Clin Med Flashcards
First step of Foreign Body Removal from skin?
Evaluate Sensation and Circulation
how long should you spend trying to find a skin foreign body?
30 minutes
“Limit your time. If it is taking you more than 30 minutes – your turn is done”
Every patient who comes in with foreign body in skin is leaving with _____
tetanus booster (Tdap)
what’s the #1 cause of foreign body sensation?
glass
glass is ______ but very small pieces are _______.
Glass is RADIOPAQUE, but very small pieces are MISSED ON XRAY.
what bacterial pathogen is most suspected in puncture wounds?
Pseudomonas Aeruginosa
what terrible infectious condition may develop after puncture wound?
osteomyelitis
What abx are used to treat puncture wound pseudomonas aeruginosa?
> 16 y/o? Ciprofloxacin
<16 y/o? Ceftazidime
How does Covid-19 enter the body?
transmission = resp droplets, some fomites (mostly in healthcare setting)
attaches to ACE2 receptor to enter host cell, spike proteins mediate entry into cell
(these are on type II alveolar cells, intestines, kidney, heart, blood vessels)
what are common s/s of Covid-19 infection?
Cough 60-86%
Dyspnea 53-80%
**Anosmia or ageusia 64-80%
**Fever 44-90%
GI symptoms may start first
what are risk factors for severe Covid-19 disease?
Age >75
Hypertension
Diabetes
Obesity (Body mass index >40)
(these four are the worst….ESPECIALLY high BMI)
How are steroids used for Covid-19 infection?
outpatient treatment?
NO STEROIDS OR ABX!
inpatient treatment?
if pt needs O2 - decadron
How are monocloncal antibodies used for Covid-19?
outpatient treatment?
if high risk for disease progression - Bamlanivimab (“bam”) or casirivimab+imdevimab (regeneron)
inpatient treatment?
if pt needs O2 - same -mabs as above
How do Covid-19 vaccines work?
mRNA vaccines - code for spike proteins to elicit immune response (~94-95% efficacy at reducing viral load)
adenovirus vaccines - use adenovirus to carry spike protein genetic material
Covid 19 dx tests/imaging:
what are typical findings on chest XRay?
classic presentation is a multifocal pneumonia
Covid 19 dx tests/imaging:
what are typical findings on chest CT?
“ground glass opacities”
(but don’t go getting CT’s on everyone….ties up CT, it has to be decontaminated after each Covid pt, use this image with caution)
what is the difference between cellulitis and abscess?
cellulitis is diffuse, no focal point of infection
abscess = focal point that can be incised and drained, it is usually
- painful
- fluctuous
- erythematous
what is the difference between faruncle and carbuncle?
furuncle = single “boil”, develops around a hair follicle
carbuncle = coalescence of severe furuncles (sucks to be you
match the c’s: Carbuncle + Coalesce)
Do you know the Staph Aureus Algorithm for I & D?
I hope so…Ms. Painter kept saying that if you know it, you’re good to go
what are three ways staph is spread?
- Contact with others
- Autoinoculation
- Metastases can occur through polymorphonuclear neutrophils (PMN)
for abscess I & D, do most patients require antibiotic treatment?
no, no they do not
define SIRS
systemic inflammatory response syndrome
**remember this is just an inflammatory response”
HR <90
RR >20
WBC >12000
Temp >100.4F
buzzwords for acute PE findings on CXR
westermark’s sign or
hampton’s hump
what are the two defining factors for hypertension emergency?
hypertension
- plus -
end organ damage
what is a unique factor of Bell’s Palsy that distinguishes it from stroke?
forehead symptom involvement
what parts of the body are considered to be 9% of surface area of body (Rule of Nines)?
head
arm (full circumference)
anterior leg
posterior leg
what parts of the body are considered to be 18% of surface area of body (Rule of Nines)?
anterior torso (from clavicles to pubic bone) posterior torso
what parts of the body are considered to be 1% of surface area of body (Rule of Nines)?
genitalia
palm
what are characteristics of 1st degree burn?
epidermis is only layer affected
no blistering (think sunburn)
treatmt: lotion then emollient, OTC analgesia, drink lots of water
what are characteristics of 2nd degree burn?
aka “partial thickness”
- blistering
- epidermal loss
- exudate
- blanches
- painful
when do we refer to burn center (or call them for consult) for a second degree (partial thickness) burn?
when it overlies a joint (think of Brennan)
or if the burn is on a child (they need their skin to grow with them)
what do we always use to treat burns of the face?
bacitracin
what do we NEVER use to treat burns of the face?
