Case Files EM Flashcards
1
Q
What is the treatment of choice for strep, and how long?
A
PCN for 10 days
2
Q
What steroids is given to patients with bad strep throat, if clinically indicated?
A
Dexamethasone
3
Q
What is the classic x-ray sign for epiglottitis?
A
Thumb print sign
4
Q
What is the treatment for epiglottitis? Abx choice?
A
ENT referral
Cefuroxime
5
Q
What are the abx of choice for retropharyngealabscess?
A
PCN and metronidazole
6
Q
What is the usual presentation of Ludwig’s angina?
A
Submaxillary, sublingual, or submental mass with infx s/sx and trismus
7
Q
What are the abx for Ludwig’s angina?
A
PCN and metronidazole
8
Q
Which has trismus: peritonsillar abscess, or retropharyngeal abscess?
A
Peritonsillar
9
Q
What are the abx for peritonsillar abscess?
A
PCN and metronidazole
10
Q
What are the components of the CENTOR criteria? (4)
A
Cervical adenopathy
Exudates
No cough
Fever
11
Q
What intervals are troponins obtained to r/o MI?
A
1 (immediately), 4, and 12
12
Q
What are the components of the TIMI risk score? (7)
A
- Age over 65
- H/o CAD
- 3+ CAD risks
- Use of ASA in prior week
- 2+ anginal events in 24 hours
- ST segment deviation
- Increased cardiac biomarkers
13
Q
What is the goal door to balloon time for STEMI?
A
90 minutes
14
Q
What is the ship and drip method for STEMI?
A
Ship to PCI hospital under 90 minutes away
Start heparin and abciximab
15
Q
What are the drugs that should be administered to NSTEMI patients?
A
Beta blockers (if no HF) LMW heparin Clopidogrel
16
Q
What are the drugs that MI patients are started on for life once out of the hospital? (4)
A
ASA
ACEIs
Statins
Beta-blockers
17
Q
What causes bradyarrhythmias with an MI?
A
If SA node is infarcted from RCA occlusion
18
Q
What meds should be avoided in patients with a right ventricular infarction?
A
NTG
HIgh dose morphine
19
Q
What should patients in newly diagnosed A-fib receive upon arrival to the ED?
A
IV and cardiac/pulse ox
20
Q
What is the most common underlying cause of atrial fibrillation?
A
HTN
21
Q
Why is it that AF begets AF?
A
Causes degeneration of the electrical and contractile tissue, causing more foci to occur
22
Q
What is the single most important goal of therapy for treating AF in the ED?
A
Rate control
23
Q
What is the treatment for hemodynamically unstable AF?
A
Cardiovert
24
Q
What is the timeframe for cardioversion for AF in the ED? What is done if this is not met?
A
- Less than 48 hours
- move to anticoagulate for 3 weeks, then convert in 3 weeks, OR TEE + cardiovert
25
Why is it that pts with WPW should not receive rate control for AF?
nodal blocking agents can lead to accelerated conduction down the accessory pathway, leading to VF
26
How does digoxin slow the HR?
Increases parasympathetic tone
27
When does the 48 hour rule not apply for hemodynamically stable patients in AF? (3)
- Mitral valve disease
- Severe LV dysfunction
- h/o embolic stroke
28
What is the difference between sinus tach and atrial tach, in terms of EKG changes, and treatment?
P wave morphology different than sinus
| Will not respond to vagal maneuvers or adenosine
29
What are the EKG findings and the treatment for AVNRT?
P waves buried in QRS
| Vagal maneuvers/ Adenosine
30
What are the EKG findings and the treatment for AVRT?
Inverted P waves
| Vagal maneuvers / adenosine
31
What are the EKG findings and the treatment for junctional tachycardia?
Inverted P waves before or after QRS
| Will NOT respond to vagal maneuvers or adenosine.
32
What are the EKG findings and the treatment for antidromic AVRT?
Retrograde P waves may or may not be visible
| Avoid beta blockers, CCBs, and adenosine
33
What is the triad for DKA?
Hyperglycemia
Ketosis
Metabolic acidosis
34
The absence of what lab finding exclude the diagnosis of DKA?
No ketones in the urine means not DKA
35
How long should insulin be delivered to patients in DKA?
