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Emerg > ECEs: Chest, abdo, pelvis > Flashcards

ECEs: Chest, abdo, pelvis Flashcards

1
Q

What is the DDx for abdo pain in the RUQ?

A 
Hepatitis
Biliary colic, Cholecystitis/Cholangitis
Pancreatitis
Pneumonia, Pleural effusion, PE
DEADLY: Chole, pancreatitis, PE
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2
Q

What is the DDx for abdo pain in the LUQ?

A

Pancreatitis
Gastritis
Pneumonia, Pleural effusion, PE
DEADLY: Pancreatitis, PE

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3
Q

What is the DDx for abdo pain in the RLQ?

A

Appendicitis
Ectopic pregnancy, PID, tubo-ovarian abscess, ovarian torsion
Testicular torsion, epidiymitis, orchitis
Renal colic
DEADLY: ectopic pregnancy

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4
Q

What is the DDx for abdo pain in the LLQ?

A

Diverticulitis
Ectopic pregnancy, PID, tubo-ovarian abscess, ovarian torsion
Testicular torsion, epidiymitis, orchitis
Renal colic
DEADLY: Diverticulutis, ectopic pregnancy

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5
Q

What is the DDx for epigastric abdo pain?

A

Gastritis, dyspepsia, PUD, duodenitis
Pancreatitis
ACS (Cardiac)
DEADLY: Pancreatitis, ACS

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6
Q

What is the DDx for periumbilical abdo pain?

A

Colitis, Perforation, Obstruction
Aortic dissection, AAA
DEADLY: … all except colitis.

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7
Q

What is the DDX for suprapubic abdo pain?

A

UTI, renal colic
Obstruction
Deadly: none.

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8
Q

What is the DDx for R or L flank abdo pain?

A

Colitis, perforation, Obstruction
Renal colic, pyelonephritis
AAA
DEADLY: Perforation, obstruction, AAA

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9
Q

What are the risk factors for ruptured ectopic pregnancy?

A 
Hx of STI/PID
Recent IUD
previous ectopic
Fallopian tube surgery, tubal ligation
Smoking
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10
Q

What are the risk factors for ruptured AAA?

A

Elderly, HTN/DM, smoking, trauma

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11
Q

What are the risk factors for pancreatitis?

A

EtOH, biliary pathology

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12
Q

What is the classic clinical presentation of cholangitis?

A

Charcot’s triad: fever, RUQ pain, jaundice

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13
Q

What are the risk factors for mesenteric ischemia?

A

Elderly, CAD, CHF, dehydration, infection

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14
Q

What are the risk factors for bowel obstruction?

A

Operative or malignant history, elderly

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15
Q

What are the risk factors for bowel perforation?

A

Risk factors for diverticulitis or ulcer; malignancy; instrumentation (eg colonoscopy)

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16
Q

What are the risk factors for complicated diverticulitis?

A

Elderly, low-fibre diet, Western population

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17
Q

What would you elicit on Hx for acute abdo pain?

A

OPQRST

Associated Sx: N/V, fever, chills; BM; urinary Sx; pelvic discharge/bleeding

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18
Q

What labs would you order for acute abdo pain?

A

CBC, lytes, BUN/Cr, LFTs, lipase, lactate, B-hCG

Consider: CK, troponin

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19
Q

What imaging & other Ix would you order for acute abdo pain?

A

ECG, CXR, consider bedside US

Consider formal US (biliary, ectopic, AAA); consider CT abdo/pelvis

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20
Q

How do you acutely manage acute abdo pain, in general?

A

ABCs
Analgesics
Anti-emetics
NPO; consult surgery as needed

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21
Q

What is the “deadly six” DDx for acute chest pain?

A 
PET MAT:
Pulmonary embolism
Esophageal rupture/mediastinitis
Tension pneumothorax
Myocardial infarction
Aortic dissection
Tamponade
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22
Q

What are the cardiac causes of acute CP?

