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Emergency Medicine > EM #1 > Flashcards

EM #1 Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

What is most common reason for people coming into ED?

A

lack of access to other providers

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2
Q

What percent of patients come to the ED because of lack of access to other providers?

A

80%

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3
Q

What GCS classifies a severe TBI?

A

under 9

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4
Q

Who has the highest rate of mortality from TBI?

A

young (15-24yo) and old (over 65yo)

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5
Q

What is the leading cause of TBI?

A

MVA (alcohol #2?)

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6
Q

Who is at risk for TBI?

A 
young/old
low income
unmarries
ethnic minorities
inner city residents
men
individuals w/substance abuse
individuals w/ hx TBI
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7
Q

What classifies moderate GCS?

A

9-12

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8
Q

What classifies minor TBI?

A

13-15

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9
Q

What is GCS?

A

15-point scale used to rate mental status and function (used to rate severity of brain injury and predict outcome)

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10
Q

When should GCS be administered?

A

at triage and repeatedly during eval (any decrease is DANGER sign!)

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11
Q

What are type of TBI primary injuries?

A
  1. 3 types of tissue deformation (compression, tensile, shear)
  2. mechanical injury to neurons/axons
  3. coup/countrecoup
  4. acceleration and deceleration
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12
Q

What are secondary TBI injuries?

A

Minutes-days AFTER initial injury:

  • microscopic/cellular
  • cerebral arterial dilation
  • hemorrhage
  • cerebral edema/increased icp
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13
Q

What are signs of basilar skull fracture?

A
  • Battles sign (ecchymoisis of mastoid)
  • Raccoon eyes (periorbital ecchymoses)
  • CSF rhinorrhea
  • hemotympanum
  • vertigo
  • decreased hearing
  • 7th nerve palsy
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14
Q

What are signs of patient NOT having significant intracranial injury?

A
  • No HA
  • No vomiting
  • under 60
  • no intoxication
  • no memory problems
  • no physical evidence of trauma above clavicles
  • no seizure
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15
Q

Who gets a CT?

A

-GCS under 15 2hrs after injury
-suspected skull fracture
-any signs of basilar skull fracture
-2 or more episodes of vomiting
-65 or older
-amnesia before/after impact
dangerous mechanism (pedestrian, ejected from vehicle, fall over 3ft/5 stairs)
-ANY neuro deficits
-Oral anticoag use

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16
Q

What is a post-traumatic seizure?

A
  • w/n first week after injury (most w/n first day)

- If happens, increases risk of post-traumatic epilepsy to 1/4 (resistant to typical anticonvulsant tx)

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17
Q

When does post-concussion syndrome occur?

A

occurs even with mild TBI and occurs days-weeks after initial concussion

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18
Q

What are sxs of post-concussion syndrome?

A 
HA
dizziness
memory problems
depression/anxiety
difficulty concentrating
sleep problems
difficulty concentrating
restlessness/irritability
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19
Q

What are common areas of brain contussion?

A

orbitofrontal cortex, anterior temporal lobe, posterior portion of superior temporal gyrus

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20
Q

What can brain contussion lead to?

A

herniation, midline shift, increased ICP

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21
Q

What are cerebral contussions and intracerebral hemorrhage associated with?

A

subarachnoid hemorrhage

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22
Q

What is a diffuse axonal injury?

A

acceleration/deceleration MOI where shear forces injure axons in white matter

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23
Q

What is a common cause of diffuse axonal injury?

A

shaken baby syndrome

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24
Q

Where does diffuse axonal injury commonly occur?

A

junction of grey and white matter

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25
Q

How do you classify diffuse axonal injury?

A

Mild- coma 6-24hrs, usually recover w/o sequelae
Moderate- Coma over 24hrs, wake up w/long-term sequela
Severe- prolonged coma, persistent vegitative state

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26
Q

How do you treat diffuse axonal injury?

A

supportive

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27
Q

What is the most common CT abnormality in patients with moderate/severe TBI?

A

subarachnoid hemorrhage

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28
Q

How does a subarachnoid hemorrhage present?

A

blood in CSF, headache (severe), photophobia, meningeal signs

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29
Q

What can subarachnoid hemorrhage lead to?

A

Increased ICP due to blockage of CSF outflow at 3rd and 4th ventricles

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30
Q

What is a slow/venous bleed of bridging veins?

A

subdural hematoma

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31
Q

Who is at risk of getting subdural hematomas?

