CDEM Cases Flashcards
The classic triad of ruptured AAA is…
How can the pain be described, radiation? location?
A continuous abdominal bruit and a palpable abdominal thrill are suggestive of an _______?
Heme-positive or grossly bloody stools can be indicative of an _________?
pain, hypotension, pulsatile abdominal mass
The pain is usually acute, severe and constant and located in the abdomen, back, or flank. The pain can radiate to the chest, thigh, inguinal region, or scrotum.
Aortovenous fistula
aortoenteric fistula.
Type of Access need in the context of AAAs, Blood products?
Ideal study for detection of AAAs
Other imaging?
Two large-bore intravenous lines should be established with blood sent to the lab for type and crossmatch in anticipation of large transfusion requirement
Ultrasonography is the ideal study for detection of AAA.
CT w/ Intravenous contrast is desirable, but not essential, for emergency department exams.
If US is not available for dx of AAAs, what other test can be used? What will be seen
When should Resuscitation of a patient with AAA begin.
Who should be consulted in the process of making this diagnosis?
Plain film radiographs of the abdomen can be diagnostic if ultrasound and CT are not readily available
A curvilinear calcification of the aortic wall or a paravertebral soft tissue mass can be found.
Resuscitation should have been started during your primary survey. Patients with ruptured AAA may require crystalloid and blood products.
An unstable patient with AAA requires emergent surgical consultation and transfer to the operating room. Any delay in surgical care will result in an increased mortality
Intial elvation, Peak Elevation, and Return to Baseline of?
Myoglobin?
CK-MB?
Troponin I
Myoglobin 1-4 6-7, 18-24 h
CK-MB 4-12. 10-24, 48-72
Trop I 3-12, 10-24, 3-10 d
Reason to get certain test in the context of ACS?
CBC CXR CMP Echocardiogram Stress testing
CBC (anemia may be a cause),
CXR (may show pulmonary edema or other causes of chest pain),
electrolyes, BUN and creatinine (may effect treatment regimens),
echocardiogram (usually after admission to look for regional wall motion abnormality),
stress testing (either exercise or chemically-induced exertion to look for EKG changes and/or decreased radionuclide uptake in the ischemic region).
What does OMI stand for in Emergency Resuscitation.
What is the use of CAB vs ABC in the acute setting .
Length of palpation of the Carotid Pulse during CAB, what if no pulse is found?
When a patient is really sick, say “OMI.” OMI stands for oxygen, monitor, and IV – these interventions are appropriate for every critically ill patient regardless of the cause.
ABC is for the living and CAB is for the dead. The goal of the CAB assessment, which is the standard of care in cardiac arrest, is to rapidly determine whether to initiate CPR.
for less than ten seconds while simultaneously observing for respiratory effort.
For less than ten seconds while simultaneously observing for respiratory effort. If at the end of ten seconds you are not 100% certain that the patient has a pulse, start CPR.
Steps of the “A” in the primary survey
At what GCS would require intubation
Look - examine for swelling of tongue, lips, or neck, foreign bodies, loose teeth, vomitus or secretions.
Listen -Noisy breathing is obstructed breathing, so listen with the naked ear to the sound of respiration
Feel - alpate the neck and upper chest for crepitus, which can be a sign of pneumothorax or tracheolaryngeal injury
GCS of 9 or less requires intubation
What are the steps of the evalutions of “B” in the primary survey
Inspect?
Ausculate?
Percuss?
Inspect: look for cyanosis, JVD (tension pneumothorax or cardiac tamponade), asymmetric movement of the chest (flail chest), accessory muscle use (tension pneumothorax) or open chest wounds (open pneumothroax).
Ausculate: listen for stridor (upper airway injury), lung breath sounds (pneumo or hemothorax)
Percuss: feel for hyper-resonance (pneumothorax) or dullness (hemothorax), subcutaneous emphysema (airway injury), paradoxical movements (flail chest) crepitence & point tendnerness(rib fractures) or bruising (pulmonary contusion).
