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]
2
Q
Troponin sensitivities peak at ? Hrs
A
3-6 hours
3
Q
Myoglobin peaks at ? Hrs and is back to NML at ? Hrs
A
Peaks = 1-4 hours
NML = 24 hours
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
5
Q
Time frame for PCI and Thrombolytics in chest pain
A
PCI = 90 minutes
Thrombolytics = 30 mins if PCI is not available
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)
7
Q
Pitting edema with hx of of CABG with cool extremities and AMS ; what type of shock is suspected
A
Cardiogenic
8
Q
Cardiogenic shock treatment
A
Treatment: Fluid resuscitation, pressors (dopamine), and treat the underlying cause
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)
10
Q
What JVD pressure is assoc with Cardiogenic shock?
A
Greater than 8 cm
11
Q
Serum BNP will often be what in obese patients?
A
Low
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
13
Q
CXR findings assoc with HF and Cardiogenic shock
A
Kerley B Lines
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
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
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
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)
18
Q
What pulmonary capillary wedge pressure is assoc with pulmonary edema
A
Less than 18 mmHg
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
20
Q
Two types of neurally mediated syncope
A
Vasovagal - neurogenic
Situational - coughing vomiting carotid sinus stimulation
21
Q
What are three reasons someone might have cardiac syncope
A
Arrhythmias
Structural obstruction
Severe MI
22
Q
What population commonly experiences Orthostatic hypotension
A
Elderly
Diabetics
Taking certain meds; diuretics vasodilators
23
Q
When is CT not recommended after a syncopal episode
A
Asx
Insignificant trauma
After normal neuro exam
24
Q
Cardiomyopathy is often in the absence of what 3 things?
A
Coronary artery disease
Hypertension
Valvular disease
25
What physical exam finding is consistent with HOCM
Mid systolic crescendo decrescendo murmur
26
Decompensating HOCM patients can benefit from what medicine? And what does it do?
BB or Phenylephrine
Maintains sinus rhythm and increases afterload
27
Long term txm of HOCM
ICD
28
Restrictive cardiomyopathy is a
Diastolic dysfunction
29
Restrtrice cardiomyopathy may present like what 4 things?
Exertional dyspnea
Arrhythmia
Crackles
Edema
30
What are 3 causes for myocarditis
Virus
Bacteria
Cocaine
31
4 sxs assoc with myocarditis
CP
Friction Rub
Flu Like sxs
New Onset CHF
32
Since myocarditis is commonly viral what it’s he best acute management
Antivirals
Then VAD/Transplant
33
How much fluid is physiologic around the heart
Up to 50mL
34
Acute pericarditis is heard better when?
Sitting up and forward
35
Txt for acute pericarditis and post MI
Tx: NSAIDS + colchicine; if post MI ASA + colchicine
36
What vitals are consistent with PE
sxs of shock; SBP<90 x 15min OR HR <40
37
What rhythm is common in PE
Tachy!
38
What are 3 big indicators of end organ damage in hypertension
Papilledema
Encephalopathy
Nephropathy
39
ED Hypertensive treatments of choice based on classification
Urgency = sodium nitroprusside
Emergency = clonidine
Malignant = diastolic over 140; hydralazine
40
Best treatment for pulmonary hypertension
Tx: Diuretics, O2, tx underlying cause, refer (basically ADHF tx)
41
Diagnostic criteria for aortic dissection
Diagnostic Criteria (2/3): pain, widened mediastinum, pulse/BP variation (>20mmHg)
Imaging: CXR (>8cm @ T4)
42
Stanford type A dissection is managed how vs. Type B
Stanford A (ascending aorta): Surgical emergency
Stanford B (descending aorta only): Medical therapy (beta-blockers) unless complications
are present
43
Study of choice for aortic dissection
CT ; can be diagnosed based off CXR
44
Management for descending aortic dissection
Tx: morphine, esmolol (goal of 100-120 SBP),
beside TEE in unstable,
CT in stable (SOC)
+/- Nitroprusside after BB
Immediate vascular surgery referral
45
What is the rule of repair in aortic aneurysm
Surgical repair if > 5.5 cm or expands > 0.5cm in 6mo or >1cm in 1yr
Nml <3cm
46
Management of aortic aneurysm
Tx: HTN control (BB), statins, quit smoking
47
What is the PaO2 goal in ARDS
Greater than 60mm
48
Pleural effusion with sxs of dyspnea at rest ; management?
