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
