CDEM Cases Flashcards
1
Q
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 _________?
A
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.
2
Q
Type of Access need in the context of AAAs, Blood products?
Ideal study for detection of AAAs
Other imaging?
A
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.
3
Q
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?
A
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
4
Q
Intial elvation, Peak Elevation, and Return to Baseline of?
Myoglobin?
CK-MB?
Troponin I
A
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
5
Q
Reason to get certain test in the context of ACS?
CBC CXR CMP Echocardiogram Stress testing
A
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).
6
Q
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?
A
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.
7
Q
Steps of the “A” in the primary survey
At what GCS would require intubation
A
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
8
Q
What are the steps of the evalutions of “B” in the primary survey
Inspect?
Ausculate?
Percuss?
A
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).
9
Q
In the context of Tension Pneumo, where should the the angiocath be inserted
A
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
10
Q
Definition of Classesof Shock; HR, BP, Findings, Blood losss, Treatment
I?
II?
III?
IV?
A
Class I: Normal- fast HR, Normal BP, 40% Blood Loss, Treat with Normal Saline + Blood Products
11
Q
What is the typical significance of blown pupil
A
Loss of the parasympathetic outflow from the occulomotor nerve, often due to uncal herniation
12
Q
GCS Coma Scale
Eyes?
Verbal?
Motor?
A
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
13
Q
Treatment of pulmonary contusion
blunt cardiac injury?
How do traumatic aortic disruption get dx, if at all
A
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.
14
Q
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?
A
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.
15
Q
Test to consider in the in the Trauma survey Imaging?
A
Type and Screen CBC ABG and Lactate BMP or CMP UA EtoH EkG CXR with c-spin flims Fast Scan Retrograde urethrogram
16
Q
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
A
Prior Antipyretic use
BP = 80 + (2 × age in years)
Furosemide 20-80mg iv
Amiodarone 150mg-300mg IV
17
Q
Voltage to used in the event of cardioversion
Defibrillation?
A
100-200J Biphasic
200 J (biphasic )
18
Q
ECG finding in the event of PE. Axis, HR, Lead V1?, Lead II, P wave morphology? The classic finding?
A
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
19
Q
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.
A
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
20
Q
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
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.
21
Q
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
A
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.
22
Q
Contraindictions of MTX Tx.
Expected course after therapy initiation. Pain?
A
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.
23
Q
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?
A
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
24
Q
What is the combined sensitivity of CRP and WBC in dx of acute appendicitis
Abx to used in Appendicitis Uncomplicated vs Complicated
A
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
25
Important disease to rule/out in the context of appy, in males (GU)
Stones and Torsion
26
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).
27
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.
28
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.
29
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.
30
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
31
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).
32
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.
33
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.
34
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
35
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.
36
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
37
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)
38
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.
39
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.
40
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.
41
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.
42
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.
43
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
44
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
```
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
```
46
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
47
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.
48
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.
49
What is the median survival in patient with a recent diagnosis of CHF
Most patients succumb to their illness within five years
50
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 (
51
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
52
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 (
53
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
54
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.
55
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.
56
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
57
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.
58
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.
59
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
60
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.
61
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.
62
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%
63
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.
64
Treatment for HAP, what if MRSA is suspected
Zosyn Plus: Imipenem, Meropenem, Cefepime, Ceftazidime
Anti-MRSA agent: Vancomycin, Linezolid
65
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
66
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
67
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
68
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.
69
THe "Ds" of Vertbrobasilar Syndromes
D”: diplopia, dysarthria, dysphagia, droopy face, dysequilibrium, dysmetria, and decreased level of consciousness.
70
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
71
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;
72
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.
73
Pure sensory stroke
Location of Infarct and presentation
contralateral thalamus (VPL), internal capsule, corona radiata, midbrain
Marked by persistent or transient numbness, tingling, pain, burning, or another unpleasant sensation on one side of the body.
74
Mixed sensorimotor stroke
Location of Infarct and presentation
thalamus and adjacent posterior internal capsule, lateral pons
This lacunar syndrome involves hemiparesis or hemiplegia with contralateral sensory impairment
75
Want is the most common CT finding in the context of a stroke
Findings on St that may indicate the presence of stroke on CT (3)
normal brain; radiologic changes associated with stroke are usually not visible on CT for several hours
CT is hyperdensity representing acute thrombus or embolus in a major intracranial vessel; subtle hypoattentuation causing obscuration of the nuclei in the basal ganglia and loss of gray/white differentiation in the cortex
76
Reason the need of EKG in the context of Stroke
Other test that may be need in the context of stroke. Heme? CV?
What are some supportative measure that cane be started in the event that a patient does not meant criteria for a rTPA? Resp? Vitals? Lytes?
What drug can be given to patient's no getting rTPA, that will decrease recurrent stroke. When can it be given?
Need exclude contemporaneous acute MI or atrial fibrillation as these conditions are frequently associated with thromboembolic stroke.
CBC, chemistries, PT/INR, aPTT, and cardiac markers are recommended to assess for serious comorbid conditions and aid in selection of therapy.