Thoracentesis
49
When do you need to act on hemoptysis ; what do yo do
100-1000mL in 24 hours = MASSOIVE
Airway control; intubate ; unstable = bronchoscopy
50
If stable minor hemoptysis get what?
CXR
51
What labs should follow a suspected bronchitis induced minor ARDS
CBC
UA
Coags
52
What is the criteria for admission over PNA
CURB 65
Confusion
Urea [20+]
Respiratory [30+]
Bp [less 90/60]
Age over 65
Greater than 2 consider; greater than 3 ADMIT
53
Management for community acquired PNA both w/ and w/o comorbids
W/o = macrolide
W/ = B-lactam+Macrolide ; FQ
54
Location and size needle for thoracentesis
2-3 ICS -mid clavicular
3-4th anterior axillary line
14 gauge 2 inch needle
55
After Transthoracic procedures get what
CXR or U/s to verify placement
56
At what time after simple pneumothorax observation can you send home?
3-6Hrs
57
Acute management of asthma exacerbation
Acute treatment: oxygen, nebulized SABA, ipratropium bromide, and oral steroids
58
In COPD patients with SaO2 less than 88% do what?
Non invasive positive pressure ventilation
59
Go to treatments for nausea and vomiting ; antiemetics
Ondansetron
Droperidol
Scopolamine / Prochlerperazine
60
GI cocktail
Maalox
Droperidol
Viscous lidocaine
61
What patients presentation gets colon cancer workup
Older than 50 with new onset constipation
CBC CMP TSH
62
What is considered acute diarrhea
Less than 14 days ; likely VIRAL
63
sxs of a viral gastroenteritis
Viral = secretory, nonbloody +/- nonbilious nonbloody vomiting
Lack of fever, no severe systemic sx except in kids <2 yrs
64
What is the difference between loperamide and pepto bismol
Loperamide = Anti-motility (think movement of bowel contents) vs
Anti-secretory (think acid secretion)
65
Good ABX for bacterial [travelers] diarrhea
CIPRO 500mg BID or AZITHROMYCIN QD x 3 days ;
66
Diarrheal treatment if you suspect parasites
Metronidazole 750 mg TID x 10 days
67
C Diff management
Metronidazole 500mg TID PO!!!!
Severe = vancomycin 125mg QID PO!!!
68
What type of bacterial diarrhea is suspected after ABX use?
C Diff
69
Esophageal varices are commonly due to what ; presents how
Portal hypertension
+/- jaundice ; ascites ; hematemesis
70
5 differentials for BRBPR
Hemorrhoids
Anal Polyps
Colon Cancer
Fissures
Diverticulosis
71
Mallory Weiss v Boerhaves
MW = partial thickness tear
Boerhaves = full thickness tear
Think esophageal perforation
72
When is it okay for expectant txt in swallowed foreign body
Distal to pylorus
Not corroding metal
73
When is expectant therapy okay with swallowed foreign body
If below the pylorus
Not corroding - metal
74
Epigastric pain, hunger pangs, postprandial pain ; think what
Peptic ulcer disease
Gold standard = upper GI endoscope
75
Study of choice for acute pancreatitis ; chronic
CT w/ contrast ;
ERCP
+Grey Turner/ Cullens sign
76
Best management for acute pancreatitis
Treatment: IV fluids (best), analgesics, bowel rest
77
What is boas sign
Referred Right sub scapular pain
Chole!
78
Presentation of cholecystitis
RUQ pain after a high-fat meal
Low-grade fever, leukocytosis, jaundice
79
Dx criteria and best test for cholecystitis
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
80
Choledocholithiasis gold standard dx
ERCP
81
60 % of acute cholangitis due to what
Choledocholithiasis
82
Organisms that commonly cause acute cholangitis (4)
Organisms: E. coli, Enterococcus, Klebsiella, Enterobacter
83
Organisms commonly responsible for acute cholangitis
Organisms: E. coli, Enterococcus, Klebsiella, Enterobacter
84
Charcots vs Reynolds’s pentad
Charcots = Jaundice + RUQ pain + Fever
Reynolds = + hypotension + AMS
85
Management for acute cholangitis
Treatment: ERCP, Cipro + metronidazole, fluids, analgesia, cholecystectomy (performed post-acute)
86
Explain prehepatic ; intra-hepatic; post-hepatic jaundice
PRE = hemolytic ; RBC breakdown ; dark urine/dark stool
INTRA = LIVER Hepatitis / ETOH / Cirrhosis ;
POST = obstructive ; cholestasis/pancreatic cancer; dark urine/white stools
87
Increased AST / ALT ; 2:1 think
ETOH
88
Increased ALT and AST > 1000 think?
