E MED Flashcards
Top ddx for abdominal free fluid in female with UPT negative
Ruptured ovarian cyst
Mx of biliary cholangitis
Abx(roc and flagyl) + ERCP
Most common triggers of pancreatitis
1.Biliary stones
2.Alcohol
Most common causes of small bowel intestinal obstruction
- Hernia
- Adhesions(if prev abdo surgery)
Most useful POCTs for abdo pain
UPT
Urine dipstick
ABG/istat
Capillary glucose
ECG
bedside Ultrasound
Facets of Mx of Asthma exacerbation
O2
Salbutamol
Ipratropium
Corticosteroids
MgSO4 if severe
Intubation if severe
Tension pneumothorax definition
Pneumothorax with hemodynamic instability(tachycardia,hypotension cyanosis,cardiac arrest)
Aspiration site for pneumothorax
2nd intercostal space mid clavicular line
Chest tube insertion site
Triangle of safety
Above 5th intercostal space/above level of nipples
Posterior to edge of pec major
Anterior to edge of lat dorsi
Radiological sign for SAH
Star sign on NC CT Brain
Mx of SAH
BP control to prevent hematoma expansion
Thus IV antihypertensive eg Labetalol,nifedipine
Types of primary headaches
Tension headache
Cluster headache
Migraine +- aura
Mx of migraine
1st line:paracetamol, nsaids and antiemetics
2nd line: migraine specifics 3g triptans, ergotamine
Migraine prophylaxis eg topiramate, beta blockers
Causes of heart blocks
ACS(AV node supplied by RCA)
Drugs(AV nodal blocking agents eg BB,CCB,digoxin)
Electrolytes eg K+
Myocarditis
MOA of calcium gluconate
Stabilises cardiac membrane by reducing gradient between resting membrane potential and threshold
Toxins that are exacerbated by excessive oxygenation
Chlorine poisoning
Ammonium Chloride poisoning
Toxins where intubation may not be necessary due to their respiratory alkalemic effect
Salicylate,toxic alcohols,metformin
Types of toxidromes
Fast
Slow
Wet
Dry
Antidote for opioids
Naloxone(Narcan)
Triad of opioid toxidrome
Pinpoint pupils,respi depression, unconscious
Triad of serotonin syndrome
Neuromuscular excitability
AMS
Autonomic dysfunction
ECG changes of Na channel poisoning,K channel poisoning
Na channel: QRS prolongation
K channel: QTc prolongation
Methods of decreasing GIT removal of poisoning
Gastric lavage
Single dose activated charcoal
Whole bowel irrigation
Physical removal from bowels
Name antidotes for paracetamol, salicylate, opioids and TCAs
Paracetamol: N acetyl cysteine
Salicylate: Na bicarb
Opioids: Naloxone
TCA: Na bicarb
Main clinical concern in a patient with hemoptysis
Airway compromise(choking) rather than hemodynamic instability due to blood loss
expected HR in a severe asthma episode
> 110
Markers of imminent respiratory arrest
AMS, Bradycardia and a silent chest
What is the cause of metabolic acidosis in asthma
Beta adrenergic stimulation leading to increased lactate pdn
Best drug for rapid sequence intubation(RSI) in asthma
Ketamine, which also helps reduce bronchospasm
Most common causes of ARDS
Trauma
Sepsis
DDx for low consciousness and respiratory depression
Opioid overdose
Brainstem stroke/bleed
Common causes of type 1 respiratory failure( Hypoxemia)
Acute pulmonary oedema(APO) or acute lung injury
Common causes of type 2 respiratory failure( Hypercapnea)
- Airflow obstruction
- Decreased respiratory compliance
- Decreased respi muscle power 2* NMJ issues
- Central respi failure causing decreased respi drive
sign of chronic respiratory failure
1.pH is only decreased by 0.03/ 10mmHg compared to 0.08 in acute RF
2. Compensatory polycythemia
3.Cor pulmonale
FiO2 of assisted breathing
Room Air: 0.21
Nasal cannula: +0.04/L
Venturi:0.4-0.6
Non rebreather mask: 0.6-0.9
Berlin definition of respiratory failure
- Acute onset <1/52
- Bilateral opacities consistent w APO, on CXR or CT
- P/F ratio <300, minimum 5cmH2O PEEP
4.Not fully explained by CHF or fluid overload
Invx for asthmatic pt
- FBC tro infection
- RP tro hypoK induced by salbutamol
- CXR tro pneumothorax
- ABG
ABG differences in mild vs severe asthma
pH: alkalemia vs acidemia
PaCO2: low vs high
PaO2: normal vs low
bicarb: normal vs low
Outpatient Mx of pneumonia
Macrolides eg Clarithromycin(clacid)
Fluoroquinolones eg levofloxacin
Ddx for ST elevations in AvR
Proximal LAD occlusion
LMCA occlusion
Triple vessel disease
Cardiopulmonary causes of raised troponins
AMI
Myocarditis
Pulmonary embolism
Heart Failure
Tachydysrhthmias
Non cardiopulmonary conditions causing raised troponins
Renal failure
Sepsis
Stroke
SAH
Role of CXR in chest pain evaluation
- Check for Cx of AMI eg APO
- Check ETT is placed correctly
- Rule out other causes of chest pain eg aortic dissection, pneumothorax, pulmonary embolism
What does unexplained hypoxaemia with a clear CXR raise suspicion of?