A

people with cerebral atrophy (elderly, alcoholics)

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32
Q

How do subdural hematomas appear on CT scan?

A

Concave, CRESENT-shaped

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33
Q

Are subdural hematomas acute or chronic?

A

Can be both!

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34
Q

What is the initial clinical presentation of someone with an epidural hematoma?

A

brief LOC followed by a lucid period

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35
Q

Which artery is the source of bleeding?

A

Middle meningeal artery (from temporal blow to head)

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36
Q

How do epidural hematomas appear on CT?

A

Football shaped

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37
Q

What are late findings in someone with an epidural hematoma?

A

fixed, dilated pupil on ipsilateral side with contralateral hemiparesis

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38
Q

What is a type A brain herniation?

A

Subfacial (cingulate) herniation

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39
Q

What is a type B brain herniation?

A

Uncal herniation

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40
Q

What is a type C brain herniation?

A

downward

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41
Q

What is type D brain herniation?

A

External herniation

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42
Q

What is type E herniation?

A

Tonsillar herniation

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43
Q

What are the 3 types of brain herniation that are caused by focal, ipsilateral space-occupying lesions (tumor, hemorrhage)?

A

A, B, E

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44
Q

What is the definition of ICP?

A

volume of brain, volume of CSF, volume of blood, volume of mass lesion (all NON-COMPRESSIBLE!)

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45
Q

How do you calculate CCP?

A

MAP- ICP

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46
Q

When is CCP critical?

A

50-70

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47
Q

How do you adjust CCP?

A

Increase MAP (IVP, pressors) or Decrease ICP (osmotic diuresis, HOB elevation, burr holes, hyperventilation)

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48
Q

What is one of the most common pre-hospital procedures?

A

spine immobilization

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49
Q

Who is at risk for C-spine injuries?

A
  • 80 percent cervical fractures in males
  • 25 percent involve alcohol
  • Elderly (osteoporosis)
  • Other (RA, downs, chronic steroids)
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50
Q

Where does the cord that controls motor movement cross?

A

Medulla

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51
Q

Where does the cord that controls pain/temp cross?

A

At level in spinal cord

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52
Q

Where does the cord that controls vibration/proprioception cross?

A

Medulla

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53
Q

Where is the most common location to injure ones spine?

A

Cervical (55 percent)

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54
Q

What are primary spine injuries?

A

frature, dislocation, tearing ligament, disruption of discs

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55
Q

What are characteristics secondary spine injuries?

A
  • minutes to hours after injury

- AVOID HYPOTENSION!

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56
Q

How do you dx a cord injury?

A

MRI

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57
Q

Hhow do you treat a cord syndrome?

A

dexamethasone

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58
Q

What is MOI of central cord syndrome?

A

forced hyper-flexion of neck

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59
Q

How does central cord syndrome present?

A
  • muscle weakness (more in upper extremity)
  • lose pain and temp sensation in cape-like distribution
  • proprioception/vibration intact
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60
Q

What is the prognosis for central cord syndrome?

A

Will probably recover fine

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61
Q

What is MOI of Anterior Cord Syndrome?

A

hyperextension of neck (ex: MVA, vascular injury, vertebral compression fracture)

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62
Q

Who is anterior cord syndrome more common in?

A

elderly

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63
Q

How does anterior cord syndrome present?

A
  • weakness and loss of pain/temp on both sides distal to lesion
  • vibration/proprioception intact
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64
Q

What is prognosis for anterior cord syndrome?

A

not great

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65
Q

What is MOI of Brown-Sequard syndrome

A

Penetrating injury (stabbing) that paralyzes half of cord

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66
Q

How does Brown-Sequard syndrome present?

A
  • Loss of strength strength and proprioception/vibration on same side of injury
  • loss of pain/temp on opposite side
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67
Q

What is NEXUS?

A

Criterion for when NOT to get C-spine xray

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68
Q

What are criteris in NEXUS? (5)

A
  • No posterior midline cervical spine tenderness
  • No evidence of intoxication
  • Normal level of alertness
  • No neuro deficits
  • No painful distracting injury
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69
Q

What is next step if meet all NEXUS criteria?

A

ok to remove collage, no imaging needed

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70
Q

What is next step if yes to at least ONE of NEXUS criteria?

A

C-spine xray or CT

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71
Q

What are the 3 views to get for C-spine imaging?

A
  • long AP
  • lateral
  • mouth
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72
Q

What must a lateral c-spine xray include?

