COMAT EM Flashcards
Two most common causes of PUD:
H. Pylory
NSAIDs
Classic triad of NPH:
- Urinary incontinence
- Abnormal gait
- Dementia
[“wet, wobbly and wacky”]
What is the next step after heme-positive urine dipstick?
Microscopic urine analysis to differentiate between myoglobinuria (rhabdo) and hemoglobinuria (hemolysis)
What are the steps of management of anterior epistaxis (nose bleed)?
- Compress nasal ala against septum
2. Topical vasoconstrictive agents (alpha receptor agonists: epinephrine, oxymetazoline, phenylephrine)
How is the diagnosis of PID confirmed?
Transvaginal ultrasound which typically shows thickened fluid-filled fallopian tubes, possibly with associated tubo-ovarian abscess and/or free pelvic fluid.
Patients receiving TNF inhibitors (Adalimumab, etanercept, or infliximab) for autoimmune conditions are at risk for:
Reactivation of latent TB
[check for latent TB with T-cell interferon gamma release assay (IGRA) before starting these agents]
Patients with complete heart block who present with hypotension what is the next step?
Immediate pacing with transcutaneous cardiac pacing to prevent cardiovascular collapse.
What kind of edema is noted on extremities in patients with severe hypothyroidism?
Non-pitting edema (myxedema)
How is end-organ perfusion monitored in septic shock?
- HR
- BP
- Urine output (more than 0.5 mL/kg/hr is normal)
- Mental status (brain perf)
What are the first steps in management of patients with septic shock?
- Adequate venous access with two large-bore (16-gauge or larger) IV lines
- Immediate crystalloid bolus of 1 to 2 L over 30-60 minutes
- If patient’s hypotension persists with fluid challenge, then central venous access should be obtained to allow for central administration of vasopressor drugs.
What is the treatment of newly diagnosed Bells Palsy?
Oral steroids
[herpes simplex virus activation is the likely cause of facial nerve palsy in post presentation; however, antiviral agents are not indicated in all cases of bp while steroids are]
What is the first step in management of patient presenting with priapism (prolonged erection lasting more than four hours)?
Doppler ultrasound
[to differentiate between low flow and high flow priapism]
Avascular necrosis of the femoral head that occurs in children, usually without preceding illness. It causes pain and a limp and is evident n radiographs of the hip based on widening and flattening of the femoral head:
Legg-Calve-Parthes disease
What is the duration of action for naloxone?
30 minutes
[vs Heroin is 4-5 hours; therefore, multiple doses of naloxone or a continuous infusion may be needed to treat an episode of an opioid overdose]
What is the most likely complication in hypothermic patients?
Atrial and ventricular arrhythmias
[cardiac monitoring should be used]
Classes of hemorrhage:
Class I: 15% blood volume loss, no HD changes
Class II: 15-50% blood volume loss, tachycardia and narrowed pulse pressure
Class III: 30-40% blood volume loss, hypovolemic shock
Class IV: 40% blood volume, , tachycardia>140 beats/min, hypotension, and tachypnea >35 breaths/minute. End organ hypoperfusion manifesting with confusion or stupor and negligible urine output
What are the initial treatments of hemolytic transfusion reaction?
IV fluids in large bolus
Immediate cessation of the blood transfusion
Blood test performed on a pregnant woman to measure the amount of fetal hemoglobin transferred from the fetus to the mother’s bloodstream:
Kleihauer-Betke test
[The amount of RhoGAM needed to prevent development of maternal anti-Rh antibodies depends on how much fetal blood she is exposed to]
What can be beneficial for bell palsy treatment for patient presenting within the first three days or paresis?
Oral steroids (prednisone)
What is the treatment of scabies?
Oral ivermectin
What is the next step of management of patients who survive out-of-hospital, sudden cardiac arrest?
[after mechanical ventilation and IV vasopressors]
Therapeutic hypothermia
[to improve neurologic outcomes]
What is the treatment of vibrio vulnificus, a curved gram negative rod?
Doxycycline and ceftazidime
What is the first step in management of patient with acute liver failure with severe hepatic encephalopathy?
Endotracheal intubation to protect the airways
Mortality risk from SJS is influenced by what factors?
Age
Comorbidities
What factors make the patient more prone to vulvovaginal candidiasis?
Moist environments created by tight-fitting or occlusive clothing
Diabetes
Immunosuppressed
Increased estrogen level [Oral contraceptives or pregnant]
The presentation of large bowel obstruction depends on what?
Whether or not colon contents can reflux into the small bowel.
[If there is a single point of obstruction and an incompetent ileocecal valve=>colon contents are able to reflux back into the small bowel and the patient may have feculent vomiting.
If there is a closed loop obstruction (as in volvulus) or a competent ileocecal valve, the contents of the colon are unable to exit proximally=>pressure builds up, and wall tension is greatest at the region with the greatest diameter, i.e. cecum, the area of the colon most likely to perforate]
What is the management of human bite wounds?