Acute hepatitis
89
Increased ALT : AST but less than 500 ; think?
Chronic hepatitis
90
Dark urine represents what?
Increased direct bilirubin
91
Dark urine represents what?
Increased direct bilirubin
92
Increased bilirubin without increased LFTs =
suspected familial bilirubin disorders
(gilbert’s, Dubin-johnsons) and hemolysis
93
What is psoas sign fro acute appendicitis
RLQ pain with hip extension
94
What will the CT show for diverticulitis
Fat stranding and bowel wall thickening
95
Management for diverticulitis ; sxs abscess, fistula, perf, phlegmon, intractable n/v, immunocomp; no bleeding !!!
Tx: Metro + Cipro, pain control, liquid diet or foods as tolerated ; colonoscopy 6wks post
flare to eval f/ CA
96
MC cause of SBO vs LBO
SBO = adhesions or hernias, cancer, IBD, volvulus, and intussusception
LBO = cancer, strictures, hernias, volvulus, and fecal impaction
97
Do not excise hemorrhiods if?
ED if immunocomp, children, pregnancy, portal htn, on
anticoags, coagulopathy
98
When thinking of prerenal AKI think what? Labs? TXM?
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
99
Intrinsic kidney injury think? Labs? TXM?
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
100
Cellular casts by presentation
WBC casts =
RBC cast=
Muddy casts =
Hyaline casts =
Waxy =
WBC casts = pyelonephritis
RBC cast= glomerulonephritis
Muddy casts = ATN
Hyaline casts = normal
Waxy = chronic renal disease
101
Postrenal causes of AKI
Obstruction: kidney stones, BPH, tumors, congenital or structural abnormalities
102
AKI’s can cause what 3 things
ATN
Glomerulonephritis
Interstitial nephritis
103
ATN presentation
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
104
Interstitial nephritis
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-
105
Interstitial nephritis presentation?
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-
106
Glomerulonephritis: IGA nephropathy, postinfectious, membranoproliferative
Presentation?
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
107
What is Dx criteria for glomerulonephritis
Dx: proteinuria + RBC in urine; usually caused by group A beta-hemolytic strep
108
Goal of TXM for rhabdo
Tx: IVF x 24-72h (4mL/kg/h w/ urine output of 3-4mL/kg/h)
109
What is the most common cause of increased phosphates
Acute renal failure
Hypoparathyroidism ; PTH level controls serum calcium/phosphate
110
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?
Hyperphosphatemia
111
Crush injuries Diabetic ketoacidosis Nontraumatic rhabdomyolysis Overwhelming systemic infections Tumor lysis syndrome Metabolic or respiratory acidosis
All can cause what?
Hyperphosphatemia
112
TXM for Hyperphosphatemia
IVF + Acetazolamide [phosphate binders]
113
Causes of hypophosphatemia
Hyperparathyroidism
Alcoholism
Burns
Starvation
CKD
Diuretics
114
How can hypophosphatemia present clinically?
Anorexia and muscle weakness
Heart failure
Seizures and coma
Osteomalacia
115
What is defined as hypocalcemia
serum total calcium < 8.4 mg/dL
ionized fraction of calcium < 4.4 mg/dL
116
What is the MC cause of hypocalcemia
Hypopararthyroidsim
117
2 signs of low calcium
Trousea’s and Chovsteks ; prolonged QT interval
118
Hypercalcemia is defined as
serum total calcium > 10.5 mg/dL
ionized fraction of calcium > 5.6 mg/dL
119
Stones, bones, abdominal groans, psychiatric moans”, EKG: shortened QT interval.
polyuria, constipation, anorexia renal stones muscle weakness, confusion
Think?
