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Emergency Medicine > EM #2 > Flashcards

EM #2 Flashcards

1
Q

What interview technique should you use if someone is profoundly SOB?

A

yes/no questions

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2
Q

What are asthma risk factors? (5)

A
  • Current steroid use/recent withdrawal
  • comorbid conditions
  • serious psyc illness (dx-dx interactions, poor-self care)
  • illicit drugs (COCAINE)
  • low socioeconomic class)
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3
Q

What are risk factors fro death from asthma? (5)

A
  • Prior intubations
  • previous ICU admissions for asthma
  • recent/frequent ED visits for asthma
  • Use of 2+ albuterol inhalers in past month
  • use of air conditioning
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4
Q

What are warning signs for severe asthma exacerbation? (7)

A
  • Peak flow under 180 L/min
  • PaO2 under 60mmHg
  • PCO2 over 45mmHg
  • mental status change
  • cardiac arrhythmias
  • pulsus paradoxus over 20mmHg
  • pneumothorax
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5
Q

What SaO2 do you want to keep as asthmatic patient above?

A

95

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6
Q

What do you want to be continually monitoring on an asthmatic patient?

A

Pulse ox

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7
Q

What is the MOA of albuterol? (4)

A
  • Relaxes bronchial smooth muscle
  • decrease histamine release
  • inhibit microvascular leakage into airways
  • increase mucocilliary clearance
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8
Q

How often should you eval an asthmatic patient?

A

after EACH treatment (subjective response, PFT)

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9
Q

What are common SE of albuterol?

A

tachycardia, tremor, anxiety

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10
Q

What is an alternative to albuterol is someone is allergic to it?

A

levoalbuterol

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11
Q

What class of drug is albuterol?

A

B2 agonist

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12
Q

What class of drug is levoalbuterol?

A

B2 agonist with some B1 activity

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13
Q

What is the MOA of steroids in regards to asthma exacerbation?

A
  • Inhibit airway inflammation
  • reverse B-R downregulation
  • block leukotriene synthesis
  • Inhibit cytokine production and adhesion protein activation
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14
Q

In simple terms, how do steroids help with asthma exacerbation?

A

speed recovery and reduce recurrence!

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15
Q

What route of steroid admin has NO role in acute asthma exacerbations?

A

inhaled!

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16
Q

What is a drug commonly given during asthma exacerbation that produces beonchodilation but also has cardiac SE?

A

epinephrine

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17
Q

Who do you have to be careful of giving epinephrine to?

A

elderly peeps

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18
Q

What is an alternative to epi that can be given for asthma exacerbations that has LESS CARDIAC SE?

A

terbutaline

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19
Q

What are 3 other drugs that aren’t commonly used for asthma exacerbations but were in the ppt?

A
  • theophylline
  • Mg sulfate (relaxes smooth muscle)
  • Heliox
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20
Q

What is status asthmaticus?

A

severe, prolonged asthma attack which can not be broken by usual treatment

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21
Q

What can status asthmaticus lead to?

A

severe acidosis

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22
Q

What should be done before crisis of cardiac arrest in status asthmaticus?

A

Intubation

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23
Q

What are criteria for admission for asthma exacerbation? (5)

A
  • FAILURE OG POST-TREATMENT PFT to increase by 15 percent above initial value, or absolute PFT under 200
  • Repeat visit w/n 3 days with no improvement of sxs
  • changes in MS
  • persistent hypoxia
  • persistent increase in work of breathing
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24
Q

What are the 3 steps in COPD management?

A
  1. Medication therapy and supplemental O2
  2. positive pressure ventilation
  3. Intubation
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25
Q

How do you tx COPD? (4)

A
  1. Bronchodilator (ipratropium)
  2. Steroids (start ASAP for all exacerbations)
  3. NIPPV (bipap)
  4. High-flow oxygen
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26
Q

What should you do ASAP for any patient that has mentat status change, increased resp. distress w/cyanosis and acute detrioration?

A

Intubate ASAP!

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27
Q

What are criteria for hosp admission for COPD? (5)

A
  • marked increase in rxs instability
  • onset new physical signs (cyanosis, peripheral edema)
  • failure of initial med management to end exacerbation
  • new arrhythmias
  • older age
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28
Q

What do you have to be careful of when giving a patient high-flow oxygen in COPD patients?

A

excessive O2 can cause resp. depression and resp. arrest secondary to loss of hypoxia-induced ventialtory drive?

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29
Q

What can cause a young person to have COPD?

A

alpha-1 antitrypsan deficiency syndrome

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30
Q

What are 3 take home points on COPD?

A
  1. give as much O2 as needed
  2. Steroids and lots of nebs
  3. avoid intubation at all costs
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31
Q

What are risk factors for a spontaneous pneumothorax?

A
  • tall, thin, male

- smokers

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32
Q

What is the most common part of the lung affected by spontaneous pneumothorax?

A

apex (top)

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33
Q

What are sxs of spontaneous pneumothorax?

A
  • abrupt onset pleuritic chest pain and dyspnea

- decreased breath sounds

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34
Q

What is tx for spontaneous pneumothorax?

A

Depends on size and location!