A

DEADLY: MI, aortic dissection, tamponade

Pericarditis, Myocarditis, Endocarditis

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23
Q

What are the respiratory causes of acute chest pain?

A 
DEADLY: PE, tension pneumo
Pneumonia
Pleural effusion
Acute chest syndrome (sickle cell)
Lung or mediastinal mass
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24
Q

What are the GI causes of acute chest pain?

A

DEADLY: Esophageal rupture/mediastinitis
Esophagus: Mallory-Weiss tear, esophageal spasm
Stomach: GERD, ulcer
Pancreas: pancreatitis
GB: biliary colic, cholecystitis, cholangitis

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25
Q

What is dyspepsia?

A

sensation of pain or discomfort in the upper abdomen, often recurrent. Not specific to etiology (can be recurent postprandial, could be MI, could be ulcer).
(may be described as indigestion, gassiness, early satiety, postprandial fullness, gnawing, or burning)

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26
Q

What are the MSK, neuro, & psych causes of acute chest pain?

A 
Intramuscular pain
Rib pathology
Herpes zoster
Rib pathology
None deadly.
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27
Q

What history do you want to elicit for acute chest pain?

A

OPQRST, cardiac risk factors, PE risk factors, recent trauma, neuro Sx

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28
Q

What parts of the physical exam are important for acute chest pain?

A

General appearance
Cardiac & resp exams
Neuro screen
Vitals, Pulse

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29
Q

What are the initial Ix for acute chest pain?

A

Tests: ECG, CXR; consider CT pulmonary angio
Labs: CBC, lytes, abdo panel, cardiac markers; consider D-dimer

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30
Q

What are the cardiac markers? (bloodwork)

A

CK and TnI (Creatine kinase & troponin I)

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31
Q

What is the general management for acute chest pain?

A 
ABCs
Monitors
Oxygen
Vitals
IV access
Gather equipment
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32
Q

What is the acute management for ACS?

A 
ASA
Nitro (avoid in RV infarct)
Clopidogrel/ticagrelor
LMWH
code STEMI (PCI vs thrombolytics)

mnemonic:
ANCLE: ASA, Nitro, Clopidogrel, LMWH, Emergent cardio consult

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33
Q

What is the acute management for PE?

A

Anticoagulation

Consider thrombolysis for massive PE

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34
Q

What is the acute management for esophageal rupture?

A

Urgent thoracic surgery consult
IV Abx
NPO
Further imaging

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35
Q

What is the acute management for tension pneumothorax?

A 
Needle decompression (2nd intercostal space at midclavicular line)
Chest tube (4th or 5th intercostal space)
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36
Q

What is the acute management for cardiac tamponade?

A

Pericardiocentesis

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37
Q

What is the acute management for aortic dissection?

A

Urgent vascular surgery consult
IV labetolol (to reduce BP & HR)
Surgery vs medical management

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38
Q

What is the HEART score?

A

Risk stratification score for acute chest pain.
For pt ≥21 presenting with Sx suggestive of ACS
H: History
E: ECG
A: Age
R: Risk factors
T: Troponin (initial)

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39
Q

What are the risk factors that increase the HEART score?

A 
HTN
Hypercholesterolemia
DM
Obesity
Smoking
FHx (parent/sibling with CVD <65)
Atherosclerotic disease
1-2: +1
3 or more: +2
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40
Q

What features add points to the ECG part of the HEART score?

A

+1: LBBB, LVH, repolarization changes

+2: ST depression/elevation (not due to LBBB, LVH, digoxin)

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41
Q

What troponin levels are suspicious for ACS, according to the HEART score?

A

Initial troponin 1-2X normal limit: +1 point

Initial troponin >2X normal limit: +2 points

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42
Q

How does the HEART score deal with age and history? (points)

A

History: slightly/moderately/highly suspicious gets 0/1/2 points
Age: <45 / 45-64 / ≥65 gets 0/1/2 points

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43
Q

What is the risk of major adverse cardiac event (MACE) with different HEART score ranges?