A

T1

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73
Q

What happens if injury at C4?

A

loss of spontaneous breathing

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74
Q

What happens if injury at C5?

A

loss of shoulder shrug

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75
Q

What happens if injury at C6?

A

loss of flexion at elbows/triceps reflex

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76
Q

What happens if injury at C7?

A

loss of extension at elbow/triceps reflex

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77
Q

What happens if injury at C8/T1?

A

Loss of flexion in fingers

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78
Q

What happens in injury at T1/T2?

A

loss of intercostal muscle and abd muscle use

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79
Q

Which xray view shows 70 percent of abnormalities?

A

lateral neck

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80
Q

Which xray view do you use to see spinous processes are in straight line?

A

Long AP view

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81
Q

Which xray view do you use to see lateral margins of C1 and C2?

A

open mouth

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82
Q

Which xray view do you use to see contour lines and vertebral bodies?

A

lateral neck

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83
Q

Which xray view do you use to see distance between odontoid peg and lateral masses?

A

open mouth

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84
Q

Which xray view do you use to see the distances between spinous processes?

A

long AP view

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85
Q

Which xray view do you use to see intervertebral disc space?

A

lateral neck

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86
Q

Which xray view do you use to see prevertebral soft tissues?

A

lateral neck

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87
Q

Do normal xrays r/o significant cord injury?

A

Nope (always use clinical judgement!)

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88
Q

What is a Jefferson fracture?

A

C1

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89
Q

What is MOI of Jefferson fracture?

A

axial loading (diving)

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90
Q

What is an odontoid fracture?

A

C2 (more than half of a all C2 fractures)

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91
Q

What are sxs of Jefferson and odontoid fractures?

A

may have few sxs because no spinal cord injury, but both very unstable!

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92
Q

What is a hangmans fracture?

A

C2

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93
Q

What is MOI of hangmans fractures?

A

Forced hyperextension of neck (Falls, MVA, hanging)

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94
Q

What is a clay shovelers fracture?

A

stable fracture of spinous process (no neuro problems)

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95
Q

What is a burst compression fracture?

A

Involves posterior half of vertebrae (may result in retropulsed fragments that can impinge on spinal cord and cause neuro damage)

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96
Q

What are S/S of Cauda Equina syndrome?

A
  • bowel/bladder dysfunction
  • decreased rectal tone
  • saddle anesthesia
  • decreased lower extremity DTRs
  • sciatica
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97
Q

What percent of ED visits are for people over 65?

A

25 percent

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98
Q

What are factors in geriatric ED medicine?

A
  • longer stays
  • multiple medical problems
  • polypharm
  • vague/atypical sxs
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99
Q

What are cardiovascular changes in elderly? (5)

A
  • Decreased HR, CO, EF
  • Impaired ventricular compliance
  • Thickening valves
  • Decreased response to sympathetic stimuli
  • Increased prevalence of CAD, CHF
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100
Q

What are pulm changes in elderly? (6)

A
  • Decreased lung compliance, increased CW stiffness
  • Decreased strength/endurance of resp. muscles
  • Decreased vital capacity, expiratory flow
  • Decreased mucocilliary clearance mechanisms
  • Increased sensitivity to narcotic-induced resp. depression
  • Increased incidence of small airway closure
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101
Q

What are renal changes in elderly? (6)

A
  • decreased GFR
  • Decreased renal mass, blood flow, permeability
  • Decreased ability to concentrate urine (decreases ability to conserve H2O)
  • Dysregulation of renin-angiotensin system
  • Impaired Vit D metabolism
  • Decreased thirst mechanism
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102
Q

What are GI changes in elderly? (4)

A
  • Impaired swallowing
  • Impaired GI mucosal protection
  • Decreased GI motility and absorption
  • Impaired hepatic drug clearance
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103
Q

What are MSK changes in elderly? (2)

A
  • Decreased muscle mass

- Decreased bone density

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104
Q

What are intergumentary changes in elderly? (4)

A
  • Decreased subcutaneous fat, loss of elastic collagen
  • Decreased glandular function
  • Skin thin and fragile
  • Increase benign/malignant skin changes
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105
Q

What are neuro changes in elderly? (5)

A
  • Neuronal loss
  • Increased stroke risk
  • Cerebral atrophy
  • Impaired memory and cognition
  • Impaired sensory function
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106
Q

What are come complications of falls in elderly?