Ventilatory support and oxygenation, prevention of hyperthermia, cardiac monitoring and treatment, and control of blood pressure and blood glucose
77
What drug can be given to patient's no getting rTPA, that will decrease recurrent stroke. When can it be given?
What if the person has had TPA?
Aspirin within 48 hours after stroke has been shown to improve outcomes by reducing the rate of early recurrent stroke. In stroke patients not receiving rtPA, oral administration of aspirin within 24 – 48 hours of stroke onset is recommended.
aspirin should not be administered for at least 24 hours after administration of rtPA.
78
What is the Exclusion Criteria for TPA therapy Trauma? Bleeding? Masses? Surgery? BP? PLT? Heparin or other Anticoaugulation? Glucose? Ct Findings?
Significant head trauma or prior stroke in previous 3 months
Symptoms suggest subarachnoid hemorrhage
Arterial puncture at noncompressible site in previous 7 days
History of previous intracranial hemorrhage
Intracranial neoplasm, arteriovenous malformation, or aneurysm
Recent intracranial or intraspinal surgery
Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)
Active internal bleeding
Acute bleeding diathesis, including but not limited to
Platelet count 1.7 or PT >15 seconds
Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated laboratory tests
Blood glucose concentration 1/3 cerebral hemisphere)
79
Utility of NGT aspiration in the dx and treatment of GI bleeding.
What patient are at the most risk of ischemia in the context of low Hbgs
It help localize the source (upper versus lower) and assess the rate of bleeding.
elderly patient
80
Criteria for the correction of low hbg
GI? Amount of Blood loss? Hbg Changes? Hbg levels? Organ Function
Massive upper or lower GI bleed (e.g., passing 1000 mL maroon-colored thin liquid stools every 20-30 minutes or NGT putting out a steady stream of bright red blood with continuous suction)
Hemoglobin dropping >3 g/dL over 2-4 hours in the setting of active bleeding
Hemoglobin below 9 g/dL in the setting of active bleeding
Anemia induced end-organ injury (e.g., myocardial ischemia)
81
What is the most rapid means of correcting hight PT. Supplement that can be used to correct the PT
Patient that may benefit from platlet infusion that have normal PLT levels.
A BUN/Cr ratio greater than or equal to 36 is suggestive of what? What must also be considered.
FFP; Vitamin K
patients with severe GIB and presumed platelet dysfunction from aspirin or clopidogrel use.
UGIB but volume depletion or renal insufficiency must also be considered.
82
What type of medications must be administrated to the patient with Esophageal Varicies with bleeding? Prophalaxis vs Bleeding control
How about in the prophalaxis in the case of Petic Ulcer Disease.
Why do patient with GI bleeding need and EKG? Who is the most at risk of negative cardiac sequalae
prophylactic antibiotics– typically a floroquinolone such as ciprofloxacin - if the patient is going to get and EGD and Octreotide
Medical therapy for a bleeding ulcer involves high-dose IV infusion of a proton-pump inhibitor
ECG
To evaluate for myocardial ischemia. It is especially critical in any patient over the age of 50 who has a history of heart disease, chest pain, trouble breathing, or manifestations of shock
83
First three things that should be done in the context of a suicide attempt arriving in the Emergency dept.
1) Assess the primary survey
2) Order an EKG
3) Order a safety companion or standard suicide precautions
84
1What are the parts of the coma cocktail and are they attempting to correct?
What should be done in the event that the above does not reverse the patient symptoms?
Hypoxia: Place on 100% O2 nonrebreather (also useful prior to intubation)
Hypoglycemia: obtain a point of care fingerstick blood glucose
Opioids: administer Narcan 0.4 to 2mg IV to reverse opiates
With an unresponsive patient, if these measures do not reverse the patient’s symptoms, then intubation should be performed.
85
Thing that must be made available in the event of needed intubation. Oxygenation?
Utility of Atropine in Intubtions Lidocaine?
The patient should be pre-oxygenated as early as possible by placing a non-rebreather mask with 15 L/min of oxygen flowing
high flow nasal oxygen during pre-oxygenation
Atropine given to infants to blunt vagal stimulation
Lidocaine given to a patient with an intracranial hemorrhage to blunt a further increase in intracranial pressure?
86
Intubation Sedatives
Dosage Onset and Duration, and major side effect of Propofol.
1.5 mg/kg, 30 sec onset, last 5-10 min. can lead to hypotension
87
Intubation Sedatives
Dosage Onset and Duration, and major advantage of Etomidate
1-2 mg/kg Onset: 10-15 sec Lasts: 5-10 min Minimal change to blood pressure
88
Intubation Sedatives
Dosage Onset and Duration, and major side effects of Ketamine
Onset: 45-60 sec Lasts: 10-20 min Raises blood pressure, brochodilation, increases secretions
89
Intubation paralytics
Dosage Onset and Duration, and major side effects of Succinylcholine
Onset: 45 sec Lasts: 5-10 min Causes hyperkalemia, fasiculations
90
Intubation paralytics
Dosage Onset and Duration, and major side advantage of Rocuronium
1 mg/kg Onset: 60-75 sec Lasts: 40-60 min Lasts much longer, so have a plan should intubation fail
91
How can proper placement of of the endotrachal tube be confirmed.? CO2? PE? Imaging?
end tidal CO2 detection (color change or waveform capnography), auscultation of bilateral breath sounds on insufflations with the bag-valve mask, and chest x-ray confirmation of correct tracheal ETT positioning
92
Factor that predicthich patients may be difficult to ventilate with BVM. MOANS?
