Clin Med Dx, Tx, Buzzwords Flashcards
For patients presenting with ACS symptoms, how quickly should an EKG be obtained?
<10 min
Patients with STEMIs should receive early re-perfusion therapies; what is the target door-to-cath lab time?
<90 minutes
What is the door-to-drug time goal for patients dx with STEMI?
<30 minutes
What is the tx protocol for a patient with STEMI?
MONA: Morphine (if nitro is ineffective at relieving pain) O2 if <92% sat Nitro (sublingual x3, then drip) ASA 325
+ Heparin, clopidogrel
Upon admission will also receive ACE-i, BB, statin, but not administered in ED
Which leads view the septal cardiac region? What is the associated vessel?
V1 and V2
Ass’d vessel: Proximal LAD
Which leads view the anterior cardiac region? What is the associated vessel?
V3 and V4
Ass’d vessel: LAD
Which leads view the lateral cardiac region? What are the associated vessels?
I, V5, V6, aVL (L side)
aVR (R side)
- V5 and V6 are ass’d with LAD, LCx, or RCA
- I and aVL are associated with the LCx
aVR apparently we just ignore, idk
Which leads view the inferior cardiac region? What are the associated vessels?
II, III, aVF (“F” for “feet”!)
Ass’d vessels: RCA or LCx (usually RCA)
Your patient presents with severe, sudden, sharp chest pain and CXR shows a widened mediastinum and tracheal deviation.
How is definitive Dx made and what is the treatment?
Suspicious for aortic dissection.
Definitive Dx via CTA (though CXR and bedside US are useful)
Tx:
Keep BP and HR low with esmolol, nitroprusside
- 100-120 systolic
- 60-70 HR
Control pain with morphine/fentanyl, and get emergent vascular or CT surgical consult.
It’s the 5th of July, and you have a patient presenting with HR 160, palpitations, and dizziness.
- Likely Dx and Tx?
- What might be seen on EKG?
- What might have contributed to this condition?
A-Fib (with rapid ventricular response)
Treat by managing HR: IV diltiazem (unless WPW is suspected, in which cause procainamide should be used).
On EKG, will see irregularly irregular ventricular response with no discernible P waves
Excessive EtOH (“holiday heart”) can be a precipitating factor
Pt presents with HR >200, delta waves on EKG, and an irregular rhythm. What is important to consider when treating?
Likely WPW – blocking the AV node can cause the patient to crash. Do NOT use BBs or CCBs, use ibutilide or procainamide.
Pt presents with SOB and CXR shows Kerley B lines. What is the likely Dx and how is it treated?
CHF exacerbation: Lasix and nitro are the mainstays of treatment.
Lasix should be started after getting CMP, BUN, and Cr.
Nitro should be used only in small boluses to avoid tanking the pt.
What is the atypical etiologic agent associated with PNA in an alcoholic patinet?
Klebsiella
What is the atypical etiologic agent ass’d with PNA in a pt with CF?
Pseudomonas
What is the atypical etiologic agent ass’d with PNA in an HIV+ patient?
Pneumo jirovecii
What is the atypical etiologic agent ass’d with PNA in a pt with IV drug use?
Staph aureus
What are the criteria for admitting a PNA patient?
CURB-65:
Confusion Uremia RR > 30 BP < 90 systolic Age >65
What’s the ED’s “kill everything” antibiotic cocktail?
Vanc + zosyn
Your patient is young, tachycardic, and experiencing coughing and syncope. What should jump to the top of your Ddx? How is Dx made and what is the Tx?
PE
Gold std Dx via pulm angiography, but CT chest PE protocol is used
Tx = heparin or LMWH (ex: enoxaparin/lovenox)
Consider thrombolytics vs thrombectomy if patient is hemodynamically unstable or the embolus is large.
Buzzword: Westermark sign
Decreased vascularity of the lungs seen on CXR –> PE
Buzzword: Hampton’s hump
Wedge-shaped infarct of the lungs seen on CXR –> PE
Patient presents post-MVA with SOB and tracheal deviation seen on CXR. What is the likely Dx and how is it managed?
