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ED > ED Clinicals > Flashcards

ED Clinicals Flashcards

1
Q

At first thought of ACS involvement what do you do?

A

OMI [O2; Monitors=ECG/CXR]

MONA [Morphine; O2; Nitro ASA]

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2
Q

Troponin sensitivities peak at ? Hrs

A

3-6 hours

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3
Q

Myoglobin peaks at ? Hrs and is back to NML at ? Hrs

A

Peaks = 1-4 hours

NML = 24 hours

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4
Q

Anterior

Inferior

Posterior

Lateral

Wall MI Locations?

A

Anterior = 1 AVL V2 V6

Inferior = 2 3 AVF

Posterior = (I, aVL, V5-6). Reciprocal ST in 3 and AVF

Lateral = depressions in V1-V3

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5
Q

Time frame for PCI and Thrombolytics in chest pain

A

PCI = 90 minutes

Thrombolytics = 30 mins if PCI is not available

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6
Q

6 contraindications to Thrombolytics in Ischemic stroke?

A

 Prior intracranial hemorrhage (ICH)

 Known structural cerebral vascular lesion.

 Known malignant intracranial neoplasm.

 Ischemic stroke within 3 months.

 Suspected aortic dissection.

 Active bleeding or bleeding diathesis (excluding menses)

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7
Q

Pitting edema with hx of of CABG with cool extremities and AMS ; what type of shock is suspected

A

Cardiogenic

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8
Q

Cardiogenic shock treatment

A

Treatment: Fluid resuscitation, pressors (dopamine), and treat the underlying cause

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9
Q

What type of murmur is assoc with Cardiogenic shock ? And what are the two types of HF

A

S4 = diastolic HF (HFpEF) ( ejection fraction is usually
normal, impaired relaxation)

S3 = Systolic HF (HFrEF) with volume overload -
tachycardia, tachypnea. (Rapid ventricular filling
during early diastole is the mechanism responsible for
the S3; impaired wall motion/contraction)

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10
Q

What JVD pressure is assoc with Cardiogenic shock?

A

Greater than 8 cm

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11
Q

Serum BNP will often be what in obese patients?

A

Low

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12
Q

BNP vs ProBNP levels for HF

A

BNP > 500 HF likely; BNP <100 HF unlikely

proBNP >900 HF likely; proBNP <300 HF unlikely

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13
Q

CXR findings assoc with HF and Cardiogenic shock

A

Kerley B Lines

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14
Q

Class 1 HF vs Class 4 HF

A

Class I (< 5%) without any limitation of physical activity

Class IV (35 - 40 %): Patients who are not only unable to carry on any physical activity
without discomfort but who also have symptoms of heart failure or anginal syndrome
even at rest

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15
Q

Treatment of hypertensive HF

A

o Nitro—(if HTN) to reduce preload
IV Nitroprusside if need further preload reduction

o Loop diuretics after BP control

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16
Q

Normotensive HF treatment

A

o Loop diuretics o ACE/ARB not recommended in acute setting (good f/ chronic HF)

o BB not recommended in acute setting

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17
Q

Chronic HF treatment [systolic vs diastolic]

A

Systolic left heart failure: Ace Inhibitor + β-blocker + Loop Diuretic

Diastolic heart failure: Ace inhibitor + β-blocker or CCB (do not use diuretics in stable
chronic diastolic failure)

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18
Q

What pulmonary capillary wedge pressure is assoc with pulmonary edema

A

Less than 18 mmHg

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19
Q

What 5 etiologies can present with pulmonary edema

A

o Cardiac tamponade

o Cardiogenic pulmonary edema (CHF)

o Myocardial Infarction

o Pericarditis

o Myocarditis

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20
Q

Two types of neurally mediated syncope

A

Vasovagal - neurogenic

Situational - coughing vomiting carotid sinus stimulation

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21
Q

What are three reasons someone might have cardiac syncope

A

Arrhythmias
Structural obstruction
Severe MI

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22
Q

What population commonly experiences Orthostatic hypotension

A

Elderly
Diabetics
Taking certain meds; diuretics vasodilators

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23
Q

When is CT not recommended after a syncopal episode

A

Asx
Insignificant trauma
After normal neuro exam

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24
Q

Cardiomyopathy is often in the absence of what 3 things?

A

Coronary artery disease

Hypertension

Valvular disease

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25
Q

What physical exam finding is consistent with HOCM

A

Mid systolic crescendo decrescendo murmur

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26
Q

Decompensating HOCM patients can benefit from what medicine? And what does it do?

A

BB or Phenylephrine

Maintains sinus rhythm and increases afterload

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27
Q

Long term txm of HOCM

A

ICD

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28
Q

Restrictive cardiomyopathy is a

A

Diastolic dysfunction

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29
Q

Restrtrice cardiomyopathy may present like what 4 things?

A

Exertional dyspnea
Arrhythmia
Crackles
Edema

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30
Q

What are 3 causes for myocarditis

A

Virus

Bacteria

Cocaine

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31
Q

4 sxs assoc with myocarditis

A

CP
Friction Rub
Flu Like sxs
New Onset CHF

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32
Q

Since myocarditis is commonly viral what it’s he best acute management

A

Antivirals

Then VAD/Transplant

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33
Q

How much fluid is physiologic around the heart

A

Up to 50mL

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34
Q

Acute pericarditis is heard better when?

A

Sitting up and forward

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35
Q

Txt for acute pericarditis and post MI

A

Tx: NSAIDS + colchicine; if post MI  ASA + colchicine

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36
Q

What vitals are consistent with PE

A

sxs of shock; SBP<90 x 15min OR HR <40

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37
Q

What rhythm is common in PE

A

Tachy!