A

Scores 0-3: 1-2%
Score 4-6: 12-17%
Score ≥ 7: 50-65%

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44
Q

What is the HEART pathway?

A

HEART score + 0h and 3h troponin; decision aid to ID patients that are safe for early discharge.

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45
Q

What is the PERC rule?

A

Rules out PE in patients who are already considered low-risk: if negative, patients do not require further workup for PE.

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46
Q

What are the PERC rule criteria?

A 
Age ≥ 50
HR ≥ 100
SaO2 < 95% on RA
Unilateral leg swelling
Hemoptysis
Recent surgery or trauma (<4w out)
Prior PE or DVT
Hormone use (OCP, estrogen, HRT)
If the patient has none of the above, and is considered low risk for PE, no further testing for PE is needed.
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47
Q

What is tachypnea?

A

RR > 18 in adults

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48
Q

What is hyperpnea?

A

High minute ventilation to meet metabolic demands

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49
Q

What are the DDx categories for shortness of breath?

A

Pulmonary
Cardiac
Toxic-Metabolic
Neuro-endocrine

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50
Q

What is the pulmonary DDx for shortness of breath?

A 
Airway obstruction
Respiratory failure
Anaphylaxis
Pulmonary embolism
Tension pneumothorax
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51
Q

What is the cardiac DDx for shortness of breath?

A 
Pulmonary edema (LV failure)
MI
Tamponade
Pericardial effusion
Arrythmias
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52
Q

What is pulmonary edema?

A

acute, severe left ventricular failure with pulmonary venous hypertension and alveolar flooding

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53
Q

What is the toxic-metabolic DDx for shortness of breath?

A

Toxin ingestion (Organophosphates, CO)
Sepsis
DKA

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54
Q

What is the neuro-endocrine DDx for shortness of breath?

A

Thyrotoxicosis
Guillain-Barre
ALS
MS

55
Q

What are Well’s criteria?

A

Risk stratification for PE

  • Clinical SSx of PE
  • PE #1 Dx (or equally likely)
  • Malignancy w/ treatment within 6 months or palliative
  • HR > 100
  • Immobilization at least 3 days OR surgery in the previous 4 weeks
  • Previous PE or DVT (objectively diagnosed)
  • Hemoptyis
56
Q

What history is important for shortness of breath?

A

OPQRST, recent travel, trauma, PE risk factors (Well’s, PERC), sick contacts

57
Q

What physical exam components are important for workup of shortness of breath?

A

GA
Sx of respiratory distress
Cardiac & resp exams

58
Q

What labs are done for shortness of breath?

A 
CBC, lytes
BUN/Cr
VBG
Cardiac enzymes
Consider D-dimer
59
Q

What tests are done for shortness of breath?

A

ECG, bedside U/S, CXR

60
Q

What general management is done for shortness of breath?

A

ABCs

Monitors, oxygen, vitals, IV access

61
Q

When should you intubate someone with shortness of breath?

A

If not protecting airway, or in significant respiratory distress

62
Q

What is the empiric treatment for anaphylaxis?

A

Epinephrine, antihistamines, steroids, fluids

63
Q

What is the empiric treatment for asthma/COPD in ED?

A

Oxygen, bronchodilators, corticosteroids
(short-acting beta-agonist eg salbutamol, short-acting anticholinergic eg ipratropium; methyprednisolone IV or prednisone PO)
Consider Abx

64
Q

What are the SSx of an ectopic pregnancy?

A

Abdo pain + Hx amenorrhea + new-onset vaginal bleeding
6-8w after LMP
If ruptured, may have SSx of hypovolemia, shoulder tip pain

65
Q

What is the incidence of ectopic pregnancy?

A

1.5-2% of all known pregnancies

66
Q

Name 5 risk factors for ectopic pregnancy

A 
Previous ectopic
Assisted reproduction techniques
Tubal surgery
PID
Smoking
IUD in situ
Endometriosis
Infertility
Pelvic surgery
Known pelvic adhesions from intra-abdominal process (eg Crohn’s)
67
Q

What will you find on physical exam in ectopic

A 
The physical exam may be unremarkable. 
May have:
Adnexal tenderness, cervical motion tenderness, abdo tenderness
Adnexal mass, uterine enlargement
SSx of hypovolemia (do orthostatic)
68
Q

What Ix should be performed for suspected ectopic?

