CDEM curriculum part 1 Flashcards
What initial actions should be taken in pts presenting with abd pain?
Perform the primary survey
Order a pregnancy test in women of child-bearing age
Order blood products in unstable pts with suspected hemorrhage
Order bedside imaging in pts whose presentation is concerning for pneumoperitoneum or hemoperitoneum
Order abx early int he setting of sepsis, peritonitis, or perforation
Provide analgesia
Obtain immediate surgical consultation in the setting of hemodynamic instability or a rigid abdomen
What system most commonly needs the attention of the clinician in the setting of abdominal pain for the primary survey?
Circulatory system
What should be done immediately for abdominal pain in conjunction with hemodynamic instability?
Fluid resuscitation
What should be immediately ordered in the unstable pt with abdominal pain in whom hemorrhage is diagnosed or highly suspected?
Typed and crossed blood
Women of childbearing age who present with abdominal pain…
Are presumed to have an ectopic pregnancy until proven otherwise
When a pt of childbearing age with abdominal pain is unstable, what can be done?
Place a Foley to obtain urine for beta-hCG testing
What beside imaging tools can be used in the setting of abdominal pain?
Portable XR and u/s with concern for pneumoperitoneum or hemoperitoneum
Upright CXR or lateral decubitus abdominal film in the case of perforated viscus
U/s for ruptured AAA or ruptured ectopic pregnancy
When should prompt abx be given for abdominal pain?
Sepsis
Peritonitis
Perforated viscus
When should immediate surgical consultation be obtained with abd pain?
Presentation of abd pain involves hemodynamic instability and/or a rigid abdomen
Consider which specialty to consult based on the likely dx
Life- or organ-threatening dxs you must consider in pts with abd pain
Ectopic pregnancy Appendicitis AAA PID/TOA Biliary dz Bowel obstruction Perforated viscus Mesenteric ischemia Testicular ACS as a critical extra-abdominal cause of abdominal pain
Initial actions for AMS pts
Initial assessment for immediate threats
ABCDE approach
Airway: hypoxia is a potentially reversible cause of AMS
Breathing: inadequate ventilation can cause AMS. In pt with AMS and depressed respiratory status, consider narcotic overdose
Circulatory: Hypotension should prompt IVF bolus and an immediate search for the cause
Neurologic disability: Use GCS or AVPU scale. Look for seizure activity. Check pupils. Pay attention to spontaneous movements.
Expose and perform a head to toe look
Deep in mind rapidly reversible causes for AMS
What do all AMS pts need at a minimum?
Assessment of ABCs
Cardiac monitoring and pulse ox
Supplemental oxygen if hyperemic
Bedside glucose testing
IV access
Eval for signs of trauma and consider C-spine stabilization
Consider naloxone administration if narcotic overdose is suspected
Mnemonic for causes of AMS
Alcohol Epilepsy, Electrolytes, and Encephalopathy Insulin Opiates and Oxygen Uremia Trauma and Temperature Infection Poisons and Psychogenic Shock, Stroke, SAH, and Space-Occupying Lesion
What are three broad classifications of AMS?
Delirium
Dementia
Psychosis
Delirium characteristics
Rapid onset Fluctuating course Often abnl vital signs Altered level of consciousness Visual hallucinations PE often abnl Prognosis poor if cause not treated Organic underlying cause
Dementia characteristics
Slow onset Progressive course Usually nl vital signs Normal level of consciousness Rare hallucinations PE often nl Prognosis progressive Organic underlying cause
Psychosis characteristics
Variable onset Variable course Usually nl vital signs Variable level of consciousness Auditory hallucinations PE often nl Prognosis variable Functional underlying cause
What is a true medical emergency in AMS?
Delirium
What is a good tip for psychosis?
Assume an organic etiology until it can be clearly ruled out
What to ask family, friends, caretakers, nursing home workers, and witnesses for AMS
Can you tell me what you see different about the pt?
Can you describe how he/she is different?
When did this change start?
What do you think might have caused this?
