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Clerkship (CC3) > EM > Flashcards

EM Flashcards

1
Q

How many seconds does each little box in an ECG convert to?

A

40 msec

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2
Q

How many seconds is one big box?

A

200 msec

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3
Q

What is the upper limit of normal QTc?

A

M 440msec

F 460msec

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4
Q

What is a normal QRS complex length?

A

120 msec (0.12 s)

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5
Q

What is the rate?

A

80

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6
Q

What is the rate

What is this rhythm?

A

52 ish

Sinus bradycardia

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7
Q

What is the rhythm?

Do you need to do anything to this person?

A

1st degree block

No

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8
Q

What is the normal PR interval

A

120-200 msec

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9
Q

What is the rhythm?

A

2nd degree block, Mobitz I

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10
Q

What is the rhythm?

A

Mobitz type 2

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11
Q

How do you differentiate between types of 2nd degree heart block?

Which one is less dangerous?

A

Mobitz 1 - lengthening PR interval until there’s a dropped QRS

Mobitz 2 - high degree AV block

Mobitz 1 less dangerous than 2 (2 -> 3)

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12
Q

What is the rhythm?

A

Complete heart block (3rd degree)

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13
Q

What is the classification framework for tachycardias?

A

Narrow or Wide

Regular or Irregular

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14
Q

What is the rhythm?

A

Sinus tachycardia

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15
Q

What is the rhythm?

A

Supraventricular tachycardia

AVRT / AVNRT

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16
Q

What is the rhythm?

A

Atrial flutter with fixed block

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17
Q

What is the treatment for supraventricular tachycardia?

A

Adenosine

Cardioversion if unstable

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18
Q

How do you treat atrial flutter?

A

Cardioversion

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19
Q

What is the rhythm?

A

A fib

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20
Q

What is the rhythm?

What is the most common clinical cause/correlate?

A

Multifocal atrial tachycardia

Cor pulmonale

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21
Q

What is the rhythm?

A

A flutter with irregular block

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22
Q

What is the rhythm

A

Ventricular tachycardia

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23
Q

What can “convert” a narrow/regular tachy into something that “looks” like vtach?

A

LBBB or RBBB

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24
Q

What types of medications can cause this rhythm?

What types of electrolytes can also lead to it?

A

Torsades de pointes (QT prolongation)

Antimicrobials, antidepressants, anti-seizure medications

Hypo K+ or Hypo Mg++

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25
Q

What is the intrinsic rate of depolarization of the atria? the AV node? the ventricles?

A

Atria <60

AV 40-60

Ventricles (20-40)

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26
Q

What is this rhythm? What is the most common cause of this rhythm?

A

Accelerated junctional rhythm

Digoxin

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27
Q

What is this rhythm?

A

Accelerated idioventricular rhythm

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28
Q

At what point do we consider multiple premature ventricular contractions a tachy?

A

A triplet

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29
Q

What does __geminy refer to?

A

The number of beats between premature contractions

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30
Q

Why is transvenous pacing the next step after trying transcutaneous pacing?

A

Pain restricts the amount of current that you can deliver

The current is less reliable / less effective?

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31
Q

25yo M with chest pain x 2 days. PMHX: none. BP 125/82.

What is the rhythm? How do you manage this patient?

A

1st degree block

Maybe some investigations–but not overly concerned (could do trops / electolytes / cxr but more likely non-cardiac cause of chest pain)

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32
Q

What’s the rule for estimating rate based on the number of big blocks on ECG?

A

300/150/100/75/60/50/43

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33
Q

60yo F with chest pain and dyspnea for past hour. BP 85/40.

What is the diagnosis? What do we need to manage them?

A

brady to 40s, 3rd degree block

ABCs, pacing, call cardiology for pacemaker r/o ischemia?

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34
Q

62yo M chest pain and dyspnea for past 24 hours. PMHX: none. BP 85/55..

Diagnosis? Mgmt?

A

Brady to 30-40 Mobitz 2

Unstable / likely hypotensve, try atropine, pacing.

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35
Q

50yo F with chest pain x 24 hours. PMHX: none. BP 130/90.

Dx? Mgmt?