Until metabolic acidosis resolves
36
What is the rate of insulin infusion for DKA? At what BG level should dextrose be added?
0.1 U/kg/hour
| 250 mg/dL
37
When can K be given immediately in DKA?
if patients have a low to normal serum K. Otherwise, give NS until normal
38
What additional electrolyte should be given to patients in DKA to maintain the added K?
Mg
39
What is a major complication of DKA, particularly in children?
Cerebral edema
40
What is the role of using bicarb in DKA?
Not effective, even at low pH
41
What is the temperature needed to diagnose SIRS?
x ∉ [36,38]
42
What is the HR needed to diagnose SIRS?
More than 90 bpm
43
What is the RR or PaCO2 needed to diagnose SIRS?
RR over 20
| PaCO2 less than 32 mmHg
44
What is the WBC count needed to diagnose SIRS?
Over 12000 or less than 4000
45
What is the definition of sepsis?
SIRS + infection source
46
What is the definition of severe sepsis?
Sepsis + one sign of organ failure OR hypoperfusion
47
What is the definition of septic shock?
Sepsis + hypotension
48
What is the goal central venous pressure in early goal-direct therapy? what about if mechanically ventilated?
8-12 mmHg (over 12 if mechanically ventilated)
49
What is the goal MAP in early goal-direct therapy?
Over 65 mmHg
50
What is the role of steroids in septic shock?
Do not use unless suspect adrenal insufficiency
51
What are the general ventilator settings to be used in ARDS?
Low tidal volumes
| PEEP
52
What causes DIC?
ACtivation of both coagulation cascade, and anticoagulant cascade
53
When should platelets be given in DIC?
If less than 5000, or less than 30000 with bleeding
54
What is the goal central venous oxygen saturation ScvO2) in sepsis?
Over 70%
55
What are the components of the AMPLE mnemonic for history taking in the trauma patient?
```
Allergies
Medications
Past mhx
Last meal
Events leading up to incident
```
56
What are the three stages of shock?
Compensated
Progressive
Irreversible
57
The normal manifestations of shock do not apply to what three categories of patients?
Pregnant women
Athletes
Alter autonomic nervous system (e.g. beta blockers)
58
What characterizes the progressive stage of shock?
Arterial pressures fall
59
What amount of blood loss is characteristic of Classes I-IV of ATLS classifications?
Less than 750
750-1500
1500-2000
Over 2000
60
What HR is characteristic of Classes I-IV of ATLS classifications?
Less than 100
More than 100
More than 120
More than 140
61
What BP (general, not numbers) is characteristic of Classes I-IV of ATLS classifications?
Normal
Normal
Decreased
Decreased
62
What pulse pressure (general, not numbers) is characteristic of Classes I-IV of ATLS classifications?
Normal
Decreased
Decreased
Decreased
63
What RR is characteristic of Classes I-IV of ATLS classifications?
12-20
20-30
30-40
More than 40
64
What urine output is characteristic of Classes I-IV of ATLS classifications?
More than 30 mL/h
20-30
5-15
None
65
What mental status findings are characteristic of Classes I-IV of ATLS classifications?
Slight anxious
Mild
Anxious/confused
Lethargic
66
What are the five areas that should be assessed in every trauma patient?
```
External bleeding
Thorax
Peritoneal cavity
Pelvis/retroperitoneal
Soft tissue compartments
```
67
What organ metabolizes lactate? What is the significance of this?
Liver
| Liver failure will always have elevated lactate
68
What is the best clinical estimate of preload?
LVEDV
69
What is the ratio of fluids to blood in hemorrhagic volume resuscitation?
3:1
70
When is transfusion indicated in the hemorrhagic trauma patient?
If 2-3L of IVFs do not bring the pt out of shock
71
True or false: hypotension in a trauma pt is hemorrhage until proven otherwise
True
72
Why is local wound exploration of the chest not a good idea?
Procedure itself can penetrate the pleura
73
Why is it that a chest tube should be placed in a ventilated patient, regardless of the size of the pneumothorax?
Tension may result from PEEP
74
What is the role of CT in detecting diaphragmatic injuries?