A 
CBC
Beta hCG
Group &amp; Screen (Rh type)
TVUS
If unstable: Cross and type
69
Q

What beta hCG findings suggest ectopic pregnancy?

A

> 5000 mIU/mL: should be able to see intrauterine pregnancy on transabdominal US
1500 mIU/mL: should be able to see on TVUS
If above these levels and no IUP visualized, suggestive of ectopic

70
Q

When is ectopic pregnancy medically managed, and with what?

A 
Methotrexate. 
Use if: 
Hemodynamically stable
Able &amp; willing to comply with followup
Pretreatment serum BhCG < 5000
Ectopic size <3.5cm
No FHR activity
71
Q

When is methotrexate contraindicated?

A

Breastfeeding
Immunodeficiency
Significant hepatic, renal, or hematologic disease

72
Q

What are the indications for surgical management of ectopic pregnancy?

A

Ruptured ectopic, esp if hemodynamically unstable
Inability to comply with or contraindications to medical therapy
Failed medical therapy
Also consider if beta hCG > 5000, tubal size >3.5cm, or fetal cardiac activity

73
Q

What is the DDx for first-trimester bleeding?

A

Physiological: spotting due to placenta implantation
Abortion
Abnormal pregnancy (ectopic, molar)
Trauma (post-coital)
Genital lesion: cervical polyp, neoplasms, etc
Infection: chlamydia, gonorrhea, etc.

74
Q

What is the clinical presentation of someone with spontaneous abortion?

A

Pain
Bleeding
N/V, fever, chills

75
Q

What is the incidence of spontaneous abortion?

A

15% of clinically recognized pregnancies

76
Q

What are the maternal & environmental risk factors for spontaneous abortion?

A

Age, previous SA, smoking, maternal medical Hx (systemic disease like DM, thrombophilia), cocaine use, local trauma (eg amniocentesis)

77
Q

What accounts for 50% of miscarriages?

A

Chromosomal abnormalities

78
Q

What is the exam for spontaneous abortion?

A

Vitals
Abdo exam
Examination of cervical os
Bimanual exam

79
Q

What history and exam findings point to threatened abortion?

A

Vaginal bleeding ± cramping

Cervix closed, U/S shows viable fetus

80
Q

What history and exam findings point to inevitable abortion?

A

Increased vaginal bleeding, cramps, ± rupture of membranes

Cervix closed until products start to expel, then external os open

81
Q

What history and exam findings point to incomplete abortion?

A

Extremely heavy bleeding and cramps ± passage of tissue

Cervix open

82
Q

What history and exam findings point to complete abortion?

A

Bleeding with passage of complete sac and placenta

Cervix open

83
Q

What history and exam findings point to missed abortion?

A

No bleeding. U/S detection of fetal death.

Cervix closed. U/S shows absent FHR and possibly small (for gestational age) fetus

84
Q

What investigations are done for spontaneous abortion?

A

Ultrasound

Group and screen (Rh- needs anti-D)

85
Q

Which classifications of abortion need management?

A

Inevitable, Incomplete, and Missed abortions need management.
Complete abortions don’t need management
Threatened abortions get expectant management, until resolution or progression (old rec was rest for threatened, but no evidence)

86
Q

What is the management for spontaneous abortion?

A

Expectant, Medical, or Surgical

87
Q

What is the most common reason for urinary retention?

A

BPH, leading to obstruction (53% of cases)

88
Q

What are the overarching etiologies of elimination dysfunction?

A

Outflow obstruction
Bladder innervation
Pharmacologic
Infection

89
Q

What physical exam components are important in assessing urinary retention?