A

Brady to 50

Mobitz 1 wenckebach

If chest pain isn’t ischemic sounding, then monitor / observe.

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36
Q
  1. 62 yo F with chest pain and dyspnea on an ER stretcher. Nurse goes to check on patient. Had previously been talking, now unresponsive, no pulse.
  2. 62 yo F with chest pain and dyspnea on an ER stretcher. Nurse goes to check on patient. Patient is talking and still has chest pain. O/E: BP 80/60, sats 92% RA. (Same rhythm as above.)
  3. F with palpitations on an ER stretcher. Nurse goes to check on patient. Patient is talking. O/E: BP 124/86, sats 99% RA. (Same rhythm as above.)

Dx? Mgmt?

A

230bpm VTach

  1. Start CPR, shock, epi, shock, amio
  2. get IV access, cardiovert 100J (give fentanyl)
  3. adenosine 6mg bolus
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37
Q

82 year old M with chest pain. While waiting in the ambulance bay in ER, becomes unresponsive.

Dx? Mgmt?

A

V fib

ABCs, start cpr, shock, epi, shock, amio

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38
Q

45 yo M with confusion. Tells you to “go away” when you talk to him. Admits to 10 beer tonight, started on an antipsychotic 1 week ago. BP 80/50, sats 92% RA.

A

Torsades de pointes

Sedation, cardioversion, give Mg++, get lytes

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39
Q

82yo F from home alone, found unresponsive. Pt was not answering son’s phone calls for 24h, so son went to check on her and called 911. EMS has been doing CPR on patient for 20 minutes, now in ER. Still no pulse.

DDx, Mgmt.

A

PEA

Epinephrine, continue CPR

Treat underlying cause, POCU

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40
Q

30 yo M, palpitations for 2 hours. No other symptoms. PMHX/Meds/Allergies: none. BP 124/80.

DDx

Mgmt

A

rate 180, AFib

Cardiovert (if < 12 hrs if no Hx of stroke or TIA) or procainamide

If >48 hrs, do NOT cardiovert. beta blocker or calcium channel blocker

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41
Q

70yo F palpitations for 2 hours. BP 110/60.

Dx ? Mgmt?

A

A flutter

Cardiovert

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42
Q

22 yo M student. Palpitations for 6 hours. Got 2 hours of sleep last night, has exam today, drank 4 energy drinks. Talkative, BP 130/78, sats 98% R/A.

A

Adenosine 12mg bolus

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43
Q

22 yo M student. Palpitations for 6 hours. Got 2 hours of sleep last night, has exam today, drank 4 energy drinks. Talkative, BP 130/78, sats 98% R/A.

Dx

A

Premature Ventricular Contraction

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44
Q

62yo F cough, fever, wheezing x 6 days. 50 pack-year smoker. PMHx: COPD. Puffers not helping. BP 106/68, RR 26, sats 96% r/a

A

Cor pulmonale

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45
Q

What are some classic ECG findings of PE?

A

Sinus tachycardia

S1 ( negative deflection of the S wave in lead 1)

Q3 (negative Q wave in lead 3)

T3 (negative T wave lead 3)

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46
Q

What kind of axis deviation is expected with PE?

A

Right

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47
Q

What is the DDx for 2 day hx of sharp pleuritic chest pain x2 days in a 37yo F smoker?

A

PE

Pneumothorax

MSK (diagnosis of exclusion)

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48
Q

What investigation would be best to diagnose a PE?

A

CT pulmonary angiogram

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49
Q

How can you rule out a PE?

A

Wells < 2 + Negative D-Dimer

PERC rule (Age <50, HR < 100, O2 sat on RA >94% with no suspicious clinical Hx or signs)

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50
Q

How do you manage a PE

A

Anticoagulation (e.g. DOAC, warfarin, LMWH / heparin)

Thrombolysis (worried about intracranial bleeding risk - only give to hypotensive / hypoxic ppl)

Send home with f/u for risk factors

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51
Q

What are the most likely diagnoses in this 60yo M with 5 day hx of exertional chest pain and a negative abdomen

A

ACS

COPD

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52
Q

How do you differentiate between stable angina and an unstable angina on history?