Only gets bigs ones
75
What are the s/sx of abdominal trauma that necessitate surgical exploration? (4)
Shock
Peritonitis
Gunshot wound
Evisceration of abdominal contents
76
True or false: a wound that does not penetrate the abdominal fascia may be irrigated and closed without further diagnostic studies
True
77
pt with midline neck tenderness with a negative CT should have what?
Flexion/extension plain films
78
What are the Nexus criteria for neck CTs? (5)
1. No posterior midline TTP
2. No intoxication
3. Normal level of alertness
4. No focal neurological deficits
5. No painful distracting injuries
79
What are the s/sx of anterior, posterior, and central cord syndrome?
```
Anterior = no motor or pain
Posterior = no vibration sense or proprioception
Central = Upper extremity weakness
```
80
What are the three steps of the canadian neck CT rule?
1. High risk factors (age over 65, PE findings, or mechanism)
2. C-spine TTP, ambulatory, or delayed pain
3. Able to rotate neck
81
Why is it that neck fractures with neurological compromise may cause respiratory compromise?
C3-5 phrenic nerve innervation
82
What is the role of steroids in the treatment of a spinal cord injury?
No longer used 2/2 increased sepsis
83
True or false: breaks in either the ulna, or the radius are treated closed, whereas if both are involved, then open treatment
True
84
What is the treatment for a colles fracture?
Closed reduction
85
What is the treatment for carpal injuries?
Call the surgeon
86
What amount does epi come in (in terms of mg / dose)?
All are generally 1 mg per dose
87
What is the best way to titrate epi in patients?
Add 1 mg of epi to 1 L of fluid, and infuse 1-4 mL per min
88
What is the treatment for pts on beta blockers in anaphylaxis?
Glucagon--activates the adenylate cyclase pathway independent of beta receptor
89
What is the oxygen saturation target for adults with asthma? Infants? Pregnants?
90% in adults and at least 95% in infants, pregnant women, and patients with coexisting heart disease.
90
What amount of inhaler use is recommended in the ED?
In the ED, patients can receive 4 to 8 puffs every 15 to 20 minutes for the first hour of therapy and then every 30 minutes thereafter for 1 to 2 more hours.
91
What is the role of leukotriene agonists in the treatment of asthma?
Only for chronic control
92
What is the role of Mg in the treatment of asthma?
Used in severe cases, and competes with Ca for uptake into the sarcoplasmic reticulum
93
What is the role of theophylline in the treatment of asthma?
None, really.
94
What is the role of BiPAP in the treatment of acute asthma exacerbation?
Should be tried prior to intubation
95
Besides uncontrollable asthma, what are the four major indications for admission for asthma?
1. new onset
2. Multiple Hospitalizations
3. Severe CAD
4. social/medical issues that impair access
96
What are the initial ventilator settings for asthma patients?
AC mode, 8-10 rate, 6-8 mL/kg
97
Any trauma to the head, face, neck or spine, should prompt concern for what sort of injury?
C-spine
98
What causes an acquired saddle nose deformity (not syphilis)?
Hematoma of septal cartilage causes necrotic breakdown
99
Name the appropriate suture size: face
5-0
| 6-0
100
Name the appropriate suture size: scalp
3-0
| 5-0
101
Name the appropriate suture size: chest
3-0
| 4-0
102
Name the appropriate suture size: beck
3-0
| 4-0
103
Name the appropriate suture size: abdomen
3-0
| 4-0
104
Name the appropriate suture size: extremities
4-0
| 5-0
105
Name the appropriate suture size: joints
3-0
| 4-0
106
Name the appropriate suture size: oral
3-0
| 5-0
107
how long should sutures stay in place for in the face?
5 days
108
Where is the first stitch placed with lacerations through the vermillion border?
Exact approximation of the border
109
What should be done with ear lacerations?
Consult ENT of plastics
110
What may happen if a stitch is placed within the cartilage of the ear?
Avascular necrosis
111
When length of laceration of the buccal mucosa require closure?
More than 2 cm d/t food particles, infx
112
What is the treatment for tetanus, besides supportive?
TIG
| Tetanus vaccination on opposite side of TIG
113
How many tetanus shots are needed to be considered fully immunized?