A 
Focused physical exam:
palpate/percuss bladder for fullness 
Inspect for purulent/bloody meatal discharge
DRE: prostate size, sphincter tone
Neuro: DTR, anal wink, saddle anesthesia
90
Q

What historical components are important in evaluating urinary dysfunction?

A

BPH Hx, trauma, medications (incl OTC), neuro

91
Q

Name 5 medications that can cause urinary retention

A

Antiarrythmics, anticholinergics, antidepressants, antihistamines, antihypertensives, antiparkinsonian agents, antipsychotics, hormonal agents, muscle relaxants, sympathomimetics, others

92
Q

When should you not place a catheter?

A

When there is any evidence of urethral trauma: call Uro

93
Q

What are the categories of urinary incontinence?

A

Urgency, Stress, and Mixed

94
Q

What is urge incontinence, and what is the etiology?

A

Sudden strong urge to void –> involuntary leakage

Due to bladder (detrusor overactivity)

95
Q

What is stress incontinence, and what is the etiology?

A

Involuntary leakage with sudden increase in intra-abdominal pressure
Urethra/sphincter weakness
Post-partum pelvic musculature weakness

96
Q

What are neurological causes of urinary retention?

A

Intracranial: CVA, tumour, Parkinson’s, cerebral palsy
Spinal cord: injury, disc herniation, MS
Peripheral: DM, post-surgical
(there are others, this is the short list)

97
Q

What investigations are done for urinary retention?

A 
CBC, lytes
BUN, Cr
Urinalysis, C&amp;S
Cystoscopy
Urodynamic studies
Post-void residual
98
Q

What are the indications for electrical cardioversion?

A

Paroxysmal SVT
Atrial fibrillation/Atrial flutter
Ventricular tachycardia

99
Q

What are the pre-medication options before electrical cardioversion?

A

Midazolam 1-5mg (+/- fentanyl 50-200mcg)
Propofol 50-150mg IV
Ketamine 0.25-1.5mg/kg IV
Etomidate 20mg IV

100
Q

What is synchronized cardioversion?

A

Delivery of a low-energy shock that is timed with the patient’s cardiac cycle (synchronized with the peak of the QRS complex)

101
Q

What is unsynchronized cardioversion?

A

Delivery of a high-energy shock, with no time delay (delivered as soon as button is pressed on defibrillator)

102
Q

What can happen if a low-energy shock is delivered at the wrong point in the cycle?

A

If the shock occurs on the t-wave (during repolarization), there is a high likelihood that the shock can precipitate VF (Ventricular Fibrillation)

103
Q

What are the indications for synchronized cardioversion?

A

unstable atrial fibrillation
atrial flutter
atrial tachycardia
supraventricular tachycardias

104
Q

When is unsynchronized cardioversion used?

A
  • there is no coordinated intrinsic electrical activity in the heart (pulseless VT/VF), or
  • the defibrillator fails to synchronize in an unstable patien
105
Q

What “dose” of electricity is given in synchronized cardioversion?

A

pSVT/Aflutter: 150J biphasic or 300J monophasic

Vtach/Afib: 200J biphasic or 360J monophasic

106
Q

What is the management of stable atrial fibrillation or flutter?

A

If HR > 120: rate control

Then consider rhythm control

107
Q

What are the medical management options for acute narrow complex afib with HR >120?

A 
Diltiazem 20mg IV
Verapamil 2.5-4mg IV
Metoprolol 5mg IV
Amiodarone 150mg over 10min
Digoxin 0.5mg IV
108
Q

What are the medical management options for acute wide complex afib with HR >120?

A

Procainamide 30mg/min to 17mg/kg

Amiodarone 150mg over 10min

109
Q

What is the general initial management of Vfib or pulseless vtach?

A

Intubate, ventilate, early IV/IO access (med admin)

Treat reversible causes

110
Q

Name 7 reversible causes of Vfib/Vtach

A 
Hypovolemia
Hypoxia
Acidosis
Hyper/o kalemia
Hypothermia
Toxins
Ischemia
111
Q

Should you start CPR or shock first?

