ECEs: Chest, abdo, pelvis Flashcards
What is the DDx for abdo pain in the RUQ?
Hepatitis Biliary colic, Cholecystitis/Cholangitis Pancreatitis Pneumonia, Pleural effusion, PE DEADLY: Chole, pancreatitis, PE
What is the DDx for abdo pain in the LUQ?
Pancreatitis
Gastritis
Pneumonia, Pleural effusion, PE
DEADLY: Pancreatitis, PE
What is the DDx for abdo pain in the RLQ?
Appendicitis
Ectopic pregnancy, PID, tubo-ovarian abscess, ovarian torsion
Testicular torsion, epidiymitis, orchitis
Renal colic
DEADLY: ectopic pregnancy
What is the DDx for abdo pain in the LLQ?
Diverticulitis
Ectopic pregnancy, PID, tubo-ovarian abscess, ovarian torsion
Testicular torsion, epidiymitis, orchitis
Renal colic
DEADLY: Diverticulutis, ectopic pregnancy
What is the DDx for epigastric abdo pain?
Gastritis, dyspepsia, PUD, duodenitis
Pancreatitis
ACS (Cardiac)
DEADLY: Pancreatitis, ACS
What is the DDx for periumbilical abdo pain?
Colitis, Perforation, Obstruction
Aortic dissection, AAA
DEADLY: … all except colitis.
What is the DDX for suprapubic abdo pain?
UTI, renal colic
Obstruction
Deadly: none.
What is the DDx for R or L flank abdo pain?
Colitis, perforation, Obstruction
Renal colic, pyelonephritis
AAA
DEADLY: Perforation, obstruction, AAA
What are the risk factors for ruptured ectopic pregnancy?
Hx of STI/PID Recent IUD previous ectopic Fallopian tube surgery, tubal ligation Smoking
What are the risk factors for ruptured AAA?
Elderly, HTN/DM, smoking, trauma
What are the risk factors for pancreatitis?
EtOH, biliary pathology
What is the classic clinical presentation of cholangitis?
Charcot’s triad: fever, RUQ pain, jaundice
What are the risk factors for mesenteric ischemia?
Elderly, CAD, CHF, dehydration, infection
What are the risk factors for bowel obstruction?
Operative or malignant history, elderly
What are the risk factors for bowel perforation?
Risk factors for diverticulitis or ulcer; malignancy; instrumentation (eg colonoscopy)
What are the risk factors for complicated diverticulitis?
Elderly, low-fibre diet, Western population
What would you elicit on Hx for acute abdo pain?
OPQRST
Associated Sx: N/V, fever, chills; BM; urinary Sx; pelvic discharge/bleeding
What labs would you order for acute abdo pain?
CBC, lytes, BUN/Cr, LFTs, lipase, lactate, B-hCG
Consider: CK, troponin
What imaging & other Ix would you order for acute abdo pain?
ECG, CXR, consider bedside US
Consider formal US (biliary, ectopic, AAA); consider CT abdo/pelvis
How do you acutely manage acute abdo pain, in general?
ABCs
Analgesics
Anti-emetics
NPO; consult surgery as needed
What is the “deadly six” DDx for acute chest pain?
PET MAT: Pulmonary embolism Esophageal rupture/mediastinitis Tension pneumothorax Myocardial infarction Aortic dissection Tamponade
What are the cardiac causes of acute CP?
DEADLY: MI, aortic dissection, tamponade
Pericarditis, Myocarditis, Endocarditis
What are the respiratory causes of acute chest pain?
DEADLY: PE, tension pneumo Pneumonia Pleural effusion Acute chest syndrome (sickle cell) Lung or mediastinal mass
What are the GI causes of acute chest pain?
DEADLY: Esophageal rupture/mediastinitis
Esophagus: Mallory-Weiss tear, esophageal spasm
Stomach: GERD, ulcer
Pancreas: pancreatitis
GB: biliary colic, cholecystitis, cholangitis
What is dyspepsia?
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)
What are the MSK, neuro, & psych causes of acute chest pain?
Intramuscular pain Rib pathology Herpes zoster Rib pathology None deadly.
What history do you want to elicit for acute chest pain?
OPQRST, cardiac risk factors, PE risk factors, recent trauma, neuro Sx
What parts of the physical exam are important for acute chest pain?
General appearance
Cardiac & resp exams
Neuro screen
Vitals, Pulse
What are the initial Ix for acute chest pain?