Screen for delirium
In AMS, look for a h/o…
DM (DKA, HHNK)
HTN (hypertensive encephalopathy or med overdose)
Enocrine dz (Thyroid, Addisons)
Renal failure
CA (paraneoplastic syndrome, sodium, calcium)
Dementia
Cardiovascular and cerebrovascular dz
Seizure
Psychiatric issues
Med effects are also very common causes of AMS in the elderly
PE of AMS: overall categories
GCS Vitals Neuro status Content of thought and speech Assess for focal motor findings CV exam Abd exam GU and rectal exam Skin, extremity, MS exam
Vital signs with AMS
Does the pt have a fever?
Is the pt bradycardic or tachycardic?
Is the pt bradypneic or tachypneic?
Is the pt hypotensive or severely hypertensive?
Neurologic status with AMS
Level of alertness
GCS or AVPU
How difficult is it to keep the pt awake?
Content of thought and speech with AMS
Does the pt stay focused? Is their speech tangential? Is the pt appropriately oriented? Does the pt keep asking the same questions over and over? Are they reacting to internal stimuli?
Assess for focal motor findings with AMS
Is there weakness or pronator drift?
Cranial nerve exam
Remember the brainstem is where isolated structural or ischemic lesions can cause decreased arousal. Decreased level of consciousness with cranial nerve findings is a brainstem lesion until proven otherwise
Evaluate for tremulousness or abnormal reflexes
Common in withdrawal states or metabolic derrangements
CV exam for AMS
Are there arrhythmias that predispose to embolic strokes?
Is there a murmur? Endocarditis?
Is there evidence of good peripheral circulation?
Are there pulmonary findings that indicate pneumonia (sepsis) or pulmonary edema (hypoxia)?
Are there bruits over the carotid arteries?
Abd exam in AMS
Is there ascites, caput medusa, liver enlargement, or tenderness (hepatic encephalopathy)?
Is the abdomen tender (appendicitis, intussusception, abdominal sepsis source, mesenteric ischemia)?
GU and rectal exam in AMS
Is the pt making urine (uremic encephalopathy)
Are there signs of urinary, vaginal, prostatic, or perineal infection?
Is there melena or blood in the stool?
Skin, extremity, MS exam in AMS
Are there petechiae (meningococcemia)?
Is there a dialysis graft (uremic encephalopathy)?
Are there track marks from injection drug abuse?
Are there transdermal drug patches?
Is the skin jaundiced (hepatic encephalopathy)?
Is there nuchal rigidity or meningismus (CNS infection)?
Are there signs of trauma (raccoon’s eyes, Battle’s sign, hemotympanum)?
Are there infectious sources noted (decubitus ulcers, cellulitis, abscesses)?
Are there masses or LAD that might indicate CA (paraneoplastic syndrome)?
Approach to diagnostic tests with AMS
Diagnostics should not be run in a shotgun fashion
With an undifferentiated presentation, liberal use of diagnostic studies is frequently necessary
Think of the main categories of causes for AMS and use diagnostic testing if any of these categories cannot be ruled out by H and P alone
Main categories to consider for diagnostic testing for AMS
Metabolic or endocrine causes -Rapid glucose -Serum electrolytes -ABG or VBG (with co-oxymetry for carboxy-or met-hemoglobinemia) -Thyroid function tests -Ammonia level -Serum cortisol level -Toxic or medication causes Levels of meds (anticonvulsants, digoxin, theophylline, lithium, etc) -Drug screen -Alcohol level -Serum osmolality -Infectious causes CBC with diff UA and culture BCx CXR LP (with opening pressure) Always CT first if you suspect increased ICP Traumatic causes Head CT/cervical spine CT Neurologic causes -Head CT (usually start without contrast for trauma or CVA) -MRI (if brainstem/posterior fossa pathology suspected) -ECG (if non-convulsive status epilepticus suspected) Hemodynamic instability causes -ECG -Cardiac enzymes (silent MI) -Echocardiogram -Carotid/vertebral artery u/s
How to make the dx of what’s behind the AMS
Mental status changes are often multifactorial
Initial diagnostic maneuvers are primarily determined by the hx and PE exam findings
Often, presumptive tx is begun at this point
