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EM Flashcards

1
Q

What is the preferred imaging to diagnose a parapharyngeal abscess in the ED?

A

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

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2
Q

Smoke inhalation exposes patients to which toxins

2

A

Carbon monoxide
Hydrogen cyanide

Treat with sodium thiosulfate

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3
Q

Treatment of carbon monoxide inhalation

A

100% oxygen and hyperbaric oxygen in severe cases

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4
Q

Treatment for hydrogen cyanide inhalation

A
  1. Induction of methemoglobinemia with nitrites (pulls cyanide off ETC)
  2. Detoxification of cyanide with thiosulfate
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5
Q

How to evaluate for suspected urethral injury

A

Retrograde urethrogram to look for extravasation of contrast

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6
Q

How do you investigate suspected testicular torsion

A

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

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7
Q

What happens to troponin I after acute MI

A

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

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8
Q

Lung abscess occur most commonly in who

A

Aspiration in patients with poor oral hygiene

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9
Q

What are the criteria for pseudotumor cerebri?

A

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

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10
Q

Which types of meningitis do you give close contact prophylactic antibiotics to?

A

N. meningitidis and Hib
Adult: Ciprofloxacin 500 mg po
Child: Rocephin IM or Rifampin PO

Alternative: Azithromycin

Both gram -

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11
Q

Alcohol dehydrogenase has the greatest affinity for?

A

Ethanol then
Methanol then
Etylene glycol

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11
Q

Treatement for ethylene glycol poisoning

A

Dialysis is definitive treatment
Fomepizole and ethanol drop are temporiing measures to inhibit alcohol dehydrogenase from changing alcohol to its toxic metabolites

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12
Q

What are the presenting clinical features of fungal Histoplasm capsulatum pulmonary disease?

A

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

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13
Q

When is retrograde urethrogram used

A

Patients with syspected pelvic trauma or urethral injury

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14
Q

Findings suggestive of central vertigo

A

Acute onset
Continuous
Normal head impulse test
Multidirectional nystagmus
Skew deviation present

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15
Q

Formula for determining anion gap

A

Na - Cl - HCO3
Normal should be less than 12 mM/L

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16
Q

ECG findings in PE

A

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.

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17
Q

Reversal of warfarin therapy or vitamin K deficiency in bleeding patient or in a patient requiring urgent (<6 hours) surgery

A

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

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18
Q

What is the quickest way to correct hyperkalemia

A

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.

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19
Q

Define biliary colic

A

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

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20
Q

Hallmark of necrotizing enterocolitis on AXR

A

Intramura air
Pneumatosis intestinalis

Can also have: free air, fixed loops, ileus, thickened bowel wall, portal venous gas

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21
Q

What is the progression of liver dysfunction based on liver function tests

A

Plalets down
INR up
Albumin down
Bilirubin up

The W

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22
Q

What is the triad of Horner syndrome and what is important to be ruled out in the differential?

A

Miosis, anhidrosis, ptosis
Must rule out carotid artery dissection (bc sympathetic chain is so close in proximity) with CT angiogram

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23
Q

What is the triad of mastoiditis

A

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

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24
Q

When is a tube thoracostomy indicated?

A

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!”

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25
Q

What are signs of radial nerve injury in fractures?

A

Drop wrist
Sensory impairment on the dorsum of the wrist
Difficulty with supination

Check during humeral shaft fractures

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26
Q

What cardioprotective agent is given in hyperkalemia?

A

Calcium gluconate or calcium chloride

Stabilize cardiac myocyte membrane

Hyperkalemia can cause bradycardia

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27
Q

MC etiology of encephalitis

A

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

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28
Q

Laparotomy is mandatory if penetrating trauma and?

A

Shock
Peritonitis
Evisceration
Free air in abdomen
Blood in NG tube, Foley or on digital rectal exam

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29
Q

Most comonly injured organs in penetrating abdominal injury

A

Small bowel
Liver
Colon/rectum
Stomach

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30
Q

What age group has the highest rate of suicide completion?

A

Over age 75
Male
White or Indigenous
Windowed or divorced

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31
Q

Findings suggestive of central vertigo

A

Acute and continuous
Normal head impulse test
Multidirectional nystagmus
Skew deviation present

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32
Q

Treatment for acute cholecystitis

A

IV AB

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33
Q

Treatment of beta blocker overdose

A

Glucagon, calcium cloride, insulin with dextrose,

Causes bradycardia, AV block, hypotension

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34
Q

Most common pediatric elbow fracture

FOOSH

A

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

35
Q

Clinical features of chorioamnionitis

A

Temperature
Tachycardia
Tenderness of uterus
Foul discharge

RX IV Ampicillin gentamycin clindaycin

Suspect in pregnant lady with PROM

36
Q

How to tell if source of bleeding is fetal?

A

Apt test
NaOH mixed with blood

If supernatant turns pink it is fetal and if it turns yellow it is maternal

37
Q

Classic neurological deficit in central cord syndrome

A

Upper extremity weakness greater than lower

Caused by cervical motor axons being closer to the midline than the lumbar motor axons

38
Q

What are the symptoms of anterior cord syndrome?

A

Deficit of bilateral motor function and pain/temperature sensation with sparing of vibration/position sensation

39
Q

Treatment for S pneumoniae pneumonia in a pediatric patient

A

Amoxicillin

or cefuroxime
or cefotaxime

40
Q

MC etiology of endocarditis of a prosthetic valve vs native valve

A

Coag negative Staph vs Streptococcus viridan

41
Q

Classic triad of NPH

Normal pressure hydrocephalus

A

Wet - incontinence
wacky - dementia
wobbly - ataxia

42
Q

Which antihypertensives are safe and effective in pregnancy for rapid control of BP?