Rate that breaths should be delivered through the BVMS
```
Mask Seal (trauma, blood, beards)
Obesity
Age (>55)
No teeth (leave dentures in)
Stiff (lungs, neck)
```
Starting respiratory rate should be 10-12 breaths/minute, which can be accomplished by the provider counting 5 to 6 seconds between each delivered breath.
93
Side Effects of NPPV? Skin? Emesis? ITPressure? Increased Lung Volumes?
ncreased intrathoracic pressure, decreased venous return, leading to decreased blood pressure.
skin breakdown may occur when associated with long-term use
contraindicated in an actively vomiting patient, and carries the risk of aspiration
barotrauma and air trapping
94
Treatment VT/Pulseless Torsades/VF
| CPR? Drugs Doses? Drugs Specific for TdP?
CPR
Early defibrillation
Antiarrythmitcs
Epinephrine 1mg 1:10,000 dilution, IV push every 3-5 minutes
Amiodarone: 1st dose 300mg IV bolus. 2nd dose 150mg IV bolus
Magnesium (for torsades de pointes): 1-2grams IV diluted in 10mL normal saline over 30-60 seconds
95
Treatment PEA/Asystole
Drugs? Causes?
High quality CPR
Epinephrine 1mg IV every 3-5 minutes
Search for and treat underlying reversible causes
96
What is the ratio for change in glucose for change in serum NA
In hyperglycemia, for each 100 mg/dL of glucose above the normal range then laboratory reported sodium decreases by 1.6 mmol/L
97
Typical cause of hypovolemic hyponatremia
Tests?
Renal causes of true hyponatremia
Typically due to GI tract (with renal conpensation) or renal losses of Na containing fluids. Less commonly due to third spacing (pancreatitis) or skin losses (burns)
Urine Sodium
Low (20 mEq/L)— renal loss of sodium ( diuretic excess, decreased aldosterone (ACE inhibitors), ATN)
98
Euvolemic Hyponatremia? Endocrine? Psych? Surgery? Iatrogenic? Drugs?
Test?
SIADH, Psychogenic polydipsia, Postoperative hyponatremia, Hypothyroidism, Oxytocin use, Administration/intake of a relative excess of free water
haloperidol (Haldol), cyclophosphamide, certain antineoplastic agents
Urine not maximally dilute, i.e. Uosm >100mOsm/kg H2O
BUN
99
Causes of Hypovolemic hypernatremia
stores are depleted, but more water loss
than sodium loss
Renal loss—from diuretics, osmotic diuresis (most commonly due to glycosuria
in diabetics)
Extrarenal loss—from diarrhea, diaphoresis, respiratory losses
100
Isovolemic hypernatremia causes General? Specific?
Isovolemic hypernatremia (sodium stores normal, water lost)
• Diabetes insipidus
• Insensible respiratory (tachypnea
101
Hypervolemic hypernatremia causes General? Specific? Endocrine?
Sodium excess
Iatrogenic—most common cause of hypervolemic hypernatremia (e.g., large
amounts of parenteral NaHCO3, TPN)
• Exogenous glucocorticoids
• Cushing syndrome
102
Intrepertation of Urine Chloride in the context of Hypochloremia
Low (20mmol/L) – Chloride resistant indicate mineralocorticoid excess
103
Drugs that can causes a false increase in the Cr.
Salicylates, H2-blockers, fibrates,
104
Causes of Hypermagnesemia Renal? Endocrine? Drugs?
When do patient become symptomatic
Excess intake in patient with CKD, Addison’s, hypothyroidism, Li intoxication
Not symptomatic until 4-6mg/dL
105
Hypomagnesemia? GI? Renal? Intracellaur? Test?
Reduced intestinal absorption – malnutrition/malabsorption, chronic diarrhea
Increased urinary losses – renal tubular disorders, ketoacidosis
Intracellular shifts – hypokalemia, hypocalcemia
Obtain Spot urinefractional excretion of Mg2+: >2% suggests renal losses
106
Conditions in which Tropinin can be elevated
Myocarditis, cardiac surgery, angina, unstable angina, congestive heart failure, renal failure, pulmonary embolism
107
"Benign" causes of ST elevations. Features
Ventricular Paced Rhythm - can look like LBBB with wide QRS
Benign Early Repolarization -Benign early repolarization usually represents a normal variant most often seen in young, healthy patients. "notching of the j-wave in lead 4
Left Ventricular Hypertrophy (LVH) ST elevations as LBBB with ST elevations present in leads with deep S waves(V1-3) and ST depressions or T wave inversions present in leads with tall R waves(I, AVL, V5-6).
