Ch 2: Emergent Cases; Danger Signals

Question 1

Cardiovascular System

Answer 1

Acute myocardial infarction (MI), Congestive heart failure (CHF), Deep vein thrombosis (DVT), Abnormal aortic aneurysm (AAA)

Question 2

Skin and Integumentary System

Answer 2

Angioedema/Anaphylaxis, Stevens-Johnson syndrome, Meningococcemia, Rocky Mountain spotted fever (RMSF), Lyme disease

Question 3

Gastrointestinal System

Answer 3

Acute abdomen (surgical abdomen), Acute appendicitis, Acute pancreatitis

Question 4

Men’s Health

Answer 4

Testicular torsion, Priapism

Question 5

Psychosocial Mental Health

Answer 5

Depression with suicidal plan, Acute mania with psychosis, Severe anorexia

Question 6

Nervous System

Answer 6

Cerebrovascular accident (CVA), Temporal arteritis headache, Subarachnoid bleeding “headache”

Question 7

Head, Eyes, Ears, Nose and Throat

Answer 7

Sudden vision loss, or rapid worsening of vision, Herpes keratitis, Temporal arteritis, Acute angle-close glaucoma

Question 8

Pulmonary System

Answer 8

Anaphylaxis, Severe asthmatic exacerbation (impending respiratory failure), Pulmonary emboli

Question 9

Renal System

Answer 9

Acute pyelonephritis

Question 10

Women’s health

Answer 10

Dominant breast mass that is attached to surrounding tissue, Ruptured tubal ectopic pregnancy

Question 11

Treatment of anaphylaxis (in primary care)

Answer 11

Notes:
1) If only 1 clinician is present: Give an injection of epinephrine 1:1000 dilution 0.3 to 0.5 mg IM STAT, and then call 911. May repeat dose within 5 minutes in case of poor response

2) ED treatment medications: epinephrine IM, 100% oxygen by face mask, an antihistamine (H1 blocker) such as diphenhydramine (Benadryl), an H2 antagonist such as ranitidine; a bronchodilator such as albuterol (short-acting beta-2 agonist); and systemic glucocorticosteroids such as prednisone
3) Patients with an atopic history (asthma, eczema, allergic rhinitis) with nasal polyps are at higher risk for aspirin and NSAID allergies
4) Anaphylaxis is classified as a Type I IgE-dependent reaction
5) Biphasic anaphylaxis occurs in up to 23% of cases (symptoms recur within 8-10 hours after initial episode). This is the reason why these patients are prescribed a Medrol Dose Pack and a long-acting antihistamine after being discharged from the ED
6) The most common triggers for anaphylaxis in children are foods. Medications and insect stings are the most common triggers in adults.

Question 12

Prioritizing other Emergent Cases

Managing the airway, breathing and circulation (the ABCs) is always a top priority. If no ABCs, next priority is acute or sudden change in mental status and LOC from baseline. If ABCs do not apply think AMPICILLIN

Answer 12

A Acute
M Mental Status changes
P Pain
I Infection
CILLIN No meaning, Makes mnemonic easier. 

Notes:
1) Any recent changes in LOC, even one as subtle as difficulty with normal conversation, should ring a bell in your head and remind you of the AMPICILLIN mnemonic

2) Notice the words “normal conversation.” Do not overread the question and ask yourself what they mean by “normal conversation.” Take it at face value

3) Changes in LOC on the test are usually subtle changes. Signs to watch for:
- difficulty answering questions
- slurred speech
- seems confused
- does not understand instructions/conversations
- sleepy/lethargic, and so forth

Question 13

Geriatrics
Elderly: Ages 65-84-“young gerontologicals”
Frail elderly > 85

Answer 13

Notes:
1) Elderly pts who lose weight are at higher risk of complications and death. An unintentional weight loss of 10% is pathologic in any age group

2) An elderly patient who becomes agitated and confused at night is probably experiencing “sundowning.” Sundowning is seen in patients who have dementia. In addition, elderly patients are also at higher risk for delerium (temporary mental state, not a disease).
3) Some elderly patients with bacterial infections (i.e. UTI) can become acutely confused. Elderly pts with UTIs may not exhibit fever or the other classic symptoms of a UTI