A

Labetalol or hydralazine

43
Q

How does ondansetron work?

A

Serotonin 3 receptor blocker that reduces intestinal fluid secretion

Used for diarrhea

44
Q

What kidney stones are radiolucent?

A

Uric acid stones
Occur 10% of the time

45
Q

What is the FAST scan for?

A

Designed to assess for hemoperitoneum
U/S of the RUQ, LUQ suprapubic and subxiphoid regions
SX view is to check for effusion or tamponade

46
Q

Managements of shoulder dystocia

A

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)

47
Q

Nystagmus that changes direction based on the gaze direction is suggestive of what type of vertigo

A

Central cause

48
Q

Where does the rash of meningococcemia start?

A

Petechiae of wrists and ankles (can also be light pink macules that become petechiae later)

They look smudged and can have gray centers

49
Q

What antibiotics are indicated for the most common pathogens in the neonatal period

A

Cefotaxime
Ampicillin

GBS, streptococci, gram - bacilli, pneumococcus, Listeria

50
Q

Describe the rash of RMSF

A

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

51
Q

Symptoms of cholinergic toxidrome

A

SLUDGE
Salivation, lacrimation, urination, defecation, GI upset, emesis

BBB
Bronchorrhea, bronchospasm, bradycardia

Muscle weakness, flaccid paralysis

Rx atropine and pralidoxime

52
Q

What malignancy is associated with hyperviscosity syndrome (leukostasis)?

A

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

53
Q

Next step in management if you suspect bacterial meningitis?

A

Give ANTIBIOTICS before the LP
Dexamethasone + ceftriazone + vancomycin

Report to Public Health

54
Q

When CD4 count drops to below 250 cells per mcl what infection is commonly seen in AIDS patients?

A

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

55
Q

How to treat SSRI overdose

A

Generally benign in overdose causing mild GI and CNS symptoms and rarely causing cardiac abnormality

56
Q

Most common complication of mitral stenosis

A

Atrial fibrillation

This is due to severe atrial hypertrophy that results from the stenosed mitral valve preventing flow into the left ventricle

57
Q

Treatment of tubo ovarian abscess

A

Ampicillin + clindamycin + gentamycin

Abscesses 4-6 cm in diamete respond well to AB 85% of the time
>10cm in diamete require surgery

58
Q

Wernicke triad

A

Ataxia
Confusion/delirium
Ophthalmoplegia/nystagmus

Can progress to Korsakoff which is anterograde amnesia and compensatory confabulation

Rx Thiamine

59
Q

Treatment of magnesium sulfate toxicity

Mag sulfate is used is preeclampsia

A

Calcium gluconate

60
Q

Common cause of epididymitis

Hint: two age groups

A

< 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

61
Q

What do macrolide drugs cover for?

Erythromycin, azithromycin and clarithromycin

A

Legionella, Chlamydia pneumoniae, Mycoplasma

H influenza
S pneumo

62
Q

What neurological condition should be suspected in a fat, fertile female with diffuse headaches or visual symptoms?

A

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

63
Q

HSP triad

A

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.

64
Q

Test of choice for diagnosing aortic dissection

A

CT angiogram

MRI is most specific but less convenient

65
Q

Antipseudomonal antibiotics

A

Cephalosporins (ceftazidime, cefepime), beta lactam or beta lactamase inhibitors (piperacillin/tazobactam), monobactams (aztreonam), carbapenems (imipenem, meropenem), aminoglycosides, fluoroquinolones

66
Q

Two types of necrotizing fasciitis

A

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

67
Q

What does ampicillin-sulbactam cover

A

Anaerobes and gram -s

68
Q

Treatment for beta blocker overdose

A

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

69
Q

MRSA treatment

A

Doxycycline

70
Q

Indications for replantation

A
  1. Age: kids better results than adults
  2. Thumb and multiple digit are higher priority
  3. Multiple LEVEL amputation is a contraindication
  4. Clean cut have greater success
  5. Avulsion and crush are relative contraindications
  6. Wrist and forearm amputations
  7. Single digit between PIP and DIP
71
Q

Round, red, tender nodules asymmetrically arranged on shins, knees, arms with associated arthralgia and malaise

A

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

72
Q

LP findings in pseudotumor cerebri

A
  • 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

73
Q

What to do for ASA overdose?

A

GI decontamination (charcoal), hydration, enhanced excretion

Alkalinize urine with IV bicarb with a urine pH goal of 7.5 - 8

MAY NEED HEMODIALYSIS

74
Q

What kind of surgery is done for pancreatitis?

A

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

75
Q

What are the four stages of hepatic encephalopathy?

A

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)

76
Q

Most important sign of compartment syndrome? Symptom?

A

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)

77
Q

UTI treatment

A

Simple - TMP SMX or nitrofurantoin

Complicated - cipro or ampicillin/gentamycin or ceftriaxone

78
Q

Cause of asymptomatic urethritis

A

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

79
Q

Features of neuroleptic malignant syndrome

A

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???

80
Q

What is a myxedema coma?

A

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

81
Q

Throbbing pain vs stabbing pain in headaches

A

Throbbing on one side = migraine
Stabbing behind or around eyes = cluster

82
Q

Diagnosis and treatment of B pertussis

A

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

83
Q

Treatment of thyroid storm

A

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

84
Q

qSOFA for septic shock criteria

A
  • Respiratory rate ≥22/min
  • Altered mentation
  • Systolic blood pressure ≤100 mmHg

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