Pulmonary embolism
Mx of STEMI
DAPT: SOLUBLE aspirin in water+ticagrelor/clopidogrel
O2 only if necessary
Judicious fluid challenge
Fentanyl if severe pain
Send to cath lab for PCI
Impt facets of answering a ED management question
- Triage into which category
- Place on continuous spO2 and ECG monitoring
- Judicious fluid challenge
- POCT, bloods and imaging studies
5.Who needs to be referred
Mx of Acute Pulmonary Edema
1st line: High dose IV GTN to reduce preload and afterload + NIV/intubation
Ace inhibitors
IV furosemide 30mins after GTN, make sure pt not hypovolemic
Beta blockers CI in APO
Triggers for decompensated heart failure
1.ACS
2.Arrhythmia eg AF
3 Non compliance to med/fluid restriction
4.Uncontrolled HTN
5.Progressive valvular disease eg MR
6.High output cardiac failure- thyrotoxicosis,anemia etc
7.Post partum CMP
Signs of pulmonary embolism on ECG
Right heart strain: Sinus tachycardia and T wave inversions
Classically but kess commonly S1Q3T3
Mx of massive pulmonary embolism
- Thrombolysis with rTPA
- Perc or open thrombectomy or embolectomy
Mx of submassive pulmonary elbolism and low risk PE
Submassive:Heparin/clexane
Low risk:NOACs eg rivaroxaban/apixaban
6 Life threatening causes of chest Pain
Unstable angina
STEMI/NSTEMI
Aortic dissection
Pulmonary embolism
Tension Pneumothorax
Esophageal rupture
Why do right sided leads in Inferior MI?
To rule out RV infarct, where giving GTN will cause hypotension
What should be ruled out in chest pain with neurological Sx?
Aortic dissection
Ddx for dengue
Zika,chikugunya,other viruses
Indications for platelet transfusion in dengue
Severe bleeding manifestations eg ICH,BGIT
Causes of wide complex tachycardia
- VT
- Drugs eg TCA poisoning
- HyperK
4 aberrancy?
Cushings triad
Widened pulse pressure
Bradycardia
Irregular respiration
A reflex to increased ICP
Definition of open book pelvic fx
Fratured at 2 points eg SIJ and pubic symphysis
Format of handover from paramedics in trauma
MIST
Mechanism
Injury
Signs
Treatment given
What is massive transfusion protocol
Equal ratio of blood:platelets:plasma
O+ blood
Stroke mimics
Hypoglycemia
Seizures
Todd’s paralysis
Brain bleed
Space occupying lesion
CNS infections
Toxic causes
Headache red flags
Thunderclap headache:SAH
Progressively worsening sx: Tumor
Neurological symptoms: Stroke
Meningism:Meningitis
Trauma
Red flags for headache
Thunderclap headache:SAH
Signs and sx of testicular torsion
Testicular pain
Abdominal pain
Retracted testis
Vomiting
Loss of cremasteric reflex
Invx for suspected testicular torsion
Surgical exploration
US testis for whirlpool sign(if it does not delay surgery)
Mx of testicular torsion
Orchidopexy
Orchidectomy
Sepsis 7
Take 2
-Blood cultures
-Lactate and BG
Give 2
-high gflow O2
-IV abx
+-IV fluids and hydrocortisone
Monitor
-UO
-NEWS2
Mimics of inferior MI
Aortic dissection involving right coronary artery
How to rule out aortic dissection
Differential arm BPs
RR and RF delay
Widened mediastinum >8mm on AP
Mx of hyperK
Insulin bolus
Calcium gluconate to stabilise cardiac membrane
Resonium
Nebulised Salbutamol
Dextrose to maintain normogly
Contraindications to IDC
High riding prostate
Bleeding around meatus
Bruising around perineum
Treatment of SVT
Vagal maneuvers: Carotid massage, blow thru tube
Pharm: Adenosine
Synchronised cardioversion
Treatment of VT
Stable: Amiodarone
Unstable
Epi+amiodarone+defibrillation
Treatment of VF
Epi+amiodarone+defibrillation
Ddx of SVT
Sinus tachycardia
A fib
A flutter
Weakest wall of orbital cavity
Medial wall with medial blowout fx
NOT orbital floor
Mechanism of injury in extra dural hemorrhage
Middle meningeal artery rupture or injury to dural veins
Common signs in intracranial hemorrhage
Effacement of ventricles
Midline shift
Treatments for respiratory acidosis
Treat underlying cause
NIV or Intubation: increased RR and tidal volume
Main considerations in placing chest tube
Triangle of safety(behind pec major, in front of lat dorsi,4th intercostal space or above)
Right above the rib to avoid damaging the neurovascular structures below the rib
6 Hs and 5 Ts of reversible causes of cardiac arrest
Hypovolemia
Hypoxia
Hypothermia
Hypo/Hyperkalemia
Hypoglycemia
Hydrogen(acidosis)
Toxins(DO)
ECG signs of pulmonary embolism
- Sinus tachycardia
- Signs of right heart strain(RAD, RBBB, right sided ischemia)
- S1Q3T3
ddx of narrow complex tachycardia1
sinus tachy
A fib
A flutter
SVT
ddx of ST elevation in AvR
- TVD(Triple Vessel Disease)
2.Proximal LAD occlusion - Critical but not total LMCA occlusion
Torsades de pointes mx
Magnesium sulphate
Sync cardioversion
What is water bottle shaped heart on CXR a sign of?