Hypercalcemia
120
TXM of Hypercalcemia
IVF
Furosemide
121
Pearls: hypercalcemia in the elderly is cancer until proven otherwise Young adults think hyperparathyroidism
Pearls: hypercalcemia in the elderly is cancer until proven otherwise Young adults think hyperparathyroidism
122
Correcting chronic low sodium can lead to
Osmotic demyelination syndrome
123
Hyponatremia often presents with what
Hypokalemia
124
TXM of hyponatremia
Acute treatment=50 mL bolus of 3% saline
Chronic IV NS
125
5 causes of hypernatrmia
Diabetes insipidous
Fluid loss from vomiting diarrhea
Skin sweating heavy!
DKA or HHG
elderly lack of thirst
126
What is the progression from hyperkalemia with EKG changes
sine waves, V-tach and V-Fib
127
Treatment for hyperkalemia
C BIG K
IV Insulin, Glucose, Albuterol, calcium gluconate, Lasix
128
With Hypokalemia make sure you check what?
Magnesium!
129
LR do not work well in what patients
Those with Liver disease
130
When is D5W contraindicated
Contraindicated in renal failure, cardiac compromise, and increased intracranial pressure
131
What is commonly seen in dehydration
Metabolic Acidosis
low pH and low CO2
132
Central DI is commonly due to what?
Low ADH
133
What drugs can cause DI
Kidney related drugs like lithium and demeclocycline for hyperparathyroidism
134
Management for DI
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
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?
SIADH
136
What 4 meds can cause SIADH
Carbamazepine, HCTZ, NSAIDs, TCA
137
Stone management based on size
<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
When does testicular torsion need surgery
Tx: surgery w/i 4-6h to preserve fertility
139
Acute epididymits pathophysiology
Acquired by the retrograde spread of organisms through vas deferens
140
Epididymitis pathogens based on age
men < 35 chlamydia and gonorrhea men > 35 E.coli
141
TXM for epididymitis based on age
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
Dx criteria for ectopic
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
Female severe abdominal or shoulder pain, peritonitis,
tachycardia, syncope, orthostatic HTN
Think?
TXM?
Ectopic
TXM = Methotrexate
144
4 common pregnancy emergencies before 20 weeks
N/V and HG
Septic ectopic
Molar
Spontaneous abortion
145
Chronic vs. gestational hypertension
Chronic = before 20 weeks EGA
Gestational = after 20 weeks
W/ negative proteinuria
TXM = Labetalol
146
premature separation of implanted placenta
Is what?
Abruptio placentae
147
Placenta previa
extends near, over or beyond cervical os
148
S/sx: dyspnea, orthopnea, cough, CP, edema, JVD
+ Pregnancy
Think?
PERIPARTUM Cardiomyopathy
149
S/sx: fever, leukocytosis, tachy, pelvic pain
Postpartum
Think?
Endometritis
150
o S/sx: pain, fever, CMT, d/c, leukocytosis o Can lead to infertility
Think?
PID
Caused;; GC/Chlamydia
151
PID TXM.
Ceftriaxone IM
+ Doxy
152
TSS often has what involvement
TXM?
3 system
GI
Heme
Renal
Hepatic
CNS
TXM = Nafcillin
153
2 of what 4 for septic shock?
Temp >100.4 or <96.8
HR >90
RR >20 or PaCO2 <32
WBC >12k or <4k
154
What is the classic triad of meningitis
Fever over 38C
Nuchal Rigidity
HA
155
If you suspect mengitis and pt is stable do what
CT before LP
156
Bacterial vs Viral Meningitis findings
Bacterial: ↑ Protein ↓ Glucose, ↑ opening pressure
Viral: normal pressure, increased WBC (lymphocytes)
157
For meningitis what is the management if its is highly suspected
ABX first
Then CT before LP
158
What do you check for before LP
ICP; papilledema
159
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?
Infective endocarditis
160
Empiric treatment for infective endocarditis
Empiric treatment: IV vancomycin or ampicillin/sulbactam PLUS aminoglycoside
161
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?