A
  • TBI
  • C-spine injury
  • Fracture
  • hematoma
  • intra-abd injury
  • lacerations
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107
Q

What are risk factors for falls in elderly?

A
  • hx falls
  • increased age
  • female
  • cognitive impairment
  • dizziness/balance problems
  • peripheral neuropathy
  • hx stroke
  • psychotropic drugs
  • arthritis
  • orthostatic hypotension
  • vision impairment
  • PD
  • DM
  • Etoh use
  • trip hazards in home
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108
Q

do elderly patient having an MI always have chest pain?

A

no

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109
Q

What are risk factors for serious disease in elderly?

A 
Temp over 103
RR over 30
WBC over 11k
HR over 120
positive CXR
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110
Q

What are common causes of delirium?

A
  • infection
  • hypoxia
  • metabolic (Na, glu)
  • CVA
  • polypharm
  • substance abuse/withdrawal
  • med SE
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111
Q

What percent of all ED visits are due to adverse drugs effects in patients over 65?

A

11%

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112
Q

What are reasons geriatric patients are more susceptible to med SE?

A
  • changes in drug metabolism/kidney function

- increased risk drug-drug reaction

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113
Q

What are some high risk drugs for geriatric patients?

A
  • anticholinergics
  • insulin
  • sulfonylureas
  • warfarin
  • digoxin
  • benzos
  • diphenhydramine/antihistamine
  • opioids
  • antipsychotics
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114
Q

What is the most common type of burn?

A

thermal burn

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115
Q

When should you suspect myocardial depression in a burn patient?

A

Burn over 40 percent of TBSA

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116
Q

What temperature causes a thermal burn?

A

over 115 degreed F

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117
Q

What is the severity of a burn based on?

A

depth, extent, location

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118
Q

What is the outermost layer of skin called?

A

epidermis

119
Q

What is the layer of skin that contains capillaries/nerves/hair follicles?

A

dermis

120
Q

What layer of skin is a layer of adipose tissue and connective tissue?

A

hypodermis

121
Q

When should you re-eval burn depth?

A

24-72 hrs

122
Q

Who/when should you definitely re-eval burn depth in?

A
  • under 5, over 55
  • volar surface of arms
  • medial thighs
  • perineum
  • ears
  • esp. thin skin!
123
Q

What type of burn has red, dry painful skin with NO blistering?

A

superficial burns

124
Q

Do superficial burns blanch with pressure?

A

yas

125
Q

What layer of skin is involved with superficial burns?

A

epidermis only

126
Q

How long does it take for superficial burns to heal?

A

heals w/n 4-7 days w/o scarring

127
Q

What type of burn is red, moist, painful and HAS BLISTERS?

A

superficial partial thickness

128
Q

What layers of skin are involved in superficial partial thickness?

A

epidermis and extends into dermis

129
Q

Does skin blanch in superficial partial burns?

A

yas

130
Q

How long does it take superficial partial burns to heal, and is there scarring?

A

heals w/n 14-21 days w/o scarring

131
Q

What type of burn is the skin white/yellow and pressure can be felt but no overt pain?

A

deep partial thickness

132
Q

Is blanching present in deep partial thickness burns?

A

nope

133
Q

What other sensation is lost with deep partial thickness burn?

A

2-point discrimination

134
Q

How long does it take deep partial thickness burns to heal and is there scarring?

A

healing 21 days- 3 months, scarring common

135
Q

What type of burn presents as charred, black-pale and waxy white, leathery and is PAINLESS?

A

full thickness burns

136
Q

How long does it take full thickness burns to heal?

A

will NOT heal spontanesouly, need skin graft

137
Q

What layers of skin are involved in a 4th degree burn?

A

extends into deeper tissue (fat, bone, muscle)

may require amputation

138
Q

When is total body surface area used to describe the extent of a burn injury?

A

only for burns more severe than superficial

139
Q

What percent of a persons body is their head and neck?

A

9 percent

140
Q

What percent of a persons body is their entire chest and abdomen?

A

18 percent

141
Q

What percent of a persons body is their back and butt?

A

18 percent

142
Q

What percent of a persons body is one entire arm (front and back?

A

9 percent

143
Q

What percent of a persons body is one entire leg (front and back)?

A

18 percent

144
Q

What can you use to estimate 1 percent of BSA?

A

A persons hand (including fingers)

145
Q

What can be used to better estimate BSA in children as their head size relative to body?

A

Lund-Bowder diagram

146
Q

What burn locations make burns more serious?