Tests: ECG, CXR; consider CT pulmonary angio
Labs: CBC, lytes, abdo panel, cardiac markers; consider D-dimer
What are the cardiac markers? (bloodwork)
CK and TnI (Creatine kinase & troponin I)
What is the general management for acute chest pain?
ABCs Monitors Oxygen Vitals IV access Gather equipment
What is the acute management for ACS?
ASA Nitro (avoid in RV infarct) Clopidogrel/ticagrelor LMWH code STEMI (PCI vs thrombolytics)
mnemonic:
ANCLE: ASA, Nitro, Clopidogrel, LMWH, Emergent cardio consult
What is the acute management for PE?
Anticoagulation
Consider thrombolysis for massive PE
What is the acute management for esophageal rupture?
Urgent thoracic surgery consult
IV Abx
NPO
Further imaging
What is the acute management for tension pneumothorax?
Needle decompression (2nd intercostal space at midclavicular line) Chest tube (4th or 5th intercostal space)
What is the acute management for cardiac tamponade?
Pericardiocentesis
What is the acute management for aortic dissection?
Urgent vascular surgery consult
IV labetolol (to reduce BP & HR)
Surgery vs medical management
What is the HEART score?
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)
What are the risk factors that increase the HEART score?
HTN Hypercholesterolemia DM Obesity Smoking FHx (parent/sibling with CVD <65) Atherosclerotic disease 1-2: +1 3 or more: +2
What features add points to the ECG part of the HEART score?
+1: LBBB, LVH, repolarization changes
+2: ST depression/elevation (not due to LBBB, LVH, digoxin)
What troponin levels are suspicious for ACS, according to the HEART score?
Initial troponin 1-2X normal limit: +1 point
Initial troponin >2X normal limit: +2 points
How does the HEART score deal with age and history? (points)
History: slightly/moderately/highly suspicious gets 0/1/2 points
Age: <45 / 45-64 / ≥65 gets 0/1/2 points
What is the risk of major adverse cardiac event (MACE) with different HEART score ranges?
Scores 0-3: 1-2%
Score 4-6: 12-17%
Score ≥ 7: 50-65%
What is the HEART pathway?
HEART score + 0h and 3h troponin; decision aid to ID patients that are safe for early discharge.
What is the PERC rule?
Rules out PE in patients who are already considered low-risk: if negative, patients do not require further workup for PE.
What are the PERC rule criteria?
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.
What is tachypnea?
RR > 18 in adults
What is hyperpnea?
High minute ventilation to meet metabolic demands
What are the DDx categories for shortness of breath?
Pulmonary
Cardiac
Toxic-Metabolic
Neuro-endocrine
What is the pulmonary DDx for shortness of breath?
Airway obstruction Respiratory failure Anaphylaxis Pulmonary embolism Tension pneumothorax
What is the cardiac DDx for shortness of breath?
Pulmonary edema (LV failure) MI Tamponade Pericardial effusion Arrythmias
What is pulmonary edema?
acute, severe left ventricular failure with pulmonary venous hypertension and alveolar flooding
What is the toxic-metabolic DDx for shortness of breath?
Toxin ingestion (Organophosphates, CO)
Sepsis
DKA
What is the neuro-endocrine DDx for shortness of breath?
Thyrotoxicosis
Guillain-Barre
ALS
MS
What are Well’s criteria?
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
What history is important for shortness of breath?
OPQRST, recent travel, trauma, PE risk factors (Well’s, PERC), sick contacts
What physical exam components are important for workup of shortness of breath?
GA
Sx of respiratory distress
Cardiac & resp exams
What labs are done for shortness of breath?
CBC, lytes BUN/Cr VBG Cardiac enzymes Consider D-dimer
What tests are done for shortness of breath?
ECG, bedside U/S, CXR
What general management is done for shortness of breath?
ABCs
Monitors, oxygen, vitals, IV access
When should you intubate someone with shortness of breath?
If not protecting airway, or in significant respiratory distress
What is the empiric treatment for anaphylaxis?
Epinephrine, antihistamines, steroids, fluids
What is the empiric treatment for asthma/COPD in ED?
Oxygen, bronchodilators, corticosteroids
(short-acting beta-agonist eg salbutamol, short-acting anticholinergic eg ipratropium; methyprednisolone IV or prednisone PO)
Consider Abx
What are the SSx of an ectopic pregnancy?
Abdo pain + Hx amenorrhea + new-onset vaginal bleeding
6-8w after LMP
If ruptured, may have SSx of hypovolemia, shoulder tip pain
What is the incidence of ectopic pregnancy?