Infective endocarditis
162
What is the time frame for cluster headaches
Circadian periodicity: short-lived (15-180 min) cluster attacks; attacks occur daily
in clusters followed by remission
163
TXM for tension headache
NSAIDs
164
TXM for migraine HA
Tx: Abortive – triptans, antiemetics, NSAIDs, dopamine receptor antagonist
165
GCA TXM
Prednisone 60 mg PO
166
Papilledema will often present with what?
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
What do you need for dx of pseudoturmor cerebri
LP
168
Management of subarachnoid hemorrhage
CT non Con ; of neg but still suspect —> LP
169
Most significant and treatable cause of stroke?
HTN
170
MC cause of ischemic stroke vs hemmorhagic
Ischemic = MCA thrombotic
hemorrhagic = HTN ; aneurysm ; AVM’s
171
Hemmorhagic stroke affecting anterior circulation think what sxs? And where?
hemispheric s/s (aphasia, apraxia, hemiparesis,
hemisensory loss, visual field defect)
ACA and MCA
172
Hemmorhagic stroke of the posterior circulation will present with what sxs? And Where ?
coma, drop attack, vertigo, n/v, ataxia
[vertebral/basilar arteries]
173
Basilar hemmorhage will present with what sxs?
coma, cranial nerve palsies, apnea, drop attack, vertigo
174
Lacunar infarct can cause what sxs
silent, pure motor or sensory
175
IV TPA is good treatment for hemmorhagic stroke within what time frame
4.5 hours onset
176
What med is beneficial in TIA without hemmorhage [ischemic]
ASA
177
Carotid artery dissection vs vertebral artery dissection sxs?
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
Study of choice for cervical artery dissection
CT Angio
179
Vestibular neuritis presentation
non positional , no hearing loss/tinnitus, tx: meclizine
180
Labyrinthitis presentation
like vestibular neuritis + hearing loss tinnitus ,
tx: meclizine + steroids
181
Acoustic neuroma presentation
ataxia, neurofibromatosis type II, MRI findings: vertigo, hearing loss,
tinnitus, and ataxia;
tx = surgery
182
Defintion of status epilepticus ?
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
What helps with isoniazid toxicity?
B6!
184
Seizures management ; lasting longer than 60 minutes
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
Simple vs complex partial seizures
Partial = FOCAL
Simple = no AMS ; retained consciousness
Complex = w/ AMS ; lip smacking ; post ictal confusion
186
TXM partial seizure
Tx - phenytoin, and carbamazepine are drugs of choice
187
Explain absent seizure ; TXM
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
Generalized tonic-clonic seizure ?
Tonic-clonic: convulsive (grand mal) – bilaterally symmetric, begins with LOC
189
What is the definition of myoclonic ?
muscle jerking, no tonic phase, occurs in the morning
190
Diagnostic approach to seizure?
Diagnostic approach: check electrolytes, glucose, pregnancy test, ECG, EEG, neuroimaging for adults with first seizure (CT/MRI)
191
What are the three zones of frostbite
Zone of COAG = necrotic white no circulation
Zone of stasis = mottled red ; may convert to full thickness
Zone of hyperemia = outer
192
Degrees of burns? [1-4]
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
Treatment of frostbite
Tx: thaw once refreezing risk eliminated (98.6-102.2F x 20-30m), opioids, tetanus,
elevate and immobilize
194
MC cause of hypothermia
Impaired thermoregulation
195
What is the cardio respiratory response to hypothermia
Peripheral vasoconstriction w/ inc HR and BP —> Brady, HoTN, myocardial
irritability as it progresses
Inc risk f/ dysrhythmias
Osborn J waves
196
Hypothermia txm
Tx in general: heat the room, remove wet clothes, dry pt
197
When do you give warmed IV Fluids
Impaired
82.4-89.6 F
198
Unconscious stage 3 hypothermia [less than 82.4 F] management?
ECLS/ECMO, warm saline bladder lavage, warm humidified gases
199
TXM heat cramps
Tx: fluid & salt replacement and rest in cool place
Mild: PO rehydration
Severe: IV NS
200
Sxs of heat cramps + N/V, HA, dizzy, orthostatic HoTN o May see rhabdo; No CNS impairment
Think?
TXM?
Heat Exhaustion
TXM = PO electrolytes IVF
201
Best txm for heat stroke?