In the context of Tension Pneumo, where should the the angiocath be inserted
The treatment is a needle decompression using 14-16 gauge long angiocath inserted at midclavicular line in the second intercostal space, over the rib to avoid the neurovascular bundle
Definition of Classesof Shock; HR, BP, Findings, Blood losss, Treatment
I?
II?
III?
IV?
Class I: Normal- fast HR, Normal BP, 40% Blood Loss, Treat with Normal Saline + Blood Products
What is the typical significance of blown pupil
Loss of the parasympathetic outflow from the occulomotor nerve, often due to uncal herniation
GCS Coma Scale
Eyes?
Verbal?
Motor?
Eyes
4 – Spont
3 – Loud voice
2 – To Pain
1- None
Verbal
5 – Oriented 4 – Confused 3 – Inapprop words 2 – Incomprehensible sounds 1 – No Sounds
Motor
6 – Obeys 5 – Localizes to pain 4 – Withdraws to pain 3 – Abnormal flexion posturing 2 – Abnormal extension posturing 1 – None
Treatment of pulmonary contusion
blunt cardiac injury?
How do traumatic aortic disruption get dx, if at all
Treated by proper oxygenation and ventilation (often with intubation), and maintaining normovolemia.
Cardiac Injury: Treatment consists of medicating dysrhythmias that effect hemodynamics.
They may show a widened mediastinum on CXR. This can be confirmed with CT scan or angiography of the aorta and requires prompt surgical correction.
How much blood can hide in the pelvis?
Treatment of Pelvic instability in the context of trauma.
Point of the rectal exam during the secondary survey, neurologically, urologically, vascularlly?
5L
Treatment involves stabilizing the pelvis by wrapping a sheet around it (to compress), longitudinal traction and pelvic binders
On the rectal exam, look for diminished sphincter tone which can be a sign of a spinal cord injury. Exam prostate to check position as a high-riding prostate can be sign of a pelvic fracture or urethral injury. Finally, assess for rectal wall integrity and gross blood.
Test to consider in the in the Trauma survey Imaging?
Type and Screen CBC ABG and Lactate BMP or CMP UA EtoH EkG CXR with c-spin flims Fast Scan Retrograde urethrogram
What medication use must be inquired about in the and infant that is febrile in the ED setting?
Formula estimating the BP in small children
What medications should be be available in case of heart failure in the situation of ACS, dose?
What drug and dose should be available in the event of vtach in ACS
Prior Antipyretic use
BP = 80 + (2 × age in years)
Furosemide 20-80mg iv
Amiodarone 150mg-300mg IV
Voltage to used in the event of cardioversion
Defibrillation?
100-200J Biphasic
200 J (biphasic )
ECG finding in the event of PE. Axis, HR, Lead V1?, Lead II, P wave morphology? The classic finding?
Sinus tach - most common
Complete or incomplete RBBB – associated with increased mortality; seen in 18% of patients
Right Axis Deviations -Right axis deviation – seen in 16% of patients. Extreme right axis deviation may occur, with axis between zero and -90 degrees, giving the appearance of left axis deviation
Dominant R wave in V1 – a manifestation of acute right ventricular dilatation.
Right atrial enlargement (P pulmonale) – peaked P wave in lead II > 2.5 mm in height.
SI QIII TIII pattern – deep S wave in lead I, Q wave in III, inverted T wave in III. This “classic” finding is neither sensitive nor specific for pulmonary embolism
AFib or Flutter
Symptoms of Esophageal rupture, and key exam finding
Pain medication can used in the context of Abdominal Pain if BP is tenuous.
When is the earilest that the IUP can be detected on TVU/S
When is the yolk sac detected, and if present were is the pregnancy likely located.
Intense Substernal Chest Pain after vomiting or endoscopic procedure; Hamman’s crunch (crackle sound heard or felt in time w/ heart beat)
Fentanyl
4.5-5 weeks after the last menstrual period (LMP)
A yolk sac is typically identified at 5-6 weeks and the presence of a yolk sac has 100% predictive value for an intrauterine pregnancy
When is the the fetal pole, and the embryonic cardiac activity seen on U/S
Cell type that is response of the production of HCG, when do level double in pregnancy.
What is the definition of discriminatory zone.