A
  • circumferential burns
  • burns covering joints
  • burns involving face (eyes), hands, feet, genitalia/perineum
147
Q

What defines a minor burn? (7)

A
  • partial thickness under 10% BSA pts 10-50yo
  • Partial thickness under 5% BSA under 5yo, over 50yo
  • full thickness burns under 2% BSA w/o other injury
  • may NOT involve face/hands//feet/perineum/genitalia
  • may NOT cross joints
  • may NOT be circumferential
148
Q

Who gets referred to a burn center?

A

Basically anything other than a minor burn

149
Q

What should you do immediately when treating minor burns?

A

Cool them!! with cool/room temp H2O

150
Q

What do you clean minor burns with?

A

mild soap and H2O

151
Q

What topical antibiotics do you use for minor burns?

A
  • silver sulfadiazine (not under 2yo)

- bacitracin, triple abx ointment, honey

152
Q

What do you want to avoid when treating minor burns?

A

lanolin (increased itchiness)

153
Q

What vaccine do you want to give burn victims?

A

tetanus

154
Q

What do you use during the final phase of healing of a burn?

A

non-perfumed moisturizing cream

155
Q

How soon should someone with a minor burn follow up?

A

in 24 hours, then in 1 week

156
Q

What is the most common cause of death in burn victims?

A

smoke inhalation injury

157
Q

What does smoke inhalation lead to?

A

rapid airway edema

158
Q

What are signs of smoke inhalation injury?

A
  • carbonaceous sputum
  • singed facial/nasal hairs
  • facial burns
  • oropharyngeal edema
  • voice changes
  • assume injury if person confined in fire environment
159
Q

What should you be concerned about with a burn that is over 15 percent BSA?

A

hypovolemia

160
Q

What is the Parkland formula?

A

determines how much fluid to give to burn patients?

161
Q

How do you calculate the parkland formula?

A

percent BSA + wt(kg) + 2cc

162
Q

What is the timing of fluid resuscitation in burn patients?

A

half in first 8hrs, remaining over 16 hrs

163
Q

What do you use to calculate how much fluid to give children?

A

Galveston formula

164
Q

What should you monitor for while cooling a burn that is over 10 percent BSA?

A

hypothermia!

165
Q

What lab do you want to order to check for muscle breakdown in burn patients?

A

CPK

166
Q

What do you have to be mindful of with circumferential burns?

A

eschar

167
Q

When should an eschartomy take place?

A

12-24 hrs after injury

168
Q

What can an NTG trial for CP help with?

A

angia, esophageal spasm, cervical disc disease

169
Q

A patient presents with central CP that worsens when supine and improves with sitting and leaning forward

A

pericarditis

170
Q

What PE finding do you have with pericarditis?

A

friction rub

171
Q

What is the most common cause of pericarditis?

A

viral (coxsackie)

172
Q

What are other causes of pericarditis?

A
  • uremia
  • early post-MI (2nd-3rd day)
  • neoplastic disease
  • Dresselers syndrome (2-6 weeks post-MI)
  • others (trauma, drug-induced, radiation, autoimmune)
173
Q

What are the ECG findings in pericarditis?

A

diffuse ST-elevation (all leads except Avr and V1)

174
Q

What imaging stusy do you have to do on all pericarditis patients to confrim resolution?

A

echo!

175
Q

How do you treat pericarditis?

A

NSAIDS

176
Q

What do you want to avoid with pericarditis?

A

anticoag! (potential risk to bleed into pericardium)

177
Q

What are risk factors for a PE?

A
  • STASIS
  • cardiac d/o (afib, HF)
  • hypercoagability (OCP, neoplasm, factor V leiden)
  • trauma
  • chemo
  • smoking
178
Q

What are the 3 sxs that most patients with PE have at least one of?

A
  • tachypnea
  • dyspnea
  • pleuritic chest pain
179
Q

What lab do you want to order for PE?

A

d-dimer! (sensitive, but not specific)

180
Q

What is the initial imaging of choice for PE?

A

-Helical CT angiography

non-invasive, requires contrast

181
Q

What is the definitive imaging test?

A

pulmonary angiography (invasive!)

182
Q

How do you treat PE?

A

Full anticoag x3-6 months

183
Q

What is the INR goal for pts with PE on coumadin?

A

2-3

184
Q

Who has atypical presentations of STEMIs?