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38
Q

What are 3 big indicators of end organ damage in hypertension

A

Papilledema

Encephalopathy

Nephropathy

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39
Q

ED Hypertensive treatments of choice based on classification

A

Urgency = sodium nitroprusside

Emergency = clonidine

Malignant = diastolic over 140; hydralazine

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40
Q

Best treatment for pulmonary hypertension

A

Tx: Diuretics, O2, tx underlying cause, refer (basically ADHF tx)

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41
Q

Diagnostic criteria for aortic dissection

A

Diagnostic Criteria (2/3): pain, widened mediastinum, pulse/BP variation (>20mmHg)

Imaging: CXR (>8cm @ T4)

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42
Q

Stanford type A dissection is managed how vs. Type B

A

Stanford A (ascending aorta): Surgical emergency

Stanford B (descending aorta only): Medical therapy (beta-blockers) unless complications
are present

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43
Q

Study of choice for aortic dissection

A

CT ; can be diagnosed based off CXR

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44
Q

Management for descending aortic dissection

A

Tx: morphine, esmolol (goal of 100-120 SBP),

beside TEE in unstable,

CT in stable (SOC)

 +/- Nitroprusside after BB

 Immediate vascular surgery referral

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45
Q

What is the rule of repair in aortic aneurysm

A

Surgical repair if > 5.5 cm or expands > 0.5cm in 6mo or >1cm in 1yr

Nml <3cm

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46
Q

Management of aortic aneurysm

A

Tx: HTN control (BB), statins, quit smoking

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47
Q

What is the PaO2 goal in ARDS

A

Greater than 60mm

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48
Q

Pleural effusion with sxs of dyspnea at rest ; management?

A

Thoracentesis

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49
Q

When do you need to act on hemoptysis ; what do yo do

A

100-1000mL in 24 hours = MASSOIVE

Airway control; intubate ; unstable = bronchoscopy

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50
Q

If stable minor hemoptysis get what?

A

CXR

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51
Q

What labs should follow a suspected bronchitis induced minor ARDS

A

CBC

UA

Coags

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52
Q

What is the criteria for admission over PNA

A

CURB 65

Confusion
Urea [20+]
Respiratory [30+]
Bp [less 90/60]

Age over 65

Greater than 2 consider; greater than 3 ADMIT

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53
Q

Management for community acquired PNA both w/ and w/o comorbids

A

W/o = macrolide

W/ = B-lactam+Macrolide ; FQ

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54
Q

Location and size needle for thoracentesis

A

2-3 ICS -mid clavicular

3-4th anterior axillary line

14 gauge 2 inch needle

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55
Q

After Transthoracic procedures get what

A

CXR or U/s to verify placement

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56
Q

At what time after simple pneumothorax observation can you send home?

A

3-6Hrs

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57
Q

Acute management of asthma exacerbation

A

Acute treatment: oxygen, nebulized SABA, ipratropium bromide, and oral steroids

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58
Q

In COPD patients with SaO2 less than 88% do what?

A

Non invasive positive pressure ventilation

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59
Q

Go to treatments for nausea and vomiting ; antiemetics

A

Ondansetron

Droperidol

Scopolamine / Prochlerperazine

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60
Q

GI cocktail

A

Maalox
Droperidol
Viscous lidocaine

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61
Q

What patients presentation gets colon cancer workup

A

Older than 50 with new onset constipation

CBC CMP TSH

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62
Q

What is considered acute diarrhea

A

Less than 14 days ; likely VIRAL

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63
Q

sxs of a viral gastroenteritis

A

Viral = secretory, nonbloody +/- nonbilious nonbloody vomiting
Lack of fever, no severe systemic sx except in kids <2 yrs

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64
Q

What is the difference between loperamide and pepto bismol

A

Loperamide = Anti-motility (think movement of bowel contents) vs

Anti-secretory (think acid secretion)

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65
Q

Good ABX for bacterial [travelers] diarrhea

A

CIPRO 500mg BID or AZITHROMYCIN QD x 3 days ;

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66
Q

Diarrheal treatment if you suspect parasites

A

Metronidazole 750 mg TID x 10 days

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67
Q

C Diff management

A

Metronidazole 500mg TID PO!!!!

Severe = vancomycin 125mg QID PO!!!

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68
Q

What type of bacterial diarrhea is suspected after ABX use?

A

C Diff

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69
Q

Esophageal varices are commonly due to what ; presents how

A

Portal hypertension

+/- jaundice ; ascites ; hematemesis

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70
Q

5 differentials for BRBPR

A

Hemorrhoids

Anal Polyps

Colon Cancer

Fissures

Diverticulosis

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71
Q

Mallory Weiss v Boerhaves

A

MW = partial thickness tear

Boerhaves = full thickness tear

Think esophageal perforation

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72
Q

When is it okay for expectant txt in swallowed foreign body

A

Distal to pylorus
Not corroding metal

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73
Q

When is expectant therapy okay with swallowed foreign body

A

If below the pylorus

Not corroding - metal

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74
Q

Epigastric pain, hunger pangs, postprandial pain ; think what

A

Peptic ulcer disease

Gold standard = upper GI endoscope

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75
Q

Study of choice for acute pancreatitis ; chronic

A

CT w/ contrast ;

ERCP

+Grey Turner/ Cullens sign

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76
Q

Best management for acute pancreatitis

A

Treatment: IV fluids (best), analgesics, bowel rest

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77
Q

What is boas sign

A

Referred Right sub scapular pain

Chole!

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78
Q

Presentation of cholecystitis

A

 RUQ pain after a high-fat meal

 Low-grade fever, leukocytosis, jaundice

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79
Q

Dx criteria and best test for cholecystitis

A

 Ultrasound SOC - gallbladder wall >3 mm, pericholecystic fluid, gallstones

 HIDA is the best test (Gold Standard) - when ultrasound is inconclusive

 CT scan - alternative, more sensitive for perforation, abscess, pancreatitis

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80
Q

Choledocholithiasis gold standard dx

A

ERCP

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81
Q

60 % of acute cholangitis due to what

A

Choledocholithiasis

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82
Q

Organisms that commonly cause acute cholangitis (4)

A

Organisms: E. coli, Enterococcus, Klebsiella, Enterobacter

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83
Q

Organisms commonly responsible for acute cholangitis

A

Organisms: E. coli, Enterococcus, Klebsiella, Enterobacter

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84
Q

Charcots vs Reynolds’s pentad

A

Charcots = Jaundice + RUQ pain + Fever

Reynolds = + hypotension + AMS

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85
Q

Management for acute cholangitis

A

Treatment: ERCP, Cipro + metronidazole, fluids, analgesia, cholecystectomy (performed post-acute)

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86
Q

Explain prehepatic ; intra-hepatic; post-hepatic jaundice

A

PRE = hemolytic ; RBC breakdown ; dark urine/dark stool

INTRA = LIVER Hepatitis / ETOH / Cirrhosis ;

POST = obstructive ; cholestasis/pancreatic cancer; dark urine/white stools

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87
Q

Increased AST / ALT ; 2:1 think

A

ETOH

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88
Q

Increased ALT and AST > 1000 think?