108
What is a wellen's sign and what is its importance in Dxing MI
Wellen’s syndrome is a pattern of deeply inverted or biphasic T-waves in V2-V3. Although this is not a true STEMI, this pattern is highly suggestive of critical stenosis of the LAD. It is important to recognize this finding as these individuals are at increased risk for a large anterior wall MI in the next few days or weeks.
109
Findings on the EKG associated with hypokalemia. P waves, T waves, other findings. Evolution of the EKG in the finding is not corrected?
increased amplitude and width of P wave, T wave flattening and inversion, prominent U waves and apparent long QT intervals due to merging of the T and U wave.
110
Finding on the EKG associated with Hypercalcemia? QRS? findings in severe hypercalemia?
QT interval. In severe cases Osborn or J waves might be seen or ventricular fibrillation might ensue.
111
Indication for abx therapy in the context of a drained abscess. Nature of the Abscess? Skin Findings? Other illnesses. Immunostatus? Age? time after inital drainage
Severe or extensive disease (i.e.: abscesses in multiple sites, recurrences)
Rapid disease progression with cellulitis
Associated systemic illness (i.e.: fever)
Immunosuppression or complicating co-existing conditions
Extremes of age
Abscess in area that is difficult to drain (i.e.: genitalia, face)
Septic phlebitis
Lack of response to I&D alone
112
Abx therapy for abscess, Coverage?
Coverage should be directed at MRSA with antibiotics such as oral trimethroprim-sulfamethoxazole, doxycycline or clindamycin.
113
What consideration must be made for the eldery with opiate thx. GI, Psych
Safe starting dose for morphine and how much can it be uptitrated in the event of inadequate patient control.
reater risk of developing constipation, sedation, and confusion when treated with opioids, and it is reasonable to adjust doses to account for age-related changes in pharmacokinetics.
0.1 mg/kg (7mg in the 70kg M), morphine can be safely titrated using doses of 0.025-0.05 mg/kg (3-4mg in 70kg M) every 5-15 minutes following the initial bolus.
114
Dosing for Hydromorphone IV. Benefit compared to morphine, risk?
Titration?
0.015 mg/kg (1 mg in a 70kg male). It is reported to cause less nausea, vomiting, and pruritus than morphine, however it is often associated with a greater risk of respiratory depression.
can titrate up to half a gram per 15 mins
115
Advantages of Fentanyl. Speed? Half life?
Dosing? Titration
It has the advantage of acting rapidly (within 1-2 minutes) and having a shorter half-life, allowing for serial reexaminations (e.g., of the head-injured patient).
initial dose of 1-1.5 μg/kg. (70mcg SKM)
Fentanyl can be safely repeated every 15 minutes at doses of 0.25-0.5 μg/kg (17 mcg) .
116
When are PO opiates useful (pain-level)
Dosing for oxy and hydrocodone. Timing
less severe pain
They are both given as 0.05-0.15 mg/kg (4mg -10mg) of the opioid component, and can be repeated every 4-6 hours.
117
Acetaminophen dosing, Max dose in a 6h, in a day?
10-15 mg/kg PO/IV (70 -100mg SKM)
| dont give more than a 1000mg per hour, or 75 mg/kg/day (5250 mg SKM)
118
Ibuprofen dosing, max dose in 6 hours. Patient to avoid giving..
5-10 mg/kg PO (350 mg - 600 mg SKM)
Dont give more than 600 mg in 6 hrs.
Avoid in elderly, renal disease
119
Ketorolac dosing, max dose in 6 hours.
0.5 mg/kg IV/IM (3.5 mg SKM),
no more than 15 mg IV/30 mg IM in 6 hours.
120
Why can Hyperkalemia be associated with thrombocytosis?
Leukocytosis?
Potassium moves out of platelets after clotting has occurred. Thus, the serum potassium concentration normally exceeds the true value in plasma by 0.1 to 0.5 meq/L
121
Types of arrhythmias seen with hyperkalemia?
Other Symptoms? GI, MS?
2nd or 3rd degree heart block, wide complex tachycardias, and progression to ventricular fibrillation and asystole.
nausea, vomiting, and diarrhea,
muscle cramps, generalized weakness, paresthesias, tetany, and focal or global paralysis.
122
In what population of patient should Ca gluconate be avoid in for the treatment of Hyperkalemia
Use caution when administering calcium salts in patients with digoxin toxicity.
123
Some characteristic findings with elevated potassium levels include:
K 6.5-7.5?
K 7.5-8.0 ?
K 10-12?
Peaked T waves
Widening of QRS, decreased amplitude of P waves
Sine wave, ventricular fibrillation, asystole
124
Conditions the increases the risk of hypoglycemia
```
Adrenal insufficiency
Alcohol abuse (chronic)
Diabetics (predisposing factors – use of long acting insulin, oral hypoglycemic agents)
Insulinoma
Liver disease
Sepsis
```
125
Criteria for discharge of a patient with hypoglycemia, timing of episode? Neuro? GI? PMH? Underlying cause? PCP? Patient characteristics?