A
  • elderly (fatigue, abd pain)
  • women (right-sided pain)
  • diabetes (painless MI)
185
Q

What is the dose of aspirin you give someone with STEMO?

A

160-325mg

186
Q

What is the ECG criteria for STEMI?

A
  • Over 2mm ST elevation precordial leads

- Over 1mm ST elevation limb leads in 2 adjacent leads

187
Q

What do you give for pain during STEMI?

A
  • NTG (0.4mg SL q5min up to 3 doses)– avoid if SBP under 90
  • Morphine sulfate
  • BB
188
Q

What labs do you want to order serially with STEMI?

A
  • CK-MB
  • troponins
  • INT/PTT
189
Q

What are the 3 different reperfusion strategies for tx of STEMI?

A
  • PCI (requires facility available)
  • fibrinolytic
  • facilitate PCI
190
Q

What is the ideal “door to balloon” time for PCI?

A

90 min

191
Q

What is the goal time for keeping ischemic time undeR?

A

120 min

192
Q

How soon do you want to initiate fibrinolytic therapy?

A

w/n 30min

193
Q

What are contraindications for fibrinolytic therapy?

A
  • hx hemorrhage
  • prior stroke w/n 1 yr
  • internal bleeding
  • recent head trauma
  • recent surgery (w/n 3 wks)
  • over 65yo
194
Q

What is a Type A aortic dissection?

A

dissection starts at aortic arch, proximal to L subclavian

195
Q

What is a Type B aortic dissection?

A

dissection starts proximal to descending aorta beyond subclavian

196
Q

What are sxs of aortic dissection?

A
  • CP radiating to back
  • HTN usually present
  • sometimes femoral bruits
197
Q

What urgent imaging do you want to get in ED?

A

multiplanar CT (need low threshold)

198
Q

What is ASAP tx for aortic dissection?

A

Lower dat BP! (goal is SBP 100-110)

199
Q

What do you use to lower BP in aortic dissection?

A

BB initial drug of choice (IV labetolol, esmolol)

200
Q

What does a Type A aortic dissection need for tx?

A

urgent surgery

201
Q

What does Type B aortic dissection need for tx?

A

surgery or medical rx (if not surgical candidate)

202
Q

What is the major difference between NSTEMI and UA

A

NSTEMI has elevated cardiac markers because cell necrosis has started, UA does not

203
Q

What are S/S of UA/NSTEMI?

A

sxs AT REST

204
Q

What is the dx criteria for an NSTEMI?

A

at least one value over 99th percentile

205
Q

What does the ECG look like for NSTEMI/UA?

A

ST depression, T-wave inversion

206
Q

What are risk factors for an adverse event from UA/NSTEMI?

A
  • over 65
  • 2 or more CHD risk factors
  • coronary stenosis
  • 2 or more angina episodes w/n 24 hrs
  • ASA use in 7 days
  • elevated cardiac biomarkers
207
Q

What should you do if you suspect someone is having UA/NSTEMI but exam is unremarkable, 1st biomarkers unremarkable and no ECG changes?

A

continue to monitor and do serial ECG’s and cardiac markers

208
Q

What should all patients be put on post NSTEMI/UA?

A

ASA!

209
Q

What is a complication of pericarditis?

A

cardiac tamponade!

210
Q

What are S/S of cardiac tamponade?

A
  • marked elevation of LV/RV diastolic pressures
  • soft heart sounds
  • MARKED DECREASE CO
  • pulsus paradoxus
211
Q

What is pulsus paradoxus?

A

systolic BP drops over 10mmHg w/inspiration

212
Q

How does cardiac tamponade appear on CXR?

A

cardiomegaly

213
Q

How does cardiac tamponade appear on ECG?

A

low voltage/amplitude (due to effusion blocking electricity)

214
Q

How do you dx cardaic tamponade?

A

Echo!

215
Q

How do you treat cardiac tamponade?

A

pericardiocentesis (subxiphoid approach)

Send fluids to cytology

216
Q

What are causes of acute pulmonary edema?

A
  • Acute MI/severe ischemia
  • progression of heart failure (acute deterioration)
  • acute volume overload of LV (MR, etc. )
217
Q

What are precipitating factors to acute pulmonary edema?

A
  • discontinuation of meds
  • excessive Na intake
  • tachy arrhythmia
  • intercurrent infection
  • MI
218
Q

How do you dx acute pulmonary edema?