Tension pneumo - often seen post trauma and can cause tracheal deviation.
Manage immediately w/ needle decompression, but definitive Tx is chest tube placement.
Pt with hx of liver failure presents with SOB. CXR shows blunting of the costophrenic angle. What is the likely Dx and how is it treated?
Pleural effusion (in this case, secondary to third spacing caused by liver failure).
Tx with thoracentisis and use Light’s criteria to determine transudative vs exudative cause.
Light’s Criteria:
- Fluid protein : serum protein >0.5
- Fluid LDH : serum LDH >0.6
- Fluid LDH >2/3 upper limit of normal
What is the tx for a patient presenting with asthma exacerbation?
- Duoneb (albuterol [SABA] + ipatropium [SAMA])
- IV prednisone
- IV Mg (bronchodilation)
Intubation as needed
Pt presents with exertional dyspnea and cough with sputum. CXR shows hyperinflation and a flattened diaphragm. What is the most significant risk factor for this condition? How is Dx made? How is it treated?
Smoking is the biggest RF for COPD.
Dx is not made in the ED: requires PFT showing obstructive pattern.
Tx includes smoking cessation, O2 therapy, possibly CPAP/BIPAP, and duoneb treatment.
Use Gold criteria to determine if antibiotics are necessary:
SOB + purulent or increased sputum
In these patients use AZ, doxy or levofloxacin for 3-5 days + prednisone for 5 days
What are the qSOFA criteria for identifying septic patients?
2+ of the following:
GCS <15
SBP <100
RR 22+
What is the primary difference between SIRS and sepsis? What are their similarities?
Sepsis requires a source of infection.
Both require 2+ of the following:
- Temp >100.4
- RR 20+ (or PaCO2 <32)
- HR 90+
- WBC <4,000 or >12,000
- WBC showing left shift (>10% bands)
What constitutes “severe” sepsis?
Lactic acid >2
Systolic BP <90
What constitutes septic shock?
A patient with severe sepsis (lactic acid >2 and SBP <90) who does not respond to crystalloid fluid resus after at least 30 mL/kg bolus
What are the 6 key components for treating septic shock?
- Rapid identification (qSOFA)
- Obtain blood cultures before abx
- Early abx (zosyn then vanc – in that order) w/in first 3 hours
- Aggressive crystalloid resus (30mL/kg) w/in first 3 hours
- Initial and f/up lactic acid values if initial is >2
- Vasopressors: NE
What antibiotics are used for patients in septic shock and why?
Broad-spectrum antibiotics are used. Ceftriaxone, Zosyn (pipercillin/tazobactam), or levofloxacin were emphasized.
Vancomycin is added for MRSA coverage but must be initiated AFTER the broad spectrum agent.
How are burns on the face treated?
ONLY use bacitracin on the face.
No SSD, no triple antibiotic.
As soon as healing occurs, switch to facial lotion (ex Cetaphil) and keep very well moisturized and use sunscreen every day
How are partial thickness burns (not on the face) managed?
Keep covered, moist, and antimicrobial.
Silver gel/xeroform or petroleum gauze are often used.
Never wrap a dry burn.
How are deep partial thickness burns treated?
Aggressive, daily debridement; consider silver dressing
A burn that is pink, has blistered, blanches quickly, weeps significantly, and is very painful would likely be categorized as what?
Superficial partial thickness (quick blanching and significant weeping –> superficial)
A burn that is erythematous with blistering, exudate, pain and blanching would likely be categorized as what?
Partial thickness
A burn that blanches and weeps slowly may be classified as what?
Deep partial thickness
A burn that is pale or cherry red, is dry and non-blanching can be classified as what?
Full thickness
Rule of 9s!
Head = 9% Each arm = 9% Torso: - Anterior = 18% - Posterior = 18% Each leg = 18% Genitalia = 1%
(Each palm is approximately 1% but is figured into the “arm” 9% above)
Describe the progression of the stages of wound healing.
Hemostasis –> inflammation –> proliferation –> remodeling and maturation
During the process of wound healing, when does inflammation peak?