Silver sulfadiazine (SSD)
what do we use to treat 2nd degree burns (not the face)?
Take away: keep covered, moist, preferably antimicrobial
the details:
- Silver gel/Xeroform or Petroleum Gauze QOD
- Bacitracin/Xeroform QD
- SSD rarely, but useful in certain circumstances
characteristics of full thickness / third degree burn
- pale OR cherry red
- dry
- non-blanching
when do we refer to burn center?
Any full-thickness burn
Partial thickness burns >10% TBSA
Burns involving face, hands, feet, genitalia, perineum, or major joints, regardless of TBSA
Electrical burns, including lightning
Chemical burns
kids
other miscellaneous reasons
how long do we flush chemical burns?
> 10 minutes
if pt presents with chem burn, and says they’ve flushed it, flush it as though no flushing had been done - you can’t flush too much
what is the role of OT for burn pts?
PARAMOUNT to burn healing to maintain or restore function
what is the role of compression for burn pts?
to flatten scars
three criteria for qSOFA
RR >= 22
AMS (using GCS)
SBP <= 110 mm Hg
clinical criteria defining septic shock
persistent hypOtension (MAP <= 65 mm Hg) requiring vasopressors to maintain
serum lactate level >2 mmol/L (18 mg/dL) despite vol resuscitation
two main factors of sepsis management per Dr. Banderas
resuscitation from hypoperfusion
(give 30mL/kg IV crystalloid (NS or LR), but not too fast for the heart failure patients…we want MAP of 65 mmHg)
abx therapy
(get blood cultures first, from two sites on the body)
be a good steward!
according to Dr. Banderas ~
what are the five primary empiric antibiotic alternatives when broad spectrum coverage is needed?
meropenem (broadest coverage of beta lactams)
piperacillin/tazobactam (gram +, gram -, pseudomonas)
levofloxacin
piperacillin/tazobactam + levofloxacin
piperacillin/tazobactam + gentamicin
** plus/minus Vanc or Linezolid for MRSA as needed
according to Dr. Banderas~
what do we use to kill pseudomonas?
1st Line Therapy = antipseudomonal penicillin + aminoglycoside (i.e. gentamicin)
Alternatives:
- antipseudomonal pcn + quinolone
Dr. B highlighted
- cefepime
- ceftazidime
- fluoroquinolone (ciprofloxacin and levofloxacin)
(don’t forget no pregnant ladies or kids get fluoroquinolones!)
Dr. Spencer’s list of broad spectrum abx:
ceftriaxone (or any 3rd or 4th gen cephalosporin)
pipercillin/tazobactam (aka Zosyn)
ampicillin/sulbactam (aka Unasyn)
levofloxacin
meropenem/ertapenem
According to Dr. Norgard, what is the first step for treating AFib (irregular narrow complex tachycardia)?
RATE CONTROL - urgent rate control
gotta get HR <100 bpm and eliminate symptoms
According to Dr. Norgard, what do we use to accomplish the first step for treating AFib (irregular narrow complex tachycardia)?
BB (probably esmolol)
or
Non-DNP CCB (verapamil or diltiazem)
or maaayyyyybeeee digoxin, but it’s not the Go-To, b/c it takes 1-2 hrs; you can add it on to BB or CCB
According to Dr. Norgard, when do we use electrical cardioversion on AFib?
when the pt is hemodynamically unstable…then “shock it out”!
what are our three main “weapons” against acute bradycardia?
atropine (antimuscarinic)
dopamine IV (beta 1 and alpha 1 agonist)
epinephrine IV (beta 1 and alpha 1 agonist)
what drug has FDA approval for use against VTach and VFib?
amiodarone
when do use amiodarone in real life (besides what the FDA approved it for)?
