EM Flashcards
What is the preferred imaging to diagnose a parapharyngeal abscess in the ED?
CT of the neck
Lateral neck x-ray are the preferred initial imagining modality for RPA but do not provide useful info for parapharyngeal infections
Smoke inhalation exposes patients to which toxins
2
Carbon monoxide
Hydrogen cyanide
Treat with sodium thiosulfate
Treatment of carbon monoxide inhalation
100% oxygen and hyperbaric oxygen in severe cases
Treatment for hydrogen cyanide inhalation
- Induction of methemoglobinemia with nitrites (pulls cyanide off ETC)
- Detoxification of cyanide with thiosulfate
How to evaluate for suspected urethral injury
Retrograde urethrogram to look for extravasation of contrast
How do you investigate suspected testicular torsion
US doppler with probe over testicular artery
In ED do emergent urologic consultation and urgent orchidopexy (within 6 hours ideally)
Twisted testicle causing venous occlusion and engorgement and infarction
Sx: acute onset severe scrotal pain, swelling, retracted testicle, absent cremasteric reflex
What happens to troponin I after acute MI
Highly specific for cardiac muscle
Rises between 3-6h post infarct
Peaks 12-24 h
Normalizes within 7 days
Specificity is excellent 6 hr post infarct
Sensitivity does not approach 100% until 12 h
Lung abscess occur most commonly in who
Aspiration in patients with poor oral hygiene
What are the criteria for pseudotumor cerebri?
Raised ICP with papilledema but without mass, hydrocephalus, infection or hypertensive encephalopathy
Criteria:
1. Symptoms of raised ICP
2. No localized signs except CN V1 palsy
3. Pt awake/alert
4. Normal neuroimaging
5. LP opening pressure >25 cm H20 wuth normal CSF
6. No better explanation for increased ICP
Dandy’s Criteria
MC presenting symptom is headache worse lying down and in AM
MC complication is permanent vision loss
Women of childbearing age more commonly affected
Which types of meningitis do you give close contact prophylactic antibiotics to?
N. meningitidis and Hib
Adult: Ciprofloxacin 500 mg po
Child: Rocephin IM or Rifampin PO
Alternative: Azithromycin
Both gram -
Alcohol dehydrogenase has the greatest affinity for?
Ethanol then
Methanol then
Etylene glycol
Treatement for ethylene glycol poisoning
Dialysis is definitive treatment
Fomepizole and ethanol drop are temporiing measures to inhibit alcohol dehydrogenase from changing alcohol to its toxic metabolites
What are the presenting clinical features of fungal Histoplasm capsulatum pulmonary disease?
Asymptomatic in most people, in endemic regions at least 80-90% has positive skin testing by age 20
Endemic to Mississippi and Ohio River valley
When is retrograde urethrogram used
Patients with syspected pelvic trauma or urethral injury
Findings suggestive of central vertigo
Acute onset
Continuous
Normal head impulse test
Multidirectional nystagmus
Skew deviation present
Formula for determining anion gap
Na - Cl - HCO3
Normal should be less than 12 mM/L
ECG findings in PE
Normal sinus is most common cardiac rhythm
Sinus tachycardia is the most common cardiac arrhythmia
S1 Q3 T3
A large S wave in lead I, a Q wave in lead III and an inverted T wave in lead III together indicate acute right heart strain. This pattern only occurs in about 10% of people with pulmonary embolisms and is similar to the ECG findings of a left posterior fascicular block, or LPFB. Recall that sinus tachycardia is actually the most common ECG finding during a pulmonary embolus.
Reversal of warfarin therapy or vitamin K deficiency in bleeding patient or in a patient requiring urgent (<6 hours) surgery
Prothrombin complex concentrate
Exist as dry powder
Stored at room temp
Can be prepared in minutes
Quick infusion time
Do not need ABO typing
Contain Vitamin K dependent coag factors, protein C/S
What is the quickest way to correct hyperkalemia
Nebulized albuterol
Activate NaKATPase via B2 receptor to shift potassium into cells
(These medications stimulate the cellular uptake of potassium, helping to lower blood potassium levels)
HOWEVER GIVE CALCIUM GLUCONATE FIRST
Calcium counteracts the effects of elevated potassium on cardiac cells and helps stabilize the heart’s electrical activity.
By administering calcium, the cell membranes in the heart become less excitable, reducing the risk of life-threatening cardiac arrhythmias associated with hyperkalemia. However, it’s important to note that calcium does not lower potassium levels but rather protects the heart from the harmful effects of high potassium.