Frequently reasssess the pt
In some cases, the dx will not be definitively made in the ED
R/o other organic causes of behavioral changes
Tx of AMS causes
May include:
Dextrose for hypoglycemia
Naloxone for opioid toxicity
Supportive care and sedation for agitated withdrawal states
IVF for dehydration, hypovolemia, hypotension, or hyperosmolar states, such as HHNS or hypernatremia
Empiric abx for suspected meningitis, urosepsis, PNA, etc
Rewarming or aggressive cooling for temperature extremes
Fomepazole, pyridoxine, digoxin-fab fragments or other antidotes for specific toxins
Controlled reduction of BP with nitroprusside, labetolol, or fenoldepam for hypertensive encephalopathy
Hypertonic saline for profound hyponatremia with seizures or AMS
Glucocortcoids for metastatic CNS lesions with vasogenic edema
Consider thiamine for suspected Wernicke’s encephalopathy
Dispo of AMS
The majority of pts with AMS will require hospitalization
Examples of pts with AMS who can safely be d/c-ed home
Seizure- pts with known seizure d/os found to have low anticonvulsant levels may be d/c-ed if meds can be loaded and appropriate safe f/u can be assured
Hypoglycemia- diabetic pts found to be transiently hypoglycemic and improve with dextrose may be d/c-ed if a clear reason can be found, they are not on long acting agents, and appropriate supervision and safe f/u can be assured
Narcotic overdose- when properly treated and observed in the emergency department, these pts may be safely d/c-ed home
What factors can dispo with AMS be dependent on?
How sick is the pt?
The cause identifiable and easily reversed?
Has the cause been fixed?
Did the pt return to nl?
Is the situation likely to return?
If it does return, is there adequate social support to recognize it and bring the pt in for medical care?
ICU vs floor in AMS pts- what is the decision based on?
Hemodynamic stability Etiology of the AMS Expected course Need for close monitoring Airway management issues Institutional resources
When you first walk in the room for a CP pt, what should be done?
If arrest, call a code: initiate CAB, multi-disciplinary help
Determine sick vs not sick clinical gestault
Assess primary survey: ABCs and vital signs (stable vs unstable)
Primary survey of pts with CP
If not in arrest assessment of all high-risk pts with CP should always begin with getting an initial impression then assessing the ABCs paired with vital signs
Simultaneously, the team begins initiating tx
Consider placing a set of defibrillator/cardioversion pads on those pts who appear sick
High-risk pts with undifferentiated CP should receive an EKG within _____ of arriving to the ED
5-10 mins
How many EKGs should be taken in a pt with CP?
Serial EKGs in pts with ongoing CP improve sensitivity for STEMI
What are the diagnoses you must consider in pts with CP?
ACS PE Thoracic aortic dissection Tension pneumo Esophageal rupture Pericarditis with potential tamponade
Key historical features of ACS
CP
Weakness
Nausea
Fatigue
Key exam features of ACS
Variable: possible diaphoresis, ill appearance, or rales
Key historical features of PE
Pleuritic CP
SOB
RFs
Key exam features of PE
Tachycardia
Clear lungs
Unilateral leg swelling
Key historical features of aortic dissection
Sudden onset severe ripping pain to back with paresthesia or paralysis
Key exam features of aortic dissection
Unequal BPs
Abnormal pulses
Neurologic deficits
Key historical features of tension pneumo
Sudden onset severe unilateral pleuritic CP
Key exam features of tension pneumo
Hypotension
Unequal breath sounds
Tracheal deviation
Key historical features of esophageal rupture
Intense SSCP after vomiting or endoscopic procedure
Key exam features of esophageal rupture
Hamman’s crunch (crackle sound heard or felt in time with heart beat)
Key historical features of pericarditis/tamponade
Pleuritic CP and dyspnea
Key exam features of pericarditis/tamponade
Muffled heart sound
Distended neck veins
Hypotension
Less acute possible sources for CP
Costochondritis
Pleurisy
Gastroesophageal reflux
Anxiety attack