Brief episode
Full neurologic recovery
Able to eat
No major co-morbid conditions that require hospital admission
Cause of the episode identified and addressed
Treatment plan to prevent future episodes understood by the patient
Hypoglycemia accidental
Relapse unlikely (no long-acting insulin or oral agents, nor prolonged excretion or metabolism)
Ability to do home glucose monitoring
Responsible person able to be with the patient
Follow-up arranged
126
Admission Criteria for patient with hyperglycemia, Cause? Neuro? Glu Levels?
Cause of hypoglycemia due to long acting insulin or oral agents (the Sulfonylurea class of diabetic medications are well known to produce hypoglycemic states)
No obvious cause
Persistent neurologic deficits
Persistent or recurrent hypoglycemic episodes in the ED
127
Medications that are associated to thyrotoxicosis. Tx for CV, Psych, Immuno, Endocrin? Imaging, Increased comsumption?
Amiodarone - odine induced, contains 37% iodine by weight
Lithium - Painless thyroiditis.
Interferon α - Painless thyroiditis, Graves disease
Interleukin-2 - Painless thyroiditis, Graves disease
Iodinated contrast - Induction of thyroid autonomy
Radioactive iodine - Thyroid destruction (Early in therapy), Graves disease (Late in therapy)
Increased iodine intake - Iodine induced. (Jod-Basedow phenomenon)
128
Triggers for Thyroid Storm? ID? CV? Endocrine? Neuro? Iatrogenic? GU? Trauma? Meds?
```
Infection
Discontinuing medications for hyperthyroidism
Myocardial infarction
Stroke
Thyroid surgery
Self-administration of thyroxine or thyroid supplements
Treatment with radioactive iodine
Pregnancy
Diabetic ketoacidosis
Non-thyroid surgery
Trauma
Iodinated contrast exposure
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129
Initial labs in the context of diagnosis of thyroid storm?
If the patient has a suspected TS, when should treatment begin in the context of lab test?
```
Thyroid stimulating hormone (TSH) level.
Free thyroxine (T4) level.
Free triiodothyroxine (T3) level.
```
130
Steps in treating thyroid storm: Stop hormone production? Medications
Propylthiouracil - Inhibits T4 & T3 production by inhibiting iodination of thyroglobulin. Blocks T4 to T3 conversion by peripheral tissues.
Methimazole - Blocks new hormone synthesis.
131
Steps in treating thyroid storm: Inhibit hormone release? Medications? x4
Potassium Iodide - Blocks release of hormone from thyroid.
Lugol’s Solution - Blocks release of hormone from thyroid.
Sodium ipodate - Blocks release of hormone from thyroid. Inhibits T4 to T3 conversion.
Iopanoic acid - Blocks release of hormone from thyroid. Inhibits T4 to T3 conversion.
132
Steps in treating thyroid storm: Inhibit peripheral effects of thyroid hormone? Medications? x2
Propranolol - Reduces symptoms due to increased adrenergic tone. Inhibits T4 to T3 conversion.
Esmolol - Reduces symptoms due to increased adrenergic tone. May be preferred in setting of possible heart failure due to short half-life.
133
Steps in treating thyroid storm: Glucocorticoids.? Medications? x2
Dexamethasone (Preferred) or hydrocortisone
- Inhibit the peripheral conversion of T4 to T3. Promote vascular stability. Treat possible relative adrenal insufficiency.
134
Definition of Heat stroke Temp? Other findings
Classic setting? and Patient Populations?
Classic Neuro and Psych findings?
Drugs that make Heat stroke for likely
is defined as hyperthermia usually greater than 40 C associated with severe CNS dysfunction and anhidrosis
during environmental heat waves ; Very young, the elderly, and the chronically and mentally ill.
Irritability, delusions, hallucinations, seizures or coma.
Diuretics, antihypertensives, anticholinergics, and neuroleptics
135
Demo of exertional heatstroke
Symptoms? Neuro? GI? MS?
oung healthy individuals who are unable to dispel heat due to endogenous heat production. Athletes and military recruits are typically affected and EHS is the third leading cause of death for high school athletes.
Abdominal cramping, nausea, vomiting, myalgias, diarrhea, headache, dizziness, dyspnea, weakness, or syncope typically precede exertional heatstroke.
136
Dangerous sequale of exertional heatstroke? Renal? MS? Heme? Lytes?
atients with EHS are much more likely to experience rhadomyolysis, acute renal failure, coagulopathy, lactic acidosis, and hypoglycemia than patients with classic heatstrokes.
137
Physical findings and Features of Heat stroke? MS? Fluid Shifts? Neuro? Derm? Others
Heat Cramps - intermittent, severe cramps in muscles fatigued by excessive exercise salt deficiency and usually occur in the first days of excessive work in a hot, humid environment.
Heat Edema - edema of the feet and ankles in unacclimatized individuals exposed to warm tropical or subtropical climates
Heat Syncope - loss of consciousness caused by intravascular shunting to the cutaneous circulation, pooling in the lower extremities due to prolonged standing, and volume depletion. Effects the eldery
Prikcly Heat - acute inflammatory skin condition caused by blockage of the sweat glands and a secondary staph infection; pruritic vesicles in the clothed areas that extend producing deeper vesicles
Heat Exhaustion - ague malaise, fatigue, nausea, vomiting, weakness and headache in the setting of heat stress. salt depleted from rehydration with hypotonic solutions
138
Intial Action and Primary survey with ?heatstroke?
