
- SLR is sensitive, but not specific
| - crossed SLR (where SLR on opposite leg produces pain down ipsilateral leg) is specific, but not sensitive
33
What is the pharmacologic treatment for cauda equina syndrome while waiting for surgery?
Steroids
34
What is the treatment for spinal infection?
abx and surgical decompression
35
What is the most sensitive s/sx for cauda equina?
Urinary retention / incontinence
36
What is the most common infectious cause of death in the US?
Pneumonia
37
What is the definition of hospital acquired pneumonia?
Pneumonia that arises 48 hours or more after hospital admission
38
What is healthcare associated pneumonia?
Pneumonia that occurs in a patient with substantial healthcare contact (intravenous antibiotics, chemotherapy, or wound care within the past 30 days; nursing home or long-term care facility resident; hospitalization for 2 or more days within the past 90 days; hemodialysis).
39
hospital acquired and healthcare associated pneumonia are most commonly caused by which organisms?
Aerobic, gram-negative bacilli, (e.g. pseudomonas, e. Coli, klebsiella)
40
Pneumonia that causes rust colored sputum = which bacteria? Currant Jelly sputum?
Rust = strep pneumo
| Currant jelly = klebsiella
41
What are the s/sx of Legionnaires disease?
Severe illness with cough, lethargy, GI s/sx
42
What is the abx of choice for community acquired pneumonia in an otherwise relatively health pt, who has not had abx in the pst 3 months? What if they have comorbid conditions and/or used abx in the past 3 months?
Azithromycin
| Levofloxacin
43
What are the abx used to treat pneumonia that requires ICU admission?
Beta lactam + (azithromycin or fluoroquinolone)
44
What is the abx of choice for aspiration pneumonia?
Clindamycin
45
Patients with concern for HAP or HCAP who are at a risk for multidrug-resistant pathogens should receive a 3-drug combination therapy of which abx?
1. cefepime imipenem
2. cipro piperacillin tazobactam
3. linezolid or vanco
46
Which has a greater potential for hemorrhage and significant volume depletion: upper or lower GI bleeding?
Upper
47
Why is upper endoscopy so crucial in diagnosing the cause of upper GI bleed?
Slow bleeding ulcer vs hemorrhagic varices require different treatments
48
What anatomic landmark is used to distinguish upper from lower GI bleeds?
Ligament of Trietz
49
If a patient has lower GI bleeding, what age determines if they should have a colonoscopy, of sigmoidoscopy?
Under 40, sigmoid. Otherwise full colon
50
What is the major risk factor for an aortoenteric fistula?
H/o prior AAA reconstruction
51
What pharmacotherapy should be given to all pts with upper GI bleeds undergoing treatment?
PPIs
52
Is tylenol use a risk factor for ulcers?
No
53
What condition always needs to be r/o with CHF exacerbations?
MI
54
What is a major issue with treating diastolic heart failure?
They are preload dependent, so must carefully diurese them o/w risk hypotension
55
Why is intra-arterial monitoring of BP needed in CHF pts who are hypotensive?
Noninvasive techniques inaccurate, as there is peripheral vasoconstriction
56
When is a BNP lab most useful? What values are indeterminant?
In determining between COPD vs CHF
x ∈ [100,500] means indeterminant
57
What medication can be given to CHF exacerbation pts to rapidly reduce their pulmonary congestion?
NTG
58
What is the treatment for cocaine intoxication?
Benzos + supportive care
59
Why should haldol be avoided in acute cocaine intoxication"?
Lowers seizure threshold
60
What is the drug f choice to decrease HTN in cocaine intoxication?
Alpha-1 antagonists like phentolamine
61
Rotatory nystagmus is classic for what street drug intoxication?
PCP
62
What are the EKG changes associated with cocaine intoxication?
Widening of QT interval, wide complex dysrhythmias
63
What amount of acetaminophen is considered toxic?
More than 200 mg/kg or more than 10 g in one day
or 6 g over two days
64
NAC is most effective if administered within what timeframe of acetaminophen ingestion?
8 hours
65
What is the toxic metabolite of acetaminophen? What produces it, and what reduces it?
NAPQI produced by the p450 enzyme system, is reduced by glutathione
66
What is the MOA of NAC in the treatment of acetaminophen overdose?