A

Predictable pain with predictable exertion = stable angina

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53
Q

Would you expect to see ECG findings or a positive troponin in stable / unstable angina?

A

No

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54
Q

Where do you send someone with unstable angina? What further investigations are needed?

A

Admit for further workup

Echo & stress test for risk stratification +/- angiogram; possible stenting.

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55
Q

How do you differentiate between NSTEMI and unstable angina?

A

Abnormal ECG with signs of ischemia.

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56
Q

What are the ischemic changes that can been seen on ECG in the context of NSTEMI?

A

ST depression

P inversion

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57
Q

What does a positive troponin indicate + positive ECG findings?

A

NSTEMI or STEMI

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58
Q

Where do we send patients with STEMI?

A

Cath lab

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59
Q

When do you need serial troponin?

A

If it’s taken too soon after the onset of chest pain, it’s not reliable, if it comes back negative but 3+ hrs later should be good.

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60
Q

How do you manage ACS?

A

Antithrombotic: Aspirin 160mg chewed + clopidogrel / ticagrelor

Anticoagulation: IV heparin

Do not MONA indiscriminately.

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61
Q

What is the diagnosis?

A

STEMI

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62
Q

What can you do with a STEMI if you can’t get to a cath lab.

A

Give fibrinolytic

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63
Q

32y trans male some SOB, 6 day hx of nausea and diarrhea, sharp bilateral shoulder pain x 1 day some chest pressure. bland Phx, mild tachycardia and tachypnea. What is the most likely diagnosis? What are the ECG changes?

A

Pericarditis. Diffuse ST elevation and depression of the PR interval.

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64
Q

How do you manage pericarditis?

A

R/o effusion with point of care u/s

Treat underlying cause

Give NSAID 14 days, steroid if refractory

Send home with f/u

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65
Q

What investigations are indicated for suspected pericarditis?

A

ECG

CXR

CBC, ESR, CK/Troponin

+/- echo

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66
Q

What are the 6 can’t miss chest pains

A

ACS, PE, pneumothorax, aortic dissection, tamponade, esophageal perforation

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67
Q

How would you identify a scaphoid fracture on exam

A

Point tenderness in snuffbox and/or volar side opposite snuffbox

68
Q

What do you need to do if you suspect scaphoid fracture?

A

Don’t rely on imaging throw them in a thumb spica

69
Q

What is the diagnosis?

A

Avulsion of the triquetrum

70
Q

What is the diagnosis?

A

Lunate dislocation

71
Q

What are the key questions to ask about when you have a fall?

A

Mechanism of fall, LOC?, hit your head?

Vitals, GCS, Spine pain

72
Q

What is the diagnosis?

What is the sign?

What is the management?

A

Occult radial head fracture

Sail sign (anterior fat pad)

Sling arm, try ranging in a few days.

73
Q

What is the diagnosis?

What do you want to probe?

A

Montaggia fracture (midshaft ulnar fracture, radial dislocation)

Ask about IPV.

74
Q

What is the diagnosis?

75
Q

What is your exam in the patient with a suspected hip fracture?

A

Look for a leg length discrepancy, rock the ankle, check distal neurovascular status.

76
Q

What is the hand anatomy?

77
Q

What is the anatomy?

78
Q

What is the fracture?

A

Subcapital fracture

79
Q

What is the diagnosis?

What other fracture do you worry about?

A

Tibial avulsion

Maisonneuve fracture (fibular head fracture)

80
Q

What is the diagnosis? What do you worry about?

A

corner fracture of the femur

nonaccidental injury

81
Q

What is the salter harris classification?

82
Q

What is the salter harris classification?

83
Q

What is the salter harris classification

84
Q

What is the acronym for the first things that need to happen with resus?

A

MOVIE

Monitors - cycle blood pressure as fast as possible.

Oxygen by nasal prongs

Vitals

2 large bore IVs

ECGs

85
Q

What are the ABCDE..G?

A

Airway

Breathing

Circulation

Disability (neuro, GCS, pupils)

Environment (undress patient)

Glucose

86
Q

What are the 4 universal antidotes?

