COMBANK EM COMAT Flashcards
Tx of symptomatic LBBB
- LBBB considered a STEMI-equivalent
- reuires thrombolysis
consent for minor if parents not present
- after appropriate attempts have been made to contact parent, an adult who presents with the child may give consent for tx
- if child old enough to understand medical condition and tx plan, tey may give consent themselves
- this only applies to tx necessary for stabilization and emergency medical conditions
at what age is child old enough to understand medical condition and tx plan
have to assess. But recc is over 14yo
sx of iritis
ciliary flush (redness/irritation around the iris itself) and miosis
acetaminophen dosing for kids
10-15mg/kg q6h
not to exceed 75mg/kg in a day
ibuprofen dosing for kids
10mg/kg q6h
(not to exceed 40 mg/kg in a day)
- can only use in kids >6mo
buckle fx
- aka torus fx
- seen in kids
- bulging of bony cortex or periosteum, usually involving metaphysis, following compressive forces
buckle fx tx
splinting in a position of function with ortho f/u in 1w
vent settings:
I:E ratio for COPD/asthmatics
1:4
vent settings:
PEEP normal
- should be 5 mmHg PEEP
- important in drownings
vent settings:
FIO2 normal
- start at 100%
- once PaO2 comes back, decrease to 40-60%
Cushing’s triad
- HTN, bradyC, irregular respirations
- indicates SAH
mechanism of SAH vs epidural hematoma
- SAH can form spontaneously (Ex/ from uncontrolled HTN), while epidural need trauma
prolactin and SZ’s
prolactin is a very acute phase reactant. Will be elevated for a short time following SZ.
- time sensitive test, has to be drawn w/in 15-30min after SZ activity
- can help r/o or r/i pseudoSZ
posterior Chapman’s points for adrenal gland
between spinous and transvers processes of T11 and T12 posteriorly
pancreas ant and post CP’s
- ant: lateral to the costal cartilage between the 7th and 8th ribs on the R
- post: transverse process of T7 and T8 on the R
sympathetic viscerosomatic reflex at C4-C5
reflexes of the phrenic nerve
timeline for primary closure of wound
6hr deadline for suturing
spasmodic croup vs viral laryngotracheobronchitis
spasmodic croup has same path but is short interval of spasm without associated fever or retractions
what does low O2 sat on pulse ox but normal PaO2 on ABG mean?
methemoglobinemia
— tx is methylene blue
anterior wall MI, ST elevation seen in leads …
V1-V4
lateral wall MI, ST elevation seen in leads …
V5, V6, I, and AVL
when anterolateral or inferolateral this changes to V5-V6, and I and/or AVL
inferior wall MI, ST elevation seen in leads …
II, III, AVF
with reciprocal ST flattening in anterior leads (V1-V3)
nosebleed management steps
- Direct pressure (regardless of severity)
- Spray alpha-adrenergic agonist (oxymetazoline, aka Afrin) to vasoconstrict blood vessels
- cautery (silver nitrate or electric)
- nasal packing (gauze, balloon, thrombogenic foam)
uveitis sx and exam
- ocular pain, blurred vision, injected sclera
- slit lamp shows cells and flare in anterior chamber
corneal abrasion sx and exam
- pain, FB sensation, eye redness, can have decreased visual acuity
- fluorescein stain slit lamp exam showing epithelial defect/FB
conjunctivitis sx (viral, allergic, bacterial)
- allergic/viral: clear watery DC, stringy white mucus
- bacterial: yellow purulent DC
- viral: additional reauricular adenopathy
central retinal vein occlusion sx and exam
- GRADUAL PAINLESS monocular vision loss
- see optic disc edema, numerous retinal hemorrhages, cotton wool spots in macular edema, and dilated congested veins (blood and thunder appearance of retina)
central retinal vein occlusion sx vs central retinal ARTERY occlusion
- vein sx occur gradually,
artery sx sudden-onset
central retinal artery occlusion sx and exam
- SUDDEN PAINLESS unilateral vision loss
- exam shows cherry red macula and pale spot between macula and optic disc
risk factors for central retinal artery occlusion
temporal arteritis, trauma with fat embolus, sickle-cell dz, diabetes, hyperviscosity syndrome (multiple myeloma), atherosclerotic plaque embolization to retinal a (usually from internal carotid a)
acute angle closure glaucoma sx and exam
- SUDDEN onset PAINFUL unilateral vision loss, blurry vision with halos around lights, HA, n/v
- exam shows fixed and dilated pupil nonreactive to light (or sluggish), injected conjunctiva, steamy/hazy cornea, elevated IOP
succinylcholine SEs and Contraindications
- SE: malignant hyperthermia, increased IOP, hyperK, rhabdo