Evaporative cooling
Remove clothing
bolus IVF
202
Brown recluse presentation ; TXM?
May have necrosis, painless bite Tx: dapsone, abx if infected
“Working in garage”
203
Black widow txm ; presentation
HTN, tachy Tx: IV calcium to protect heart, opiods f/ pain, BZDs f/ spasms, antivenom
204
Scorpion bite presention/ txm?
Peripheral nervous system sxs; affects sodium channels
Tx: antidote + fluids Dispo: admit if septic
205
Dog and cat bites management
Augmentin ; rabies vaccine ; clean the wound!
206
Rattle snake bite presentation ; TXM?
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
Coral snake presentation; txm?
Tx: 3-5 vials of antivenom IV
208
How to tell venomous snakes?
Red on yellow, kill a fellow. = coral snake
Red on black, venom lack.
209
GCS greater than 13 with submersion/drowning accident ; management
Clear cervical spine
Observe 4-6 hours
Check SaO2 greater than 95%
Discharge
210
GCS less than 13 ; or SaO2 less than 95%; with submersion/drowning accident ; management
Clear cervical spine
O2 supplementation
Get labs; CXR ; UA drugs
Monitor temperature/ acid base / volume status
ADMIT
211
S/sxs of DKA
3 Ps ; confusion ; abd pain ; fatigue
Tachy ; hpotn ; Kussmauls
212
Dx criteria for DKA
Dx criteria: BG > 250 + AGMA (pH <7.3 + bicarc <18)
May have hyperkalemia—get EKG immediately once DKA suspected
213
TXM for DKA
IVF!
214
3 main factors that contribute to HHG
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
HHG management
IVF (15-20mL/kg/hr), correct electrolytes, insulin after initial fluid resuscitation
K is the most important!
216
Hypoglycemia management
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
Why does thyrotoxicosis usually occur?
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
Thyrotoxicosis mangement
Tx: BB, methimazole, PTU, steroids, iodide
219
Adrenal crisis management
Tx: IVF steroids supportive care +/- pressors
220
Orbital cellulitis management
Postseptal (Orbital) Cellulitis
o Tx: IV vanc + ampicillin-sulbactam o Dispo: admit
221
Preseptal cellulitis txm
Kelflex
222
Conjunctivitis differences? Management?
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
MC cause of viral conjunctivitis
Adenovirus
224
TXM herpes keratitis?
Tx: if on lid, PO antiviral. If on conjunctiva, topical trifluridine
225
What can you get to r/o retinal detachment in vitreous hemmorhage
Ocular U/S
226
Eval for what if recurrent sub conjunctival hemmorhage
Coagulopathies
227
When are cycloplegics indicated and common ones?
Corneal foreign body
Cycloplegics = paralyze the cilia muscle ; relax accommodation
Cyclopentalate
Tropicamide
228
Blow out fracture management
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
What size eyelid laceration heals spontaneously
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
Ocular chemical injuries are usually do to what?
Alkali over acidic solutions
231
Acute angle closure gluacoma presentation ; management
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
Optic neuritis affects what vision / management?
Color vision
MRI
233
No eye pain + RAPD Sudden onset Pale retina w/ cherry red spot Often proceeded by amaurosis fugax
think?
CRAO
Central retinal artery occlusion
234
No eye pain Sudden onset Blood and thunder retina Altitudinal or sectoral vision loss
Think?
CRVO
Central retinal vein occlusion
235
No eye pain Sudden onset; flashes/floaters; veil/curtain Can be total or sectorial vision loss
Think
Retinal detachment
236
MANAGEMNT sudden onset SNHL
SNHL prednisone 60mg x 7-14d w/ close f/u
237
Live objects in the ear do what?
Drown in 2% lidocaine
238
o s/sx: trismus, swelling, pain, erythema ; prior dental infection
Think?
TXM?
Masticator space infection
IV Clindamycin = TXM
239
Medication management of anterior epistaxis
oxymetazoline or phenylephrine
then direct pressure x 10-15min
If failed direct pressure x2
cautery by ENT doc
240
If packing is to be in place for episatxis longer than 48 hours do what?
Rx: Augmentin
Admit for posterior packing
241
Peri orbital bruising in the absence of trauma is suggestive of what
Nasal fracture
242
MANAGEMNT of septal hematoma
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
ANUG triad and management
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
Oral thrush txm?