A fetal pole and embryonic cardiac activity are usually seen by 6-7 weeks.
β-hCG is a glycoprotein hormone produced by trophoblasts that doubles approximately every 48-72 hours in the first trimester
he discriminatory zone of β-hCG is the level at which an IUP should be visible by transvaginal ultrasonography, typically 1500-2000 mIU/mL.
What are the goals of Ed management of unstable woman with presensations of Ectopic Pregnancy? Medications?
Benefit of the use of MTX in the context of Ectopic Preg
What is the percent of treatment failure of MTX? Next step
fluid and blood resuscitation, pain management, and OB-GYN consultation + (RhoGAM) should be administered to any Rh-negative woman.
most successful method to medically manage a patient with ectopic pregnancy and may preserve fertility better than surgical interventions
36% of patients necessitating administration of a second dose of methotrexate if β-hCG values are not decreasing as expected.
Contraindictions of MTX Tx.
Expected course after therapy initiation. Pain?
hemodynamic instability, inability to return for follow-up, breastfeeding, immunodeficiency, renal, liver or pulmonary disease, peptic ulcer disease, and blood dyscrasias.
Patients receiving methotrexate often experience abdominal pain 3-7 days after administration which is thought to be secondary to tubal abortion or expanding hematoma within the fallopian tube.
Four populations that are very likely to have non-classic presentation of appendicitis?
What qualities and size on ultrasound would indicate the presence of likely appendicitis?
What can is in the event that a patient can not tolerate oral contract for CT 2/2 to vomiting during acute appy
What population of patient get MRI for Acute Appy?
The elderly,the pregnant, the young and the immunocompromised
An appendix greater than 6-7 mm in diameter and noncompressible is indicative of appendicitis. Other findings that support the diagnosis are increase wall thickness, fecalith, and increased vascularity
rectal contrast
MRI is typically reserved for pregnant patients with a nondiagnositic ultrasound
What is the combined sensitivity of CRP and WBC in dx of acute appendicitis
Abx to used in Appendicitis Uncomplicated vs Complicated
98 percent
uncomplicated appendicitis - ampicillin-sulbactam, or cefoxtin, or a combination of metronidazole and ciprofloxacin.
Complicated appendicitis (perforation, abscess, immunocompromised) - carbapenem, such as meropenem or imipenem, Zosyn or another extended spectrum beta-lactamase inhibitor
Important disease to rule/out in the context of appy, in males (GU)
Stones and Torsion
In Pelvic inflammatory Disease, Ideal tests to get. If FHC is suspected? Confirmatory test?
When is U/S indicated in PID? What other disease can be ruled/out
Further testing should include urinalysis, CBC with differential, and liver function studies (if Fitz-Hugh-Curtis syndrome is suspected). The most appropriate testing for Neisseria gonorrhea and Chlamydia trachomatis is by nucleic acid amplification and hybridization determination
Pelvic ultrasound is warranted if TOA is suspected or the diagnosis is unclear. It is particularly useful to rule out other diseases that may present with pelvic pain such as a ruptured ovarian cyst (free fluid in the pouch of Douglas) or ovarian torsion (absence of blood flow to one ovary on pelvic ultrasound with doppler).
Does treatment of PID require a precise microorganism dx
Abx treatment for in the ED
If allergic cephlosporins
No, Once the CDC minimal criteria is met, women should be treated with antibiotics that cover the multiple organisms potentially responsible for this disease
Cefoxitin 2 grams IV q 6 hours with Doxycycline 100 mg PO or IV q 12 hours OR
Cefotetan 2 grams IV q 12 hours with Doxycycline 100 mg PO or IV q 12 hours.
Clindamycin 900 mg IV q 8 hours with Gentamycin.
Outpatient treatment for PID.
When might you consider adding metronidazole
Ceftriaxone 250 mg IM OR Cefoxitin 2 grams IM and Probenecid 1 gram PO. Doxycycline 100 mg BID for 14 days must also be prescribed.
The addition of Metronidazole 500 mg BID for 14 days should be considered in women with more severe infection or history of uterine instrumentation within the preceding 3 weeks.