- contraindications: ocular surgery, penetrating eye injurys, closed-angle glaucoma, hx acute malignant hyperthermia, myopathies associated with elevated serum CK, truamas that may result in rhabdo (burns, crush)
Bell’s palsy tx
- corticosteroids alone or with antivirals
- no scan needed
activated charcoal doesn’t work for:
- ionic compounds (Li, Ca, K, Na, Mg, Fluoride, I)
- heavy metals: (Arsenic, Pb, Mercury, Fe, zine cadmium)
- acids/bases
- hydrocarbons (alkenes, alkanes, alkly halides, aromatics)
- essential oils
- alcohols (acetone, ethanol, ethylene glycol, methanol, isopropanol)
lithium tox sx
AMS, n/v, defecation, urination, tachyP, sweating
epinephrine antidote
phentolamine (alpha-1 adrenergic blocker)
signs of prerenal cause of kidney dysfunction
BUN:CR>20
UNa <10
FENa <1%
FEUrea <35%
regions affected by C1-C2 level parasympathetic dysfunction
(via vagus n) kidney upper ureter ovaries, testes ascending colon, transverse colon
regions affected by S2-S4 level parasympathetic dysfunction
(via pelvic splanchnic nn) lower ureter bladder urethra prostate uterus, proximal fallopian tubes descending colon, sigmoid colon, rectum
how to test for CO poisoning
ABG to measure carboxyhemoglobin levels (>15% in smokers, >3% in non-smokers)
sx of CO poisoning
HA, n/v, AMS
subarachnoid hemorrhage on CT
high-attenuating, amorphous substance that fills in the normally dark, CSF-filled subarachnoid spaces around the brain. Normally black subarachnoid cisterns and sulci appear white in acute hemorrhage.
subarachnoid hemorrhage sx
sudden HA with maximal intensity at onset (thunderclap, worst HA of life)
nv, meningismus, or LOC
subdural hematoma on CT
“cresecent”-shaped area of hemorrhage
epidural hematoma on CT
“lens”-shaped area of hemorrhage
s/sx opioid overdose
- classic triad: depressed or altered mentation, decreased RR, pin point (miotic) pupils
- decreased bowel sounds,
hemodynamic instability, bradyC, hypoT, apnea, hypothermia
review other overdose s/sx and tx
(maybe in psych cards)
Tx of esophageal variceal bleeding
- airway management
- hemodynamic stabilization
- emergent upper endoscopy
- resuscitation with IV fluids or blood produces for massive hemorrhage
- continual octreotide or somatostatin
- treatment of coagulopathy (ex/ anticoagulant reversal)
- abx prophylaxis
GCS components & score range
eye opening
motor response
verbal response
3-15
GCS: eye opening scoring
4 - opens eyes spontaneously
3 - opens eyes in response to speech
2 - opens eyes in response to painful stimulus
1 - doesn’t open eyes
GCS: motor response scoring
6 - follows commands
5 - makes localized movement in response to painful stimulation
4 - makes nonpurposeful movement in response to noxious stimulation
3 - flexes upper extremities/extends lower extremities in response to pain
2 - extends all extremities in response to pain
1 - makes no response to noxious stimuli
GCS: Verbal response scoring
5 - oriented x 3 4 - converses, may be confused 3 - replies with inappropriate words 2 - incomprehensible sounds 1 - no response
“J” or Osborne waves associated with…
hypothermia
(not pathognomonic though)
— can also see T wave inversions, interval prolongation (PR, QRS, QT), and dysrhythmias
signs of hypothermia
- core temp <95F
- decreasing metabolic activity: bradyC, hypoT, dysrhythmias
- “J” or Osborne waves
acute psoas spasm presentation
torso flexion
low back pain radiating to the pelvic area
increased pain with standing
tx of B blocker OD
Obs or Glucagon (competitive inhibition)
warfarin reversal for INR 3.5-5 (w/o major bleeding)
lower warfarin dose or omit a dose
warfarin reversal for INR 5-9 (w/o major bleeding)
skip next 1-2 doses
+ administer 1-2.5mg Vit K orally
warfarin reversal for INR >10 (w/o major bleeding)
skip next 1-2 doses
+ administer 2.5-5mg Vit K orally
warfarin reversal for elevated INR w/ major bleeding
10mg Vit K IV
3-4u FFP
splint for
- ulnar fx
- scaphoid fx
- DeQuervain’s dz
- spiral fx of ulna and radius
- ulnar gutter splint for ulnar fx
2-3. radial gutter splint for Scaphoid fx and DeQuervain’s dz - Sugar Tong splint for spiral fx of ulna and radius
w/u for fever of unknown origin in kid less than 3yo
blood cultures
urine
CSF
chest radiograph
age where you can’t give ceftriaxone
less than 30 days old
— displaces bilirubin resulting in jaundice, kernicterus, and brain damage
tx of tension PTX vs simple PTX
Tension PTX needs immediate decompression with needle thoracostomy followed by chest tube placement.