Define biliary colic
Gallstone transiently impacted in the cystic duct causing intermittent pain
vs cholecystitis where the pain is constant
Tests: Lipase to determine if pancreatitis and bilirubin to determine if bile duct obstruction
Hallmark of necrotizing enterocolitis on AXR
Intramura air
Pneumatosis intestinalis
Can also have: free air, fixed loops, ileus, thickened bowel wall, portal venous gas
What is the progression of liver dysfunction based on liver function tests
Plalets down
INR up
Albumin down
Bilirubin up
The W
What is the triad of Horner syndrome and what is important to be ruled out in the differential?
Miosis, anhidrosis, ptosis
Must rule out carotid artery dissection (bc sympathetic chain is so close in proximity) with CT angiogram
What is the triad of mastoiditis
Otorrhea
Tendersness over the mastoid
Retroauricular swelling with protruding ear
Infection of mastoid cells, MC seen 2 weeks after onset of untreated AOM
Do a CT to investigate
When is a tube thoracostomy indicated?
To drain abnormal air or fluid from the pleural space
Pneumothorax (if large, progressive, pt is vented, tension pneumothorax), hemothorax, empyema, pleural effusion
“Pneumothorax, hemothorax, pleural effusion too, Tube thoracostomy is what you gotta do!”
What are signs of radial nerve injury in fractures?
Drop wrist
Sensory impairment on the dorsum of the wrist
Difficulty with supination
Check during humeral shaft fractures
What cardioprotective agent is given in hyperkalemia?
Calcium gluconate or calcium chloride
Stabilize cardiac myocyte membrane
Hyperkalemia can cause bradycardia
MC etiology of encephalitis
Viral
HSV, VZV, EBV, CMX, enterovirus, parechovirus, West Nile, influenza, other respiratory viruses, HIV, mumps, measles, rabies, polio
Enteroviruses such as coxsackie account for more than half of all cases
Laparotomy is mandatory if penetrating trauma and?
Shock
Peritonitis
Evisceration
Free air in abdomen
Blood in NG tube, Foley or on digital rectal exam
Most comonly injured organs in penetrating abdominal injury
Small bowel
Liver
Colon/rectum
Stomach
What age group has the highest rate of suicide completion?
Over age 75
Male
White or Indigenous
Windowed or divorced
Findings suggestive of central vertigo
Acute and continuous
Normal head impulse test
Multidirectional nystagmus
Skew deviation present
Treatment for acute cholecystitis
IV AB
Treatment of beta blocker overdose
Glucagon, calcium cloride, insulin with dextrose,
Causes bradycardia, AV block, hypotension
Most common pediatric elbow fracture
FOOSH
Spracondylar fracture
MC ~ 7 years old, rare in adults
Can injury the median nerve
Treat with long arm plaster slab
If displaced > 50% then consider surgery
Clinical features of chorioamnionitis
Temperature
Tachycardia
Tenderness of uterus
Foul discharge
RX IV Ampicillin gentamycin clindaycin
Suspect in pregnant lady with PROM
How to tell if source of bleeding is fetal?
Apt test
NaOH mixed with blood
If supernatant turns pink it is fetal and if it turns yellow it is maternal
Classic neurological deficit in central cord syndrome
Upper extremity weakness greater than lower
Caused by cervical motor axons being closer to the midline than the lumbar motor axons
What are the symptoms of anterior cord syndrome?
Deficit of bilateral motor function and pain/temperature sensation with sparing of vibration/position sensation
Treatment for S pneumoniae pneumonia in a pediatric patient
Amoxicillin
or cefuroxime
or cefotaxime
MC etiology of endocarditis of a prosthetic valve vs native valve
Coag negative Staph vs Streptococcus viridan
Classic triad of NPH
Normal pressure hydrocephalus
Wet - incontinence
wacky - dementia
wobbly - ataxia
Which antihypertensives are safe and effective in pregnancy for rapid control of BP?
Labetalol or hydralazine
How does ondansetron work?
Serotonin 3 receptor blocker that reduces intestinal fluid secretion
Used for diarrhea
What kidney stones are radiolucent?
Uric acid stones
Occur 10% of the time
What is the FAST scan for?
Designed to assess for hemoperitoneum
U/S of the RUQ, LUQ suprapubic and subxiphoid regions
SX view is to check for effusion or tamponade
Managements of shoulder dystocia
McRoberts manuever and suprapubic pressure resolve 90% of cases
Hyperflexion of the materal hips (mom’s knees to chest) which moves the symphysis pubis over the fetal anterior shoulder
Can further try to release the posterior shoulder by rotating it anteriorly with hand in the vagina, manual corkscrew, episiotomy, rollover (on hands and knees)
Nystagmus that changes direction based on the gaze direction is suggestive of what type of vertigo
Central cause
Where does the rash of meningococcemia start?