A

-BNP

CXR (lungs with vascular redistribution– “BUTTERFLY PATTERN” of alveolar edema

219
Q

How do you treat acute pulmonary edema?

A
  • Keep SaO2 over 91 (means over 60 Po2)
  • morphine sulfate (venodilator)
  • IV diuretics
  • nitrates
220
Q

IS afib usually seen with or without an underlying cario/pulm pathology?

A

with cardio/pulm pathology!!

221
Q

How long do you need to have afib before thromboemboli is a risk?

A

48-72hrs!

222
Q

How do you treat someone who is stable with afib acutely?

A

rate control is first priority (IV diltiazem or BB (esmolol))

223
Q

What should you do if someone has been in afib for more than 48 hours?

A

FULL ANTICOAG x3 weeks

224
Q

How do you treat chronic/recurrent afib?

A
  1. Rhythm control

or

  1. Rate control + anticoag
225
Q

What are different ways to cardiovert?

A
  1. DC cardioversion

2. Ibutilide (IV agent for rapid convertion)– monitor continuous ECG for 4 hours

226
Q

When do you need to treat a HTN emergency by lowering bp w/n few hours? (3)

A
  • asymptomatic pt w/BP over 220/120
  • High BP (200/100) w/optic disc edema or progressive target organ (kidneys/heart) complications
  • perioperative htn
227
Q

What warrants substantial BP decrease w/n 1 hr? (3)

A
  • Hypertensive encephalopathy (HA, confusion, altered MS)
  • Hypertensive nephropathy (Hematuria, proteinuria)
  • Malignant HTN (enceph and neph and papilledema)
228
Q

At what BP do you want to lower BP during an ischemic stroke?

A

over 200/100 (not if below)

229
Q

How do you treat htn emergencies?

A

Lower BP to no more than 25 percent w/n 2hrs, then more gradual (2-6 hrs)

230
Q

What happens with excessive BP reduction?

A

coronary, cerebral, renal ischemia

231
Q

When is the one exception that you want to aggressively lower BP as fast as possible?

A

acute aortic dissection

232
Q

What are some meds you can use to lower BP during a htn emergency?

A

Nicardipine, Clevipine, IV NTG, labetolol, esmolol, diuretics

233
Q

What is the pathology behing aortic aneurysms?

A

atherosclerosis, cystic something necrosis

234
Q

Where do most aortic aneurysms take place?

A

75 percent below renal arteries

235
Q

What is PE finding with aortic aneurysms?

A

pulsatile, non-tender mass

236
Q

Who should get screened for aortic aneurysms?

A

Male smokers over 60yo with at least one of following:

  • FH AAA
  • PRESENCE OF PAD/ATHEROSCLEROSIS
  • presence of peripheral artery aneurysms
237
Q

What is the risk of rupture of aortic aneurysms?

A

Under 5cm- 1-2 percent over 5yrs

Over 5cm- 20-40 percent over 5yrs

238
Q

What is the tx for aortic aneurysms?

A
  • operative excision for rapidly expanding or symptomatic

- Endovascular placement of stent/graft for non-surgical candidates

239
Q

Who should get surgery for their AAA?

A
  • anyone symptomatic

- If asymptomatic: always surgery if over 6.5cm, probable surgery if over 5cm

240
Q

Who is the chance of shoulder re-dislocation high in?

A

young ppl, athletes

241
Q

What shoulder reduction technique would you want to use on an elderly person?

A

external rotation technique

242
Q

What shoulder reduction technique uses weights, and takes time?

A

Stimson’s technique

243
Q

Which shoulder reduction technique requires 2 ppl?

A

traction counter-traction

244
Q

Who is traction counter-traction reduction good to do on?

A

-muscular pts and ppl with dislocation for long-time

245
Q

What is the scapular rotational maneuver good for?

A

muscular patients

246
Q

Following reduction, how long should a shoulder be immobilized for?

A

2-4 weeks

247
Q

What do you need to be careful of in the elderly when immobilizing their shoulder after reduction?

A

adhesive capsulitis/frozen shoulder

248
Q

What do you need to check following shoulder reduction?

A
  • circulator and sensory status (axillary nerve)

- post-reduction xrays

249
Q

Should pts with shoulder dislocation go for ortho f/u?

A

ALWAYS!

250
Q

What do you need to consider when a patient presents with a laceration?

A

possible deep structures involvement (tendons, nerves, bones, glands)

251
Q

What are the 3 stages of laceration healing?