Simple PTX treated with chest tube.
what’s urushiol
causative agent in Rhus dermatitis or poison ivy dermatitis
pancreatitis s/sx
fever, epiG pain rad back, n/v, shock, Cullen’s sign, Grey Turner sign
Cullen’s sign
periumbilical discoloration
seen in pancreatitis
Grey Turner Sign
flank discoloration
- due to pancreatic retroperitoneal hemorrhage
(seen in pancreatitis)
Boorhaave syndrome
complete esophageal rupture
most often from extremely foreceful emesis or sudden ride in intraesophageal pressure
posterior wall MI ECG findings
tall R waves in V1-V3
ST depression in leads V1-V3
(sometimes aka inferolateral)
Todd’s paralysis
transient post-ictal paralysis
- may occur for up to 36h post-seizure
- typically disappears fairly quickly
- focal deficit (usually unilateral)
status epilepticus
sz activity lasting longer than 5 continuous minutes or that is refractory to anti-epileptics
- tx: IV/IM benzos
cocaine intox
sympathomimetic toxidrome: tachyC, hyperT, tachyP, hyperthermia, mydriasis
- can see nasal perforation, or “crack lung” (black sputum production and hypersensitivity pneumonitis)
PCP intox
AMS (comatose to profound psychomotor agitation), hallucinations, HTN, tachyC, multi-directional nystagmus
anticholinergic toxicity sx
hot as a hare (hyperthermia) blind as a bat (mydriasis) dry as a bone (dry skin/mucous membranes) red as a beet (flushed) mad as a hatter (AMS)
- also tachyC, U retention
anticholinergic toxicity tx
Suportive: IV fluids, Benzos prn
- Physostigmine if severe
cholinergic toxicity tx
atropine
pralidoxime
influenza tx for only A not A and B
rimantadine
amantadine
SIADH lab findings
elevated urine osmolality
elevated urine sodium
euvolemic hyponatremia
acid-base of salicylate toxicity
- initally presents with respiratory alkalosis due to increased RR
- then metabolic acidosis
salicylate toxicity sx
abdominal pain (epigastric) n/v irritability (poss anxiety or acutepsychoses) tinnitus tachyC and tachyP
salicylate toxicity tx
activated charcoal if within first hour
also sodium bicarb (to cause alkalinization of urine)
acetaminophen toxicity sx
n/v, abdominal pain (RUQ)
pallor, diaphoresis
signs of acute liver failure (scleral icterus, jaundice, AMS)
acetaminophen toxicity tx
N-acetylcysteine
benzo toxicity sx
decreased RR
somnolent
tx for barbiturate toxicity
none (supportive)
imaging for suspected appy
abd US first.
