ECEs: Neck up, peripheral, & systemic Flashcards
What is altered mental status?
Decrease in LOC
What is the DDx for altered mental status (overal mnemonic)?
DIMS: Drugs Infection Metabolic Structural
What are some drug-related causes of altered mental status? (4 categories; name at least 1 example of each)
Abuse (opiates, benzos, alcohol, illicit drugs)
Accidental (carbon monoxide, cyanide)
Prescribed (Beta-blockers, TCAs, ASA, acetaminophen, digoxin)
Withdrawal (Benzos, EtOH, SSRIs)
What are some infectious causes of altered mental status? (2 categories, 3 examples each)
CNS: meningitis, encephalitis, cerebral abscess
Systemic: sepsis, UTI, pneumonia, skin/soft tissue, bone/joint, intra-abdominal, iatrogenic (indwelling lines or catheter), bacteremia
What are some metabolic causes of altered mental status? (4 categories, 1 example each)
Kidneys: electrolyte imbalance, renal failure, uremia
Liver: hepatic encephalopathy
Pancreas: hypoglycemia, DKA, HHS
Thyroid: hyper or hypo
What are some structural causes of altered mental status? (3 categories, 2 examples each)
Cardiac: ACS, dissection, arrythmias, shock
Brain: Stroke, Sz, hydrocephalus, surgical lesions
Bleeds: any ICH – epidural hematoma, subdural hematoma, SAH; acute or chronic
What are important components of the history in altered mental status?
Collateral from family/friends/EMS Onset, progression Preceding events Comparison to baseline Trauma PMHx, Rx
What are important components of the initial/acute physical exam in altered mental status?
Standard rapid assessment:
ABCs, primary survey
vitals including temp & glucose
rapid neuro exam (GCS, focal deficits)
What labs would you order for altered mental status?
CBC, lytes, BUN/Cr, LFTs, INR/PTT, serum osmolality, VBG, troponin, urinalysis, drug levels
What tests (non-BW) would you order for altered mental status?
ECG, CXR, CT head
How do you acutely manage altered mental status, in general?
Supportive + Treat underlying cause Universal antidotes Broad spectrum Abx Warm/cool, BP control Consider admitting for workup
What are the universal antidotes?
dextrose, oxygen, naloxone, thiamine
What are the 3 most common primary types of headache?
Migraine, Cluster, and Tension
What is the typical presentation of migraine?
POUND: Pulsatile, Onset 4-72h, Unilateral, N/V, Disabling
photo/phonophobia, recurrent, +/- aura
What is the typical presentation of cluster headaches?
Unilateral sudden sharp retro-orbital pain
<3h
Usually at night
Autonomic: congestion, rhinorrhea, lacrimation, facial flushing
pseudo-Horner’s syndrome (ptosis, miosis, anhidrosis, and hyperemia)
precipitated by EtOH, smoking
What is the typical presentation of tension headache?
tight band-like pain, tense neck/scalp muscles, precipitated by stress or lack of sleep
What is the intracranial DDx for headache?
Bleed: epidural, subdural, subarachnoid, intracerebral
Infection: meningitis, encephalitis, brain abscess
Increased ICP: mass, cerebral venous sinus thrombosis
What is the extracranial DDx for headache?
Acute angle closure glaucoma
Temporal arteritis
Carotid artery dissection
CO poisoning
What are red flags for headache?
Sudden onset Thunderclap Exertional onset Meningismus Fever Neuro deficit Altered mental status
What are the symptoms of increased ICP?
persistent vomiting
headache worse lying down and in the morning
What components of the physical exam are important for assessing headache?
Vitals, detailed neuro exam
Neck flexion for meningeal irritation
Eye exam (slit lamp, IOP)
Temporal artery tenderness
What investigations should be done for headache?
Most benign headaches do not require further investigation.
Neuroimaging based on Ottawa SAH rule.