Tx: topical nystatin if mild; mod-severe PO azole
245
What virus causes hand foot and mouth?
Coxsackie
246
Enamel + dentin fracture management
Cover exposed dentin w/ cement + close f/u
247
Enamel dentin pulp fracture management
Control bleeding w/ sterile gauze, cover dentin w/ cement + close f/u
248
Quinckes edema? And Assoc with what?
Uvular edema
GABHS
249
Management of PTA
tx: needle aspiration <1cm deep to avoid ICA AND PCN and metro
250
Treatment of adult epiglottis
Tx: O2, IVF, IV Ceftriaxone or Pip-taz
251
Treatment of severe post tonsillectomy hemmorhage
silver nitrate an option
nebulized epi or TXA if serious hemorrhage
252
Leading cause of death in patients with sickle cell dz
Acute Chest Syndrome
New infiltrate on CXR w/ fever, cough, wheezing, tachypnea, or chest pain
253
Primary survey of trauma
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
MC type of injury missed in primary/secondary survey
Orthopedic!
255
Post resuscitation priorities
- 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
eFAST views?
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
Cerebral profusion pressure and ICP association
CPP=MAP-ICP; therefore when ICP increases CPP decreases
CPP ~60-80; MAP 70-100; ICP <20
258
GCS criteria
Eye
4 = spontaneous
3 = command
2 = to pain
1 = eyes dont open
259
GCS criteria
Verbal
5 = responds / Oriented
4 = confused speech
3 = inappropriate words
2 = incomprehensible sounds
1 = no response
260
GCS Criteria
Motor
6 = obeys commands
5= localizes to pain
4 = withdraws to pain
3= DECORTICATE
2 = DECERBERATE
1 = no movement
261
What labs would you get in suspected skull fx
CBC
Coags
262
TXM of a linear fx w/o intracranial injury
Observe 4-6hrs and discharge
263
TXM of a depressed fx
Neurosurgery consult and seizure prophylactics
264
Basilar skull fx txm
neurosurgery consult + abx ppx if CSF leaking
265
What is common in Uncal herniation?
o Ipsilateral blown pupil (third nerve palsy)
o Contralateral motor paralysis
266
What is a common finding in central transtentorial herniation?
o Bilateral pinpoint pupils
o B/l Babinski, inc muscle tone
267
What is common in a Cerebellotonsilar (posterior fossa pressure) herniation?
o Pinpoint pupils
o Flaccid paralysis
268
Cerebral contusion is often assoc with what?
Subarachnoid hemmorhage
269
What is the cause of epidural hematoma commonly? And what shape?
o Usually due to blunt head trauma w/ LOC or AMS
o Convex shaped (football)
Fixed Dilated pupils
270
4 important factors of subdural hematoma?
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
What type of cervical spinal fx are unstable? (5)
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
What type of cervical spinal fx is stable?
Laminar
273
Explain what is effected in the 3 spinal cord injuries
o Corticospinal- motor; ipsilat
o Dorsal column- vibration/proprioception; ipsilat (located at the back of the spinal cord)
o Spinothalamic- pain/temp; contralat
274
Loss of motor pain and temp b/l is consistent with what injury?
Anterior cord syndrome
275
What i consistent with central cord injury?
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
Brown sequard syndrome is consistent with?
o “half cord lesion”
o Ipsilat motor/vibration/proprioception; contralat pain/temp
277
MC presenting sxs of cauda equina?
Urinary retension
278
Spinal peds imaging 2 points to keep in mind ?
CT if concern f/ Atlanto-occipital dislocation (AOD)
MRI if spinal damage suspected
279
What’s Kehrs sign and the association?
pain in shoulder when legs elevated while lying flat— splenic injury
280
Where does child abuse injuries most commonly occur?
Front of body
281
When do you do an ED thoracotomy in tension pnuemothorax
if >1500mL initially of 200mL in3h or loss of vitals
o Open Pneumothorax
282
Treatment of tension pnuemothorax
Immediate needle D followed by tube thoracostomy
283
Open sucking chest wound pneumothorax ; what txm?