At what size of the CBD is indicative of the presence of bile duct pathology
When is a HIDA Scan indicated? and what is the sensitivdity of the test
How is the test interpreted?
6mm in adults, > 8mm in elderly) indicates the likely presence of biliary duct stone or other obstruction and may be seen in choledocholithiasis and cholangitis.
HIDA scan is 90-94% sensitive for the presence of acute cholecystitis and is indicated if US is equivocal or negative for cholecystitis in the presence of a high clinical suspicion.
Lack of visualization of the GB within 4 hours after the radiotracer injection constitutes a positive study and indicates the presence of cholecystitis or cystic duct obstruction.
How long should symptoms last in bilary colic before patient should consider more invasive management of disease. Temp? Physical Signs?
Abx choice of management?
Management in the patient is critically ill and will no tolerate surgery?
They should be advised to return immediately for signs of complications of gallstones such as prolonged symptoms (> 6 hours), and/or symptoms associated with fever (> 100.4 F) or jaundice
ampicillin/sulbactam, a fluoroquinolone, or a third-generation cephalosporin +/- metronidazole
Cholecystectomy is indicated in cholecystitis, but may be delayed, especially in the critically ill patient
Why do people with SBO often complain of diarrhea
Patientsmay complain of diarrhea early in the course of bowel obstruction, with inability to pass flatus and obstipation occurring after the distal portion of the bowel has emptied (up to 12-24 hours).
Physical Exam finding on SBO, ab exam? bowel sounds?
Signs of strangulation?
abdominal distension (more prevalent in distal obstructions), hyperactive bowel sounds (early), or hypoactive bowel sounds (late)
Fever, tachycardia and peritoneal signs may be associated with strangulation.
How is SBO defined on CT with mesurements
Signs of strangulation
Obstruction is present if the small-bowel loop is greater than 2.5 cm in diameter dilated proximal to a distinct transition zone of collapsed bowel less than 1 cm in diameter.
Bowel wall thickening, pneumatosis, and portal venous gas all suggest strangulation.
What is the gold standard for the dx of pneumopertineum. What is the standard screening test?
Labs to obtain in the context of perforation of the viscus
CT; Upright Xray
T&S, initial hemoglobin/hematocrit, platelet and coagulation studies should be considered as a minimum. Additional laboratories such as the WBC, blood gas, lactic acid, renal and liver function, lipase/amylase and urinalysis
Most common location for Embolic Mesenteric Ischemia to occur.
Which Presentation of Mesenteric Ischemia has the worse prognosis?
Presentation?
ost common location of an embolus is in the superior mesenteric artery (SMA) due to the oblique angle of the SMA from the aorta.
Mesenteric artery thrombosis accounts for 20% of mesenteric ischemia cases and possibly carries the worst prognosis with a mortality of 90%
Vague and insidious symptoms such as weight loss, abdominal angina (abdominal pain after meals), diarrhea, and fear of food.
Mesenteric Vein Thrombosis
Age of patients
Symptoms?
Risk Factors?
younger patient population compared to the patient population of Mesenteric artery thrombosis or embolism
abdominal pain onset and location can be variable. no postprandial abdominal pain or food fear. May also have other accompanying symptoms such as vomiting and diarrhea
Hypercoagulable state , Recent surgery, Malignancy, Cirrhosis
Non-occlusive Ischemia”
General Cause
Specific causes
This type of mesenteric ischemia occurs in low flow states in absence of an arterial or venous occlusion.
Sepsis, hypotensive states, and drugs inducing mesenteric vasoconstriction (Digoxin, Cocaine, Alpha-agonists, Beta-blockers)
Labs in the context in Mesenteric Ischemia
Hemoconcentration, elevated amylase levels, and a metabolic acidosis. Elevated lactate, elevated D-dimer, low specificity in the aforementioned test.
Contraindiction to thrombolytic therapy in the context of Mesenteric Ischemia
If surgery is indicted, what will the surgeon do before resection. After the OR?
Recent surgery or GI bleed, recent stroke, and peritoneal signs indicating bowel infarction.