Replenishes glutathione so that NAPQI is reduced properly
67
What are the four phases of acetaminophen toxicity (name, duration)?
```
1= preinjury (30 minutes - 24 hours)
2 = Injury onset (24-72hrs)
3 = Max liver injury (72-96 hrs)
4 = recovery (4-10 days)
```
68
What are the s/sx of the four phases of acetaminophen intoxication?
```
1 = nonspecific
2 = n/v RUQ pain,
3 = liver failure s/sx, metabolic disturbances
4 = resolution
```
69
When is the best time to draw acetaminophen levels if the ingestion time is known?
4 hours post ingestion
70
When should activated charcoal be given in acetaminophen OD?
separating dose of NAC with charcoal by 1-2 hours (o/w charcoal will absorb it)
71
What is the antidote for crotalidae envenomation?
Crotalidae polyvalent immune Fab
72
What is the antidote for hypermagnesemia?
Calcium gluconate/chloride
73
What is the antidote for hypocalcemia?
Calcium gluconate/chloride
74
What is the antidote for black widow spider bite?
CaCl2
75
What is the antidote for CN?
amyl nitrate
76
What is the antidote for Hydrogen sulfide
Sodium nitrate
77
What is the antidote for CCB or beta blocker poisoning?
Glucagon
78
What is the antidote for hypoglycemia after oral hypoglycemic ingestion?
Octreotide
79
What is the antidote for heparin?
protamine
80
What is the antidote for Na channel blockers
NaHCO3
81
Why is theophylline intoxication so concerning
Very, very narrow TI
82
The Rumack-Matthew nomogram is not applicable for ingestions more than (__) hours prior to evaluation.
24 hours
83
What are the typical s/sx of acute chest syndrome 2/2 sickle cell disease?
Pleuritic chest pain, cough, fever, subtle findings of pulmonary exam, and opacity on CXR
84
What is the treatment of acute chest syndrome?
Supportive
85
What is the definition of acute chest syndrome?
The presence of a new lobar or segmental infiltrate on chest radiography in the presence of fever, respiratory symptoms, and/ or chest pain in patient with sickle cell disease.
86
Who is susceptible to sickle cell crises?
Homozygotes for the condition (AR inheritance pattern)
87
What is often the first physical exam finding of sickle cell disease?
Dactylitis
88
What is a major cause of death in sickle cell patients?
Pneumococcal sepsis
89
When is exchange transfusion indicated in the treatment of sickle cell crisis?
If fall in HgB by more than 2, or CNS s/sx
90
What is the treatment of strokes in children and adults with sickle cell disease?
```
Children = exchange transfusion
Adults = usual stroke meds
```
91
What is the most common cause of acute exacerbation of anemia in sickle cell patients?
Acute splenic sequestration
92
What is the treatment for splenic crisis in sickle cell patients?
pRBCs and splenectomy
93
What is usual cause of transient aplastic anemia in sickle cell disease? Treatment?
Parvovirus B19
| IVIG
94
What is the treatment for priapism 2/2 sickle cell disease?
Corpus cavernosus drainage and irrigation with epi
95
True or false: sickle cell pts are often overtreated for pain
False--very much undertreated
96
Which opiate can cause serotonin syndrome?
Meperidine
97
What is the technical definition of hypothermia?
Core body temp below 35 C or 95F
98
What is frostnip?
Deposition of superficial ice crystals on the skin. It can be a warning sign for impending frostbite. Typically it is a retrospective diagnosis because it is defined by the absence of tissue damage upon rewarming.
99
What is trench foot?
Constant exposure to low levels of cold (like 50s), cause capillary constriction and eventual destruction of surrounding tissue
100
In terms of thermoregulation, what is the hunting reactio?
of irregular, 5- to 10-minute cycles of alternating periods of vasodilation and vasoconstriction that protect the extremities against sustained periods of vasoconstriction.
101
What is the classic EKG manifestation of hypothermia?
J (Osborn) wave, which is a R wave immediately after the QRS complex
102
At what temperature does frostbite occur? What causes the damage?
When tissues are less than 0 C or 32 F
| Venous stasis, and freezing of cellular fluids
103
What is the pre freeze phase of frostbite?
Tissue temps drop to 50 F (10 C), causing a loss of sensation
104
What is the freeze thaw phase of frostbite?