A

Dextrose, oxygen (titrate to pulse ox), thiamine, naloxone

87
Q

What are 4 signs of basal skull fracture

A

Racoon eyes

Battle sign (contusion behind ear)

Blood in tympanic membrane

CSF fluid leaking from nose

88
Q

What is the dose of naloxone for overdose?

A

Start 0.2mg IM and titrate up

89
Q

What do you do when you suspect an ingestion?

A

Call poison control consult

90
Q

What labs are helpful in the suspected tox patient?

A

CBC, lytes glucose, BUN, Cr. LFTs, INR/PTT, serum osmolality, VBG, troponin, urinalysis, drug levels

Ethanol level, acetaminophen / salicylate

91
Q

What tests are indicated in the tox patient?

A

ECG in everyone

CXR if you suspect inhalation or iron ingestion

CT head if you suspect trauma

92
Q

What is the differential for decreased LOC?

A

Structural (e.g. trauma, stroke, seizure)

Metabolic abnormalities (e.g. glucose, electrolyte abnormalities)

Cardiogenic / hypoxic

Environmental (hyperthermia/hypothermia)

Substances

Infection

Psychogenic

93
Q

Once a tox patient has stabilized, what additional information do you want to seek out?

A

Type of exposure, time of exposure, intentional (suicidal ideation?) vs unintentional

94
Q

what is the focused physical for the tox pt

A

eyes/ pupils gcs mucous membranes sweating bowel sounds urinary retention

95
Q

What are the symptoms of a cholinergic poisoning?

A

DUMBBELS

Diarrhea

Urination

Miosis

Bronchospasm / bronchorrhea

Bradycardia

Emesis

Lacrimation

Salivation / sweating

96
Q

What is the syndrome of anticholinergic poisoning?

A

Hot / Red / Dry / Mad / Blind

97
Q

What toxins do you think about when you see continuous vomiting?

A

Iron, lithium, irritating toxin

98
Q

When the patient presents with seizures, what agents do you think of?

A

Cocaine, TCA, isoniazid, theophylline

99
Q

What would you see with a rat poisoning?

A

Coagulopathy

100
Q

What do you suspect when a whole family comes in with a headache?

A

Carbon monoxide poisoning

101
Q

How do you calculate an anion gap?

A

Na+ - Cl - HCO3

Normal < 10 mmol.L

102
Q

What is the differential for an anion gap metabolic acidosis?

A

MUDPILES CAT

Methanol

Uremia

DKA

Paraldehydes / paracetamol

Iron

Lactic acidosis

Ethylene glycol

Salicilates

Carbon monoxide

Aminoglycosides

Toluene

103
Q

How do you calculate an osmol gap?

A

2xNa + glucose + BUN + 1.25 EtOH

(2 salts and a sugary BUN)

104
Q

What is the ddx of an osmol gap?

A

Toxic alcohols

(e.g. ethylene glycol, methanol)

105
Q

What are the indications and contraindications for activated charcoal?

A

<2 hours from ingestion give 1 bottle (50g)

Can’t give to decreased LOC, no gut motility, if they need endoscopy.

106
Q

When do you use a gastric lavage?

A

If patient is 100% going to die from the ingestion otherwise.

107
Q

When is whole bowel irrigation indicated? What are contraindications?

A

Large tablets / things that don’t bind to activated charcoal (metals, toxic alcohols)

Unstable, unprotected airway, no bowel sounds, bowel perforation

108
Q

What is the toxic ingestion limit for acetaminophen by weight?

109
Q

For acetaminophen ingestion what do you want to do?

A

Place on monitors, 2 lg bore IV, ECG

Activated charcoal

4hrs after ingestion, get a 4hr acetaminophen level.

110
Q

What is the curve that you reference with acteaminophen?

A

Rumack matthew nomogram

111
Q

What is the antidote to ASA?

A

Bicarb (urine alkalinization) + hemodialysis

112
Q

What is the antidote to toxic alcohols?

A

Fomepizole or ethanol

hemodialysis

113
Q

What can you give to reverse organophosphates or carbamates (and other cholinergic poisoning)

A

Atropine

Diazepam for seizures

114
Q

What drug leads to seizures that are benzo resistant? What can you give?