Revascularization is done first so that any ischemic-looking bowel can recover with the return of blood flow. Once blood flow is reestablished, any bowel that remains infarcted and necrotic is then resected. Surgeons will do “second look” procedures 24-48 hours later if the viability of a section of bowel was in question during the first surgery.
What medication should be started when Mesenteric Artery Thrombosis is dx?
Treatment for MAT if surgery is not an option
heparin should be started as soon as the diagnosis is made
For non-operative candidates, percutaneous transluminal angioplasty is done.
Mesenteric Vein Thrombosis Treatment
Preventative Tx after treatment?
If there are signs of infarction, then operative care is required. Otherwise thrombectomy with endarterectomy or distal bypass is the first choice of treatment
These patients will generally require life-long anti-coagulation.
Features of testicular torsion on U/S. Vs epididymitis?
First thing in management of testicular torsion. Medications, Food?
the painful testicle is usually enlarged and hypoechoic, with decreased blood flow, compared to the asymptomatic side.
pididymitis is usually associated with increased blood flow to the testicle and the epididymis, as part of the body’s inflammatory response.
Anyone with a suspected torsion should have an IV placed. Treat pain and nausea with IV medications, and keep the patient NPO in preparation for admission to the OR. if you can, mauel distorsion can be attempted.
In the dx of ovarian torsion what condition must be ruled out in a woman with lowe abdominal pain.
Screening tool of choice for Ovarian torsion.
Does the presence of blood flow in the ovary r/o ovarian torsion
The most dangerous condition in the differential for adnexal torsion is an ectopic pregnancy.
TAU/S
No up to 50 percent of Torsions confirmed on surgery had negative U/S
Indications for the Use of NIPPV. Oxygenation?, Breating patterns?
Moderate to severe dyspnea Accessory muscle use Paradoxical abdominal movement Fatigue RR > 25 bpm pH 45
Conindications tov the Use of NIPPV. Vitals? Breathing? Level of Consciousness?
Respiratory arrest/absent respiratory drive Hemodynamic instability Aspiration Risk Airway obstruction Unable to tolerate mask Mask does not fit Altered mental status
First Tests to be obtain in the context of Congestive Failure. Why?
Other tests to obtain?
Imaging?
n electrocardiogram (EKG) is routinely evaluated to determine whether there is evidence of cardiac ischemia that has occurred in the past or is currently the etiology of the patient’s heart failure.
cardiac enzymes, Lytes, perhaps a CBC; BNP (usally over 500)
Xray
Medical management of CHF? Drugs and reasons for their use?
Nitrate like Nitroglycerin and Nitroprusside - decrease pre-load, myocardial oxygen consumption and systemic vascular resistance. The net result increases cardiac output and allows the heart to pump blood more efficiently.
Lasix - imperative to note, that many patients presenting with heart failure are, in fact, euvolemic and will become hypotensive with diuretic therapy.
What can be used in the event that a patient becomes hypotensive during CHF?
What needs to be made available if the above drugs are to used?
What other non-drug methods can used if medication can not maintain circulation in the CHF?
inotropic medications including Levophed, dopamine and other peripheral vasoconstrictors (i.e. neosynephrine
While on these medications, vital signs and evidence of end organ perfusion must be monitored carefully
Intra-aortic balloon pumps (IABP) and ventricular assist devices (VAD) may be utilized as temporary therapy.
What is the median survival in patient with a recent diagnosis of CHF
Most patients succumb to their illness within five years
In patient with a severe exacerbation of asthma is not improving with albuterol what are the next medications to be administered?
How is Moderate Asthma exacerbation defined, Mild? severe?
Subcutaneous epinephrine 0.2 mg or terbutaline 0.25 mg
mild exacerbations (> 70% predicted or personal best of PEFR), moderate exacerbations (40-69% predicted or personal best of PEFR) or severe exacerbations (
Dosing of albuterol for Children?
Side effects of albuterol therapy, Heart, Lytes ? MS?
Side Effects of theophyline. MS? GI? Neuro? CV? What should be done in the event that a patient is taking this drug and has an asthma exacerbation?