LP: if CT head -ve, but suspicion of SAH
ESR/CRP if ?temporal arteritis
What is the Ottawa SAH Rule?
Decision rule to rule out SAH.
Use in: Alert patients ≥15 years old, new severe atraumatic headache, maximum intensity within 1 hour.
If any of the following features, SAH cannot be ruled out:
- Age≥40y
- Neck pain or stiffness
- Witnessed LOC
- Onset during exertion
- Thunderclap headache (instantly peaking pain)
- Limited neck flexion on exam
How do you manage benign headaches in the ED?
Fluids: no clear evidence, but consider if dehydrated
Antidopaminergic agent: Metoclopramide 10mg IV
Analgesic: Acetaminophen 1g po
NSAIDs: Ketorolac 15-30mg IV or Ibuprofen 600mg po
Steroids: Dexamethasone 10mg po/IV (rebound migraine prophylaxis)
What is the current (2016) definition of sepsis?
Life-threatening organ dysfunction caused by dysregulated response to infection
What is SIRS? What are the criteria?
Systemic Inflammatory Response Syndrome 2 or more of: T < 36 or > 38.3 HR > 90 RR > 20 or CO2 < 32 WBC < 4 or > 12
What history is important for sepsis?
Associated symptoms
Full ROS
Comorbidities
(Trying to ID a focus)
What physical exam components are important for workup of sepsis?
Vitals
Volume status
Look for a focus
What is the full septic workup? (Labs and other tests)
Labs: CBC, lytes, extended lytes BUN/Cr LFTs VBG, Lactate INR/PTT Blood/urine C&S Tests: ECG, CXR
What is the RUSH exam (for sepsis)?
Imaging protocol: "Rapid Ultrasound for Shock and Hypotension" Includes: heart (parasternal long view, 4 chamber) IVC view Morrison’s (RUQ) and splenorenal (LUQ) views bladder window aorta pneumothorax
What is the general management for sepsis?
Monitors, oxygen, vitals, 2 large-bore IVs
What is the 3h recommendation for sepsis?
For 3h after first suspicion of sepsis Draw lactate IV fluids Draw cultures (Before Abx) Start Abx
What is the 6h recommendation for sepsis?
For 6h after first suspicion of sepsis
Repeat lactate
Fluid assessment
Maintain MAP > 65
What steps are taken for resuscitation in sepsis?
Fluids; if needed, Vasopressors; if then needed, Steroids
How is fluid resuscitation done in sepsis?
1-2L NS IV bolus initially, then guided by clinical reassessment
What vasopressors are used in sepsis resuscitation, & when?
If not fluid responsive:
norepinephrine 2-12 mcg/min
What is the role of steroids in sepsis resuscitation? What is the dosing?
If refractory to fluids and vasopressors, add steroids
Hydrocortisone 100 mg IV
What is the empiric antibiotic regimen in sepsis?
Pip-Tazo 3.375g IV + Vancomycin 1g-1.5g IV
What is the meningitic dose regimen in sepsis?
Ceftriaxone 2g IV \+ Vancomycin 2g IV \+ dexamethasone 10mg IV \+/- Acyclovir 1g IV (for HSV encephalitis)
What are two important goal-directed therapy targets in sepsis?
MAP > 65 mmHg
Urine output > .5 cc/kg/h
What are the five major toxidromes?
Sympathomimetic Sedative/Hypnotic Opioid Cholinergic Anticholinergic
What are the features of the sympathomimetic toxidrome?
MS: Restlessness, paranoia, hallucinations, mania, agitation, anxiety
Pupils: Mydriasis
Vitals: Tachycardia, HTN, hyperthermia
Other SSx: Tremor, warm skin, diaphoresis, piloerection, hyperreflexia, seizure
What substances can cause the sympathomimetic toxidrome?
Amphetamines Cocaine Serotonergic drugs LSD Ephedrine
What are the features of the sedative/hypnotic toxidrome?