48 hours for severe injuries
24 hours for minor injuries
More debris in the injury = longer inflammation
Your patient presents 30 minutes after spilling hot oil on her arm while cooking. The burn is blistered, weeping, and blanchable. What is the thickness of the burn?
Trick question, burns take 72 hours to develop
Describe the progression of scar formation in terms of changes of strength of the skin
Scars increase in strength at a rate of ~10% per week.
At 10 weeks/3 months, the skin is almost at full strength. The scar will wind up with ~80% the tensile strength of undamaged tissue.
Describe the progression of scar formation in terms of changes of thickness of the skin.
Scars will be thickest at about 6 weeks.
They will soften over the next 6 weeks.
At ~6 months, they will be at ~80% softness.
They take ~1 year to soften fully.
What is the difference between a furuncle and a carbuncle?
A furuncle develops around a hair follicle, while a carbuncle is the coalescence of several furuncles.
Carbuncles tend to be deeper and scar more.
What is the etiologic agent of most abscesses, and how is it spread?
S. aureus
Usually community acquired: lots of people are transiently colonized, some are continuously colonized.
Transmission via contact, droplet, vector, and autoinoculation.
Sites of colonization frequently include anterior nares, groin, rectum, throat, axilla, perineum, hands, and any site affected be a derm disorder that compromises the skin.
What are 4 indications for packing an abscess?
- > 5 cm
- Pilonidal abscesses
- Diabetic patients
- Immunocompromised patients
What are 6 situations in which you would NOT pack an abscess in the ED and instead do it in the OR?
In any of the following locations:
- Peri-rectal
- Anterior/lateral neck
- Hand (except paronychia/felon)
- Close to any viral nerves/vessels
- Anything in the facial “danger zone” triangle
- Breast
What is the treatment for an abscess that is accompanied by purulent cellulitis OR mild-moderate signs of systemic infection?
I&D + TMP/SMX
other options include doxy or clindamycin
What is the treatment for an abscess that is accompanied by purulent cellulitis AND signs of systemic infection?
I&D + Vancomycin (cover MRSA)
Immunocompromised patients with abscesses should also be treated with vanc
What is the #1 cause of foreign body sensation?
Glass
Your patient presents 4 days after stepping on a nail, and she is still symptomatic. What is the treatment?
Need to cover pseudomonas:
If <16 YO = ceftazidime
If >16 YO = cipro
Your patient presents with altered mental status, unilateral weakness and facial droop. She is able to verbalize but seems unable to process language appropriately. CT will likely show an ischemic event in what area?
Wenicke’s area
Your patient presents with altered mental status, unilateral weakness and facial droop. She is seems able to understand what you are saying to her, but unable to form words. CT will likely show an ischemic event in what area?
Broca’s area
Describe important time goals for treatment of a patient with suspected ischemic stroke.
Door to doc: <10 min
Door to CT: <25 min
Door to read: <45 min
Door to Tx: <1 Hr
Time from last known normal to tPA: <3 hours
How is stroke clinically differentiated from Bell’s palsy? How is Bell’s palsy treated?
Bell’s palsy involves the forehead (as well as lacrimation and taste).
Tx with prednisone.
Your patient presents with “the worst headache of my life”. What is the can’t miss diagnosis, how is it made, and how is it treated?
- Subarachnoid hematoma
- Dx via emergent non-con CT (LP not useful <6 hrs after onset)
- Tx: emergent neuro surg intervention; in mean time, manage BP, seizures, and N/V
Your patient presents with HA, n/v, and CT shows a crescent shaped bleed. What is the likely diagnosis?
Subdural hematoma
Your patient presents with HA, n/v, and CT shows a biconvex shaped bleed. What is the likely diagnosis?
Epidural hematoma
What should be avoided in the treatment of patients with migraine?
Narcotic medications - can cause rebound migraines.
What is the treatment of choice for a patient who is actively seizing?
Lorazepam
What is the MC cause of seizures?
Non-compliance with antiepileptic drugs
How is bacterial meningitis treated in a patient >50 YO?