0.5 mg/kg/h
tremor, tachycardia and mild hypokalemia due to potassium being driven into muscle cell
Side effects include tremors, nausea, anxiety, and tachyarrhythmia. In the unusual event that a patient is already receiving theophylline, a serum level should be measured
Discharged patients with asthma exacerbations should have steroid for how long?
What patient should be admitted to the hospital for asthma? SpO2? PEF or FEV1?
Steroids can be given in the form of a short burst of medication for 4-7 days or a tapered dose over 10-14 days.
Patients with poor response to treatment, persistent severe symptoms, persistent hypoxia (
Primary reasons for COPD exacerbations ID? Habits? Drugs? Chest wall disease?
DDX that must be ruled out with patient with COPD exacerbation.
Test to consider getting?
Superimposed infection, Continued smoking, Non-compliance
Lack of usual medications or oxygen therapy, Spontaneous pneumothorax
HF, acute coronary syndrome, pulmonary embolus, pneumothorax, pericardial effusion, and pneumonia
Chest x-ray, electrocardiogram, BNP (brain naturetic peptide), ABG
Common EKG finding in patient with COPD
Typical drug therapy in COPD
Side effects of steroid therapy, CV? Endocrine? Lytes? Psych? GI?
Low voltage, right axis deviation, P pulmonale- peaked P waves in II, III, aVF, (Right atrial hypertrophy), Multifocal atrial tachycardia (rare, but specific to COPD)
B2 agonist, Anticholingerics, steroids, abxs
Complications of steroid use are worsening hypertension, elevated blood sugars, gastritis, and even steroid psychosis.
What simple test can be done in the ED to “stress” test a patient with COPD and determine their dispo?
Walking the patient, if their SpO2 drops to low, then it may be necessary to admit the patient.
What are the parts of the modified Well’s Criteria
Interpretation of clincal probablity score?
Clinical symptoms of DVT (3 points)
Other diagnosis less likely than pulmonary embolism (3 points)
Heart rate >100 (1.5 points)
Immobilization (3 days) or surgery in the past 4 weeks (1.5 points)
Previous DVT/PE (1.5 points)
Hemoptysis (1.0 points)
Malignancy (1 points)
Clinical Probability: Low probability less than 2, Moderate 2-6, High more than 6
Things to look for on the xray for PE?
What is meant by S1Q3T3?
In what patient does the D-dimer have the high diagnostic utility
What group of patient is VQ scanning useless in.
Unilateral atelectesis, Hamptom’s Hump, or Westermark’s sign
Evidence of right heart strain (an S wave in lead I and Q and inverted T in lead III, the S1Q3T3 pattern)
low risk patients that have symptoms and the goal is to rule out PE.
The test becomes relatively useless if patients have other airspace disease, creating ventilation defects.
What should happen if the CTPA for PE for a patient was inadquete.
The patient should have e venous ultrasonography performed to rule out DVT, and then again several days later to evaluate for recurrent DVT after an embolic event.
In what situation might you start heparin early in a patient with PE.?
Dispo for patient with PE, why? desired INR?
When is Thrombolytic therapy indicated in PE patients
It may be started early if the patient is a high risk patient.
they are to be treated inpatient, for the purpose of anticougalation with warfarin to get an INR of at least 2-3
In the setting of a massive PE with significant cardiopulmonary compromise or submassive PE with evidence of right heart strain
What is the criteria for HCAP Healthcare-associated pneumonia (HCAP) (3x)
Common organisms (4x)
- hospitalization for ≥2 days in the preceding 90 days
- residence in a nursing home/facility
- in the past 30 days: attendance at a hospital or hemodialysis clinic, home or clinic IV therapy (antibiotics and chemotherapy), home wound care.
Pseudomonas aerugunosa, Escherichia coli Klebsiella pneumonia, Acinebacter, and Staphylococcus aureus.
Definition of HAP Hospital-acquired pneumonia, ventilator-associated pneumonia?
Classic findings of Chlamydiophila pneumonia - Upper Resp? Place of residence
Antibiotic reccomended for an aspiration pneumonia?