A

Isoniazid overdose

Pyridoxine (B6)

115
Q

How do you reverse warfarin overdose?

A

Vitamin K (nonemergent)

PCC (emergent)

116
Q

What do you give for digoxin overdose?

117
Q

What is the antidote to hydrofluoric acid?

A

calcium gluconate paste topically applied

118
Q

TCA ingestion, what’s the antidote?

119
Q

What do you give for CO poisoning?

A

Oxygen, hyperbaric

120
Q

What is the antidote for beta-blockers and calcium channel blockers?

A

Glucagon, calcium, high-dose insulin

121
Q

What is the antidote to iron poisoning?

A

Deferoxamine

122
Q

What is the antidote to heavy metals?

A

Chelators (BAL, then EDTA)

123
Q

What is the antidote to cyanide poisonning?

A

Hydroxocobalamin, sodium nitrate, amyl nitrate and sodium thiosulfate (cyanide kit).

124
Q

How do you assess eye opening for GCS

A

spontaneous 4/4

opens to sound ¾

opens to pressure (2/4)

No eye opening (¼)

125
Q

How do you score verbal response on the GCS

A

Oriented 5/5

Confused 4/5

Words 3/5

Sounds 2/5

None 1/5

126
Q

What is the basic trauma series?

A

AP Chest

AP Pelvis

127
Q

What are is the Ddx for hypotension in trauma

A
  1. hemorrhage
  2. obstructive (tension pneumo, tamponade)
  3. distributive (could be anaphylaxis that lead to trauma)
  4. cardiogenic
128
Q

How do you treat tension pneumo?

A

Long needle 2nd intercostal, midclavicular, straight in. Can go more lateral mid-axillary 4th intercostal

Should hear whoosh and immediate increase in blood pressure

Follow with chest tubeD

129
Q

what’s the diagnosis?

A

Hemothorax (supine)

130
Q

What explains the opacification of the soft tissues on the left?

A

emphysema (air under the skin)

hear crinkling when you feel

131
Q

What is the diagnosis?

A

Aortic rupture

132
Q

What is the pelvic injury?

A

Superior and inferior pubic ramus fractures.

133
Q

What’s this injury?

A

see below, fractured rami and R SI

134
Q

When do you need to bind the pelvis?

A

any time that there is pelvic instability

You want to bind around the level of the trochanters

135
Q

What is the problem here?

A

Widening of pubic symphysis, acetabular fracture, SI joint dislocated

136
Q

How do you approach the head CT?

A

Start outside in: scalp, soft tissue swelling, skull fracture / abnormality, meninges, grey/white matter, ventricles & cisterns.

137
Q

What is the diagnosis?

A

Epidural hematoma

138
Q

What is this? Is this acute or chronic? What else do you want to know?

A

Subdural hematoma

Acute because fresh blood is hyperdense here

Ask about whether they are on anticoagulants

139
Q

What is the finding?

A

Subarachnoid bleed

140
Q

What is the difference in management after CT between the spontaneous vs traumatic hemorrhage?

A

Spontaneous hemorrhage = ruptured aneurysm (want interventional radiology)

Traumatic (supportive care, decrease ICP)

141
Q

What are the 4 views of the FAST exam?

A

RUQ (pouch of morrison, interface between right liver and right kidney)

Pericardial / subxyphoid (look for pericardial effusion)

LUQ (spleen / left kidney)

longitudinal pelvis (bladder, vaginal vault / uterus (blood below uterus) or prostate).

142
Q

On ultrasound, what does fresh blood look like?

A

Black

but might be fluid, might be ascites

143
Q

How does FAST affect your management?

A

+ve FAST + unstable patient = laparotomy

+ve FAST + stable patient = STAT CT chest abdo pelvis

-ve FAST → serial FAST if not CT scanning or reassess.

144
Q

What are potential sources of bleeding that can contribute to hypotension in the trauma patient?

A

Bleeding into hemithorax, abdomen, pelvis, or long bone fracture, or external bleed

145
Q

What do we immobilize (e.g. splint)?