MS: sedation, confusion, delirium, coma
Pupils: Normal
Vitals: Hypothermia, hypotension, bradycardia
Other SSx: Nystagmus, hyporeflexia
What substances can cause the sedative/hypnotic toxidrome?
EtOH, benzos, GHB, barbiturates
What are the features of the opiate toxidrome?
MS: sedation, confusion, coma
Pupils: myosis
Vitals: hypoventilation
Other SSx: Hyporeflexia
What substances can cause the opiate toxidrome?
Opioids (e.g. morphine, heroin, fentanyl)
What is mydriasis?
dilated pupils
What is miosis?
constricted pupils
What are the features of the anticholinergic toxidrome?
MS: Psychosis, delirium, Sz, coma
Pupils: mydriasis
Vitals: tachycardia, hypertension, hyperthermia
Other SSx: dry red hot skin, urine retention, constipation
What substances can cause the anticholinergic toxidrome?
TCA atropine antihistamines Antipsychotics Antispasmodics Carbamazepine
What is a mnemonic for the anticholinergic toxidrome?
Dry as a bone, red as a beet, blind as a bat, mad as a hatter, hot as a hare
What is a simple 2-step tool to figure out the toxidrome?
Pupils
If Dilated, look at Skin.
Sweaty: sympathomimetic. Dry: anticholinergic
If Pinpoint, look at Ventilation.
High: cholinergic. Low: Opiate.
Eyes N but depressed LOC: think sedative/hypnotic.
What is the basic approach to a toxic patient?
ABCDE: ABC, then: Detect and correct: universal antidotes, correct vitals, corrext Sx (eg Sz), consider decontamination/enhanced elimination Emergency antidotes (specific)
What methods can be used to decontaminate or enhance elimination?
Activated charcoal is the gold standard for most drugs Laxatives can be an adjunct Whole bowel irrigation for Fe Topical lavage for skin or eye exposure May progress to hemodialysis NOT: ipecac, gastric lavage
Name 8 sight-threatening ocular emergencies (require urgent ophthalmology consultation)
from back of eye out:
- central retinal artery occlusion
- Retinal detachment (especially when macula threatened)
- intraocular foreign body
- endophthalmitis
- acute glaucoma
- acute iritis
- corneal ulcer
- gonococcal conjunctivitis
- chemical burn
- lid/globe lacerations
- giant cell arteritis
Name the 5 life-threatening ocular emergencies (require urgent ophthalmology consultation)
- Proptosis (r/po cavernous sinus fistula, thrombosis)
- CN3 palsy with dilated pupil (aneurysm, compressive lesion)
- Papilledema (elevated ICP)
- Orbital cellulitis
- Leukocoria: white reflex (r/o retinoblastoma)
What is the “vital sign” of the eyes?
Visual acuity: should always be assessed and documented in both eyes when presenting to ED with eye complaint
Whare are the SSx of acute angle-closure glaucoma?
Unilateral red, painful eye
Decreased visual acuity, halos around lights
Fixed, mid-dilated pupil
Nausea, vomiting
What is normal intraocular pressure?
12-22 mmHg
What is glaucoma?
Group of eye disorders caused by increase in intraocular pressure (eg due to impaired drainage). Causes progressive optic nerve damage.
What is acute angle closure glaucoma?
Glaucoma associated with a physically obstructed anterior chamber angle: iris obstructs the canal of Schlemm (which drains fluid)
What are the SSx of ocular chemical burn?
History (Known exposure to acids or alkali) Pain Decreased visual acuity Cornea defects or vascularization Iris and lens damage
What are the SSx of orbital cellulitis?
Red, painful eye Decreased visual acuity Headache, fever Lid erythema, edema, and difficulty opening eye Conjunctival injection and chemosis Proptosis, ophtalamoplegia, ± RAPD
What are the SSx of retinal artery occlusion?
Sudden, painless, monocular vision loss
RAPD
Cherry red spot and retinal pallor on fundoscopy
What are the SSx of retinal detachment?