A
  1. Inflammatory phase
  2. Proliferative phase
  3. Remodeling phase
252
Q

Which stage of healing has granulation, contractions, and epithelization?

A

proliferative phase

253
Q

Which stage of healing has new collagen which increases tensile strength?

A

remodeling phase

254
Q

How strong is scar tissue compared to the original tissue?

A

80 percent as strong

255
Q

Which stage of healing involves hemostasis and baceteria/debris phagocytosis?

A

Inflammatory phase

256
Q

What do you want to know in pts PMH when they have a laceration?

A

Immunization status! (Td/tdap)

257
Q

What is primary intention wound closure?

A

Wound edges are approximated at time of injury

allows for best cosmetic result

258
Q

When is primary intention a good option for wound closure?

A

clean, uncomplicated wounds

259
Q

What is secondary intention wound closure?

A

Wound is NOT surgically closed

allowed to heal on own through granulation and re-epiphelization

may be chosen as closure method for wounds over 1hrs old

260
Q

What is tertiary intention?

A
  • delayed primary or secondary closure

- wound intentionally left open for 1-several days and then surgically closed

261
Q

Why do you use tertiary intention?

A

to allow tissue edema to reduce (orthopedic injuries)

also done with wounds with likely chance of infection (incision post-ruptured appendix)

262
Q

What do all topical anesthetics have?

A

vasocontriction

263
Q

What is the “ket to success” in terms of topical anesthetic?

A

blanching

264
Q

What do you use to clean lacerations?

A

-saline, sur-clens, chlorohexate, butsomething

265
Q

How do you remove grease from laceration?

A

bacitracin/polysporin ointment

266
Q

How do you deal with dusky or “ragged” wound edges?

A

debride and trim to decrease change of necrotic tissue

267
Q

When are staples a good closure choice for a laceration?

A

Fast and easy, good for NON-COSMETIC areas (head, extremities)

268
Q

What are some tips to laceration closure on limbs?

A
  • immobilize below/above
  • temp. tourniquet during repair
  • carefule w/anterior shin laceration (Esp. elderly)
  • careful with tension in pre-tibial lacerations
269
Q

When do you want to use abx for lacerations?

A

-animal bites (esp. cats), fight bites

270
Q

What abx do you want to use for bite lacerations?

A

augmentin

271
Q

How long until suture removal?

A

4-14 days

272
Q

When is it controversial to close laceration?

A

Under 6 hours, over 12 hours

273
Q

What is often associated with subungal hematoma?

A

distal phalanx tuft fracture

274
Q

How do you treat subungal hematoma?

A

nail trephination

275
Q

When do you do nail trephination for hematoma?

A
  • ALWAYS if over 50 percent of nail

- also helps with pain

276
Q

What is conscious sedation?

A

pharm agents used to depress patients LOC while they still maintain their own patent airway and airway reflexes

277
Q

What are commonly used agents in conscious sedation?

A

benzos, narcotics, hypnotics, dissociative agents

278
Q

What do you want to monitor when patient is conciouslly sedated?

A
  • continuous pulse ox
  • BP
  • cardiac monitor
279
Q

What is the most common pathogen of abscesses?

A

S. aureus

280
Q

Where do you want to incise an abscess?

A

at the apex or site of drainage

281
Q

How long should incised abcess be kept dressed?

A

24-72 hrs and then recheck, re-irrigate

282
Q

Who is paronchia more common in?

A

smokers

283
Q

What is the most common pathogen in paronychia?

A

S. aureus

284
Q

How do you treat paronychia?

A

abx (dicloxacillin, bactrim/doxy/clinda if MRSA)

285
Q

What is not effective in the treatment of paronychia?

A

topical abx

286
Q

What type of dislocation are ankle dislocations usually?

A

POSTERIOR

287
Q

What is the primary concern in ankle dislocations?

A

neurovascular compromise (can lead to permanent nerve damge, tissue necrosis)

288
Q

What is tx of ankle dislocation?

A

IMMEDIATE REDUCTION and immediate ortho consult

289
Q

What is typically associated with ankle dislocations?

A

fractures!

290
Q

What is the most commonly dislocated joint in the body?

A

PIP of finger

291
Q

What should always be done in the eval of finger injuries?

A

xray!

292
Q

Do you want to do xray before or after finger reduction?

A

BEFORE usually (unless long time to get xray)

293
Q

When is sedation discouraged in FB removal?

A

nasal FB removal

Emergency Medicine (3 decks)

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