  • usually, do nothing and repeat cxr in 24hrs
  • need decompression for emergent situations
  • thoracic referral
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35
Q

What so you have to be worried about with a trauma pneumothorax?

A

tension pneumothorax

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36
Q

Do the sxs of pneumothorax usually correlate with extent of collapse?

A

nope

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37
Q

How do you treat trauma pneumothorax?

A
  • emergent needle decompression

- chest tube placement

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38
Q

Patient presents with pleuritic chest pain, dyspnea and hemoptysis?

A

classic triad of pulmonary embolism

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39
Q

What are risk factors for PE?

A
  • recent long-travel
  • recent surgery
  • recent immobilization
  • hemoptysis
  • h/o cutting d/o
  • hx cancer
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40
Q

What is the first step in dx suspected PE?

A

determine pretest probability

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41
Q

What happens if the patient had a high pretest probability for PE?

A

STRAIGHT TO IMAGING!

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42
Q

What happens if the patient has a low pretest probability?

A

PERC

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43
Q

What are the components of PERC? (8)

A

Need to say yes to ALL:

  • under 50
  • HR under 100
  • O2 sat on room air over 94 percent
  • no hx DVT/PE
  • no recent trauma/surgery
  • no hemoptysis
  • no exogenous estrogen
  • no clinical sxs of DVT
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44
Q

What happens if the patient doesn’t pass PERC?

A

IMAGING

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45
Q

What happens if patient passes PERC?

A

Wells criteria

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46
Q

What are the wells criteria? (7)

A
  • clinical sxs of DVT (3)
  • PE most likely dx (3)
  • surgery/bedridden for 3 or more days w/n 4 weeks (1.5)
  • hx DVT/PE (1.5)
  • HR over 100
  • hemoptysis (1)
  • active cancer (tx w/n 6 months) (1)
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47
Q

What score classifies as a LOW risk wells score?

A

under 4

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48
Q

What score classifies as a moderate risk wells score?

A

4.5-6

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49
Q

What score classifies as a high risk wells score?

A

over 6

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50
Q

What happens if patient is moderate-high risk Wells Score?

A

IMAGING

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51
Q

What happens if patient is LOW-risk wells score?

A

D-Dimer to r/o PE!

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52
Q

What is the imaging test of choice for PE?

A
  • CT chest with IV contrast

- VQ scan

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53
Q

What is tx for PE?

A
  • oxygen
  • pressor if BP unstab;e
  • fibrinolysis
  • anticoag
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54
Q

When will d-dimer usually be positive?

A

Pregnancy

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55
Q

What are common pneumonia pathogens?

A
  • H. influenzae
  • Klebsiella
  • Staph
  • Legionella
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56
Q

How do you treat pneumonia?

A
  • Oxygen!

- abx EARLY! (macrolides, quinolone)

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57
Q

When should you consider admission for someone with pneumonia?

A
  • VS unstable
  • bilateral pneumonia
  • significant comorbidities
  • immunecompromised
  • elderly
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58
Q

What are the 5 steps for a medical provider in domestic violence?

A
  1. screening
  2. assessment
  3. intervention
  4. documentation
  5. referrals
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59
Q

What are victims of DV more at risk for?

A
  • stroke
  • heart disease
  • asthma
  • alcoholism
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60
Q

What are feelings victims of DV feel?

A
  • want abuse to end, but not relationship
  • still love abuser
  • have no support from family/friends
  • have children w/abuser and fear safety for them
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61
Q

When should you screen for DV?

A

screen at EVERY visit!! (explain that you ask everyone these questions)

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62
Q

What should you do for assessment of DV?

A
  • injuries, pattern of abuse
  • immediate safety (safe houses)
  • danger and potential lethality
  • potential suicide/homicide risk
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63
Q

What are injuries and patterns of abuse? (5)

A
  • injury inconsistent w/hx (fractures)
  • bruising (multiple areas, different stages of healing, symmetrical)
  • burns
  • abrasions (scratches, forearms)
  • pattern injury (hand print, objects)
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64
Q

Where are common areas of injuries of DV? (6)

A
  • back of head
  • neck/shoulders
  • face
  • posterior arm
  • thighs
  • butt
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65
Q

What is validation during DV visit?

A
  • express concern for health and safety privately
  • offer support/service
  • RESPECT choices
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66
Q

How should you document DV?

A
  • use direct quotes as much as possible
  • document PE findings on body map
  • take pictures w/patients consent
  • ask patient if they want to report
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67
Q

What is the most lethal form of DV?

A

strangulation

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68
Q

What is the best predictor for future homicide victims?

A

strangulation

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69
Q

What percent of DV victims have experienced stangulation?

A

50 percent

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70
Q

What structures are affected during strangulation?

A
  • carotid arteries
  • jugular veins
  • tracheal occlussion
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71
Q

What are sxs of strangulation?

A
  • voice change (hoarseness)
  • difficult/painful swallow
  • memory loss/mental status change
  • loss of bladder/bowel control
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72
Q

What is a physical exam finding of strangulation?

A

PETECHIAE (face, eyes, eyelids)

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73
Q

What can patients of strangulation die from?