Petechiae of wrists and ankles (can also be light pink macules that become petechiae later)
They look smudged and can have gray centers
What antibiotics are indicated for the most common pathogens in the neonatal period
Cefotaxime
Ampicillin
GBS, streptococci, gram - bacilli, pneumococcus, Listeria
Describe the rash of RMSF
Starts on wrists and ankles then spread centrally to arms, legs, trunk, palms, soles
10% of patients are spotless
Investigate with skin biopsy and serology (indirect fluorescent AB test)
Treat with doxycycline
Symptoms of cholinergic toxidrome
SLUDGE
Salivation, lacrimation, urination, defecation, GI upset, emesis
BBB
Bronchorrhea, bronchospasm, bradycardia
Muscle weakness, flaccid paralysis
Rx atropine and pralidoxime
What malignancy is associated with hyperviscosity syndrome (leukostasis)?
AML
- Severely elevated WBCs > 50 x 10^9 per L
Can occur in ALL, CML and CLL but only rarely symptomatic
Leukostasis is a medical emergency - large number of blasts interfere with circulation and lead to hypoxia and hemorrhage and can cause diffuse pulmonary infiltrate, CNS bleeding, respiratory distress, AMS, and priapism
Treat with cytoreductive therapy ie hydroxyurea
Next step in management if you suspect bacterial meningitis?
Give ANTIBIOTICS before the LP
Dexamethasone + ceftriazone + vancomycin
Report to Public Health
When CD4 count drops to below 250 cells per mcl what infection is commonly seen in AIDS patients?
Pneumocutis pneumonia
Funcgal opportunistic infection
Extertional dyspnea, non productive cough, low grade fever, malaise
Treat with TMP SMX and add corticosteroid if Pa)2 < 70 mmHg
2nd line therapy = pentamidine
How to treat SSRI overdose
Generally benign in overdose causing mild GI and CNS symptoms and rarely causing cardiac abnormality
Most common complication of mitral stenosis
Atrial fibrillation
This is due to severe atrial hypertrophy that results from the stenosed mitral valve preventing flow into the left ventricle
Treatment of tubo ovarian abscess
Ampicillin + clindamycin + gentamycin
Abscesses 4-6 cm in diamete respond well to AB 85% of the time
>10cm in diamete require surgery
Wernicke triad
Ataxia
Confusion/delirium
Ophthalmoplegia/nystagmus
Can progress to Korsakoff which is anterograde amnesia and compensatory confabulation
Rx Thiamine
Treatment of magnesium sulfate toxicity
Mag sulfate is used is preeclampsia
Calcium gluconate
Common cause of epididymitis
Hint: two age groups
< 35 yo = N gonorrhea or C trachomatis
> 35 yo or anal intercourse = E coli
Treat < 35 with ceftriaxone and doxy, treat >35 with ofloxacin or TMPSMX
Sudden onset scroal pain and swelling with radiation to flank, relief of pain when lifting testicle, fever, normal cremaster reflex
What do macrolide drugs cover for?
Erythromycin, azithromycin and clarithromycin
Legionella, Chlamydia pneumoniae, Mycoplasma
H influenza
S pneumo
What neurological condition should be suspected in a fat, fertile female with diffuse headaches or visual symptoms?
Pseudotumor cerebri aka idiopathic intracranial hypertension
Rx lifestyle change, acetazolamide to decrease CSF, thiazide/furosemide and if all these fail consider serial LPs or ventriculoperitoneal shunt placement
Follow q2y, repeat imaging to monitor for tumor, ophthalmology follow up
HSP triad
Palpable purpura
Abdominal pain
Arthritis
Vasculitis of small vessels often with URTI 1-3 wk prior
The rash of HSP is characteristic: A maculopapular eruption on the legs and buttocks and almost never involving the upper extremities or trunk.
Test of choice for diagnosing aortic dissection
CT angiogram
MRI is most specific but less convenient
Antipseudomonal antibiotics
Cephalosporins (ceftazidime, cefepime), beta lactam or beta lactamase inhibitors (piperacillin/tazobactam), monobactams (aztreonam), carbapenems (imipenem, meropenem), aminoglycosides, fluoroquinolones
Two types of necrotizing fasciitis
Type 1: polymicrobial (MC in immunocompromised)
Type 2: monomicrobial, usually GAS (MC in healthy)
Rapidly spreading painful infection of fascia with necrosis of tissue
Rx urgent surgical debridement of all necrotic tissue then penicillin + clindamycin or vancomycin + clindamycin
What does ampicillin-sulbactam cover
Anaerobes and gram -s
Treatment for beta blocker overdose
Supportive
If having cardiovascular complications consider IV fluids, atropine, glucagon and calcium
If still having problems consider epinephrine
If STILL having problems use insulin and glucose
Dialysis is worthless to try
MRSA treatment
Doxycycline
Indications for replantation
- Age: kids better results than adults
- Thumb and multiple digit are higher priority
- Multiple LEVEL amputation is a contraindication
- Clean cut have greater success
- Avulsion and crush are relative contraindications
- Wrist and forearm amputations
- Single digit between PIP and DIP
Round, red, tender nodules asymmetrically arranged on shins, knees, arms with associated arthralgia and malaise
Likely erythema nodosum
Acute or chronic inflammation of subcutaneous fat
40% idiopathic
Other causes: sulfonamides, OCP, pregnancy, GAS, TB, Yersinia, sacois, Crohn’s>UC, Hodgkin’s
Treat underlying cause, consider high dose ASA or NSAIDs (naproxen or indomethacin) and bed rest
LP findings in pseudotumor cerebri
- Increased opening pressure > 25 cm H20
- NORMAL CSF
Side note: 6th cranial nerve most often affected which can cause double vision and headaches
Do MRI of brain
Treat wth acetazolamide, thiazide, or durosemide and if all else fails do serial LPs with subsequent shunt placement
What to do for ASA overdose?