- fasting blood sugar in all patients with altered mental status
- obtain rectal temperature
- rapid cooling simultaneously with any basic resuscitative measures
139
Diagnostic testing in the context of heat stroke
CMP: Evidence of Hypernatermia, Hypokalemia (early), hyperkalemia (late), LFT can be very high. BUN/Cr
UA: R/o Rhabdo
Chest X-ray:
CT: r/o other causes o
EKG: Sinus tachycardia with nonspecific ST-T wave changes.
140
Treatment for Heatstroke Access? Vitals? Primary Treatment?
Two large bore IV’s should be established for resuscitation and the patient should be placed on continuous cardiac monitoring and pulse oximetry
A thermistor probe should be placed in the rectum or esophagus to continuously monitor core temperature
Immediate cooling is the cornerstone of management of heat related illness. Rapid reduction of the core body temperature should be instituted immediately upon clinical suspicion of the diagnosis
141
Methods of Cooling. Evaporative? External (Non-invasive) Conduction? Internal (Invasive) Conduction Techniques? Medications? Use of Antipyretics
Wetting body surface with continuous fanning
Tap water immersion, Ice water immersion, Application of cold packs, Cooling blanket
Gastric, peritoneal or bladder lavage, Cold IV fluids
Dantrolene
Antipyretics should never be given to patients with heat related illness since they have no efficacy in reducing the temperature and may exacerbate the hepatic, renal and coagulopathic abnormalities associated with heatstroke.
142
Treatment of Heatstroke?
Shivering? Seizures?
Low BP?
Rhabdo?
Shivering leads to increased heat production and should be controlled with benzodiazepines. They are also the drug of choice for controlling seizures since phenytoin is not effective in this setting. Barbiturates are the second line of therapy.
Fluid resuscitation should be the initial treatment titrated to volume status and hemodynamic parameters. Heatstroke mimics sepsis as it is a distrubutive shock.
Treatment includes infusion of large amount of IV fluids and alkalinization of the urine with intravenous bicarbonate infusion to prevent myoglobin precipitation in the renal tubules. Hemodialysis may be necessary for patients with acute renal failure.
143
Changes is vitals signs in
| Mild, Moderate, and Severe Hypothermia
Mild - Tachypnea
Tachycardia without hemodynamic instability
Moderate (28-32C) - Bradycardia and Bradypnea
Severe - Bradycardial, Hypotension, Pulselessness
and Bradypnea/apnea
144
MS Changes in
| Mild, Moderate, and Severe Hypothermia
Mild - Shivering
Moderate - Cessation of shivering
Severe (
145
Respiratory Changes in lung parenchyma in Severe Hypothermia
Pulmonary edema
146
Neuro Changes in
| Mild, Moderate, and Severe Hypothermia. Mnenomic
Mild - Dysarthria, ataxia, amnesia, altered judgment, apathy, fine and gross motor impairment: “Mumbles, grumbles, stumbles, fumbles, tumbles”
```
Moderate
- Paradoxical undressing,
Decreased responsiveness,
Hyporeflexia,
Dilated and sluggish pupils,
Dysarthria
ataxia
```
Severe - Coma/unresponsiveness
Areflexia
Fixed pupils
147
Renal changes in
| Mild and Severe Hypothermia.
Mild - Polyuria
Severe - Oliguria
148
Initial Actions and Primary Survey in a hypothermia. Airway? Breathing? Circulation? Exposure? Secondary survey
Minimize jerky movement to prevent Vfib
Stabilize airway: endotracheal intubation if needed for airway protection in the unresponsive patient
Stabilize breathing: administer warm humidified O2, endotracheal intubation for respiratory failure
Stabilize circulation: monitor, ECG, intravenous access, warm IV fluids
Remove cold wet clothing, dry patient, cover with warm dry coverings or warming blanket (bear hugger). Initiate active rewarming measures.
Look for signs of accompanying cold injury, trauma, or underlying illness (secondary hypothermia)
149
Lab findings in hypothermia. CBC?, Lytes, INR?
EKG finding that may be present? QRS? PR? QT? Rhythm
Laboratory testing may reveal hemoconcentration, hypo/hyperkalemia, hypo/hyperglycemia, or abnormal coagulation.
```
J (Osborne) waves in moderate-severe cases
prolonged intervals (PR, QRS, QT)
arrhythmias (atrial or ventricular)
```
150
Rewarming in Mild Hypothermia (fluids?)
Moderate? (fluids?)
Severe? Fluids, O2, CV, Renal?
Treatment of most arrhythmia 2/2 to hypothermia
Blankets (remove cold wet clothes first) Oral hydration with sugared drinks
Electric or forced warm air blankets + often add noninvasive internal: warm intravenous fluids, warm humidified oxygen
warm intravenous fluids, warm humidified oxygen, central arteriovenous or venovenous rewarming, cardiopulmonary bypass dialysis
Provide supportive therapy, not anti-arrhythmics
151
Treatment of most Vfib 2/2 to hypothermia. Temp Consideration? Medications?