3
114
What is the bacteria classically found in animal and human bites respectively?
```
Animal = pasteurella
Human = eikenella
```
115
What is the duration of abx for bites for treating infection and prophylaxis respectively?
10-14 days if infected
| 3-5 days for prophylaxis
116
What is the 1-4 day prodrome of rabies?
Nonspecific ILI, followed by hyperactivity
117
How long should cats/dogs be observed for rabies infection?
10 days
118
True or false: postexposure prophylaxis is not needed if someone has already received the vaccine
False
119
How long does the passive immunity last with rabies IVIG?
2-3 weeks
120
Why should debridement of venomous bites not be done if there are systemic hematologic symptoms?
May be unable to control bleeding
121
What is the treatment for a snake bite in the field?
Place constriction bands that DO NOT obstruct arterial flow
122
Bites that are more than (__) hours old are, in general, left open, because of the risk of infection.
6 hours
123
What is the goal treatment time for an ischemic stroke?
60 minutes from walking in the ED
124
What is the timeframe for thrombolytics for strokes?
4.5 hours from symptom onset
125
What are the s/sx of a stroke in the territory of the posterior cerebral artery? (3)
- Lack of visual recognition
- Altered mental status with impaired memory
- Cortical blindness
126
What are the s/sx of vertebrobasilar stroke (5)?
- Dizziness/vertigo
- Diplopia
- Dysphagia
- Ataxia
- Ipsilateral CN palsies
127
What are the s/sx of basilar artery occlusion?
Quadriplegia and locked in syndrome
128
What are the s/sx of lacunar infarcts?
Pure motor or pure sensory symptoms
129
Crossed neurological symptoms generally indicate the lesion is where?
Brainstem
130
What are the early CT findings of an ischemic stroke? (2)
- Loss of the gray-white differentiation 2/2 increased water concentration in ischemic tissues
- Increased density within the occluded vessel
131
Platelet counts below what are a contraindication to tPA?
100,000
132
What are the three things that are absolutely indicated in the work up of syncope?
History
Physical
EKG
133
Over what age should syncope patients be admitted?
65
134
What medical history should syncope patients be admitted?
Heart disease
135
What is the upper limit of normal for QTc?
440 msec for men
| 460 for women
136
What patients with a DVT should be treated with anticoagulation?
All patients diagnosed with a DVT at or above the popliteal level should be treated with anticoagulation.
137
What test should be ordered in a medium and high pretest probability pt for a DVT respectively, to r/o a DVT if the US is normal?
```
Medium = d dimer
High = venography
```
138
What are the components of the Wells criteria? (7)
- DVT suspected
- Alternative dx is less likely
- HR over 100
- Immobilization or surgery in previous month
- Previous DVT
- Hemoptysis
- Malignancy
139
What are the components of the PERC criteria? (8)
- Less than 50
- pulse over 100
- SaO2 over 94
- No unilateral leg swelling
- No hemoptysis
- No recent trauma/surgery
- No prior DVT
- No hormone use
140
What is the goal when treating hypertensive emergency? Why is it not to lower the BP down to normal levels?
Reduce the MAP by 20-25% over the first hour
If too fast, then cerebral ischemia results
141
What are the three first line drugs to treat HTN emergency?
Nitroprusside
Labetalol
Nicardipine
142
How is preeclampsia diagnosed in a patient with underlying HTN?
if systolic BP has increased by 30 mm Hg or if diastolic BP has increased by 15 mm Hg.
143
What is the pathophysiology of hypertensive encephalopathy?
Acute rise in blood pressure causes endothelial cell dysfunction in the brain’s vascular supply leading to cerebral edema.
144
What does HELLP syndrome stand for?
```
Hemolysis
Elevated
LFTs
Low
Platelets
```
145
What is the drug of choice of treating HTN in pregnancy?
Hydralazine
146
What is the equation for the cerebral perfusion pressure?
MAP - ICP = CCP
147
What is the major metabolite of nitroprusside?
Cyanide
148
What is the major side effect of nicardipine?
Reflex tachycardia
149
What is the DOC of lowering BP acutely in pts with renal failure?
Fenoldopam
150
What are the two drugs of choice in treating acute HTN in the setting of an MI?