Extracellular ice crystals form, and water leaves cells osmotically
105
What is the progressive microvascular collapse phase of frostbite?
Red cells sludge and form microthrombi during the first few hours after the tissues are thawed.
106
What are the signs of superficial frostbite?
Clear vesicles
107
What are the signs of deep frostbite injury?
Hemorrhagic blisters
108
Why shouldn't patients with frostbite/hypothermia always be warmed PTA?
Interruption/refreezing tissues is disastrous
109
Why is it crucial to check BG in hypothermia?
Correction of hypoglycemia can help restore shivering reflex
110
What is done to rewarm pts with hypothermia? How long is this done for?
Warm IVFs
Place extremities in warm bath (100-105 F)
Until tissue it pliable and distal erythema is noted
111
What is the role of gentle tissue massage in frostbite?
Avoid-causes more damage
112
What is the treatment for post-frostbite care?
- Raising extremities with hand exercises to decrease venous stasis
- Wrapping extremities
- Debridement of *clear* blisters (not hemorrhagic)
113
What are the three general ways to rewarm hypothermic pts?
In order of increasing severity:
- blankets (passive external)
- warm air / bath (active external)
- Internal rewarming (warm IVFs, warm vent)
114
What is the afterdrop in terms of hypothermia?
Pts core body temp continues to drop after brought inside
115
True or false: no one is dead until they are warm and dead
True
116
What is the minimum time required to assess the need for amputation of severely frostbitten extremities?
3 weeks
117
What is the most common arrhythmia seen in hypothermic pts?
Atrial fibrillation
118
Which type of blisters in frostbite should be debrided and why?
clear blisters should be debrided since these contain thromboxane, which is bad for tissues
Hemorrhagic should not be debrided, because will worsen tissue destruction
119
What is the definition of drowning?
Death following a submersion event.
120
What is the definition of a submersion victim?
Patient with some degree of submersion distress requiring medical evaluation and treatment.
121
What is the definition of immersion syndrome?
Syncope or sudden death that occurs after submersion in water that is at least 5 ° C less than body temperature. Due to dysrhythmias induced by vagal stimulation.
122
What is the pathophysiology of pulmonary edema in drowning?
Aspirating water washes out surfactant, leading to atelectasis, decreased gas exchange, and pulmonary edema
123
True or false: Neurological deficits at the time of initial evaluation of drowning portend a poor patient outcome.
False--not necessarliy
124
Why is the Heimlich maneuver no long recommended for drowning?
Increases aspiration risk
125
What is the role of D5NS in treating drowning victims?
Avoid unless hypoglycemic--worsens outcomes
126
True or false: a head CT r/o SAH
False--may not show for some time
127
What is the classic presentation of pseudotumor cerebri?
Young, obese female with visual changes and papilledema
128
Which CNs are classically affected with a SAH?
III or VI
129
What is the gold standard of diagnosis for a SAH?
Xanthochromia (but this may not appear for up to 12 hours after onset)
130
What is the DOC for preventing arterial vasospasm post stroke or SAH?
Nimodipine
131
What is the treatment for idiopathic intracranial HTN?
Acetazolamide and Serial LPs
132
What is the MOA and use of dihydroergotamine (DHE)?
Migraine HAs
| Nospecific 5HT agonists
133
What is the MOA of sumatriptan?
5HT agonist
134
What is the definition of heat stress?
Feeling of discomfort and physiologic strain with normal core temperatures. These patients exhibit decreased exercise tolerance and no other symptoms.
135
What is the definition of heat exhaustion?
Mild dehydration, with or without sodium abnormalities. Patients have profuse sweating, thirst, nausea, vomiting, confusion and headache, and may have collapsed. Core temperatures range from 38 ° C to 40 ° C (100 ° F-104 ° F). Generally, the victim is not able to continue his/ her activities as the result of the environmental conditions.
136
What is the definition of heat stroke?
Severe dehydration with core temperature greater than 40 ° C. Patients are flushed, with hot, dry skin. Symptoms include those associated with CNS disturbances.
137
What is the definition of exertional heat stroke?
Heat stroke affecting individuals involved in strenuous physical activities.
138
What is the goal temperature in treating heat stroke? Why?
```
104 F (40 C)
Do not want to overshoot
```
139
What is heat edema? Treatment?