Wound care with debridement of devitalized tissue that can potentially become nidus for bacterial infection
Red flags for low back pain:
Neurologic deficit Fever Sudden onset of pain with spinal tenderness Trauma Known or suspected malignancy
Management of digoxin toxicity:
Mild to moderate=> treat supportively with hydration and correction of electrolyte abnormalities
Severe digoxin toxicity=>treat with hospital admission and digoxin-specific antibody fragments (Fab) as we;;.
Criteria for using digoxin-specific antibody Fab in digoxin toxicity:
- Life threatening arrhythmia or cardiac arrest
- K>5 mEq/L
Types and management of acute aortic dissection:
Stanford type A=involves s the ascending aorta and requires emergent surgery
Stanford type B=involves only the descending aorta and can be treated non-operatively with blood pressure control to a level of 120/80 mmHg or lower.
What is the rash caused by Amoxicillin allergy called?
Leukocytoclastic vasculitis
[small vessel inflammation with a neutrophilic infiltrate and necrosis with nuclear debris
Causes palpable purpura that are raised, purple areas of skin discoloration that represent blood extravasation from small vessels]
Type of distributive shock in which a lack of sympathetic tone causes decreased systemic vascular resistance, leading to hypotension:
Neurogenic shock = hypotension without tachycardia
[Results from CNS injury above the level of T6, most commonly cervical or high thoracic spinal cord injury
Due to lack of sympathetic activity, there is no compensatory increase in cardiac output
Non-responsive to fluid resuscitation]
Biceps tendon rupture most commonly occurs at proximal/distal tendon:
Proximal tendon (the attachment at the shoulder
[pain and characteristic bulge over the distal humerus (“Popeye muscle”)]
What is the management of uncomplicated cellulitis (limited area on involvement, minimal pain, no evidence of sepsis, no risk factors for serious illness (debility, extremes of age, immunocompromised status))?
Empiric antibiotic treatment
Sudden onset of severe unilateral eye pain and blurred vision associated with headache and nause:
Acute angle closure glaucoma (AACG)
[at least 3 signs and 2 symptoms from the following:
Signs: Intraocular pressure over 21 mmHg Conjunctival injection Corneal epithelial edema Mid-dilated nonreactive pupil Shallow anterior chamber with occlusion
Symptoms:
Ocular pain
Nausea and/or vomiting
Hx of intermittent blurring of vision with halos]
Other physical exam findings of AACG”
Fixed, mildly dilated pupil
Hazy appearing cornea
Hard globe
What is methemoglobin?
Oxidized form of hemoglobin that is unable to bind oxygen
[more specifically, the iron in hemoglobin is oxidized from ferrous (+2) to ferric form (+3)
Under normal conditions, reducing agent NADH and NADPH can reduce methemoglobin back to ferrous state, but under conditions of oxidative stress, methemoglobin levels will rise]
What is the effect of elevated levels above 1% (methemoglobinemia)?
Hypoxia
[decreased oxygen delivery to tissues]
What can cause methemoglobinemia?
- Exposure to oxidizing agents=local anesthetic agents (prilocaine, benzocaine) and dapsone
- Congenital enzyme deficiencies
What is the treatment of methemoglobinemia?
Methylene blue=reducing agent that allows reduction of methemoglobin back to its oxygen-carrying form
How is Malaria diagnosed?
Thick and thin preparation peripheral blood smears
[Thick prep allows for evaluation of more erythrocytes.
Thin prep aids in species id’ing]
What is the most common cause of infectious conjuctivitis?
Adenovirus
What are the accepted indication for ER thoracotomy?
1) Cardiac arrest due to penetrating trauma with witnessed pre-hospital or in-hospital cardiac activity
2) Penetrating trauma related unresponsive hypotension with systolic BP less than 70 mmHg
3) Blunt thoracic injury with unresponsive hypotension (SBP<70mmHg) or large volume bleeding via chest tube
To access pericardium, heart and great vessels, where should the incision be made?
Left 5th ICS from the border of the sternum to the mid-axillary line
Signs of acute phenytoin toxicity:
- Nystagmus
- Ataxia
[also decreases folate levels which causes megaloblastic anemia and gingival hyperplasia ]
What is the finding on imaging of patients with SCFE?
Physeal fracture
[at the growth plate of the femur that occurs in obese adolescents and preadolescents]
What are the most commonly affected organ systems in hypertensive emergency (BP >180/120 +end organ damage)?
Kidney (elevated creatinine)
Heart
Arteries
Brain
Two signs of ACL injury
- Audible pop
2. Severe knee swelling
What is the landmark for tube thoracostomy (used for drainage of fluid in case of hemothorax)?
5th ICS at the mid-axillary line
What is the treatment of Wolff-Parkinson-White syndrome
Propafenone
[Medication that would slow AV nodal conduction (CCB, BB, Adenosine) may lead to ventricular arrhythmias=>NEVER use in WPW!]
In which MI’s nitroglycerin is contraindicated?
Right ventricular infarcts because they are very preload sensitive and nitro reduces preload
What is the treatment of choice of delirium in non-cooperative patient with UTI?