Painless
Flashes of light, floaters, and curtains of blackness/vision loss
Loss of red reflex, decreased intraocular pressure
Detached areas are grey
± RAPD
What components of the eye exam should be done in ED for ocular complaints?
Visual acuity in both eyes Pupils Extraocular structures Fundoscopy Tonometry (measure intraocular pressure) Slit lamp exam
What is on the ED DDx for red eye + light sensitivity?
Iritis, keratitis, abrasion, ulcer
What is on the ED DDx for unilateral red eye?
Iritis, keratitis, abrasion, ulcer
Herpes simplex, acute angle closure glaucoma
What is on the ED DDx for red eye with significant pain?
Iritis, keratitis, abrasion, ulcer
Herpes simplex, acute angle closure glaucoma
Scleritis
What is on the ED DDx for red eye with a white spot on the cornea?
Corneal ulcer
What is on the ED DDx for red eye with a non-reactive pupil?
Acute glaucoma, iritis
What is on the ED DDx for red eye + copious discharge?
Gonococcal conjunctivitis
What does blurred vision tell you about the patient’s diagnosis?
Very little: it is a symptom of most eye issues.
Important as “the vital sign of the eye”: tells you something is wrong.
What is the management for an ophthalmologic foreign body?
Irrigation with saline.
Remove under slit lamp with swab or sterile needle.
Abx drops QID until healed
Consider tetanus prophylaxis
Ophtho consult if globe penetration suspected
What is the first Canadian C-spine rule?
- Any high-risk factor
65 or older
Dangerous mechanism
Paresthesias in extremities
What is the second Canadian C-spine rule?
2. Any low-risk factor which allows safe assessment of ROM? Simple rearend MVC Sitting position in ED Ambulatory at any time Delayed onset of neck pain Absence of midline C-spine tenderness
What is the third Canadian C-spine rule?
- Able to actively rotate neck?
45 degrees to L and R
What do you do if someone does or doesn’t clear the rules?
If not cleared: send for imaging
If cleared: no imaging needed
In which patients can you apply the Canadian C-spine rules?
Alert (GCS=15) and stable trauma patients, with concern for cervical spine injury
What are “dangergous mechanisms” according to the Canadian C-spine rules?
Fall from elevation > 3ft or 5 stairs Axial load to head, e.g. diving MVC at high speed (>100km/h), rollover, ejection Motorized recreational vehicles Bicycle struck or collision
What are the deadly spinal causes of back and neck pain?
Cauda equina and spinal cord compression
Meningitis
Vertebral osteomyelitis
Transverse myelitis
What can cause cauda equina syndrome and spinal cord compression?
Spinal metastasis
Epidural abscess or hematoma
Disc herniation
Spinal fracture with subluxation
What are the deadly vascular/thoracic causes of back and neck pain?
Aortic dissection
Ruptured AAA
Pulmonary embolism
Myocardial infarction
What are the red flags for back pain?
Bowel or bladder dysfunction Anesthesia (saddle) Constitutional symptoms K - Chronic disease, Constant pain Paresthesia Age >50 and mild trauma IV drug use/infection Neuromotor deficits
What components of the history are important for back pain?
Fracture history, CA risk, infection risk
Any other from red flags
What physical exam components are important for the evaluation of back pain?
Vitals + pulse deficits Inspect skin for infection/trauma Abdo exam for AAA Cardiac exam MSK lower back exam Neuro exam (lower extremity, reflexes, rectal tone) Post-void residual
What labs are done for back pain?
None, usually
unless indicated by clinical suspicion, eg for PE or infection
What investigations are done for back pain?
Bedside U/S: r/o AAA, assess PVR
Why is PVR a good test for cauda equina syndrome?
PVR >200 ml 90% sensitive for CES
What is the acute management of cauda equina syndrome?
Urgent MRI
Spine consult
Analgesia
IV dexamethasone
What is the acute management of ruptured AAA?