Hospital-acquired pneumonia (HAP) develops in patients ≥48 hours after hospitalization and is not incubating at the time of admission, a subtype of HAP, ventilator-associated pneumonia (VAP) develops >48-72 hours after intubation
pharyngitis, laryngitis and sinusitis, associated with outbreaks in close-contact settings (dorms, prisons)
Antibiotics with activity against gram-negative organisms such as third-generation cephalosporins, fluoroquinolones and piperacillin are recommended for treatment.
Four factors that increase the chance of pneumonia, Vitals? Hx? PE?
Pneumonia that are more likely to multi-lobar
What is the sensitivity and specificity of bedside ultrasound in dx of pneumo
Factors that predict pneumonia on chest x-ray include temperature >37.8 0C, tachycardia >100bpm absence of asthma, rales, and locally decreased breath sounds on auscultation.
Staphylococcus aureus and Pseudomonas aeruginosa
sensitivity of 86% and specificity of 89%
Why should an EKG be ordered in patients with pneumonia?
Treatment for CAP
Patients with congestive heart failure, cardiac or thoracic disease, and severe sepsis/septic shock may develop cardiac ischemia and infarction secondary to a severe pneumonia.
Macrolides, Fluoroquinolones, Doxycycline.
Treatment for HAP, what if MRSA is suspected
Zosyn Plus: Imipenem, Meropenem, Cefepime, Ceftazidime
Anti-MRSA agent: Vancomycin, Linezolid
Class System in the Pneumonia Severity Index (I-V)
CURB-65 parts and interpretation
Patients with a score in class I, II, and III have low risk for death and the clinician may consider outpatient treatment for CAP. Patients with a score in class IV of V are usually hospitalized in observation status or admission status for hospital treatment of CAP.
Confusion, urea Blood nitrogen > or = 20 mg/dL, Respiratory rate > or = 30 breaths per minute, Systolic BP or = 65.
One Point for each
A CURB-65 score of 2 may be able to have outpatient management with close follow-up or short admission/observation. Scores of 3 (mortality 14%) and 4 or 5 (mortality 27.8%) are higher risk and will need inpatient and potentially intensive care admission for patients with high scores
What is the deep sulcus sign and what does it indicate
Definition of a large tension pneumonia. What is indicated for tx?
The deep sulcus sign is suggestive of an anterior pneumothorax
A large pneumothorax is usually defined as greater than 20%. In this situation, a chest tube is usually indicated
mnemonic for the ddx on AMS
AEIOU TIPS
Alcohol, Epilespy (Electrolytes and Encephalopathy), Insulin, Opaites and Oxygen, Uremia, Trauma and Temp, Infection, Poisons and Psychogenic, Stroke, Stroke, Subarachnoid Hemorrhage and Space-Occupying Lesion
Tests that must be consider in the context of AMS.
Rapid glucose Serum electrolytes (Na+, Ca+), ABG or VBG (with co-oxymetry for carboxy- or met-hemoglobinemia) BUN/Creatinine, Thyroid function tests, Ammonia level, Serum cortisol level, Toxic or medication causes
Drug screen, ETOH, serum osmolarity, Infectious causes.
CBC with diff, UA, Blood Cultures, Chest X-ray, Lumbar puncture, CT if ICP suspected.
THe “Ds” of Vertbrobasilar Syndromes
D”: diplopia, dysarthria, dysphagia, droopy face, dysequilibrium, dysmetria, and decreased level of consciousness.
Pure motor stroke/hemiparesis Location of Infarct and presentation
posterior limb of the internal capsule, basis pontis, corona radiata
hemiparesis or hemiplegia that typically affects the face, arm, or leg of the contralateral side
Ataxic hemiparesis
Location of Infarct and presentation
posterior limb of the internal capsule, basis pontis, and corona radiata, red nucleus, lentiform nucleus, SCA infarcts, ACA infarcts
weakness and clumsiness, on the ipsilateral[1] side of the body. It usually affects the leg more than it does the arm;
Dysarthria/clumsy hand
Location of Infarct and presentation
basis pontis, anterior limb or genu of internal capsule, corona radiata, basal ganglia, thalamus, cerebral peduncle
dysarthria and clumsiness (i.e., weakness) of the hand, which often are most prominent when the patient is writing.