1.5-2% of all known pregnancies
Name 5 risk factors for ectopic pregnancy
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)
What will you find on physical exam in ectopic
The physical exam may be unremarkable. May have: Adnexal tenderness, cervical motion tenderness, abdo tenderness Adnexal mass, uterine enlargement SSx of hypovolemia (do orthostatic)
What Ix should be performed for suspected ectopic?
CBC Beta hCG Group & Screen (Rh type) TVUS If unstable: Cross and type
What beta hCG findings suggest ectopic pregnancy?
> 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
When is ectopic pregnancy medically managed, and with what?
Methotrexate. Use if: Hemodynamically stable Able & willing to comply with followup Pretreatment serum BhCG < 5000 Ectopic size <3.5cm No FHR activity
When is methotrexate contraindicated?
Breastfeeding
Immunodeficiency
Significant hepatic, renal, or hematologic disease
What are the indications for surgical management of ectopic pregnancy?
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
What is the DDx for first-trimester bleeding?
Physiological: spotting due to placenta implantation
Abortion
Abnormal pregnancy (ectopic, molar)
Trauma (post-coital)
Genital lesion: cervical polyp, neoplasms, etc
Infection: chlamydia, gonorrhea, etc.
What is the clinical presentation of someone with spontaneous abortion?
Pain
Bleeding
N/V, fever, chills
What is the incidence of spontaneous abortion?
15% of clinically recognized pregnancies
What are the maternal & environmental risk factors for spontaneous abortion?
Age, previous SA, smoking, maternal medical Hx (systemic disease like DM, thrombophilia), cocaine use, local trauma (eg amniocentesis)
What accounts for 50% of miscarriages?
Chromosomal abnormalities
What is the exam for spontaneous abortion?
Vitals
Abdo exam
Examination of cervical os
Bimanual exam
What history and exam findings point to threatened abortion?
Vaginal bleeding ± cramping
Cervix closed, U/S shows viable fetus
What history and exam findings point to inevitable abortion?
Increased vaginal bleeding, cramps, ± rupture of membranes
Cervix closed until products start to expel, then external os open
What history and exam findings point to incomplete abortion?
Extremely heavy bleeding and cramps ± passage of tissue
Cervix open
What history and exam findings point to complete abortion?
Bleeding with passage of complete sac and placenta
Cervix open
What history and exam findings point to missed abortion?
No bleeding. U/S detection of fetal death.
Cervix closed. U/S shows absent FHR and possibly small (for gestational age) fetus
What investigations are done for spontaneous abortion?
Ultrasound
Group and screen (Rh- needs anti-D)
Which classifications of abortion need management?
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)
What is the management for spontaneous abortion?
Expectant, Medical, or Surgical
What is the most common reason for urinary retention?
BPH, leading to obstruction (53% of cases)
What are the overarching etiologies of elimination dysfunction?
Outflow obstruction
Bladder innervation
Pharmacologic
Infection
What physical exam components are important in assessing urinary retention?
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
What historical components are important in evaluating urinary dysfunction?
BPH Hx, trauma, medications (incl OTC), neuro
Name 5 medications that can cause urinary retention
Antiarrythmics, anticholinergics, antidepressants, antihistamines, antihypertensives, antiparkinsonian agents, antipsychotics, hormonal agents, muscle relaxants, sympathomimetics, others
When should you not place a catheter?
When there is any evidence of urethral trauma: call Uro
What are the categories of urinary incontinence?
Urgency, Stress, and Mixed
What is urge incontinence, and what is the etiology?
Sudden strong urge to void –> involuntary leakage
Due to bladder (detrusor overactivity)
What is stress incontinence, and what is the etiology?
Involuntary leakage with sudden increase in intra-abdominal pressure
Urethra/sphincter weakness
Post-partum pelvic musculature weakness
What are neurological causes of urinary retention?
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)
What investigations are done for urinary retention?
CBC, lytes BUN, Cr Urinalysis, C&S Cystoscopy Urodynamic studies Post-void residual
What are the indications for electrical cardioversion?
Paroxysmal SVT
Atrial fibrillation/Atrial flutter
Ventricular tachycardia
What are the pre-medication options before electrical cardioversion?
Midazolam 1-5mg (+/- fentanyl 50-200mcg)
Propofol 50-150mg IV
Ketamine 0.25-1.5mg/kg IV
Etomidate 20mg IV
What is synchronized cardioversion?
Delivery of a low-energy shock that is timed with the patient’s cardiac cycle (synchronized with the peak of the QRS complex)
What is unsynchronized cardioversion?