Cover the wound w/ one way valve. Do not insert chest tube thru wound
284
With Beck’s triad , pulsus paradoxus, JVD on inspiration, narrow pulse pressure
Suspect?
Cardiac Tamponade
285
What is Becks triad?
Hypotension
JVD
Muffled heart sounds
286
Penetrating Abdominal Trauma
o Abdominal tenderness or distention on palpation w/ HOTN
Gets what txm?
Emergent Ex Lap
287
Imaging stages for blunt force abdominal trauma
FAST U/S and CT then Laparotomy or non-op management if CT dictates
288
When can you consider TXA in blunt force abdominal trauma
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
Imaging of choice for aortic rupture
CT
290
Management of aortic rupture?.
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
What can you do for impaled objects?
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
What Type of hip fx involves both greater and lesser trochanter
Intertrochanteric fx’s
293
Compartment syndrome has irreversible damage after how long
8 Hours
294
Measurements for compartment fx
Direct needle pressure >45mmhg needs decomp
DBP 30-40 > than compartment pressure GTG
<30 difference b/w DBP fasciotomy
295
Management for open fx’s
tetanus, irrigation, debridement, ABX then OR
296
How do you manage clavicle fracture
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
Management of proximal humerus fracture
>30 degree angulation or >50% displacement = urgent referral to Ortho
4 weeks in broad arm sling w/ ortho referral w/n a week
298
Management of Cholinergic syndrome SLUDGE-M (salivation, lacrimation, urination, diarrhea, GI pain, emesis, miosis)
Tx: Remove all clothing, Atropine (antimuscarinic), BZDs if seizures, 2-PAM
299
Anticholinergic syndrome consists of what sxs?
Anticholinergic Syndrome
o Red, dilated, delirium, retention, anhidrosis, tachycardia
300
Management of Anticholinergic syndrome?
Tx: activated charcoal if presents <2h after ingestion, physostigmine
301
4 examples of sympathomimetic stimulants
Cocaine, amphetamines, MDMA, ketamine
302
Management of sympathomimetic overdose
Tx: BZDs, IVF
o AVOID BB, SUCCINYLCHOLINE, ANTIPYRETICS
303
Treatment of serotonin syndrome
Tx: D/c serotonin agents, BZDs, cyproheptadine
304
What represents a toxic dose of Tylenol
>10g in 24h
>6g in 2d
>200mg/kg in kids 1-6y/o
305
Tylenol overdose management
<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
ASA overdose treatment
Tx: charcoal, whole bowel irrigation, D50 if altered regardless of BG
307
If there is no cause for apnea suspect what?
Sepsis
308
Who gets admitted for bronchiolitits ?
Dispo: Admit <3m, <34wk EGA at birth, initial SpO2
309
Stridor less than 6 months think?
<6mo
Laryngomalacia; usually dx after birth epi
Consider hemangioma if new onset after 1 st month of life
310
Stridor greater than 6 months think?
>6mo
Croup, epiglottitis (thumb sign of XR), bacterial tracheitis (aka bacterial croup),
RPA, PTA, Ludwig’s
311
Management of PNA in kids
Neonates (<1mo): ampicillin
1-3mo: e-mycin
3mo-5y: amox 90mg/kg
>5y/o: Z-pack
312
Where might you palpate a mass in pyloric stenosis ; txm?
usually presents between 6wk-6mo o Non bilious projectile vomiting ,
palpable olive shaped mass under liver edge
TXM = surgery
313
Management of intestinal obstruction
Tx: nasogastric suction, bowel rest and IV hydration +/- surgical consultation
314
Bloody or mucus diarrhea suggests?
Bloody or mucus diarrhea (w/ vomiting)
consider volvulus, intussusception,
necrotizing enterocolitis
315
When is blood normal in baby’s diaper
First 2-3 days of life
316
Infants w/ rigor mortis, livedo reticularis, pH <6, reduced core temp w/o hx of environmental
hypothermia should NOT be resuscitated
Think?
SIDS
317
Define a BRUE (5)
<1 min episode of apnea, color change, change in muscle tone, chocking, or gagging
318
Felon vs Paronychia
o Felon Incision & Drainage
o Infection at pulp
o Paronychia
o Infection near nail bed
319
Management for organophosphate OD
Atropine
320
What is significant about alkaline urine?
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