VTach
VFib
CPR
supraventricular arrhythmias
AFib prophylaxis
two drugs used for AFib with accessory pathways (hemodynamically stable)
ibutilide (class III antiarrhythmic drug, K+ channel blocker)
procainamide (class 1A antiarrhythmic drug)
on what receptors does epinephrine work
so many!
alpha 1
alpha 2
beta 1
beta 2
therefore it’s a very potent vasoconstrictor and cardiac stimulant when given IV
what three drugs do we use for cardiogenic shock (Dr. Norgard)?
DDM:
Dopamine
Dobutamine
Milrinone
(cardiogenic shock requires inotropic drugs)
what are the two CCB-dihydropyridines available as IV treatment for hypertensive crises?
nicardipine
clevidipine (sp?)
(Dr. Norgard’s favorites)
what are the two vasodilators-NO dependent drugs available as IV treatment for hypertensive crises?
sodium nitroprusside
nitroglycerin
what are the two beta blockers available as IV treatment for hypertensive crises?
esmolol
labetalol
what is the drug we usually just use for pheochromocytoma hypertensive crisis?
phentolamine
your patient has been seizing for 6 minutes - what do you grab first (after ABC’s are secure)?
benzos (we usually grab lorazepam first)
lorazepam IV
midazolam IM, buccal or intranasal
diazepam rectal if you have to (don’t put diazepam in IM)
if your patient has been seizing for 9 minutes and the benzos and barbiturates have failed, what do you try?
IV fosphenytoin
IV valproate
IV levetiracetam (trade name Keppra)
(could also use propofol, the “milk of amnesia”, if the pt is an adult)
ACS: angina represents _____
ischemia
ACS: in acute MI, you can have ST _____ or _________
ST elevation or depression
ACS: risk factors for ACS
age male FHx smoking HTN HLD DM cocaine use
s/s of ACS
chest pain n/v diaphoresis SOB light-headedness syncope palpitations chest wall tenderness
who usually comes in with ATYPICAL ACS symptoms?
elderly
diabetics
women
labs for ER work up and mgmt of ACS?
CBC
CMP
TROPONIN
+/- coags
lipas
UDS?
imaging for ER work up and mgmt of ACS?
CXR
looking for wide mediastinum and pulm edema
two types of aortic dissection
ascending aorta
descending aorta
(the ascending kind has a much worse prognosis)
what is a key finding for aortic dissection on CXR?
double density sign
common phrase for treating AFib
RATE control always before rhythm control
i.e. diltiazem for rate….then procainamide or amiodarone or electricity for rhythm if s/s have been <48 hrs
what AFib patients get electricity (cardioversion)?
the UNSTABLE ones
give them something for pain and sedation - this hurts!
four signs that might be seen on CXR for CHF pts presenting to ER:
cardiomegaly
pulm edema
pleural effusions
Kerley B lines
most common pneumonia bacterial pathogens
Strep pneumo
H. influenza
atypical pathogenic causes of pneumonia
legionella
mycoplasma
chlaydophia (?)
“walking pneumonia”
mycoplasma (“bullous myringitis”)
most common finding for pulm embolism
tachycardia
gold standard for imaging suspected pneumothorax in ER
CT is gold standard
you can use bedside US to look for lung sliding
2/3 of the crystalloid you give will go _____(where?)
third space (interstitial)
“keep in mind that 2/3 of the crystalloid you give will go to the third space (interstitial)”
what is Dr. Spencer’s favorite NSAID?
meloxicam
“Probably about as safe, cheaper, and more effective than celecoxib”
translate “sepsis” into English
“rotten flesh”
“sepsis” is Greek
risk factors for bad outcomes of sepsis (in other words, death or ICU)
Pregnancy “Advanced Age” (>65) Cancer/Immunosuppression Diabetes / Obesity Community Acquired PNA requiring hospitalization Admission to ICU (duh, what less obvious reason perhaps) Recent hospitalizations or antibiotics ?Genetic factors