Perform CPR and defibrillation per ACLS protocols, except that antiarrhythmics and repeat defibrillation should be deferred until the patient is warmed to above 30oC. Administer bretylium if available
152
What is the defination of Afterdrop?
Rewarming shock?
A patient’s temperature may decrease during rewarming (called afterdrop) as peripheral vessels dilate and increase return of cool blood from extremities to the core.
Rewarming shock (hypotension) may occur as rewarming causes vasodilatation
153
Treatment of Frostbite. Clothing? Consults? Surgery? Medications? Pain? Positioning of the Patient.
Immediately immerse the affected area in warm water (37-39oC). Remove constricting clothing and jewelry.
Surgical Consult for Debridement. amputation is usually delayed until the gangrenous tissue has clearly demarcated, a process often taking months.
ibuprofen as an anti-inflammatory agent, tetanus toxoid, elevation of the affected area, and narcotic analgesia
154
Characteristic of Coral Snake Venom. Neuro Signs? MS? REsP?
the first sign is ptosis followed by progressive neuromuscular weakness.
The patient may develop slurred speech, fasiculations, drowsiness, weakness, and trouble breathing. The cause of death in these cases is usually progressive paralysis of the respiratory muscles.
155
Characteristic of Pit vipers Venom. MS/CT? Neuro? Heme? Derm?
CV Changes?
Initially have localized edema and pain, which usually spreads proximally and involves the entire extremity
nausea, weakness, muscle fasiculations, changes in taste sensation (metallic), and sensory changes, involving the mouth, fingers, and toes
Viper bites disrupt the coagulation cascade and alter vascular permeability. This may ultimately lead to pulmonary edema and refractory shock
156
Characteristic of Black Widow Venom. Neuro, MS?
brown recluse spider (Loxosceles spp.)? Derm? Neuro? Heme
pain (local, radiating, regional) that increases over the course of an hour and may radiate proximally along the affected limb to the trunk. Muscle spasm may occur as well.
necrotic ulcerations. Local pain and burning are common. Rare hemolysis, disseminated intravascular coagulation and renal failure.
157
Actions to be performed on envenomated limb, things not to do? Exposure?
The affected extremity should be immobilized and slightly compressed, to prevent the spread of venom. A tourniquet is not indicated
ice water immersion, suction, and incision of the wound are also contraindicated
Constrictive clothing, jewelry, and accessories should be removed.
158
Intial labs in the context of a Snake Bite and Spider bites.
Indications for Antivenom, Derm? Heme? Type of Bite
Treatment Spider Bite induced Muscle spasms with...
A complete blood count, chemistry, coagulation profile (including fibrinogen, PT, aPTT) and CPK
Antivenom indications include increased swelling and erythema beyond the local bite wound and any disruption of the coagulation cascade. If a coral snake bite is suspected
benzodiazepines
159
Mechanism of Centruroides exilicauda venom toxicity. Neurotransmitters involved?
The Neurotoxin increases Sodium channel permeability resulting in sodium channel activation and cell membrane depolarization.
This results in over-stimulation of sympathetic and parasympathetic nervous systems, causing excessive acetylcholine and catecholamine release.
160
Length of symptoms associated with, Centruroides exilicauda venom toxicity.
Neuro Symptoms? Eyes, Mouths, MS?
Chlonergic symptoms? Management
symptoms may begin immediately, progress, and peak to maximum severity within several hours, and may persist for one to two days
Numbness, tingling, anxiety, nausea/vomiting, and blurred vision
hypersalivation, abnormal roving eye movements (chaotic multidirectional conjugate saccades), fasciculations, and clonus.
Hyperthermia, hypertension, tachycardia and excessive respiratory secretions. . Atropine has been reported to be helpful in managing these symptoms
161
Difference between Centruroides exilicauda venom toxicity. and black widow toxicity
When should the
Antivenom be used?
unlike black widow spider bites, scorpion stings often cause intense local pain at the site of envenomation.
hen there is severe somatic or cranial nerve dysfunction not controlled by supportive measures
162
Zones of Injury Associated with burns? x3
Zone of Coagulation - cell death is complete. This is usually nearest to the energy source and forms the eschar of the burn wound
Zone of Stasis - cells are viable but circulation is impaired. If the injury continues, then increased damage and tissue ischemia may result.
Zone of Hyperemia - there is minimal cellular injury but there is increased blood flow due to vasodilatation. This tissue usually recovers without intervention
163
Features of Temperature related Inhalation injures. mouth findings?. timeframe?
Edema, erythema, and ulcerations of lips, tongue, posterior oropharynx, and upper airway.
Onset may be delayed for up to 24hrs & resolve in 4-5
164
Features of Smoke related Inhalation injures. Target? Pathophysiology of dysfunction
Smoke tends to affect the lower airways more than the upper airways
Injury occurs when particles & soot settle in the medium and distal airways, direct thermal injury occurs when hot particles contact alveolar membranes ands maller airways are at increased risk of occlusion due to debris accumulation.
