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CDEM curriculum part 1 Flashcards

1
Q

What initial actions should be taken in pts presenting with abd pain?

A

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

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2
Q

What system most commonly needs the attention of the clinician in the setting of abdominal pain for the primary survey?

A

Circulatory system

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3
Q

What should be done immediately for abdominal pain in conjunction with hemodynamic instability?

A

Fluid resuscitation

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4
Q

What should be immediately ordered in the unstable pt with abdominal pain in whom hemorrhage is diagnosed or highly suspected?

A

Typed and crossed blood

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5
Q

Women of childbearing age who present with abdominal pain…

A

Are presumed to have an ectopic pregnancy until proven otherwise

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6
Q

When a pt of childbearing age with abdominal pain is unstable, what can be done?

A

Place a Foley to obtain urine for beta-hCG testing

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7
Q

What beside imaging tools can be used in the setting of abdominal pain?

A

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

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8
Q

When should prompt abx be given for abdominal pain?

A

Sepsis
Peritonitis
Perforated viscus

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9
Q

When should immediate surgical consultation be obtained with abd pain?

A

Presentation of abd pain involves hemodynamic instability and/or a rigid abdomen
Consider which specialty to consult based on the likely dx

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10
Q

Life- or organ-threatening dxs you must consider in pts with abd pain

A 
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
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11
Q

Initial actions for AMS pts

A

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

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12
Q

What do all AMS pts need at a minimum?

A

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

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13
Q

Mnemonic for causes of AMS

A 
Alcohol
Epilepsy, Electrolytes, and Encephalopathy
Insulin
Opiates and Oxygen
Uremia
Trauma and Temperature
Infection
Poisons and Psychogenic
Shock, Stroke, SAH, and Space-Occupying Lesion
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14
Q

What are three broad classifications of AMS?

A

Delirium
Dementia
Psychosis

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15
Q

Delirium characteristics

A 
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
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16
Q

Dementia characteristics

A 
Slow onset
Progressive course
Usually nl vital signs
Normal level of consciousness
Rare hallucinations
PE often nl
Prognosis progressive
Organic underlying cause
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17
Q

Psychosis characteristics

A 
Variable onset
Variable course
Usually nl vital signs
Variable level of consciousness
Auditory hallucinations
PE often nl
Prognosis variable
Functional underlying cause
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18
Q

What is a true medical emergency in AMS?

A

Delirium

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19
Q

What is a good tip for psychosis?

A

Assume an organic etiology until it can be clearly ruled out

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20
Q

What to ask family, friends, caretakers, nursing home workers, and witnesses for AMS

A

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

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21
Q

In AMS, look for a h/o…

A

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

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22
Q

PE of AMS: overall categories

A 
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
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23
Q

Vital signs with AMS

A

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?

24
Q

Neurologic status with AMS

A

Level of alertness
GCS or AVPU
How difficult is it to keep the pt awake?

25
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? ```
26
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
27
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?
28
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)?
29
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?
30
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)?
31
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
32
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 ```
33
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
34
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
35
Dispo of AMS
The majority of pts with AMS will require hospitalization
36
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
37
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?
38
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 ```
39
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)
40
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
41
High-risk pts with undifferentiated CP should receive an EKG within _____ of arriving to the ED
5-10 mins
42
How many EKGs should be taken in a pt with CP?
Serial EKGs in pts with ongoing CP improve sensitivity for STEMI
43
What are the diagnoses you must consider in pts with CP?
``` ACS PE Thoracic aortic dissection Tension pneumo Esophageal rupture Pericarditis with potential tamponade ```
44
Key historical features of ACS
CP Weakness Nausea Fatigue
45
Key exam features of ACS
Variable: possible diaphoresis, ill appearance, or rales
46
Key historical features of PE
Pleuritic CP SOB RFs
47
Key exam features of PE
Tachycardia Clear lungs Unilateral leg swelling
48
Key historical features of aortic dissection
Sudden onset severe ripping pain to back with paresthesia or paralysis
49
Key exam features of aortic dissection
Unequal BPs Abnormal pulses Neurologic deficits
50
Key historical features of tension pneumo
Sudden onset severe unilateral pleuritic CP
51
Key exam features of tension pneumo
Hypotension Unequal breath sounds Tracheal deviation
52
Key historical features of esophageal rupture
Intense SSCP after vomiting or endoscopic procedure
53
Key exam features of esophageal rupture
Hamman's crunch (crackle sound heard or felt in time with heart beat)
54
Key historical features of pericarditis/tamponade
Pleuritic CP and dyspnea
55
Key exam features of pericarditis/tamponade
Muffled heart sound Distended neck veins Hypotension
56
Less acute possible sources for CP
Costochondritis Pleurisy Gastroesophageal reflux Anxiety attack

DDx (5 decks)

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