Vasodilation and pooling of fluids in dependent areas
| elevate extremities
140
What is the cause, symptoms, and treatment for: heat rash
- Blockage of sweat glands, causing staph infx
- Pruritic, erythematous maculopapular rash
- Antihistamines, abx PRN
141
What is the cause, symptoms, and treatment for: heat cramps
- Salt depletion
- cramps
- IVFs
142
What is the cause, symptoms, and treatment for: heat syncope?
- vasodilation and volume depletion
- Postural hypotension
- Rehydration and remove from heat
143
What is the cause, symptoms, and treatment for: heat exhaustion
- Water and salt depletion
- Sweating, weakness
- Rest and volume replacement
144
What is the treatment for rhabdo in the setting of heat stroke?
IVFs
Mannitol
Alkanization of urine
145
What is the DOC for shivering in the setting of heat stroke?
Benzos
146
True or false: all pts with heat stroke or exhaustion should be admitted
True
147
What is the most common cause of death after a lightning strike?
Cardiac arrest
148
What is the formula for Ohm's law? What is the significance of this in electrocutions?
I = V/R
| Nerves, vessels and mucous membranes have low R, and therefore will communicate electricity
149
Burns on both hands after an electrocution indicates that the electricity flowed through what organ?
Heart = badness
150
Which is more dangerous :AC or DC? Why? Which form is lightning?
AC, since can cause the "locking on" effect
| Lightning is DC
151
In terms of lightning strikes, what is: a side flash (splash)
Current is discharged from a victim to a nearby person
152
In terms of lightning strikes, what is: ground current or stride potential
When lightning strikes ground, and enters through one foot and out the other
153
In terms of lightning strikes, what is: the flashover phenomenon
Blast effect of lighting
154
In terms of lightning strikes, what is: keraunoparalysis?
Temporary paralysis with loss of sensation. Resolves within a few hours
155
In terms of lightning strikes, what is the most dangerous area of the spinal cord to be affected?
Respiratory control center in the medulla
156
What causes the Lichtenberg figures of lightning strike burns?
Low resistance sweat
157
What HENT issue is common following lightning strikes?
TM ruptures
158
True or false: Typical signs of brain death, fixed/ dilated pupils and apnea, do not necessarily indicate brain death in electrical victims.
true
159
What is the goal urine output when transfusing someone?
1.0-1.5 ml/kg/hr
160
What are the three major complications that can result from transfusion reactions?
Acute tubular necrosis
DIC
MI
161
How can you definitively diagnose hemolytic transfusion reaction? What is involved in this test?
Direct antigen test
| anti-human-Ab against Abs on RBCs
162
What is the most common and least worrisome transfusion rxn? S/sx?
Febrile nonhemolytic transfusion rxn
| Fevers/chills, without hemodynamic instability
163
Why should fever in a first-time transfusion recipient should be treated as an acute hemolytic reaction until proven otherwise?
Since any other rxn requires previous exposure
164
What is the most common cause of an anaphylactic transfusion rxn?
IgA deficiency pt
165
Why do pts who take ACEIs harder to treat in anaphylaxis?
Cannot break down bradykinin
166
What is the pathophysiology of TRALI?
Anti-leukocyte antibodies the result in systemic inflammation, and PMN mediated lung injury
167
What are the hallmark findings of TRALI?
respiratory distress with the presence of diffuse, bilateral alveolar and interstitial infiltrates on radiographic imaging.
168
What is the relative heart pressure in TRALI vs pulmonary edema?
Low left heart pressure in TRALI
169
What is delayed hemolytic transfusion rxn?
MIld s/sx of rxn 2/2 antibody formation long after transfusion has occurred.
170
What is the prognosis for GVHD?
90% fatality rate
171
What is the pathophysiology of post-transfusion purpura? What is the most severe manifestation of this? Treatment?
- Native platelet destruction mediated by antibodies to platelet antigen PLA1.
- Intracranial hemorrhage
- Transfusion with PLA1 negative platelets
172
What is the most common bacteria isolated in stored blood?
Yersinia enterocolitica
173
When is testing of donor blood with Gram stain and culture indicated?
Any transfusion that causes hypotension and fever
174
When, generally, is platelet transfusion indicated?
Below 10,000 if not bleeding
Between 10-20000 if bleeding
Below 50000 if severe trauma
175
What is the role of diuretics in the treatment of TRALI? Why?