Leads to reduced mucociliary function
165
Features of Gas related Inhalation injures. Gas products.
CO, Co2, vinyls, burning plastics, ammonia, No2, cyanide etc
CO inhalation can range from a slight headache or confusion to chest pain, stroke, or seizure, coma, & death.
166
Care for minor burns. Cleaning?
Dressing face burns?
running warm water over the area until the skin temperature has normalized, washing the burned area thoroughly with soap & water before careful drying of area.
apply topical ointment and sterile dressing. Generally, Bacitracin is used for burns on the face
167
Reason for fluid imbalance in severe burns? Cell wise? Metabolic
Idea fluid for resuscitation of burn victims
increased microvascular permeability that leads to extracellular edema and cell membrane defects that contribute to intracellular swelling
burn patients have increased metabolic and respiratory rates that lead to increased evaporation and other insensible losses and often become hypoproteinemic leading to decreased intravascular oncotic pressures.
Lactated Ringers
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Parkland Formula?
Schedule for the hydration
Parkland formula: %TBSA burn x wt in kg x 4cc/kg = volume of LR that should be administered over the first 24 hours + maintainence fluids
Half should be given in the 8 hours following the burn and the remaining half should be given over next 16 hrs (24hrs total
169
Steps of infection control in burn victims. Dead Skin? Wound care? Preventative measures
cut away dead, necrotic tissue and exposure underlying viable tissue
Cover affected areas with antibiotic dressings and through early wound closure with skin grafting and/or commercial products.
universal precautions, Contact isolation with gown, gloves, and mask; changing of central lines
170
Behavior of the larynx in drowning process
Heart rhythms seen in drowning,
Laryngospasm can occur, but usually is overcome by brain hypoxia, thus Water aspiration
tachycadia -> brady -> PEA .-> asystole.
171
Diagnostic testing in drowning?
Vital signs and most importantly SpO2
ABG should be obtained in mechanically ventilated patients.
Core temperature
CXr as baseline, Cardiac monitoring and/or EKG should also be obtained.
172
Treatment in Drowning:
Correcting o2 sat?
When should the patient be wean of the ventilator
Supplemental oxygen with mild symptoms, . Patients with persistent hypoxia may require a trial of CPAP or intubation.
weaning should not occur for at least 24 hours as local pulmonary injury is unlikely to resolve in shorter timeframes.
173
Infection risk in drowning? where does it typically occur.
This typically appears after 3-4 days, once pulmonary edema resolves. CNS infections have also been reported.
174
Hunt and Hess Grading System for SAH
1) Asymptomatic, mild headache, slight nuchal rigidity
2) Moderate to severe headache, nuchal rigidity , no neurologic deficit other than cranial nerve palsy
3) Drowsiness / confusion, mild focal neurologic deficit
4) Stupor, moderate-severe hemiparesis
5) Coma, decerebrate posturing
175
Risk factor for SAH.
| Activity, CV lifestyle, medications, Genetics.?
Recent exertion, hypertension, excessive alcohol consumption, sympathomimetic use, and cigarette smoking are risk factors.
176
Canadian Head CT rules: indication of a High Risk for neurosurgical intervention. Neuro, Skull Changes, GI, Age?
GCS score
177
Canadian Head CT rules: indication of a Medium Risk for neurosurgical intervention. Neuro? Mechinism?
Exceptions of the Canadian Head CT Rules. Neuro, Ages, Medications, PE?
Amnesia before impact > 30 min
Dangerous mechanism ** (pedestrian,occupant ejected, fall from elevation)
Non-trauma cases, GCS
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Glucose levels that ideal in the context of head bleed
Ways the ICP can be control in the ED. BP? Bed? pain medications? Drugs and Resp?
Control blood glucose (target 140-185 mg/dL)
Monitoring/lowering blood pressure in consultation with neurosurgery
Elevating the head of the bead to 30 degrees
Providing adequate sedation and analgesia
If signs of rapidly rising ICP or herniation, considering mannitol or mild hyperventilation (target CO2 around 30 mmHg)
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First line agent for the control of an active seizure
Second?
Third?
First line: benzodiazepines (usually lorazepam)
Second line: fosphenytoin/phenobarbital/valproic acid
Third line: versed/pentobarbital/propofol infusions
180
If a patient with cardiac contusion has a reduced EF on ECHO, what is the next diagnostic
In Cases of aortic injury that is not immediately fatal, what is the imaging studies that can used to evaluate the condition
dobutamine stress test
Diagnosis is suggested is the mediastinum is widened on a CXR. A CTA (spiral CT) is diagnostic. Angiography is considered the gold standard and only performed if the spiral CT is unequivocal.
181
In the situation of trauma arrest 2/2 to penetrating Chest Trauma. How useful is closed CPR
What must be done urgently to the airway, lung fields, Chest? Vessels in the Chest?
closed CPR is futile.
Endotracheal intubation, bilateral chest tubes and ED thoracotomy which allows open heart CPR, pericardiotomy and cross clamping of the aorta.
