ED Rotation Flashcards
Fast Exam Locations
Morrisons pouch (right side) Renal splenic window (left side) Bladder Pericardial window Anterior Chest
Fluid is black
Must be 200cc to be seen on US
Morrisons pouch
Fast Exam
Morrisons pouch = between liver and kidney
Sub diaphragmatic space (above morrisons pouch)
Inferior renal view
Mid Axillary line
Start at morrisons pouch, move superior in up and down (painting) fashion to sub diaphragmic space, then move inferior in painting fashion to inferior kidney
Depth 11-15cm
Renal Splenic window
Fast Exam
Look at spleen then kidney
Check splenic renal recess for fluid
Depth 11-15cm
Inferior cardiac window
Fast Exam
Pericardial space
Just under xiphoid, 45 degree angle
Adjust Depth to 20cm
Retro vesical pouch (bladder) (pouch of Douglass)
Fast Exam
Scan bladder just above pubis symphyses
Look for bladder rupture, free fluid
Adjust Depth to 12cm
7 lethal causes of chest pain
ACS (STEMI, N-STEMI, Unstable angina) Dissection Pneumothorax Pneumonia Esophageal Rupture PE Tamponade
Lethal causes of SOB
ACS (STEMI, N-STEMI, Unstable angina) CHF Pulmonary edema PE Pneumothorax Pneumonia COPD Asthma Anaphylaxis Obstruction
Ketorolac (toradol)
Mod/severe pain
PO, IM, IV
IM = 15 or 30 mg/ml
No liver dosing,
Renal dosing = check
Peds= 6 months and up check dose
Adverse = GI, SJS, Etc
Preg Cat C
Fentanyl
Severe Pain
IM, IV, Topical patch
50-100 mcg per dose
5 min onset,
1-2 hour duration
Give zofran
Has renal dosing, no liver dosing
Morphine
ACS Dosing 2-5 mg - IV
Q 5-30 mins
Pain Dosing = 10-30mg Q4hr
Methocarbamol
500 or 750mg tablets
100mg/ml inj
Spasm = 1000mg QID PO / 1000mg IM/IV x1
Max 3000 QD
Naproxen
250- 500mg tabs
Dose 250-500mg Q12
Peds 2 and up
Adverse = GI, SJS, Etc
Preg Cat C
Heart Score
Hx= Slightly Moderate Highly suspicious
EKG= Normal Non specific changes Sig changes
Age = <45, 45-64, >65
Risk Factors= none 1-2 RF >3 risk factors
Trop= Normal limit 1-3x normal >3x normal
0-3 = D/c 4-6 = Obs 7-10 = intervention
6 week risk of major cardiac event
Points are 0, 1, 2
PERC
>50 HR >100 O2 Sat <95 Trauma/surg requiring Anesthesia <4wks Unilateral leg swelling Hemoptysis Hormone use (OCP/Estrogen/etc) Vascular (prior clot/DVT/PE)
any one = positive PERC
WELLS
HR >100 (+1.5)
S/S of DVT (+3)
PE is most likely Dx (+3)
Immobile for last 3 days or surg in last 4 weeks (+1.5)
Previous PE/DVT (+1.5)
Hemoptysis (+1)
Malignancy w/ treatment in last 6 mo (+1)
score of 4 or under unlikely (only 3 % occurrence)
Anterior Chest
Fast Exam
Probe in sagittal (vertical position)
Mid clavicular line 3rd/4th intercostal space (right side)
Look for sliding (normal)
Repeat on other side
Auscultation order post intubation
Gastric Left
Gastric Right
Left Lungs
Right Lungs
Tonopen
Anesthetize Eye (drops) Turn on Pen Calibrate Cover Use
Normal Pressure should be under 15mmhg
Eye Exam
Visualization (abnormalities, color, Foreign Bodies) Cardinal Directions PERRLA Rosenbaum/Snellen Tonopen Fluorescein stain Ophthalmoscope Slit Lamp
Fascia illiaca compartment block
Bupivacaine 0.25% or ropivacaine 1%
Not Sterile
Ultrasound
Visualize ASIS on US Move down to visualize Femoral Nerve, artery, vein Anesthetize skin Insert long needle Aspirate Inject 3-4 ml to visualize location Once location confirmed, aspirate again Inject remainder of anesthetic
Worst adverse reaction is vessel injection (toxicity)
Pelvic Exam
Always with Escort
Keep it short ~ 30 seconds
Explain everything as you go
Keep sheet pushed own so you can see their face
Have patient empty Bladder
Palpate Abdomen
Palpate inguinal lymph nodes
Position patient, end of table, stirrups, semi fowlers
Inspect and palpate external genitalia
Insert finger at bottom, have squeeze, relax
Insert speculum, vertically, rotate to correct position
Swab, Sweep cervix
Inspect Cervix
Bimanual exam
Insert finger
Palpate skin, bladder, adnexal regions
Patient Presentation
- Summary (Demo, RF’s, CC)
- OPQRST
- 5 Pertinent (+) or (-)
- VS Summary (Abnormals)
- 3 Pertinent exam findings
- DDX (Note for or against and why)
- Workup (list labs /imaging etc.)
- Treatment plan (meds, tx, consults, admit, D/C, etc)
ACS protocol
EKG within 10 minutes
Repeat EKG’s Q15-30 mins
Draw Trop Early
Redraw at hour 1
Redraw at hour 3
IV 18ga
ASA
O2
Monitor
Number 1 AFIB Rate control with any comorbidity
Diltiazem
Diltiazem
then consider Diltiazem Drip
Then consider Metoprolol etc.
(Cardizem)
non-dihydropyridine CCB
WPW Drug
Procainamide
Wide complex SVT Med
Amiodarone
(unless Delta Wave)
(No Adenosine)
Torsades
Give Mag
EKG Presentation
Rhythm Rate ST Deviations or none Axis Intervals R wave progression Previous EKG for comparison Other abnormalities
RSI Medications
Presentation
H’s & T’s
Hypovolemia Hypoxia Hydrogen ion loss Hypothermia Hypoglycemia Hypokalemia Hyperkalemia
Toxins Tamponade Tension Pneumothorax Thrombosis Trauma
H’s & T’s
Hypovolemia
Look for bleeding
Fix it
Give Fluids (bolus)
Hypovolemia Hypoxia Hydrogen ion loss Hypothermia Hypoglycemia Hypokalemia Hyperkalemia
H’s & T’s
Hypoxia
Confirm chest rise and fall
Confirm bilateral breath sounds
Check O2 source
Hypovolemia Hypoxia Hydrogen ion loss Hypothermia Hypoglycemia Hypokalemia Hyperkalemia
H’s & T’s
Hydrogen ion loss
Hypovolemia Hypoxia Hydrogen ion loss Hypothermia Hypoglycemia Hypokalemia Hyperkalemia
H’s & T’s
Hypothermia
Hypovolemia Hypoxia Hydrogen ion loss Hypothermia Hypoglycemia Hypokalemia Hyperkalemia
H’s & T’s
Hypoglycemia
Hypovolemia Hypoxia Hydrogen ion loss Hypothermia Hypoglycemia Hypokalemia Hyperkalemia
H’s & T’s
Hypokalemia
Hypovolemia Hypoxia Hydrogen ion loss Hypothermia Hypoglycemia Hypokalemia Hyperkalemia
H’s & T’s
Hyperkalemia
Hypovolemia Hypoxia Hydrogen ion loss Hypothermia Hypoglycemia Hypokalemia Hyperkalemia