Delivery of a high-energy shock, with no time delay (delivered as soon as button is pressed on defibrillator)
What can happen if a low-energy shock is delivered at the wrong point in the cycle?
If the shock occurs on the t-wave (during repolarization), there is a high likelihood that the shock can precipitate VF (Ventricular Fibrillation)
What are the indications for synchronized cardioversion?
unstable atrial fibrillation
atrial flutter
atrial tachycardia
supraventricular tachycardias
When is unsynchronized cardioversion used?
- there is no coordinated intrinsic electrical activity in the heart (pulseless VT/VF), or
- the defibrillator fails to synchronize in an unstable patien
What “dose” of electricity is given in synchronized cardioversion?
pSVT/Aflutter: 150J biphasic or 300J monophasic
Vtach/Afib: 200J biphasic or 360J monophasic
What is the management of stable atrial fibrillation or flutter?
If HR > 120: rate control
Then consider rhythm control
What are the medical management options for acute narrow complex afib with HR >120?
Diltiazem 20mg IV Verapamil 2.5-4mg IV Metoprolol 5mg IV Amiodarone 150mg over 10min Digoxin 0.5mg IV
What are the medical management options for acute wide complex afib with HR >120?
Procainamide 30mg/min to 17mg/kg
Amiodarone 150mg over 10min
What is the general initial management of Vfib or pulseless vtach?
Intubate, ventilate, early IV/IO access (med admin)
Treat reversible causes
Name 7 reversible causes of Vfib/Vtach
Hypovolemia Hypoxia Acidosis Hyper/o kalemia Hypothermia Toxins Ischemia
Should you start CPR or shock first?
Shock first if defibrillator is immediately available; if not start CPR and interrupt for defibrillator
Describe key features of high-quality CPR
5cm compression, 100-120/min, with complete chest recoil. Change compressors q2min.
Minimize interruptions, avoid ventilation >10/min, monitor end-tidal CO2
For what ECG findings do you initiate CPR?
VFib and pulseless VTach
What are the two preferred medications that can be provided during CPR?
Epinephrine: 1mg IV q3-5min
Amiodarone: 300mg IV bolus, can add 150mg IV (2nd dose)
What alternate medications can be provided during CPR?
Refractory VFib: lidocaine, 1.5mg/kg IV, q3-5min (max 3mg/kg)
Polymorphic VTach: Magnesium sulfate, 2g IV
What “dose” of electricity is given for vfib or pulseless vtach?
200J biphasic or 360J monophasic
What “dose” of electricity is given for unstable afib?
200J biphasic or 360J monophasic
For wide-complex tachycardia, when should you consider synchronized cardioversion?
Early: meds only revert VT 30% of the time
What medications can be used for wide-complex tachycardia?
Procainamide 30mg/min (max 17mg/kg)
Amiodarone 150mg over 10min (repeat x2 PRN)
What is the next step after one antidysrhythmic fails?
Electric cardioversion: multiple antidysrhythmics can have proarrythmogenic effects
What is the first step for a stable patient in paroxysmal supraventricular tachycardia (pSVT)?
Vagal manoeuvres
What vagal maneouvres can stop SVT?
Bearing down
Carotid massage
Cold wet face towel (cold face stimulus)
Coughing, gagging
What are the medication options for pSVT?
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
What is the stepwise treatment progression for pSVT?
Vagal manoeuvres
Medication
Synchronized cardioversion (if unstable)
What are the “5Hs and 5Ts” used to remember?
Reversible causes of Pulseless Electrical Activity, Asystole
What are the 5 Hs?
Hypovolemia Hypoxia Hydrogen (Acidosis) Hyper/o kalemia Hypothermia
What are the 5 Ts?
Toxins Tamponade Tension pneumo Thrombosis: coronary (MI) Thrombosis: pulmonary (PE)
What is the management of PEA/Asystole?
Ongoing CPR Treat reversible causes Epinephrine 1mg IV q3-5min Re-evaluate for shockable rhythm Until ROSC or it's called
What is the management of stable bradycardia due to first degree block or type I second degree block?
Observe
What is the management of stable bradycardia due to type II second degree block or third degree block?
Transcutaneous pacing –> transvenous pacing
What is the management of unstable bradycardia?
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
What are the signs of cardiac instability (for ACLS)?
Chest pain Shortness of breath Loss of consciousness Low BP CHF Acute MI
What are the do-not-miss abdo pain diagnoses?
Gyne: ruptured ectopic
CV: ruptured AAA, mesenteric ischemia
GI: pancreatitis, cholangitis, obstruction, perforated viscus, complicated diverticulitis