Fluid resuscitation
Immediate OR if unstable
What is the acute management of epidural abscess?
MRI to definitively diagnose
Broad spectrum Abx
Ortho consult
What is the acute management of MSK pain?
Analgesia (WHO pain ladder)
Multidisciplinary approach with GP follow-up
What are the goals of ED treatment of orthopedic injuries?
Diagnose life- or limb-threatening injury
Reduce and immobilize # as appropriate
Provide adequate pain relief
Arrange followup as necessary
What history is particularly important to gather for orthopedic injuries?
Mechanism of injury
What is a SAMPLE history?
SSx Allergies Meds PMHx Last oral intake / Last menstrual period Events (leading up to situation) Recommended for ortho injury Hx
What features should you inspect for on physical exam (of an orthopedic injury)?
SEADS: Swelling Erythema Atrophy Deformity Skin changes (eg bruises)
What features do you palpate for (in orthopedic injury)?
local tenderness swelling, warmth crepitus joint effusions subtle deformity
What are the components of joint/injury exams in ED?
Inspect, palpate, ROM (active better than passive), neurovascular status
When do you assess neurovascular status?
Initial exam, as well as before and after reduction
What are life-threatening orthopedic injuries?
Major pelvic fracture
Traumatic amputation
Massive long bone injury –> fat emboli syndrome
Vascular injury proximal to knee/elbow
What are limb-threatening orthopedic injuries?
Fracture/dislocation of ankle (Talar avascular necrosis) Crush injuries Compartment syndrome Open fractures Dislocations of knee/hip Fractures above knee/elbow
What is the ED management of an open fracture?
Splint Tetanus prophylaxis Antibiotics Neurovascular status (before and after) Dressings (to cover wound) Remove gross debris and irrigate: formally done in OR. Standard of care is surgical management within 6h.
What SSx suggest advanced vascular injury/compartment syndrome?
6 Ps: Pulse discrepancies Pallor Paresthesia/hypoesthesia Paralysis Pain (especially when refractory to usual analgesics) Polar (cold)
What characteristics of pain suggest compartment syndrome?
Pain out of proportion to injury
Pain with passive stretch
Pain refractory to usual anesthetics
What is FOOSH (in context of a fracture)?
Fall On OutStretched Hand
What is a Colle’s fracture?
Distal radial fracture with dorsal displacement
Usually due to FOOSH
What is the appearance of Colle’s fracture on exam?
Dinner fork deformity
What is the management of a Colle’s fracture?
reduction to restore radial length and correct dorsal angulation Immobilize with splint Ortho followup (outpt, or immediate referral if complicated)
When does a Colle’s fracture require emergent Ortho referral?
Articular surface involvement
What is the clinical presentation of a scaphoid fracture?
Hx of FOOSH in 15-40yo Limited wrist/thumb ROM Tenderness in anatomical snuffbox Pain on scaphoid tubercle (volar) Pain on axial loading of thumb
Why is a scaphoid fracture concerning?
High complication rate (5-40% with non-union or avascular necrosis)
What is a spica splint?
Thumb splint Immobilizes thumb (abducted) but lets fingers move. Wraps around writst.
What is the management of a scaphoid fracture?
Thumb spica splint for suspected fractures (even if negative XR) x 6-12 weeks, repeat imaging in 10 days
What can cause a proximal humeral fracture?
Young: high energy trauma
Elderly: FOOSH
What is the management of a proximal humeral fracture?
minimally displaced: closed reduction with sling immobilization
anatomic neck fractures or displaced: ORIF
What is a boxer’s fracture?
5th metacarpal fracture, angulated into palm
Usually from a blow on distal-dorsal aspect of closed fist.
What is the management of a boxer’s fracture?
Closed reduction if angulation >40
If stable, ulnar gutter splint for 4-6 weeks.
What is at risk in an anterior shoulder dislocation?