A

Acute hepatitis

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89
Q

Increased ALT : AST but less than 500 ; think?

A

Chronic hepatitis

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90
Q

Dark urine represents what?

A

Increased direct bilirubin

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91
Q

Dark urine represents what?

A

Increased direct bilirubin

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92
Q

Increased bilirubin without increased LFTs =

A

suspected familial bilirubin disorders
(gilbert’s, Dubin-johnsons) and hemolysis

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93
Q

What is psoas sign fro acute appendicitis

A

RLQ pain with hip extension

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94
Q

What will the CT show for diverticulitis

A

Fat stranding and bowel wall thickening

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95
Q

Management for diverticulitis ; sxs abscess, fistula, perf, phlegmon, intractable n/v, immunocomp; no bleeding !!!

A

Tx: Metro + Cipro, pain control, liquid diet or foods as tolerated ; colonoscopy 6wks post
flare to eval f/ CA

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96
Q

MC cause of SBO vs LBO

A

SBO = adhesions or hernias, cancer, IBD, volvulus, and intussusception

LBO = cancer, strictures, hernias, volvulus, and fecal impaction

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97
Q

Do not excise hemorrhiods if?

A

ED if immunocomp, children, pregnancy, portal htn, on
anticoags, coagulopathy

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98
Q

When thinking of prerenal AKI think what? Labs? TXM?

A

Due to hypoperfusion: Hypovolemia MC, NSAIDs, IV Contrast, ACEI, ARBS (renal artery
stenosis), HF, low BP;

Labs: BUN/Cr > 20:1; Fractional excretion of sodium is normal

TXM? IVF

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99
Q

Intrinsic kidney injury think? Labs? TXM?

A

 Nephrotoxic drugs= aminoglycosides (Gentamicin), Cyclosporine, Tumor lysis syndrome,
Vasculitis (SLE, Sarcoidosis), crystals from gout, myoglobin from rhabdomyolysis

 Labs: BUN/Cr < 20:1; Fractional excretion of sodium is elevated

 TX: IVF + diuretics to get the kidneys moving

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100
Q

Cellular casts by presentation

WBC casts = 

RBC cast= 

Muddy casts =

Hyaline casts = 

Waxy = 

A

 WBC casts = pyelonephritis
 RBC cast= glomerulonephritis
 Muddy casts = ATN
 Hyaline casts = normal
 Waxy = chronic renal disease

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101
Q

Postrenal causes of AKI

A

Obstruction: kidney stones, BPH, tumors, congenital or structural abnormalities

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102
Q

AKI’s can cause what 3 things

A

ATN

Glomerulonephritis

Interstitial nephritis

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103
Q

ATN presentation

A

 Damaged tubules means can’t concentrate urine = high FENa

 Prerenal failure is MC cause

 leads to intrinsic injury

 Drugs: amp B, cisplatin, aminoglycosides, NSAIDs, ACE

 Ischemic: dehydration, shock, sepsis

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104
Q

Interstitial nephritis

A

 Immune-mediated response usually to meds

 Drugs: PCN, sulfa, NSAIDs, phenytoin

 US: WBC casts + eos + hematuria

 Dx: renal biopsy, discontinue offending drug, steroids, dialysis if needed, usually self-

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105
Q

Interstitial nephritis presentation?

A

 Immune-mediated response usually to meds

 Drugs: PCN, sulfa, NSAIDs, phenytoin

 US: WBC casts + eos + hematuria

 Dx: renal biopsy, discontinue offending drug, steroids, dialysis if needed, usually self-

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106
Q

Glomerulonephritis: IGA nephropathy, postinfectious, membranoproliferative

Presentation?

A

 UA: oliguria, hematuria, RBC casts

 Causes: group A strep, IGA, anti-GBM, ANCA

 Post-strep glomerulonephritis = MC infectious cause of acute glomerulonephritis: either
from strep pharyngitis or strep skin infection (impetigo) ⇒ hematuria, HTN, periorbital edema

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107
Q

What is Dx criteria for glomerulonephritis

A

Dx: proteinuria + RBC in urine; usually caused by group A beta-hemolytic strep

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108
Q

Goal of TXM for rhabdo

A

Tx: IVF x 24-72h (4mL/kg/h w/ urine output of 3-4mL/kg/h)

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109
Q

What is the most common cause of increased phosphates

A

Acute renal failure
Hypoparathyroidism ; PTH level controls serum calcium/phosphate

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110
Q

hypocalcemic may have tetany

Major muscle weakness=may manifests as diplopia, low cardiac output, dysphagia, and
respiratory depression due to respiratory muscle weakness.

Mental status changes= confusion, delirium, and coma.

Think?

A

Hyperphosphatemia

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111
Q

 Crush injuries  Diabetic ketoacidosis  Nontraumatic rhabdomyolysis  Overwhelming systemic infections  Tumor lysis syndrome  Metabolic or respiratory acidosis

All can cause what?

A

Hyperphosphatemia

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112
Q

TXM for Hyperphosphatemia

A

IVF + Acetazolamide [phosphate binders]

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113
Q

Causes of hypophosphatemia

A

Hyperparathyroidism

 Alcoholism

 Burns

 Starvation

 CKD
Diuretics

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114
Q

How can hypophosphatemia present clinically?

A

Anorexia and muscle weakness

 Heart failure

 Seizures and coma

 Osteomalacia

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115
Q

What is defined as hypocalcemia

A

 serum total calcium < 8.4 mg/dL

 ionized fraction of calcium < 4.4 mg/dL

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116
Q

What is the MC cause of hypocalcemia

A

Hypopararthyroidsim

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117
Q

2 signs of low calcium

A

Trousea’s and Chovsteks ; prolonged QT interval

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118
Q

Hypercalcemia is defined as

A

 serum total calcium > 10.5 mg/dL

 ionized fraction of calcium > 5.6 mg/dL

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119
Q

Stones, bones, abdominal groans, psychiatric moans”, EKG: shortened QT interval.
 polyuria, constipation, anorexia  renal stones  muscle weakness, confusion

Think?