Beta blockers
| NTG
151
What is the only HTN emergency where rapid and aggressive lowering of blood pressure is indicated?
Aortic dissection
152
Why should patients suspected of having acute pancreatitis not undergo immediate CT scan with contrast?
Volume depletion = kidney injury
153
What is the most important first step (besides ABCs) in a young child who ingested a foreign object?
X-ray to determine location
154
What are the five areas of the GI tract that foreign objects tend to lodge in children?
- Cricopharyngeal narrowing
- Thoracic inlet
- aortic arch
- tracheal bifurcation
- Hiatal narrowing
155
What is the treatment for food impaction in the esophagus?
Endoscopy
| Glucagon/NTG to relax esophagus
156
What is the treatment for a coin lodges in a child's throat?
Endoscopy if at the cricopharyngeus
| Expectant if impacted less than 24 hours
157
What is the treatment for a battery lodged in a child's esophagus?
x-ray to confirm location, surgical consult for endoscopy if in esophagus
If lower than duodenum, then expectant
158
What is the treatment for a sharp body lodged in a child's esophagus?
X-ray to confirm location, then endoscopic removal
If past duodenum and symptomatic, surgery
159
What is the treatment for drug packet ingestion?
NOT endoscopy
Polyethylene glycol to speed movement through GI tract
O/w surgery to remove
160
What is the most common location for FB to become lodged in adults?
Distal esophagus
161
What is the treatment for all FBs that are lodged in an airway?
Endoscopic removal
162
Why must a button battery be removed ASAP?
Risk of esophageal perforation (6 hours) / esophageal burns (4 hours)
163
What is the only FB that you should never endoscopically remove?
Packets of drug 2/2 risk of rupture
164
What rectal exam finding may suggest a partial bowel obstruction?
Stool or air
165
What is a closed loop obstruction?
Blockage that occurs both proximal and distal to the dilated segment
166
What is an open loop obstruction?
Intestinal blockage is distal, allowing proximal bowel decompression of obstruction via NG suction or emesis
167
What is a simple (uncomplicated) bowel obstruction?
Partial or complete obstruction of the bowel lumen without compromise to intestinal blood flow
168
What is the most common cause of SBOs?
Adhesions from previous surgeries
169
What is the most common cause of LBOs?
Colorectal carcinoma
170
What is the use of an NG tube in a bowel obstruction?
Decompresses air/fluid in proximal segment to prevent progression of bowel distention
171
What happens to intestinal blood flow with a bowel obstruction?
Blood flow diminishes, leading to ischemia and possible bacterial invasion
172
Which usually has emesis: large or small bowel obstruction?
Small
173
Which usually has distension: large or small bowel obstruction?
Large
174
Which usually has early cramping pain: large or small bowel obstruction?
Small. Later for large
175
What usually causes/exacerbates the pain with a LBO?
postprandial
176
True or false: the presence of a recent bowel movement r/o the possibility of an obstruction
False--does NOT r/o
diarrhea is frequently reported by patients with progressive large-bowel obstruction.
177
Is localized TTP of the abdomen common in a bowel obstruction?
No--suggestive of complications involving an isolated bowel segment
178
Name the clinical implications with the associated abdominal CT finding: dilated small bowel with transition to normal sized bowel
Mechanical SBO
179
Name the clinical implications with the associated abdominal CT finding: Over 50% diameter difference between proximal dilated small bowel, and distal small bowel
High grade SBO
180
Name the clinical implications with the associated abdominal CT finding: small bows feces
Moderate to high grade obstruction
181
Name the clinical implications with the associated abdominal CT finding: intraperitoneal free fluid
If found in setting of SBO, high grade SBO
182
Name the clinical implications with the associated abdominal CT finding: thickened small bowel wall
High grade obstruction
183
Name the clinical implications with the associated abdominal CT finding: target sign
Intussusception
184
Name the clinical implications with the associated abdominal CT finding: swirl sign
Internal hernia or volvulus
185
Name the clinical implications with the associated abdominal CT finding: reduced bowel wall enhancement
Ischemic bowel wall
186
Name the clinical implications with the associated abdominal CT finding: Pneumatosis intestinalis
Ischemic bowel wall/ necrosis
187
What are the first three initial steps of managing a SBO?