GI decontamination (charcoal), hydration, enhanced excretion
Alkalinize urine with IV bicarb with a urine pH goal of 7.5 - 8
MAY NEED HEMODIALYSIS
What kind of surgery is done for pancreatitis?
Acute - can consider endoscopic sphincterotomy if severe gallstone pancreatitis but there are no other surgical options available, everything is supportive therapy
Chronic - As above as needed but remember neither endoscopy nor surgery can improve pancreatic function
What are the four stages of hepatic encephalopathy?
1: apathy, restlessness, reversal of sleep wake cycles, impaired handwriting
2: asterixis, lethargy, drowsy, disoriented
3: stupor but rousable, hyperactive reflexes, upgong Babinski
4: coma (responds to pain only)
Most important sign of compartment syndrome? Symptom?
Sign = pain with passive stretch
Symptom = pain out of proprtion to injury
rx remove constrictive dressings, elevate limb, urgent fasciotomy
Pain (not relieved by analgesics), paresthesia, paralysis/pulselessness/pallor (late findings)
UTI treatment
Simple - TMP SMX or nitrofurantoin
Complicated - cipro or ampicillin/gentamycin or ceftriaxone
Cause of asymptomatic urethritis
Non gonococcal (usually C. trachomatis)
Rx azithromycin or doxy + ceftriaxone (to cover for gonococcal in case)
More common in men < 20 years old
treat partner too
Features of neuroleptic malignant syndrome
FARM
Fever
Autonomic changes (increased HR/BP or sweaty)
Rigidity of muscles
Mental status change
Also seen in serotonin syndrome - distinguish by NMS does not have GI symptoms and there is severe global rigidity vs SS where the patient is twitchy and restless, flushed and HAS GI SYMPTOMS (vomiting, diarrhea, abd pain)
PSYCHIATRIC EMERGENCY
Rx stop drug, hydrate, cool, maybe dantrolene (muscle relax) or bromocriptine (DA agonist)
Emerg book says benzos are also a treatmentbut not in TO notes so???
What is a myxedema coma?
Medical emergency - severe hypothyroidism - 40% mortality
Hallmark: decreased mental status and hypothermia
Also can have hyponatremia, hypotension, hypoglycemia, hypoventilation, bradycardia, non pitting generalized edema
ADMIT TO ICU, corticosteroids, give L-thyroxine, mechanical vent if needed, vasopressors, rewarming, IV detrose, fluids
MONITOR FOR ARRHYTHMIA
Throbbing pain vs stabbing pain in headaches
Throbbing on one side = migraine
Stabbing behind or around eyes = cluster
Diagnosis and treatment of B pertussis
Diagnose = nasopharyngeal specimen with aspirate or swab and culture with Regan Lowe agar
Can also do serology for antibodies
Look for LYMPHOCYTOSIS on CBC
Manage with macrolides (azithro, erthyro, clarithro) and give to household contacts
Report to Public Health
Prolonged resp illness characterized by inspiratory WHOOP and cough
Very contagious - becoming more common in older individuals (not often in younger because of vaccination)
Vaccination DOES NOT confer lifelong immunity
Treatment of thyroid storm
Fluids, electrolytes, vaopressors
Cooling blanket, acetaminophen
Propanolol (but be careful in CHF)
Glucocorticoids (stop peripheral conversion of T4 to T3)
Cholestyramine (reduces enterohepatic recirculation of thyroid hormone)
PTU is the anti thyroid drug of choice and used in high doses, give iodide 1 hour later (acute inhibits release of thyroid hormone) as sodium iodide, Lugol’s solution or potassium iodide
qSOFA for septic shock criteria
- Respiratory rate ≥22/min
- Altered mentation
- Systolic blood pressure ≤100 mmHg
