Clinical questions - Emergency Medicine

Question 1

ACLS protocol for Vfib

Answer 1

Shock 360 J
> CPR 2 min
*> Rhythm check -> shock
> CPR 2 min
> Epi 1 mg q3-5 min (can use vasopressin alas for 1st or 2nd dose)
> rhythm check -> shock
> CPR 2 min
> Amiodarone 300 mg IV 1st bolus, 150 mg 2nd dose
> H&Ts
Repeat*

Question 2

ACLS protocol for PEA or asystole

Answer 2

CPR 2 min
> epi 1 mg q3-5 min
> CPR 2min
> H&Ts

Question 3

ACLS Hs

Answer 3

Hypo:
Hypovolemia - volume resuscitation
Hypoxia - intubate, O2, or chest tube (PTX)
Hypokalemia - KCl
Hypoglycemia - D50
Hypothermia - warm

Hyper:
H+ (acidosis) - bicarb 1-2 amps (common in prolonged codes)
Hyperkalemia (common in prolonged codes) - CaCl or Ca gluconate to stable myocardium OR bicarb to drive K back into cell OR Insulin + D50

Question 4

ACLS Ts

Answer 4

Tamponade - pericardiocentesis
Tension PTX - needle decompression -> chest tube
Thrombosis (MI) - LHC, thrombolytic
Thrombosis (PE) - thrombolytic, thrombectomy
Trauma - ATLS protocol
Toxins or Tablets

Question 5

Diagnosis and Findings consistent with urethral injury

Answer 5

high riding prostate
blood at the urethral meatus

Dx with retrograde cystourethralgram by Urology

Question 6

Treatment of acute EtOH withdrawal

Answer 6

IVF
IV supplemental nutrition: K, Mg, Phos, Thiamine, Glucose
Benzos - diazepam, lorazepam, chlordiazepoxide
Propofol if refractory DTs
Intubate/mechanically vent (increased mortality rates)

Question 7

Indications for emergent hemodialysis in acute renal failure

Answer 7

AEIOU

Acidosis, metabolic
Electrolytes - refractory hyperkalemia K >6.5
Intoxication/toxins
Overload with fluid refractory to diuresis
Uremia - uremic pericarditis/encephalopathy

Question 8

Dialyzable drugs and toxins

Answer 8

ISTUMBLED

INH, Isopropyl alcohol
Salicyclates
Theophylline
Uremia
Methanol
Barbiturates
Lithium
Ethylene glycol
Dabigatran (Pradaxa), divalproex (Depakote)

Question 9

Ppx for cat and dog bites

Answer 9

Augmentin

Or can use one of the following with flatly or clinda
Pen V/K
Cefuroxime
doxycycline
moxifloxacin
bactrim

Question 10

Tx of infected cat and dog bites

Answer 10

cover for Pasturella multocida

Wound Cx

IV Abx:
Unasyn
Zosyn
Timentin (ticarcillin-clavulanate)
3rd gen cephalosoporin + flagyl
Fluoroquinolone + flagyl
meropenem
ertapenem

Question 11

Heat exhaustion vs exertional heat stroke

Answer 11

Core temp by rectal temp

Heat exhaustion: difficulty with exercise, core temp 101-104, NO CNS dysfunction

Exertional heat stroke: core temp >104, with CNS dysfunction

Question 12

Td recommendations for non-tetanus prone wounds

Answer 12

Lower extremity, clean and minor

3 or more tetanus immunizations - give Td if >10 y since last dose

Uncertain or less than 3 prior tetanus immunizations - give Td (DT if under 7yo, or Tdap if 19-64) then complete series of 3

Question 13

Td recommendations for tetanus prone wounds

Answer 13

Dirt, contamination, puncture, crush injury

If 3 or more tetanus immunizations - give Td if >5 y since last

Uncertain or less than 3 prior tetanus immunizations - give Td (DT if under 7 yo or Tdap if 19-64) as well as tetanus IG 250 units IM at another site other than Td given then complete series of 3

Question 14

Treatment of carbon monoxide poisoning

Answer 14

High flow O2 via non-rebreather
intubation
hyperbaric O2

If related to smoke inhalation tx coexisting cyanide poisoning

• hydroxycobalamine
• sodium thiosulfate
• amyl or sodium nitrate

Question 15

Congenital vs acquired methemoglobinemia

Answer 15

congenital - inability to reduce ferric form of iron to ferrous leading to reduction of ability to form hemoglobin

acquired - increased amount of ferric state of Fe due to a substance

Question 16

Treatment of acquired methemoglobinemia

Answer 16

avoid triggering agents: Dapsone (used to tx PJP, dermatitis herpetiformis), topical anesthetics, nitrates, aniline dyes
Methylene blue (avoid in G6PD) or ascorbic acid
Blood or exchange transfusion
Hyperbaric O2

Question 17

Substances known to cause malignant hyperthermia

Answer 17

Volatile anesthetics
- Halothane
- -Fluranes (desflurane, enflurane, isoflurane, seroflurane)
Succinylcholine

Question 18

Treatment and monitoring of malignant hyperthermia

Answer 18

Stop affording agent
100% O2 and hyperventilate
Dantrolene

Monitor:
elytes: hyperK - CaCl, bicarb, furosemide, insulin/d50
ABG/VBG: acidosis - give bicarb
Glucose
CPK
Coags
Monitor temps - >39 C or 102.2F cool down to 101.3 or 38C
Monitor for dysrhythmias - ACLS protocols

Counsel patient to avoid agent