NPO
IVFs
NG tube decompression
188
What happens to the need to operate with continued bowel obstruction?
INcreased
189
What should be done if signs of infection are present in a patient with a bowel obstruction?
Immediate surgical referral
190
Older patients with large bowel obstruction need more what?
Fluids
191
What part of the intestines is most likely to have a large bowel obstruction?
Splenic flexure
192
More than (__) cm in colon diameter is a risk for colonic perforation?
10 cm
193
What is the most common cause of a SBO in a patient without a h/o surgery?
Hernia
194
Persistent pain in a patient with small-bowel obstruction is usually suggestive of what?
bowel ischemia or impending bowel necrosis
195
What vectors are responsible for transmitting salmonella/shigella?
Eggs and chickens
196
Why should bismuth subsalicylate be avoided in immune compromised individuals with diarrhea?
Risk of bismuth encephalopathy
197
What is the abx prophylaxis of choice for patient visiting latin american countries?
Cipro
198
What is the most common composition of renal stone?
Calcium oxalate
199
What is the composition of renal stones 2/2 chronic UTIs?
Magnesium ammonium phosphate
200
Fever, pyuria, and severe CVA TTP = ?
Pyelonephritis
201
Does the amount of hematuria correlate with the amount of obstruction?
No
202
What is the imaging of choice for renal stones?
Noncontrast CT
203
Why should you be careful with NSAID use in the setting of renal stones?
Renal insufficiency (if present) may worsen
204
When is a urological consult needed in the setting of renal stones? (4)
If infected
Stones over 7 mm
Inadequate pain control
complete obstruction
205
What causes the HTN associated with renal obstruction?
Activation of the RAAS
206
What is the mechanism o f type I, II, III, and IV or renal tubular acidosis?
```
I = inability to secrete H+
II = decreased proximal reabsorption of HCO3-
III = Inability to secrete NH3
IV = Antagonism of deficiency of aldosterone
```
207
What are the lab findings for type I, II, III, and IV of renal tubular acidosis? (K, Cl, urine pH)
I hypokalemic, hyperchloremic acidosis and urine pH over 5.5
II = hypokalemic, hyperchloremic with urine pH less than 5.5
III = normokalemic, hyperchloremic acidosis with urine pH less than 5.5
IV = Hyperkalemic, hyperchloremic, urine pH less than 5.5
208
What parts of the rectal exam are important to assess in cases of suspected neurogenic bladder?
Sphincter tone
Perianal sensation
Bulbocavernosus reflex
209
What are the four major types of medications that can cause urinary retention?
Anticholinergics
Beta agonists
Detrusor muscle relaxants
Nacrotics
210
What is the major complication associated with postobstructive diuresis?
Electrolyte abnormalities and hypotension
211
What is the first step after a complete H and P for a woman suspected of having PID?
Transvaginal US to r/o tubo-ovarian abscess / pregnancy
212
What are the three classic exam findings of PID?
Lower abdominal TTP
Adnexal TTP
Cervical motion tenderness
213
What is the usual presentation of a tubo-ovarian abscess?
Not much to PID symptoms
214
Why does the DEPP shot decrease the incidence of PID?
Lower progesterone = increased cervical mucus thickness, and thus lowers the chance of infection
215
What is the second most common cause of female infertility in the US?
Postinfectious tubal 2/2 PID
216
How does a ruptured tubal ovarian abscess present?
Shock = surgical emergency
217
What are the non-obvious indications for admission for PID? (3)
Tubo-ovarian abscess
IUD presence
Pregnant
218
What is the outpatient therapy for PID?
Ceftriaxone + doxycycline w/wo metronidazole
219
What is the general treatment for tubo-ovarian abscesses? What is not?
Abx
| Not drainage, generally
220
Does the partner need to be treated in cases of PID?
Yep
221
True or false: you can generally feel tubo-ovarian abscesses on pelvic exam
False--US is indicated
222
Draw out the facial nerve UMN, nucleus, and LMNs
draw
223
If a patient has drooping of the mouth but is able to wrinkle his or her forehead normally, what should be suspected?
UMN lesion (e.g. stroke, cerebral hemorrhage, etc.)