Vanc + ceftriaxone + ampicillin to cover Listeria
In patients <50 YO, ampicillin can be omitted because there is less likelihood of Listeria as the etiologic agent
Tx for a patient with suspected toxic ingestion presenting with respiratory depression and miosis?
Suspect opiates, treat with narcan.
Tx for a patient with suspected toxic ingestion presenting with hyperthermia, flushing, tachycardia, hallucinations and mydriasis?
Suspect anticholinergics, tx with physostigmine (and a foley to address likely urinary retention)
Tx for a patient with suspected toxic exposure presenting with excessive salivation, diaphoresis, and vomiting?
Suspect organophosphate exposure; treat with atropine (+ 2-PAM and benzos)
Tx for a patient with suspected toxic ingestion presenting somnolence, respiratory depression, and bradycardia?
Suspect sedative hypnotics/EtOH; supportive tx.
Can consider flumazenil, but prevents benzo use for seizures.
Tx for a patient with suspected APAP ingestion?
Administer activated charcoal
Labs 4 hours post ingestion or at admission + 4 hours later
N-acetylcystine if indicated by Rummack Matthew nonogram (after 4 hour mark)
What is the rule for calculating maintenance fluids?
4-2-1 rule:
- For the first 10 kg, give 4mL/kg/hr
- For the second 10 kg, give 2mL/kg/hr
- For everything over 20 kg, give 1mL/kg/hr
(25 kg patient = 11mL/kg/hr)
What is important to remember when repleting electrolytes in patients who are hypokalemic?
Do not replace K+ without first repleting Mg2+ – it won’t work.
What factors affect flow rate of IVFs?
Length of tube and diameter of tube.
Flow is inverse to length of tube
Flow is directly related to diameter
**Length of tube has a greater effect than diameter
What kind of delivery is appropriate for rapid fluid resuscitation?
2 large bore IVs
What are two important CIxs for performing nail bed trephination?
Crushed or fractured distal phalanx
Suspected melanoma
How should a nail avulsion be performed – what kind of motion should be used?
Perform a digital block, apply tourniquet, cut lengthwise and ROCK with hemostats (do not twist!)
What are some important CIx for performing an injured eye exam?
Ruptured globe
Eyelid laceration
Caustic splash exposure
Status-post corneal flap surgery (Lasik)
^ Stabilize these patients first and then send straight to ophtho
You perform an eye exam on a patient and apply fluorescein stain. Dendritic patterns are apparent. What is the suspected Dx?
HSV
What is a positive Seidel test and what does it indicate?
A “dark waterfall” seen when applying fluorescein stain - indicates a globe penetration (straight to ophtho)
What is important when performing an auricular or digital block?
Don’t use epi! No epi in lidocaine for fingers, toes, penis, or nose!
How are auricular hematomas treated?
Auricular block (no epi) I&D with 1 cm incision Dress w/ petroleum gauze, suture in place Antibiotics to cover psuedomonas: Augmentin for peds Levofloxacin for adults
Any question about epistaxis
The answer is Kiesselbach’s plexus
What is the preferred treatment for an aspirated FB?
Bronchoscopy
What is the triad associated with heat stroke?
Exposure to heat stress
CNS dysfunction
Core temp >105*F
What is the preferred method to measure core temperature in a hypothermic patient?
Esophageal probe
Where does a direct inguinal hernia occur?
Medial to the inferior epigastric vessels, through the inguinal triangle (Hesselbach’s triangle)
Where does an indirect inguinal hernia occur?
Lateral to the inferior epigastric vessels
What is the MC problem patients have post hernia repair?
Pain - lots of nerves in the abdomen.
Describe the healing process after a typical inguinal hernia repair
Mesh is used to promote dense scarring. It takes ~6 weeks for 80% scar formation, and it takes about 6 months for a full scar to provide maximum strength in the area.
What are 4 important comorbidities that need to be addressed prior to hernia repair?
Morbid obesity (goal: BMI <40)
SM
Smoking
Hernia recurrence
If any of these are present = complex hernia
What is the imaging modality of choice for assessing an incisional hernia?
CT with contrast – do NOT get a US!