A

Hypercalcemia

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120
Q

TXM of Hypercalcemia

A

IVF

Furosemide

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121
Q

Pearls: hypercalcemia in the elderly is cancer until proven otherwise Young adults think hyperparathyroidism

A

Pearls: hypercalcemia in the elderly is cancer until proven otherwise Young adults think hyperparathyroidism

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122
Q

Correcting chronic low sodium can lead to

A

Osmotic demyelination syndrome

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123
Q

Hyponatremia often presents with what

A

Hypokalemia

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124
Q

TXM of hyponatremia

A

 Acute treatment=50 mL bolus of 3% saline

 Chronic IV NS

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125
Q

5 causes of hypernatrmia

A

Diabetes insipidous

Fluid loss from vomiting diarrhea

Skin sweating heavy!

DKA or HHG

elderly lack of thirst

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126
Q

What is the progression from hyperkalemia with EKG changes

A

sine waves, V-tach and V-Fib

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127
Q

Treatment for hyperkalemia

A

C BIG K

IV Insulin, Glucose, Albuterol, calcium gluconate, Lasix

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128
Q

With Hypokalemia make sure you check what?

A

Magnesium!

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129
Q

LR do not work well in what patients

A

Those with Liver disease

130
Q

When is D5W contraindicated

A

Contraindicated in renal failure, cardiac compromise, and increased intracranial pressure

131
Q

What is commonly seen in dehydration

A

 Metabolic Acidosis

 low pH and low CO2

132
Q

Central DI is commonly due to what?

A

Low ADH

133
Q

What drugs can cause DI

A

Kidney related drugs like lithium and demeclocycline for hyperparathyroidism

134
Q

Management for DI

A

TX: Desmopressin (DDAVP) can treat central not kidney related

Kidney related low Na+ diet and HCTZ If they need IV fluids D5W ½ NS

135
Q

 Increase ADH from the pituitary gland  can be from an ectopic site (Small Cell Lung CA)  Present with hyponatremia  inability to dilute serum by excreting water through the kidneys  In other words too much water in the serum

Think?

A

SIADH

136
Q

What 4 meds can cause SIADH

A

Carbamazepine, HCTZ, NSAIDs, TCA

137
Q

Stone management based on size

A

<5 mm: likely to pass on own; lots of fluid; strain urine; analgesics;

Tamsulosin 5-10 mm: not likely to pass spontaneously; increased fluid and analgesics; elective lithotripsy/ureteroscopy with stone basket extraction

Refer to urology with a 9mm mid-ureteral stone

> 10mm: not likely to pass spontaneously and increased likelihood complications

138
Q

When does testicular torsion need surgery

A

Tx: surgery w/i 4-6h to preserve fertility

139
Q

Acute epididymits pathophysiology

A

Acquired by the retrograde spread of organisms through vas deferens

140
Q

Epididymitis pathogens based on age

A

 men < 35 chlamydia and gonorrhea  men > 35 E.coli

141
Q

TXM for epididymitis based on age

A

Over 35- E. coli
 FQ (Levofloxacin) x 10 days (21-30 days if associated prostatitis)

Under 35 – Gonorrhea and chlamydia
 Doxycycline 100 mg PO BID for 10 days PLUS Ceftriaxone 500 mg IM × 1

Patients of any age who practice anal intercourse – coverage for GC/chlamydia and
enteric pathogen infections
o Ceftriaxone 500mg IM PLUS FQ (Levofloxacin)

142
Q

Dx criteria for ectopic

A

Beta HCG is > 1,500, but no fetus in utero

 Serial increases of βHCG are less than expected (should double every 2 days):

Get
baseline βHCG and follow-up hormone levels in 48 hours  transvaginal U/s

143
Q

Female severe abdominal or shoulder pain, peritonitis,
tachycardia, syncope, orthostatic HTN

Think?
TXM?

A

Ectopic

TXM = Methotrexate

144
Q

4 common pregnancy emergencies before 20 weeks

A

N/V and HG

Septic ectopic

Molar

Spontaneous abortion

145
Q

Chronic vs. gestational hypertension

A

Chronic = before 20 weeks EGA

Gestational = after 20 weeks

W/ negative proteinuria

TXM = Labetalol

146
Q

premature separation of implanted placenta
Is what?

A

Abruptio placentae

147
Q

Placenta previa

A

extends near, over or beyond cervical os

148
Q

S/sx: dyspnea, orthopnea, cough, CP, edema, JVD
+ Pregnancy

Think?

A

PERIPARTUM Cardiomyopathy

149
Q

S/sx: fever, leukocytosis, tachy, pelvic pain
Postpartum

Think?

A

Endometritis

150
Q

o S/sx: pain, fever, CMT, d/c, leukocytosis o Can lead to infertility

Think?

A

PID

Caused;; GC/Chlamydia

151
Q

PID TXM.

A

Ceftriaxone IM
+ Doxy

152
Q

TSS often has what involvement

TXM?

A

3 system

GI
Heme
Renal
Hepatic
CNS

TXM = Nafcillin

153
Q

2 of what 4 for septic shock?

A

 Temp >100.4 or <96.8

 HR >90

 RR >20 or PaCO2 <32

 WBC >12k or <4k

154
Q

What is the classic triad of meningitis

A

Fever over 38C

Nuchal Rigidity

HA

155
Q

If you suspect mengitis and pt is stable do what

A

CT before LP

156
Q

Bacterial vs Viral Meningitis findings

A

Bacterial: ↑ Protein ↓ Glucose, ↑ opening pressure

Viral: normal pressure, increased WBC (lymphocytes)

157
Q

For meningitis what is the management if its is highly suspected

A

ABX first

Then CT before LP

158
Q

What do you check for before LP

A

ICP; papilledema

159
Q

Patient will present as → a 25-year-old with fever. She has a history of intravenous
drug use and had previously been treated for osteomyelitis. On physical exam, she is
febrile, and heart auscultation reveals a new systolic murmur at the lower left sternal
border. An echocardiogram reveals tricuspid valve vegetations.

Think?

A

Infective endocarditis

160
Q

Empiric treatment for infective endocarditis

A

Empiric treatment: IV vancomycin or ampicillin/sulbactam PLUS aminoglycoside

161
Q

Patient will present as → a 25-year-old with fever. She has a history of intravenous
drug use and had previously been treated for osteomyelitis. On physical exam, she is
febrile, and heart auscultation reveals a new systolic murmur at the lower left sternal
border. An echocardiogram reveals tricuspid valve vegetations.