224
What portion of ectopic pregnancies are linked to previous salpingitis?
1/2
225
What level of hCG is typical of an ectopic pregnancy? An increase of what % of hCG in 48 hours is suspicious for an ectopic pregnancy?
1200-1500
under 66%
226
True or false: the level of hCG reliably correlates with the size of the ectopic pregnancy
False
227
What is the medical therapy for ectopic pregnancies? MOA?
IM Methotrexate
| Interferes with folinic acid
228
What are the conditions under which methotrexate is optimal for the treatment of an ectopic pregnancy? (3)
hCG less than 5000
Fetus smaller than 3.5 cm
No detectable fetal cardiac activity
229
If a woman is not hemodynamically unstable, and an ectopic pregnancy is suspected, when is it appropriate to order and follow hCG, instead of going straight to US?
If hCG is less than 2000
230
What is the common surgical treatment for an ectopic pregnancy?
Laparoscopic salpingectomy/salpingostomy
231
What, technically, is hyperemesis gravidarum?
Intractable n/v that leads to significant volume depletion and electrolyte disturbances
232
What is the antiemetic of choice for pregnant women?
Zofran
233
What is the treatment for asthma attacks in pregnancy?
Same as if not pregnant--albuterol inhalers, inhaled corticosteroids
234
What are the indications for intubating a pregnant patient?
PaCO2 of more than 45 mmHg
235
What has been associated with preterm premature rupture of membranes (PPROM)? (3)
H/o infections
Multiple gestations
Polyhydramnios
236
What generally happens to ABG with pregnancy?
Increased minute ventilation leads to slight respiratory alkalosis, with metabolic compensation
237
True or false: chorioamnionitis always precedes fetal infection
False
238
What is the "latency" period of PPROM? What is the major concern with this?
Time difference between the ROM and the delivery
Major increase in incidence of chorioamnionitis
239
What is the usual history of PPROM?
Gushing of fluid, but may be slow leakage
240
What is the test to confirm PPROM?
Sterile speculum exam, showing pooling of amniotic fluid and positive nitrazine test of fluid
241
What is the management of PPROM?
Admit to hospital with expectant management
242
What is the earliest sign of fetal infection?
Tachycardia
243
What is the role of steroids in premature pregnancy?
Increases fetal lung maturity
244
What is the treatment of hyperthyroidism in pregnancy?
Thioamides and beta blockers
245
What are the major side effects of thioamides?
Agranulocytosis
| Leukopenia
246
What is the treatment of thyroid storm, including in pregnancy? (5)
- Thioamide
- KI
- dexamethasone
- Propranolol
- Phenobarbital
247
What is the major complication associated with pregnant pyelonephritis?
ARDS and sepsis
248
True or false: pregnant patients with pyelonephritis should almost always be admitted
True
249
True or false: If an infant has had a rectal temperature more than 38 ° C at home but is afebrile and well appearing in the emergency department, this infant still requires full workup for fever.
True
250
True or false: If the parent only reports a tactile fever and the infant is afebrile and well appearing in the emergency department, laboratory testing for fever workup is required.
False--no lab work up is needed necessarily
251
In a 1-3 month old infant, CSF with greater than or equal to (___) WBC/ mm3 or organisms on Gram stain is considered high risk for SBI.
8 WBCs
252
What is the Abx of choice for FWS in 1-3 month old infants?
Ceftriaxone
253
What is the relation between SBI and positive RSV test?
If RSV positive, 50% decrease in likelihood of SBI
254
What is considered a positive UA in a 1-3 month old infant?
More than 9 wbcs
255
What is ciliary flush?
Circumferential reddish ring around the cornea
256
What are the two major ocular risk factors for acute closed angle glaucoma?
- Hyperopia (causes shortening of eye and shallow anterior chamber)
- Age-related lens thickening
257
What types of medications can cause acute closed angle glaucoma? Why?
- Anticholinergics or sympathomimetics
| - Causes dilation of iris, and narrowing of the canal of schlemm
258
What is the definitive treatment of acute closed angle glaucoma?
Laser iridectomy
259
What is the pharmacologic therapy to reduce intraocular pressures in acute closed angle glaucoma?