Pericardial effusion
Signs of lidocaine toxicity
Circumoral numbness
Tongue paresthesia
Tinnitus
BOV
Restlessness,agitation
Seizures
Types of anaesthetia used for manipulation and reduction
Hematoma block
Biers block
Cause of abdominal pain and N/V that is often missed
Diabetic Ketoacidosis
Anion
What is a flail chest and its complications
3+ ribs that are fractured in 2 or more places
Interferes with breathing
Words to describe intracranial hemorrhages
SDH:Lentiform
EDH:Biconvex
SAH:Star sign
Treatment of VT
Pulseless: Same as VF
Unstable: synchronised cardioversion
Stable: IV amiodarone or lidocaine
Causes of shock
Cardiogenic
Obstructive
Distributive
Hypovolemic
3 main causes of obstructive shock
Tension pneumothorax
Pulmonary embolism
Cardiac tamponade
3 main causes of distributive shock
Anaphylaxis
Sepsis
Neurogenic shock
Intracranial causes of AMS
1) CVA: Stroke/hemorrhage
2) Seizure
3) Infection eg meningoencephalitis
4) Trauma
5) Space occupying lesions Encephalopathy
Encephalopathy
Extracranial causes of AMS
1) POCT: hypogly, hypoxia, hypercapnea, hypotension
2) Sepsis
3) Endocrine: Thyroid storm of hypothyroid
4) Electrolytes
5) Substances
6) Heat stroke
7) Psychiatric causes
Function of atropine
Bradycardia, to increase HR
6 Ps of compartment syndrome
Pain
Pulselessness
Paresthesia
Paralysis
Poikilothermia
Pallor
Scoring system for massive transfusion protocol
ABC Score( Assessment of Blood consumption)
Elements of Massive Transfusion Protocol
1:1:1 ratio of pRBC,FFP and Platelets/Cryoprecipitate
Eye opening scoring of GCS
4: Spontaneous
3: Sound
2: Pain
1: Nil
Verbal scoring of GCS
5: Coherent
4: Confused
3: Inappropriate
2: Incomprehensible
1: Nil
Movement scoring of GCS
6: Spontaneous
5: Localises pain
4: Moves away from pain
3: Abnormal Arm flexion
2: Abnormal arm extension
1: Nil
Type of hematoma that causes lucid interval
Epidural hematoma
Max size of urolith that will pass spontaneously
about 5mm
what is special about plasma lyte
Highest osmolarity, fluid with lowest risk of raising ICP
biggest cervical vertebrae onXR c spine
C2
Patients for which flumazenil is CI
Long term BZD use, it may causes seizure
Scoring system for Sepsis
qSOFA or SOFA
Antidote for Paracetamol overdose
N Acetylcysteine or Single Dose activated charcoal(if within 1hr)
Common Cx of giving NAC antidote
Anaphylactoid reaction( NOT anaphylaxis)
7 Ps of RSI
- Prepare equipment
- Pre oxygenate without bagging
- Pretreatment
4.Paralysis and induction - Positioning
- Placement with proof
- Postintubation(Ventilate)
continuous vs bilevel PAP indications
continuous: Fluid overload/ Pulmonary edema
bilevel: Hypercapnea eg type 2 respiratory failure
Normal pre vertebral space in C spine XR
C2: 2mm
C7:22mm
???
4 2 1 rule of fluid resus(Holliday Segar Method)
4ml/kg/hr for first 10kg
2ml/kg/hr for next 10kg
1ml/kg/hr for every kg beyond 20kg
POCTs useful for suspected AAA
Urine dipstick for hematuria
Ultrasound
best nsaid for ureteric colic
NSAIDs, reduces urteric SM tone so stone can be passed amd reduces ureteric spasm
types of non invasive ventilation
cPAP and biPAP
Cortical signs of stroke
Visual field defects
aphasia
Hemineglect
???
NEXUS C Spine Imaging rule
NSAID
Neuro deficits
Spinal tenderness
AMS/Consciousness affected
Intoxication present
Distracting injury
Electrolyte disturbance caused by salbutamol
hypoK
Mx of HyperK
Calcium gluconate
Insulin( If glucose is normal)
Dextrose drip
Salbutamol
Hemodialysis may be indicated if CKD is underlying cause
Why is atropine given together with neostigmine for NMBA reversal
To avoid cholinergic crisis
Electrolyte derangement most likely to cause neurological changes
Sodium
Best test for Hemothorax
Bedside Ultrasound