Think?

A

Infective endocarditis

162
Q

What is the time frame for cluster headaches

A

Circadian periodicity: short-lived (15-180 min) cluster attacks; attacks occur daily
in clusters followed by remission

163
Q

TXM for tension headache

A

NSAIDs

164
Q

TXM for migraine HA

A

Tx: Abortive – triptans, antiemetics, NSAIDs, dopamine receptor antagonist

165
Q

GCA TXM

A

Prednisone 60 mg PO

166
Q

Papilledema will often present with what?

A

o Blurred disc margins, cup is diminished or absent, raised or nml IOPs

o Flame shaped hemorrhages and prolonged preservation of visual acuity o MCC = raised ICP

167
Q

What do you need for dx of pseudoturmor cerebri

A

LP

168
Q

Management of subarachnoid hemorrhage

A

CT non Con ; of neg but still suspect —> LP

169
Q

Most significant and treatable cause of stroke?

A

HTN

170
Q

MC cause of ischemic stroke vs hemmorhagic

A

Ischemic = MCA thrombotic

hemorrhagic = HTN ; aneurysm ; AVM’s

171
Q

Hemmorhagic stroke affecting anterior circulation think what sxs? And where?

A

hemispheric s/s (aphasia, apraxia, hemiparesis,
hemisensory loss, visual field defect)

ACA and MCA

172
Q

Hemmorhagic stroke of the posterior circulation will present with what sxs? And Where ?

A

coma, drop attack, vertigo, n/v, ataxia

[vertebral/basilar arteries]

173
Q

Basilar hemmorhage will present with what sxs?

A

coma, cranial nerve palsies, apnea, drop attack, vertigo

174
Q

Lacunar infarct can cause what sxs

A

silent, pure motor or sensory

175
Q

IV TPA is good treatment for hemmorhagic stroke within what time frame

A

4.5 hours onset

176
Q

What med is beneficial in TIA without hemmorhage [ischemic]

A

ASA

177
Q

Carotid artery dissection vs vertebral artery dissection sxs?

A

 Carotid artery dissection–Frontotemporal HA, horner’s syndrome, CN palsy

 Vertebral artery dissection–Dizziness/vertigo, HA and neck pain (u/l or b/l)

178
Q

Study of choice for cervical artery dissection

A

CT Angio

179
Q

Vestibular neuritis presentation

A

non positional , no hearing loss/tinnitus, tx: meclizine

180
Q

Labyrinthitis presentation

A

like vestibular neuritis + hearing loss tinnitus ,

tx: meclizine + steroids

181
Q

Acoustic neuroma presentation

A

ataxia, neurofibromatosis type II, MRI findings: vertigo, hearing loss,
tinnitus, and ataxia;

tx = surgery

182
Q

Defintion of status epilepticus ?

A

s/s: ≥5 min continuous seizure activity or more than one seizure without recovery from the
postictal state in between episodes

ALWAYS CHECK POC GLUCOSE

183
Q

What helps with isoniazid toxicity?

A

B6!

184
Q

Seizures management ; lasting longer than 60 minutes

A

o IV lorazepam 1-2 doses + IV fosphenytoin OR IV phenytoin

Refractory: IV propofol OR midazolam OR phenobarbital; intubate

o seizures lasting > 60 min may result in permanent brain damage

185
Q

Simple vs complex partial seizures

A

Partial = FOCAL

Simple = no AMS ; retained consciousness

Complex = w/ AMS ; lip smacking ; post ictal confusion

186
Q

TXM partial seizure

A

Tx - phenytoin, and carbamazepine are drugs of choice

187
Q

Explain absent seizure ; TXM

A

Brief mental status change; without motor activity – blank stare driveswim
 No aura, no post-ictal state, no loss of postural tone
 MC in 5-10 yo 

Tx: ethosuximide

188
Q

Generalized tonic-clonic seizure ?

A

Tonic-clonic: convulsive (grand mal) – bilaterally symmetric, begins with LOC

189
Q

What is the definition of myoclonic ?

A

muscle jerking, no tonic phase, occurs in the morning

190
Q

Diagnostic approach to seizure?

A

Diagnostic approach: check electrolytes, glucose, pregnancy test, ECG, EEG, neuroimaging for adults with first seizure (CT/MRI)

191
Q

What are the three zones of frostbite

A

Zone of COAG = necrotic white no circulation

Zone of stasis = mottled red ; may convert to full thickness

Zone of hyperemia = outer

192
Q

Degrees of burns? [1-4]

A

o 1st degree: frost nip, reversible; no blisters

o 2nd degree: full thickness, clear blisters

o 3rd degree: hemorrhagic blisters, skin necrosis, skin like “block of wood”

o 4th degree: down to bone, no blanching, black eschar

193
Q

Treatment of frostbite

A

Tx: thaw once refreezing risk eliminated (98.6-102.2F x 20-30m), opioids, tetanus,
elevate and immobilize

194
Q

MC cause of hypothermia

A

Impaired thermoregulation

195
Q

What is the cardio respiratory response to hypothermia

A

 Peripheral vasoconstriction w/ inc HR and BP —> Brady, HoTN, myocardial
irritability as it progresses

 Inc risk f/ dysrhythmias

 Osborn J waves

196
Q

Hypothermia txm

A

Tx in general: heat the room, remove wet clothes, dry pt

197
Q

When do you give warmed IV Fluids

A

Impaired

82.4-89.6 F

198
Q

Unconscious stage 3 hypothermia [less than 82.4 F] management?

A

ECLS/ECMO, warm saline bladder lavage, warm humidified gases

199
Q

TXM heat cramps

A

Tx: fluid & salt replacement and rest in cool place

 Mild: PO rehydration

 Severe: IV NS

200
Q

Sxs of heat cramps + N/V, HA, dizzy, orthostatic HoTN o May see rhabdo; No CNS impairment

Think?
TXM?

A

Heat Exhaustion

TXM = PO electrolytes IVF

201
Q

Best txm for heat stroke?

A

Evaporative cooling

Remove clothing

bolus IVF

202
Q

Brown recluse presentation ; TXM?

A

May have necrosis, painless bite  Tx: dapsone, abx if infected

“Working in garage”

203
Q

Black widow txm ; presentation

A

HTN, tachy  Tx: IV calcium to protect heart, opiods f/ pain, BZDs f/ spasms, antivenom

204
Q

Scorpion bite presention/ txm?