- Not effective
- Problem 2/2 capillary destruction, not fluid overload, and these pts already have low left heart preload. Diuretics will exacerbate perfusion problems
176
What are the classic predisposing factors for testicular torsion?
Young, teenage athlete
177
What is the classic clinical findings of epididymitis? Treatment?
- TTP, erythema, d/c, and + Prehn sign
| - Abx, scrotal elevation
178
What is Prehn's sign, and what is it indicative of?
Relief of pain with elevation of the testicle
| Epididymitis
179
What are the s/sx of orchitis? Treatment?
- TTP, edema, and systemic s/sx.
| - Abx if bacterial. O/w supportive
180
What is the most common type of testicular tumor?
Seminomas
181
What is appendageal torsion? S/sx? Treatment?
- Twisting of one of four vestigial structures of the testes
- ACute scrotal pain with small, tender nodules
- Analgesia and bed rest
182
True or false: testicular torsion may resolve spontaneously
True
183
Testicular pain that persists for more than (___) after scrotal trauma is not normal and merits further investigation.
one hour
184
If you are able to detorse a testicle, what should be done next?
D/c with f/u for surgery
185
What skin findings in an unconscious patient is a diagnosis of hemorrhagic shock presumed until proven otherwise?
Cool and mottled skin
186
True or false: children will slowing develop signs of shock, since they cannot compensate well
False--they compensate so well, until they suddenly drop
187
What is the normal HR, BP, and RR for: 0-1 years old
120 bpm
80/40
40 breathes pm
188
What is the normal HR, BP, and RR for: 1-5 years
100 bpm
100/60
30 rr
189
What is the normal HR, BP, and RR for: 5-10 years
80 bpm
120/80
20 rr
190
the initial signs of shock, including tachycardia, skin changes, and lethargy, represent a loss of approximately what percent of the child's blood is lost?
25%
191
What is the initial treatment for hypovolemic shock in children?
20 mL/kg of warmed crystalloid
192
If vitals worsen during a head CT of a trauma patient, what should be done?
Abandon the CT, and go to surgery
193
What are grade 1-5 of the pediatric GCS verbal scores?
```
5= appropriate words or social smile
4 = cries, but consolable
3 = persistently irritable
2 = restless, agitated
1= none
```
194
What happens to the following in a child if there is less than 25% blood loss:
- Pulse
- Consciousness
- Urine output
- Pulse = Weak
- Consciousness = agitated/confused
- Urine output = unchanged
195
What happens to the following in a child if there is 25%-45% blood loss:
- Pulse
- Consciousness
- Urine output
- Pulse = tachycardic
- Consciousness = dulled pain response
- Urine output = minimal
196
What happens to the following in a child if there is over 45% blood loss:
- Pulse
- Consciousness
- Urine output
- Pulse = Hypotension, tachy, then brady
- Consciousness = comatose
- Urine output = none
197
What are the major factors that are associated with reduced independence of the elderly s/p trauma? (5)
- Shock upon admission
- GCS score of less than 7
- Over 75 years
- Head injury
- sepsis
198
What is the definition of menorrhagia?
Excessive vaginal bleeding, classically exceeding 80 mL or more than 7 days
199
What is the definition of menometrorrhagia?
Prolonged and/or excessive vaginal bleeding at irregular intervals
200
What is the definition of oligomenorrhea?
Menses at intervals greater than 35 days
201
What is the definition of amenorrhea?
Absence for more than 6 months
202
How reliable is self reported amounts of vaginal bleeding?
Very unreliable
203
Blood stains down the legs of a woman with a cc of vaginal bleeding indicates what?
Need for transfusion
204
What is the pharmacotherapy for hemodynamically stable excessive vaginal bleeding?
oral contraception
205
When should endometrial sampling be performed for dysfunctional uterine bleeding?
When pts are over 35
206
What is the acute treatment for dysfunctional uterine bleeding?
DandC or IV estrogen
207
Why is the esophagus more susceptible to perforation than other areas of the GI tract?
Lacks a serosal layer
208
What are the components of the Macker triad for Boerhaave syndrome?
Emesis
Lower chest pain
SQ emphysema
209
What causes the decreased breath sounds on the side of the rupture in Boerhaave's syndrome?