A

Fractures (& suspected)

Soft tissue injuries

Infections of hand/arm

Inflammation (gout, tenosynovitis)

146
Q

What types of injuries should be splinted with a radial gutter?

A

Distal radius or ulna fracture

Closed reduction of Colles’

147
Q

How do you splint a boxer’s fracture (4/5th metacarpal head)

A

Buddy tape the finger to its larger neighbour, ulnar gutter with wrist in slight extension and MCP’s at 90.

148
Q

How do you mold a thumb spica? What’s it good for?

A

“arm wrestle position”

Use a thumb spica for suspected scaphoid fracture, thumb dislocation or ulnar collateral ligament injury.

149
Q

What are the indications for a posterior slab / elbow?

A

Supracondylar fracture, elbow dislocation, radial head fracture, midshaft forarm fracture.

150
Q

What would you use to immobilize a metatarsal, or ankle, or distal tib/fib fracture?

A

Below knee posterior slab,

151
Q

What vaccination status do you want to obtain on hx for a laceration?

152
Q

When discharging an older adult after a fall what must you ensure they can do?

A

Walk on their own

153
Q

What are some intrinsic factors that can contribute to a fall?

A

Cardiac (ischemia, MI, arrhythmia) , vasovagal, neurological (stroke, seizure, diabetic neuropathy), metabolic (hyponatremia, hypoglycaemia), orthostasis, postural hypotension, vision or balance impairment (e.g. vertigo), anxiety / fear of falling

154
Q

What are some extrinsic factors that can contribute to a fall?

A

Medications, substance use, safety issues in the home, inconsistent gait aid use, domestic violence

155
Q

At what GCS score should intubation to protect the airway be considered?

A

“Intubate at 8”

156
Q

What workup is suggested for an older adult who presents with a fall to the ED?

A

CBC, extended lytes, albumin, Cr, random glucose

ECG

Radiographs and CT head as needed.

157
Q

What are the geriatric 5Ms?

A

Mind

Mobility

Meds

Multi-complexity

what Matters Most?

158
Q

In addition to being able to manage their ADLs, what iADLs must the older patient be capable of managing in order to have a safe discharge home?

A

Meal prep, housework & managing their meds.

159
Q

In addition to age, what other factors increase the risk of delirium? (9)

A
  1. Male
  2. Polypharmacy
  3. Mild cognitive impairment
  4. Dementia
  5. Parkinson’s
  6. Hearing or visual impairment
  7. Malnutrition
  8. Dehydration
  9. Complexity / comorbitidities
160
Q

What are the diagnostic criteria for delirium? How do you use the CAM to screen for delirium?

A

AIDA

  1. Acute and fluctuating course
  2. Inattention
  3. Disorganized thinking
  4. Altered level of consciousness

(1+2) AND (3 OR 4)

161
Q

How do you distinguish between the 3 Ds of cognitive impairment?

A

Delirium : acute, fluctuating course, altered LOC

Dementia : slow, progressive course, attention preserved.

Depression: low mood persists for >2 weeks, gradual course, consciousness / memory not affected.

162
Q

What is an approach to investigating causes of delirium?

A

DIMES

Drugs

Infections

Metabolic

Environmental

Structural

163
Q

What are some nonpharmacological steps we can take to manage delirium?

A

Get the person to a quieter area (silence alarms). Make sure they have food and water. Orient them regularly, try to mimic day/night cycle with lights. Have a support person stay with them.

Avoid urinary catheters and saline lock IVs. Avoid restraints. Keep the bed low. Promote movement

164
Q

Under what circumstances are antipsychotics indicated for delirium?

A

Remember: they don’t make delirium better and they have side effects!

Only use them if there is risk of harm and pt not responsive to non-pharm approaches or if agitation interferes with medical treatment or if patient is experiencing emotional distress due to hallucinations/delusions.

165
Q

What pharmacological options can be used for delirium?

A

Recommend 2nd gen antipsychotics before haldol, PO before IV

Low doses

Risperidone 0.25-0.5 mg PO BID PRN

Quetiapine 6.25-25 mg PO BID PRN

Haldol 0.25-0.5 mg PO BID

Clerkship (CC3) (12 decks)

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