A

Peripheral nervous system sxs; affects sodium channels

 Tx: antidote + fluids  Dispo: admit if septic

205
Q

Dog and cat bites management

A

Augmentin ; rabies vaccine ; clean the wound!

206
Q

Rattle snake bite presentation ; TXM?

A

venom consumes fibrinogen and PLTs  coagulopathy

o s/sx: n/v, weakness, fasciculations, tachypnea/cardia, HoTN, AMS,

o tx: antivenom IV, FFP prn o Dispo: admit, can d/c if no manifestations in 8-12 hrs (dry bite)

207
Q

Coral snake presentation; txm?

A

Tx: 3-5 vials of antivenom IV

208
Q

How to tell venomous snakes?

A

Red on yellow, kill a fellow. = coral snake

Red on black, venom lack.

209
Q

GCS greater than 13 with submersion/drowning accident ; management

A

Clear cervical spine

Observe 4-6 hours

Check SaO2 greater than 95%

Discharge

210
Q

GCS less than 13 ; or SaO2 less than 95%; with submersion/drowning accident ; management

A

Clear cervical spine

O2 supplementation

Get labs; CXR ; UA drugs

Monitor temperature/ acid base / volume status

ADMIT

211
Q

S/sxs of DKA

A

3 Ps ; confusion ; abd pain ; fatigue

Tachy ; hpotn ; Kussmauls

212
Q

Dx criteria for DKA

A

Dx criteria: BG > 250 + AGMA (pH <7.3 + bicarc <18)

 May have hyperkalemia—get EKG immediately once DKA suspected

213
Q

TXM for DKA

A

IVF!

214
Q

3 main factors that contribute to HHG

A
  1. insulin resistance/def 
  2. inflammatory states w/ elevated CRP and counterregulatory stress hormones
    that cause inc gluconeogenesis and glycogenolysis 
  3. Osmotic diuresis followed by impaired renal secretion of glucose
215
Q

HHG management

A

IVF (15-20mL/kg/hr), correct electrolytes, insulin after initial fluid resuscitation

K is the most important!

216
Q

Hypoglycemia management

A

Tx: 50% dextrose in water as IV bolus of 50mL (25g glucose), can repeat in 15 mins

 If pt glucose is 70 or higher continue carbohydrates to prevent recurrence

 If pt unconscious then cont IV infusion of 5% dextrose in water to maintain >100

217
Q

Why does thyrotoxicosis usually occur?

A

Primary: overactive thyroids (T3/T4); secondary: overactive pituitary (TSH)

o Clinical dx in pts w/ preexisting hyperthyroidism

 Usually precipitated after radioactive iodine therapy or withdrawal from meds

218
Q

Thyrotoxicosis mangement

A

Tx: BB, methimazole, PTU, steroids, iodide

219
Q

Adrenal crisis management

A

Tx: IVF  steroids supportive care  +/- pressors

220
Q

Orbital cellulitis management

A

Postseptal (Orbital) Cellulitis
o Tx: IV vanc + ampicillin-sulbactam o Dispo: admit

221
Q

Preseptal cellulitis txm

A

Kelflex

222
Q

Conjunctivitis differences? Management?

A

Acute Conjunctivitis
 Bacterial
o Tx: Trimethoprim+ -polymyxin B, FQ f/ contact lenses, tobramycin f/ pseudomonas

 Viral
o Supportive care, ocular decongestant and artificial tears

 Allergic
o Artificial tears, topical antihistamines (olopatadine)

223
Q

MC cause of viral conjunctivitis

A

Adenovirus

224
Q

TXM herpes keratitis?

A

Tx: if on lid, PO antiviral. If on conjunctiva, topical trifluridine

225
Q

What can you get to r/o retinal detachment in vitreous hemmorhage

A

Ocular U/S

226
Q

Eval for what if recurrent sub conjunctival hemmorhage

A

Coagulopathies

227
Q

When are cycloplegics indicated and common ones?

A

Corneal foreign body

Cycloplegics = paralyze the cilia muscle ; relax accommodation
Cyclopentalate
Tropicamide

228
Q

Blow out fracture management

A

o Dx: CT scan o All blow out fx w/ nml eye exam

call ophtho to r/o retinal tears/detachment o

Tx: PO Cephalexin

229
Q

What size eyelid laceration heals spontaneously

A

Lacs at lid margin (<1mm) = spont healing

o Lacs at lid margin (>1mm) = specialist referral

 Soft (gut or chromic) 6-0 sutures or smaller w/ vertical mattress suture

230
Q

Ocular chemical injuries are usually do to what?

A

Alkali over acidic solutions

231
Q

Acute angle closure gluacoma presentation ; management

A

 Painful, N/V, headache Needcops
 Sudden onset  Painful red eye, hazy cornea, midpoint pupil 

Get IOPS!

Tx: CAI (Acetazolamide or mannitol) + topical BB (timolol) + topical A agonist

232
Q

Optic neuritis affects what vision / management?

A

Color vision

MRI

233
Q

 No eye pain  + RAPD  Sudden onset  Pale retina w/ cherry red spot  Often proceeded by amaurosis fugax

think?

A

CRAO

Central retinal artery occlusion

234
Q

 No eye pain  Sudden onset  Blood and thunder retina  Altitudinal or sectoral vision loss

Think?

A

CRVO

Central retinal vein occlusion

235
Q

 No eye pain  Sudden onset; flashes/floaters; veil/curtain  Can be total or sectorial vision loss

Think

A

Retinal detachment

236
Q

MANAGEMNT sudden onset SNHL

A

SNHL prednisone 60mg x 7-14d w/ close f/u

237
Q

Live objects in the ear do what?

A

Drown in 2% lidocaine

238
Q

o s/sx: trismus, swelling, pain, erythema ; prior dental infection

Think?
TXM?

A

Masticator space infection

IV Clindamycin = TXM

239
Q

Medication management of anterior epistaxis

A

oxymetazoline or phenylephrine

then direct pressure x 10-15min

 If failed direct pressure x2

 cautery by ENT doc

240
Q

If packing is to be in place for episatxis longer than 48 hours do what?