Pleural effusioin
210
What is the role of endoscopy in the evaluation of Boerhaave's syndrome?
no role--may perforate further
211
What is the treatment for Boerhaave's syndrome?
NPO
NG tube
antiemetics/analgesics
212
What is the classic presentation of pericarditis?
- Pain which worsens when supine, and improves when sitting up
- Pericardial friction rub
- Diffuse ST/T wave elevation
213
What type of oral contrast should be used to evaluate for Boerhaave's syndrome? Why?
Gastrografin
| Not as irritating to tissues
214
True or false: its takes large changes in K to cause EKG changes
False--correlation between K levels and EKG changes are very poor; Patients may have severe hyperkalemia with minimal ECG changes, and prominent ECG changes with mild hyperkalemia.
215
What is the very first drug given in hyperkalemia? What does it do?
CaCl or calcium gluconate
| Stabilizes cell membranes
216
What is the difference in CaCl vs calcium gluconate? Which is used when?
CaCl is more caustic and is used only in cardiac arrest, whereas Ca gluconate is used more widely
217
What is the second line agent for hyperkalemia after CaCl? How does it work?
NaHCO3
| Shifts K into cells by increased pH of the blood
218
What is the ultimate treatment for all ESRD pts with hyperkalemia?
Dialysis
219
What is the treatment for pyelonephritis (drug, duration)?
10-14 days of a fluoroquinolone
220
What are the top three organisms that cause UTIs, in order?
E. coli
Staph saprophyticus
Proteus
221
What is the treatment for uncomplicated cystitis?
Bactrim (TMP-SMX)
222
What is the use of phenazopyridine? Side effect?
Abx for UTIs
| Orange urine
223
True or false: all pregnant pts with pyelonephritis require admission
True
224
What is the abx of choice for complicated pyelonephritis requiring inpatient admission?
TMP-SMX
| Fluoroquinolones
225
What is the treatment for asymptomatic bacteriuria in pregnant women?
PCNs or cephalosporins
226
What is unique about the treatment of male UTIs?
Always tear as complicated, and prescribe 14 days of abx
227
What are the 7 P's of intubation?
1. Prepare pt and materials
2. Preoxygenation
3. Pretreatment
4. Paralysis (induction)
5. Position and protection
6. Placement with proof
7. Postintubation management
228
What is the 3-3-2 rule for intubation?
The patient should be able to insert at least 3 fingers into his/ her mouth in the vertical orientation, between the upper and lower front teeth; the hyomental distance (from the hyoid cartilage to the chin) should be at least 3 fingers breadth; and there should be at least 2 fingers breadth between the floor of the mouth and the thyroid cartilage.
229
What is the formula to predict ET tube size in children over 2?
(age in years +16) / 4
230
What are the components for the mnemonic SOAP ME IV for the materials needed for intubation?
```
Suction
Oxygen
Airway adjuncts
Pharm
Monitoring Equipment
IV
```
231
HOw many assisted breaths should be given to a patient for preoxygenation if they're apneic?
8 ventilations over 1 minute
232
What are the advantages of using etomidate as an induction agent for RSI?
Hemodynamically neutral, and may be neuroprotective
233
What are the advantages and disadvantages of ketamine as an induction agent?
Increases BP
Protects airway reflexes
Analgesic properties
Contraindicated in pts with CAD
234
What are the contraindications to using succinylcholine as a paralytic for RSI?
Hyperkalemia will worsen
235
What is the best way to confirm ET tube placement?
Watching it go through the vocal cords (CXR cannot differentiate between tracheal vs esophageal placement)
236
What type of drug is Jimson weed?
Antimuscarinics
237
What is the best initial treatment for anticholinergic poisoning?
Benzos and physostigmine
238
Who is best treated with activated charcoal?
In patients that are awake, protecting their airway, and ingested material less than 1 hour ago
239
Who is best treated with gastric lavage?
Only patients who have ingested material less than 1 hour prior, and have a potentially life threatening ingestion
240
What is the role of nasogastric lavage in poisoning?
NASO-gastric lavage is useless. Don't do it.
241
What are the materials that are poorly absorbed by activated charcoal? (4)
Alcohols
Acids/bases
Hydorcarbons
Li/other salts
242
What is whole bowel lavage?