If doesn’t r/o appy, then CT
SIRS criteria
- temp >38C (100.4F) or <36C (96.8F)
- HR > 90
- RR > 20 or PaCO2 <32mmHg
- WBC > 12,000/mm3, < 4,000/mm3, or > 10% bands
(NO source or suspected source of infection b.c otherwise that would be sepsis not SIRS)
severe sepsis
sepsis + organ dysfunction
lactate up, U output down, acute lung injury, creatinine up, bili up, platelets down, INR up
septic shock
sepsis-induced hypotension persisting despite adequate fluid resuscitation
fluids to use in initial resuscitation after trauma
crystalloids (normal saline or lactated ringers)
- if this fails, then can do blood products (RBC, FFP)
when to use 1/2 normal saline (0.45%)
maintenance fluid in pts with water loss
ex/ DKA, gastric losses
when can you NOT use 1/2 (0.45%) NS
LIVER DZ
TRAUMA
BURNS
med tx for stable symptomatic bradyC
atropine
med tx for stable Vfib / Vtach
amiodarone
- can use for wide SVT sometimes too
med tx for stable SVT
(vagal maneuvers first)
adenosine
med tx for Afib/flutter
rate control (verapamil/diltiazem, metoprolol)
abx tx of human bit wound
Ampicillin/Sulbactam Pipercillin/Tazobactam Cefoxitin Ceftriaxone and Metro Clinda and Cipro
- has to cover aerobic and anaerobic bacterial
foods that expose to E coli O157:H7
undercooked beef, unpasteurized milk, juices, raw fruits/veggies
OMM tx of colonic sympathetics (viscerosomatic reflexes) helps with …
ileus or constipation
OMM tx of colonic PARAsympathetics (viscerosomatic reflexes) helps with …
diarrhea
contraindications to Nitro use in ACS
- Development of hypotension in pts with volume depletion
- R ventricular infarction (inferior)
- recent use of PDEi for ED
TCA overdose sx
- anticholinergic effects (dry, hot, red, blind)
- cardiac effects (prolonged QRS)
when to give tetanus prophylaxis
MINOR wounds:
- if last vacc was >10y ago
- if <3 doses tetanus toxoid vacc previously
MAJOR wounds:
- if last vacc was >5y ago
- if <3 doses tetanus toxoid vacc previously (then would also need to give human tetanus immune globulin as well)
at what hCG level can you see IUP on US
1,000-2,000 mIU/mL
dx of ectopic pregnancy
vag bleed + pain
elevated hCG
NO IUP
risk factors (previous ectopic, tubal lig, IUD, smoking, PID, multiple partners, early age of intercourse)
NO CT needed. Go to surgery.
What is TIMI risk score used for?
prognostication tool in pts with unstable angina or NSTEMI
- categorizes pt’s risk of death and ischemic events
- higher score = higher risk at 14d of all-cause mortality, enw or recurrent MI, or severe recurrent ischemia requiring urgent revascularization
How to scale TIMI risk score:
One point for each (AMERICA): Age greater than 65 Markers (elevated cardiac biomarkers) EKG (ST changes of at least 0.5mm) Risk factors (at least 3 of CAD risk factors) Ischemia (at least 2 angina episodes w/in past 24h) CAD (stenosis at least 50%) Aspirin use w/in 7d
Tx of sulfonylurea overdose
- D50
- octreotide (to inhibit additional insulin release)
- continued monitoring (12-24h effects)
human bite infectious organisms
most commonly Eikenella corrodens
- also staph and strep bacteria
s/sx of appendix testis torsion
- classic “blue dot sign”: small palpable tender nodule on the superior testis that reflects blue with light through scrotum
- usually in kids
s/sx of epididymitis
- unilateral testicular pain
- ttp
- fever
- get US to r/o testicular torsion
What can cause false positive gFOBT?
- elevated concentration of heme from recent diet of red meet
- elevated peroxidase found in some fruits and vegetables including beets
tx of Vtach with pulse vs without
- with pulse: cardiovert
- without pulse: defib
what does secondary closure mean
let wound heal on own
Sx of class I hemorrhagic shock
normal BP
HR <100
RR normal
U output normal (30 or more)
Overall normal ranges (anything above normal range moves into Class II)
blood loss of < 750 mL
Sx of class IV hemorrhagic shock
hypoT
HR >140
RR > 35
U output neglifible
pt confused, lethargic
blood loss of 2000 mL or more
heat stroke vs heat exhaustion
- heat exhaustion has no change in mental status, stroke does
- normal LFTs in heat exhaustion but not heat stroke
pericardial tamponade sx
SOB
distended neck veins
signs of shock
esp with hx trauma
opiate withdrawal sx
muscle cramps rhinorrhea sneezing yawning lacrimation (tearing) leg cramping piloerection (goose bumps) dilated pupils
treatment of PE in stable pt
- immediate anticoagulation with either unfractionated heparin or LMWH (ex/ enoxaparin)
when to use tPA in PE tx
massive PE with signs of cardaic arrest, hypoT, and R heart strain
contraindications to TPA use
suspected aortic dissection or pericarditis active internal bleeding known intracranial neoplasm ischemic CVA in the past yr previous hemorrhagic stroke ever