A

Rx: Augmentin

Admit for posterior packing

241
Q

Peri orbital bruising in the absence of trauma is suggestive of what

A

Nasal fracture

242
Q

MANAGEMNT of septal hematoma

A

I&D septal hematomas to avoid future necrosis

 b/l anterior packing w/ topical abx oint after I&D w/ 24h ENT f/u

243
Q

ANUG triad and management

A

Acute Necrotizing Ulcerative Gingivitis (ANUG)

o Triad: pain, punched out papillae, gingival bleeding
 May also have fever, bad breath
o Tx: chlorohexidine rinses bid +/- metronidazole if immunocomp

244
Q

Oral thrush txm?

A

Tx: topical nystatin if mild; mod-severe PO azole

245
Q

What virus causes hand foot and mouth?

A

Coxsackie

246
Q

Enamel + dentin fracture management

A

Cover exposed dentin w/ cement + close f/u

247
Q

Enamel dentin pulp fracture management

A

Control bleeding w/ sterile gauze, cover dentin w/ cement + close f/u

248
Q

Quinckes edema? And Assoc with what?

A

Uvular edema

GABHS

249
Q

Management of PTA

A

tx: needle aspiration <1cm deep to avoid ICA AND PCN and metro

250
Q

Treatment of adult epiglottis

A

Tx: O2, IVF, IV Ceftriaxone or Pip-taz

251
Q

Treatment of severe post tonsillectomy hemmorhage

A

 silver nitrate an option

 nebulized epi or TXA if serious hemorrhage

252
Q

Leading cause of death in patients with sickle cell dz

A

Acute Chest Syndrome
 New infiltrate on CXR w/ fever, cough, wheezing, tachypnea, or chest pain

253
Q

Primary survey of trauma

A

X-Massive hem
A-GCS<=8 —> L intubate

B->1500mL OR 200mL/hr w/ tube thoracostomy OR loss of vitals —> thoracotomy

C-whole blood

D-maintain CPP (SBP >110), euglycemia, O2

E-trauma naked; examine f/ rectal tone and gross bleeding

254
Q

MC type of injury missed in primary/secondary survey

A

Orthopedic!

255
Q

Post resuscitation priorities

A
  • Provide adequate O2 and ventilation
  • Reverse shock and stabilize hemodynamics
  • Id and treat reversible causes of cardiac arrest
  • Apply neuroprotective therapies including temperature management
  • Correct metabolic disturbances
256
Q

eFAST views?

A

Views: LUQ-RUQ-Pelvis-Cardiac-Pleura

LUQ: need superior pole of kidney in full view

RUQ: Morrison’s pouch; spine sign

Pelvis: bladder is transverse and sagittal view

Cardiac: change depth to 21; PSL w/ marker to L hip, subxiphoid marker to R shoulder

Pleura: 2ICS; Marching ants/comet tails; M-mode
beach w/ waves or barcode sign

257
Q

Cerebral profusion pressure and ICP association

A

CPP=MAP-ICP; therefore when ICP increases CPP decreases

CPP ~60-80; MAP 70-100; ICP <20

258
Q

GCS criteria

Eye

A

4 = spontaneous

3 = command

2 = to pain

1 = eyes dont open

259
Q

GCS criteria

Verbal

A

5 = responds / Oriented

4 = confused speech

3 = inappropriate words

2 = incomprehensible sounds

1 = no response

260
Q

GCS Criteria

Motor

A

6 = obeys commands

5= localizes to pain

4 = withdraws to pain

3= DECORTICATE

2 = DECERBERATE

1 = no movement

261
Q

What labs would you get in suspected skull fx

A

CBC

Coags

262
Q

TXM of a linear fx w/o intracranial injury

A

Observe 4-6hrs and discharge

263
Q

TXM of a depressed fx

A

Neurosurgery consult and seizure prophylactics

264
Q

Basilar skull fx txm

A

neurosurgery consult + abx ppx if CSF leaking

265
Q

What is common in Uncal herniation?

A

o Ipsilateral blown pupil (third nerve palsy)

o Contralateral motor paralysis

266
Q

What is a common finding in central transtentorial herniation?

A

o Bilateral pinpoint pupils

o B/l Babinski, inc muscle tone

267
Q

What is common in a Cerebellotonsilar (posterior fossa pressure) herniation?

A

o Pinpoint pupils

o Flaccid paralysis

268
Q

Cerebral contusion is often assoc with what?

A

Subarachnoid hemmorhage

269
Q

What is the cause of epidural hematoma commonly? And what shape?

A

o Usually due to blunt head trauma w/ LOC or AMS
o Convex shaped (football)

Fixed Dilated pupils

270
Q

4 important factors of subdural hematoma?

A

o Usually due to sudden accel-decel of brain parenchyma w/ tearing of bridging dural veins

o Elderly are more susceptible even from small falls

o Sxs develop w/i 14d after injury

o Concave (banana); hyperdense if acute, hypodense if old

271
Q

What type of cervical spinal fx are unstable? (5)

A

 Odontoid fx–type II-II are unstable

 Atlantoaxial dislocation —unstable

 Traumatic spondylolisthesis (pedicle fx at C2) w/ ant displacement of C2/C3 aka
Hangman’s—unstable

 Jefferson fx (burst fx of atlas)—potentially unstable

 Burst fx—unstable

272
Q

What type of cervical spinal fx is stable?

A

Laminar

273
Q

Explain what is effected in the 3 spinal cord injuries

A

o Corticospinal- motor; ipsilat

o Dorsal column- vibration/proprioception; ipsilat (located at the back of the spinal cord)

o Spinothalamic- pain/temp; contralat

274
Q

Loss of motor pain and temp b/l is consistent with what injury?

A

Anterior cord syndrome

275
Q

What i consistent with central cord injury?

A

o UE»LE sxs; usually due to hyperextension injuries
o If small  pain, temp b/l; cape distribution
o If large loss of everything

276
Q

Brown sequard syndrome is consistent with?

A

o “half cord lesion”
o Ipsilat motor/vibration/proprioception; contralat pain/temp

277
Q

MC presenting sxs of cauda equina?

A

Urinary retension

278
Q

Spinal peds imaging 2 points to keep in mind ?

A

CT if concern f/ Atlanto-occipital dislocation (AOD)

MRI if spinal damage suspected

279
Q

What’s Kehrs sign and the association?

A

pain in shoulder when legs elevated while lying flat— splenic injury

280
Q

Where does child abuse injuries most commonly occur?