Administration of Polyethylene glycol and electrolyte solution to move bowels
243
HOw many charcoal+sorbitol doses can be given before switching to regular activated charcoal?
1
244
When is hemodialysis effective in the treatment of intoxication?
If drug is highly water soluble, and thus has a low volume of distribution
245
What is charcoal hemoperfusion?
similar to arterial venous hemodialysis, except that the drug is passed through a charcoal filter prior to systemic return. This is particularly effective in phenobarbital and theophylline overdoses as they adsorb well to charcoal.
246
What is urinary alkalinization in the treatment of intoxication?
a treatment regimen that increases poison elimination by the administration of intravenous sodium bicarbonate to produce urine with a pH > 7.5. Alkaline urine facilitates ion trapping and excretion. This method is particularly useful for aspirin and phenobarbital toxicities.
247
What is the nomogram for determining when to administer NAC in acetaminophen poisoning?
Rumack-Matthew nongram
248
What is the treatment for salicylate poisoning? At what level should this begin?
levels above 30 mg/ dL should be treated with bicarbonate infusion and potassium supplementation to increase urinary elimination
249
What are the EKG manifestations of Na channel blocking drugs?
Prolonged/slurred QRS complexes
250
What are the EKG manifestations of K or Ca channel blocking drugs?
QT prolongation
251
Treatment with sodium bicarbonate for a prolonged QRS can lead to what unintended complication?
QT prolongation and Tdp
252
What happens to vital signs with sedative hypnotic ODs?
Normal vitals, usually
253
What is the goal of treatment with narcan (naloxone)?
Get pt breathing again, not necessarily to get them awake
254
Naloxone administration should be avoided in an intubated patient with opiate or opioid overdose since this will lead to what complication?
Emesis
255
What is the major difference in presentation of antimuscarinic vs sympathomimetic overdoses?
Sympathomimetics usually have diaphoretic skin, whereas anticholinergics are dry
256
What is the typical cause of mortality in pts with sympathomimetic overdose? What is used to prevent this?
Hyperthermia
| Cooling
257
Why must you sedate a pt with sympathomimetic OD if you restrain them?
Fighting could lead to rhabdo
258
What is the mnemonic for the antimuscarinic toxidrome?
Mad as a hatter
Dry as a bone
Red as a beat
Blind as a bat
259
What is the most common pathogen and abx for skin abscesses?
Staph Aureus
| TMP-SMX or vanco
260
What is the most common pathogen and abx for non-purulent cellulitis?
Beta hemolytic strep
| Cephalexin or cefazolin
261
What is the most common pathogen and abx for necrotizing soft tissue infection (NSTI)?
S aureus or clostridium
| Clindamycin /vanco / piperacillin-tazobactam
262
When are abx indicated for abscesses?
If larger than 5 cm, immunocompromised
263
What are the features of the rash and presentation of: rubella
- Pink, macular rash beginning on face, spreading to trunk and extremities
- Rash before fever with URI s/sx
264
What are the features of the rash and presentation of: rubeola (measles)
- Red to brown maculopapular rash beginning on face, spreading downwards
- Three C's: cough, coryza, conjunctivitis
- Fever before rash
265
What are the features of the rash and presentation of: roseola (HHV-6)
- Face sparing pink maculopapular rash
| - Sudden onset after high fever
266
What are the features of the rash and presentation of: Fifth disease (erythema infectiosum)
- Bright red cheeks with lacy reticular rash
| - Aplastic crises possible (parvovirus B19)
267
What are the features of the rash and presentation of: hand foot and mouth disease?
- Ulcer-like eruption in mouth with macular rash on palms and soles
- fever followed by rash
268
What are the features of the rash and presentation of: scarlet fever
- Sandpaper rash with increased redness in skin folds
| - Strawberry tongue, pastia sign
269
What are the features of the rash and presentation of: varicella
- Papules to vesicles that starts on the trunk and spreads outward.
- Lesions in different stages
270
What are the features of the rash and presentation of: lyme disease
-Erythema migrans
271
What are the features of the rash and presentation of: RMSF
- Pink macules to red papules
| - begins on wrists and spreads inwards
272
What are the features of the rash and presentation of: secondary syphilis
- Maculopapular rash that begins on trunk and spreads to palms and soles
- Appears 2-3 months after chancre
273
What is the most specific feature of a contact dermatitis?
Linear confluence