Axillary and musculocutaneous nerves
What is the management of anterior shoulder dislocation?
reduce
immobilize in internal rotation
repeat x-ray
out-patient follow-up with orthopedics
How can a shoulder dislocation be reduced?
Traction, scapular manipulation
There are many techniques, with variable success rates and complexity
What kind of dislocation should involve ortho for reduction?
Posterior dislocations
What kinds of injury should point to the Ottawa rules for assessment?
Knee, Ankle, and Foot
What are the Ottawa Ankle rules?
An ankle X-Ray series is only required if there is any pain in the malleolar zone and…
Bone tenderness at the posterior edge or tip of the lateral malleolus
OR
Bone tenderness at the posterior edge or tip of the medial malleolus
OR
An inability to bear weight both immediately and in the emergency department for four steps
What are the Ottawa Foot rules?
A foot X-Ray series is only required if there is any pain the midfoot zone and…
Bone tenderness at the base of the fifth metatarsal
OR
Bone tenderness at the navicular
OR
And inability to bear weight both immediately and in the emergency department for four steps
When should clinical judgment prevail over the criteria, according to the Ottawa Ankle and Foot rules?
When the patient…
- is intoxicated or uncooperative
- has other distracting painful injuries
- has diminished sensation in their legs
- has gross swelling which prevents palpation of the malleolar bone tenderness
How much of the distal tibia and fibula should be palpated for a full assessment, according to the Ottawa rules?
6cm
Your patient limps: is that “walking”, according to the Ottawa rules?
Yes
True or false: medial malleolar tenderness is not as important as the other features, according to the Ottawa rules
False: do not neglect the importance of medial malleolar tenderness
What are the Ottawa Knee Rules?
A knee X-Ray series is only required for knee injury patients with any of these findings:
Age 55 or older
OR
Isolated tenderness of the patella
(No bone tenderness of knee other than patella)
OR
Tenderness of the head of the fibula
OR
Cannot flex to 90 degrees
OR
Unable to bear weight both immediately and in the emergency room department for 4 steps
What is the significance of the 4 steps in the Ottawa rules (what will the patient be doing)?
Indicates transfer of weight onto both limbs twice
What is the Weber classification?
Classifies ankle fractures by level of fibular fracture relative to syndesmosis
A: below syndesmosis
B: level of syndesmosis
C: above syndesmosis
What is the management of ankle fracture?
Non-operative: non-weight-bearing below-knee cast
Operative
All Weber C are operative, and some Weber B: depends on stability of joint
What are Jones and pseudo-Jones fractures?
Both are foot fractures of the 5th metatarsal
Jones: midshaft, high incidence of non-union, watershed circulation
pseudo-Jones: proximal tubercle avulsion, few complications
How are Jones and pseudo-Jones fractures managed?
Jones: non-weight-bearing cast or surgery
Pseudo-Jones: supportive tensor, stiff-soled shoes, or below knee walking cast
What should an emerg doc know about calcaneal fractures?
Associated with fall from height
May also have injury to ankle, knee, hip, pelvis, lumbar spine
What is the usual mechanism of injury for a hip fracture?
direct force to hip, rotational force
Elderly: fall
How does a fractured hip present on exam?
Painful ROM
Shortened, externally rotated leg
How are hip fractures managed?
Based on Garden classification.
Elderly usually get hemi- or total hip arthroplasty
Young adults: ORIF
What is ORIF, in context of a fracture?
Open Reduction Interal Fixation
What is the Garden classification?
Classifies subcapital femoral neck fractures
Garden stage I: undisplaced incomplete, including valgus impacted fractures
Garden stage II: undisplaced complete
Garden stage III: complete fracture, incompletely displaced
Garden stage IV: complete fracture, completely displaced
How does prognosis change with Garden stage I & II vs III & IV fractures?
In general:
stage I and II: stable fractures – can be treated with internal fixation (head-preservation)
stage III and VI: unstable fractures – treated with arthroplasty (either hemi- or total arthroplasty)