- beta blocker (timolol)
- alpha-2-agonist (apraclonidine)
- CAI (acetazolamide) or mannitol
260
What is the role of pilocarpine in ACAG?
Miotics (pilocarpine) enhance trabecular outflow by constricting the pupil to disrupt the corneal-iris apposition.
261
What are the major difference between chlamydial conjunctivitis, and gonorrheal conjunctivitis?
Gonococcal produces copious discharge, whereas chlamydial does not.
Chlamydial is more chronic
262
How does a corneal ulcer appear clinically?
White mark
263
True or false; distinguishing a corneal ulcer from abrasion is clinically insignificant
False
264
How can you differentiate a corneal ulcer from a corneal abrasion?
hazy/ cloudy stroma lies beneath an ulcer
clear stroma is deep to most abrasions.
265
What are the s/sx of anterior uveitis? (4)
Pain
Blurred vision
Photophobia
Circumcorneal erythema
266
What is endophthalmitis?
Inflammation of the vitreous humor (primary or 2/2 hematogenous spread to eye)
267
What is a hypopyon? What is indicated if this is present?
a leukocytic exudate, seen in the anterior chamber, usually accompanied by redness of the conjunctiva and the underlying episclera.
Emergent ophthalmological referral
268
What is the difference between orbital and preseptal cellulitis?
Orbital will have more painful EOMs, blurred vision, conjunctival injection
269
True or false: subconjunctival hemorrhage are often painful and affect vision
FALSE--should be NEITHER
270
What is a hyphema? Treatment?
Blood in the anterior chamber
| Elevating head to 30 degrees, eye shield, mydriactics
271
What are the s/sx of scleritis? What usually causes it?
Severe eye pain, erythema, and decreased vision
Usually 2/2 systemic autoimmune disease
272
What is the most common systemic disease associated with scleritis?
RA
273
What are the indications to do a CT before LP in suspected meningitis? (7)
- AMS
- Focal neurological deficits
- Immunocompromised
- h/o CNS disease
- New onset seizure
- Papilledema
- h/o of evidence of head trauma
274
Name the suspected bacterial cause of meningitis with the following CSF findings:
- Gram positive diplococci
- Gram-negative diplococci
- Pleomorphic gram negative coccobacilli
- Gram positive rods
- Gram positive diplococci = strep pneumo
- Gram-negative diplococci = Neisseria meningitidis
- Pleomorphic gram negative coccobacilli = Haemophilus flu
- Gram positive rods = listeria
275
What is the abx of choice for meningitis caused by neisseria or strep pneumo?
3rd gen cephalosporin
276
Positive india ink stain = ?
Cryptococcus neoformans
277
Older or immunocompromised pts are more susceptible to meningitis caused by which organisms? Which abx should they receive?
Listeria and H flu
| Ampicillin
278
What is the role of steroids in the treatment of meningitis?
Reduces inflammation
279
What is the general treatment regimen for all meningitis cases? (3)
Vanco + cephalosporin + ampicillin
280
What are the abx for prophylaxis of meningitis in someone who is in close contact to someone who has contracted the disease?
fluoroquinolone
281
Should abx treatment be delayed for LP + CT in patients with meningitis?
No
282
Which two benzos are preferred for the acute treatment of a seizure?
Lorazepam
| Diazepam
283
What are the second line agents for acute seizure treatment? MOA?
Phenytoin or fosphenytoin
Na channel blocker
284
What is the major side effect of phenytoin?
hypotension and cardiac dysrhythmias
285
What are the major side effects of phenobarbital in terminating acute seizures? (2)
Hypotension and respiratory depression
286
What illicit drug is the most common cause of drug-induced seizures? What is the treatment for this?
Cocaine
| Benzos
287
Which antidepressant may cause seizures? What is the treatment for this?
TCAs
| Bicarb
288
What is the cause of isoniazid induced seizures? What, then, is the treatment?
Loss of B6 from INH causes a decrease in GABA production
IV pyridoxine is the treatment
289
What is the timeframe for delirium tremens?
6-48 hours after the last drink
290
What is the most common metabolic cause of a new-onset seziure? What is the most common cause of Status epilepticus?
New onset = hypoglycemia
| SE = medication noncompliance