A

Front of body

281
Q

When do you do an ED thoracotomy in tension pnuemothorax

A

if >1500mL initially of 200mL in3h or loss of vitals
o Open Pneumothorax

282
Q

Treatment of tension pnuemothorax

A

Immediate needle D followed by tube thoracostomy

283
Q

Open sucking chest wound pneumothorax ; what txm?

A

Cover the wound w/ one way valve. Do not insert chest tube thru wound

284
Q

With Beck’s triad , pulsus paradoxus, JVD on inspiration, narrow pulse pressure
Suspect?

A

Cardiac Tamponade

285
Q

What is Becks triad?

A

Hypotension

JVD

Muffled heart sounds

286
Q

Penetrating Abdominal Trauma
o Abdominal tenderness or distention on palpation w/ HOTN

Gets what txm?

A

Emergent Ex Lap

287
Q

Imaging stages for blunt force abdominal trauma

A

FAST U/S and CT then Laparotomy or non-op management if CT dictates

288
Q

When can you consider TXA in blunt force abdominal trauma

A

Consider TXA in all pts w/ traumatic abd hemorrhage as it reduces mortality if given w/n
1 hr; >3 hrs has an increased risk of death

289
Q

Imaging of choice for aortic rupture

A

CT

290
Q

Management of aortic rupture?.

A

o Antihypertensive treatment w/ a beta-blocker (esmolol or labetalol) 100-130 mmHg

o Emergency open repair or endovascular repair

o Admit to ICU for hemodynamic therapy and careful monitoring

291
Q

What can you do for impaled objects?

A

Leave object in place and emergently transport pt to OR for removal; may cut or shorten
the object to outside of the skin to facilitate transport

292
Q

What Type of hip fx involves both greater and lesser trochanter

A

Intertrochanteric fx’s

293
Q

Compartment syndrome has irreversible damage after how long

A

8 Hours

294
Q

Measurements for compartment fx

A

 Direct needle pressure >45mmhg needs decomp

 DBP 30-40 > than compartment pressure  GTG

 <30 difference b/w DBP fasciotomy

295
Q

Management for open fx’s

A

tetanus, irrigation, debridement, ABX then OR

296
Q

How do you manage clavicle fracture

A

pain control and arm sling for 3-4 weeks

 >12 yo w/ >100% displacement and/or shortened >2 cm = Ortho consult

 Medial clavicle = ortho consult (uncommon fx site)

297
Q

Management of proximal humerus fracture

A

 >30 degree angulation or >50% displacement = urgent referral to Ortho

 4 weeks in broad arm sling w/ ortho referral w/n a week

298
Q

Management of Cholinergic syndrome SLUDGE-M (salivation, lacrimation, urination, diarrhea, GI pain, emesis, miosis)

A

Tx: Remove all clothing, Atropine (antimuscarinic), BZDs if seizures, 2-PAM

299
Q

Anticholinergic syndrome consists of what sxs?

A

Anticholinergic Syndrome
o Red, dilated, delirium, retention, anhidrosis, tachycardia

300
Q

Management of Anticholinergic syndrome?

A

Tx: activated charcoal if presents <2h after ingestion, physostigmine

301
Q

4 examples of sympathomimetic stimulants

A

Cocaine, amphetamines, MDMA, ketamine

302
Q

Management of sympathomimetic overdose

A

Tx: BZDs, IVF
o AVOID BB, SUCCINYLCHOLINE, ANTIPYRETICS

303
Q

Treatment of serotonin syndrome

A

Tx: D/c serotonin agents, BZDs, cyproheptadine

304
Q

What represents a toxic dose of Tylenol

A

> 10g in 24h

> 6g in 2d

> 200mg/kg in kids 1-6y/o

305
Q

Tylenol overdose management

A

 <4h after ingestion: activated charcoal/gastric lavage and N-acetylcysteine if
APAP lvl at toxic lvl

 4-24h: N-acetylcysteine ; stop tx if APAP lvl non toxic

 Unk or >24h: N-acetylcysteine ; stop tx if APAP lvl non toxic

306
Q

ASA overdose treatment

A

Tx: charcoal, whole bowel irrigation, D50 if altered regardless of BG

307
Q

If there is no cause for apnea suspect what?

A

Sepsis

308
Q

Who gets admitted for bronchiolitits ?

A

Dispo: Admit <3m, <34wk EGA at birth, initial SpO2

309
Q

Stridor less than 6 months think?

A

<6mo
 Laryngomalacia; usually dx after birth epi

 Consider hemangioma if new onset after 1 st month of life

310
Q

Stridor greater than 6 months think?

A

> 6mo
 Croup, epiglottitis (thumb sign of XR), bacterial tracheitis (aka bacterial croup),
RPA, PTA, Ludwig’s

311
Q

Management of PNA in kids

A

Neonates (<1mo): ampicillin

 1-3mo: e-mycin

 3mo-5y: amox 90mg/kg

 >5y/o: Z-pack

312
Q

Where might you palpate a mass in pyloric stenosis ; txm?

A

usually presents between 6wk-6mo o Non bilious projectile vomiting ,

palpable olive shaped mass under liver edge

TXM = surgery

313
Q

Management of intestinal obstruction

A

Tx: nasogastric suction, bowel rest and IV hydration +/- surgical consultation

314
Q

Bloody or mucus diarrhea suggests?

A

Bloody or mucus diarrhea (w/ vomiting)

 consider volvulus, intussusception,
necrotizing enterocolitis

315
Q

When is blood normal in baby’s diaper

A

First 2-3 days of life

316
Q

Infants w/ rigor mortis, livedo reticularis, pH <6, reduced core temp w/o hx of environmental
hypothermia should NOT be resuscitated

Think?

A

SIDS

317
Q

Define a BRUE (5)

A

<1 min episode of apnea, color change, change in muscle tone, chocking, or gagging

318
Q

Felon vs Paronychia

A

o Felon Incision & Drainage
o Infection at pulp

o Paronychia
o Infection near nail bed

319
Q

Management for organophosphate OD

A

Atropine

320
Q

What is significant about alkaline urine?

A

Alkaline urine favors ionization of acidotic drugs within renal tubules preventing resorption of the ionized drug back across epithelium and enhancing elimination thru the urine - moderate to severe salicylate toxicity when criteria for hemodialysis has not been met

ED (1 decks)

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