A

Shock first if defibrillator is immediately available; if not start CPR and interrupt for defibrillator

112
Q

Describe key features of high-quality CPR

A

5cm compression, 100-120/min, with complete chest recoil. Change compressors q2min.
Minimize interruptions, avoid ventilation >10/min, monitor end-tidal CO2

113
Q

For what ECG findings do you initiate CPR?

A

VFib and pulseless VTach

114
Q

What are the two preferred medications that can be provided during CPR?

A

Epinephrine: 1mg IV q3-5min
Amiodarone: 300mg IV bolus, can add 150mg IV (2nd dose)

115
Q

What alternate medications can be provided during CPR?

A

Refractory VFib: lidocaine, 1.5mg/kg IV, q3-5min (max 3mg/kg)
Polymorphic VTach: Magnesium sulfate, 2g IV

116
Q

What “dose” of electricity is given for vfib or pulseless vtach?

A

200J biphasic or 360J monophasic

117
Q

What “dose” of electricity is given for unstable afib?

A

200J biphasic or 360J monophasic

118
Q

For wide-complex tachycardia, when should you consider synchronized cardioversion?

A

Early: meds only revert VT 30% of the time

119
Q

What medications can be used for wide-complex tachycardia?

A

Procainamide 30mg/min (max 17mg/kg)

Amiodarone 150mg over 10min (repeat x2 PRN)

120
Q

What is the next step after one antidysrhythmic fails?

A

Electric cardioversion: multiple antidysrhythmics can have proarrythmogenic effects

121
Q

What is the first step for a stable patient in paroxysmal supraventricular tachycardia (pSVT)?

A

Vagal manoeuvres

122
Q

What vagal maneouvres can stop SVT?

A

Bearing down
Carotid massage
Cold wet face towel (cold face stimulus)
Coughing, gagging

123
Q

What are the medication options for pSVT?

A

Adenosine: 6mg IV over 3 secs (1st dose), 12mg IV (2nd dose)
Diltiazem: 20mg IV over 2 min (1st dose), 25mg IV (2nd dose)
Metoprolol: 5mg IV (max 15mg)
Verapamil: 2.5-5mg IV over 2 min, repeat 5-10mg in 10 mins

124
Q

What is the stepwise treatment progression for pSVT?

A

Vagal manoeuvres
Medication
Synchronized cardioversion (if unstable)

125
Q

What are the “5Hs and 5Ts” used to remember?

A

Reversible causes of Pulseless Electrical Activity, Asystole

126
Q

What are the 5 Hs?

A 
Hypovolemia
Hypoxia
Hydrogen (Acidosis)
Hyper/o kalemia
Hypothermia
127
Q

What are the 5 Ts?

A 
Toxins
Tamponade
Tension pneumo
Thrombosis: coronary (MI)
Thrombosis: pulmonary (PE)
128
Q

What is the management of PEA/Asystole?

A 
Ongoing CPR
Treat reversible causes
Epinephrine 1mg IV q3-5min
Re-evaluate for shockable rhythm
Until ROSC or it's called
129
Q

What is the management of stable bradycardia due to first degree block or type I second degree block?

A

Observe

130
Q

What is the management of stable bradycardia due to type II second degree block or third degree block?

A

Transcutaneous pacing –> transvenous pacing

131
Q

What is the management of unstable bradycardia?

A 
Atropine 0.5mg q3-5min (max 3mg)
If not effective consider one of:
- transcutaneous pacing 
- dopamine 2-10 mcg/kg/min
- epinephrine 2-10 mcg/min
132
Q

What are the signs of cardiac instability (for ACLS)?

A 
Chest pain
Shortness of breath
Loss of consciousness
Low BP
CHF
Acute MI
133
Q

What are the do-not-miss abdo pain diagnoses?

A

Gyne: ruptured ectopic
CV: ruptured AAA, mesenteric ischemia
GI: pancreatitis, cholangitis, obstruction, perforated viscus, complicated diverticulitis

Emerg (4 decks)

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