IV Ceftriaxone
[unlikely to cooperate with oral medications]
What are the most common pathogens that cause spontaneous bacterial peritonitis?
Gram negative rods (70%): specifically E. Coli and Klebsiella
What is the test indicated in children with suspected physical abuse?
Full radiographic skeletal survey
[the classic finding in repeated physical abuse is the presence of multiple fractures in various stages of healing]
What is the classical finding in basilar skull fractures?
Dural tears, resulting in CSF leaks from nose (CSF rhinorrhea) or from ears (CSF otorrhea)
What is the acid base disturbance in salicylate poisoning
In the initial phase usually up to 24 hours, patient exhibit a primary respiratory alkalosis with an elevated pH and decreased PaCO2. Later, there is also a concomitant primary metabolic acidosis, leading to a mixed acid-base disorder.
TRALI is caused by what?
Donor antibodies targeted against recipient white blood cells, leading to immune activation and inflammation in the recipient lungs.
TRALI occurs how long after the transfusion?
2-6 hours after
What are the symptoms of TRALI?
Picture similar to ARDS
- Dyspnea
- Hypotension
- Hypoxemia
- CXR: pulmonary infiltrates without enlargement of the heart
- No signs of circulatory overload and unresponsive to fluids
Pleural fluid in empyema:
+Gram stain and/or bacterial culture
- pH<7.2
- WBC>50,000
What is the initial management of unconscious or unresponsive patient?
ABCs=>Endotracheal intubation first
What GCS is an indication for endotracheal intubation?
GCS<6
GCS:
Eye: 1-4 (does not open eyes to opens eyes spontaneously
Verbal: 1-5 (makes no sound to converses normally)
Motor: 1-6 (makes no movement to obeys commands)
What kind of pain management should elderly patients with hip fracture receive in the Emergency room?
Regional anesthesia
[specifically with femoral nerve block can reduce need for opioid analgesia]`
What are the most common causes of cardiac tamponade?
- Uremia
- Severe idiopathic pericarditis
- Metastatic pericardial disease
[requires emergency intervention with pericardiocentesis]
What is the diagnostic test of choice for acute pancreatitis?
Lipase
[more specific than amylase for acute pancreatitis]
The most commonly injured structure in mid-shaft humerus fractures:
Radial nerve
What is the management of Borhaave syndrome (spontaneous rupture of esophagus)?
NPO status
IV PPIs
IV antibiotics
[EGD not recommended in patients with evidence of sepsis]
What is the prophylaxis for PCP?
TMP-SMX
Illicit drug that causes altered mental status, unconsciousness, and impaired recall:
Gamma-hydroxibutyric acid (GHA)
[often used in conjunction with alcohol and is known as a date rape drug]
Spinal metastasis occurring BELOW the cervical spine can cause what?
Paraplegia
Spinal metastasis occurring in the cervical spine can cause what?
Quadriplegia
What is the most important aspect of management of Hyperosmolar hyperglycemic state (HHS)?
Volume repletion with IVFs
[Insulin administration is necessary but should not be initiated until electrolyte levels have been obtained]
What are the two modalities that provide mortality benefit in COPD patients?
Smoking cessation
Oxygen therapy
Bacterial thrombophlebitis of the internal jugular vein:
Lemierre syndrome
[most commonly occurs as a complication of polymicrobial pharyngitis and/or peritonsillar abscess.
Fusobacterium necrophorum is an anaerobic gram-negative rod that is the most common pathogen seen in Lemierre syndrome]
What is the management of meningitis in patients with papilledema?
CT scan first
then LP
[papilledema indicates possible elevated ICP and an increased risk of cerebral herniation with LP]
What is the most common complication of anterior shoulder dislocation?
Recurrent dislocation
[Younger age is an important predictor of recurrent dislocation (50-90% in patients <20 yo]
What are the electrolyte imbalances found in rhabdomyolysis?
Hypocalcemia (results from the deposition of calcium phosphate into the muscle)
Hyperkalemia and hyperphosphatemia (due to muscle injury and renal dysfunction)
Hyperuricemia
Elevated LDH
Elevated ALT/AST
[due to muscle injury and intracellular contents being released]
Rare drug reaction most commonly associated with antipsychotic drugs characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction:
Neuroleptic malignant syndrome (NMS)
[associated with elevated creatine kinase (CK) due to muscle injury]
Short acting, IV anesthetic agent commonly used for rapid sequence intubation:
Etomidate
What is a rare but important side effect of etomidate?
Acute adrenal insufficiency due to the suppression of the adrenal synthesis of cortisol
What is the first step in managing symptomatic bradycardia?
Atropin (0.5 mg IV per dose)
[different from the dose for PEA which is 1mg IV per dose]
What is the management of HELLP syndrome?
IV Magnesium sulfate
[should be given immediately until at least 24 hours after delivery]
When non-cross matched blood is given to a patient of unknown blood type, what type should it be?
O
Negative in reproductive age women
Positive in everyone else