A

death by carotid dissection

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74
Q

What imaging should you get for strangulation pts?

A

MRV CTA

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75
Q

What are factors that can attribute to child abuse? (7)

A
  • parents immaturity
  • lack of parenting skills
  • poor childhood experiences
  • social isolation
  • frequent crises
  • drug/etoh problems
  • domestic violence
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76
Q

What are risk factors for child abuse? (9)

A
  • DV w/n fam
  • parent psych problems
  • parent substance abuse
  • parent hx abuse
  • mental/physical disability
  • low birth weight
  • excessive crying/colicky baby
  • frequent trauma w/abusive head trauma
  • twins/multiple gestations
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77
Q

What are red flags for child abuse? (5)

A
  • injuries w/o hx trauma
  • changing hx from historian
  • different hx from one historian to the next
  • explanation inconsistent w/injury
  • delay in seeking care
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78
Q

How should you prep child for physical looking for abuse?

A

undress child completely

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79
Q

What should you ALWAYS do in exam for abuse?

A
  • fundoscopic (retinal hemorrhage)
  • intraoral exam (petechiae)
  • anogenital exam
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80
Q

Where are NON-accidental bruises found?

A
  • trunk
  • ear
  • neck
  • cheeks
  • butt
  • SYMMETRIC
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81
Q

What are locations of accidental bruises?

A
  • front of body
  • bony prominences
  • extremities
  • forehead
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82
Q

At what age should you NOT see bruising?

A

under 6 months old

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83
Q

What are characteristics of NON-accidental burns?

A
  • immersion patterns
  • sharp demarcation
  • dorsal hands
  • back
  • butt
  • feet
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84
Q

What are characteristics of accidental burns?

A
  • asymmetric
  • irregular borders
  • face, neck
  • upper torso
  • palms
  • fingers
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85
Q

What percent of fractures in children under 18 months are from abuse?

A

85 PERCENT

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86
Q

When should it abuse until proven otherwise?

A

non-ambulatory child w/humerus, femur, rib fx

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87
Q

What should you do when you find an abuse injury in a child?

A

get full skeletal survey to look for additional fractures

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88
Q

What is an ocular injury from abusive head trauma?

A

retinal hemorrhage

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89
Q

What is the best imaging to use when looking for abusive head trauma?

A

CT

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90
Q

Who is abdominal trauma from abusive more common in?

A

toddlers

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91
Q

What is mandated reporting?

A

In children under 6 months, or non-ambulatory, MUST report:

  • fracture
  • bruising
  • subdural hematoma
  • burns
  • poisoning
  • injury w/substantial bleeding
  • any confirmed abuse
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92
Q

What is the ACE study?

A

look for correlation between abuse and long-term health sequelae

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93
Q

What else should you consider if you are suspecting abuse? (4)

A
  • osteogenesis imperfecta
  • mongolion blue spot (butt)
  • coining/cupping (linear/round marks)
  • moxibustion (circular red burns)
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94
Q

What are different forms of elder abuse? (7)

A
  • physical
  • emotional (verbal/nonverbal acts that cause intimidation, pain)
  • sexual
  • financial
  • neglect (disregard for basic requirements and safety, lack of care/supervision)
  • abandonment
  • self-neglect
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95
Q

What is RADAR?

A 
R- routinely ask questions
A- ask questions in private
D- document findings (body map, photos)
A- assess for safety
R- resources and review options
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96
Q

What should you do if you suspect elder abuse?

A

report to adult protective services

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97
Q

What should you do if confirmed elder abuse?

A
  • report to adult protective services
  • alert law enforcement (physical and sexual)
  • safety planning/admission
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98
Q

What is a SAFE?

A

sexual assault forensic examiner (healthcare provider who has trained to provide medical/forensic care, collection of forensic evidence and testify in court as expert witness)

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99
Q

What is a sexual assault advocate?

A

support person who can be present in ED w/patient and continued support after

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100
Q

What are the components of a sexual assault forensic exam? (6)

A
  1. history taking
  2. physical assessment
  3. evidence collection
  4. documentation
  5. assure advocate can be present
  6. appropriate f/u, safety planning, post d/c support/tx
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101
Q

How soon does a forensic kit need to be done after assault?

A

5 days

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102
Q

How long can a kit remain anonymous?

A

90 days

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103
Q

What can you do if a patient refuses a speculum exam?

A

blind vaginal swabs

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104
Q

What do you do to visualize anatomy and hymenal ring?

A

labial traction

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105
Q

Who should you NEVER do a speculum exam on?

A

pre-pubescent female

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106
Q

What do you need to do after you have done a kit?

A

maintain chain of custody

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107
Q

Who should do the kit if a SAFE is not available?

A

ED clinician and nurse

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108
Q

What are long-term sequelae of sexual abuse? (4)

A
  • depression
  • drug/etoh use
  • PTSD
  • 13x suicide risk
  • IMPORTANCE OF ADVOCATE!
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109
Q

What can be given for PG prophylaxis?

A
  • plan B

- Ella

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110
Q

How long after assault can PG prophylaxis be given?

A

up to 5 days after assault

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111
Q

Who should you report child sexual assault to?

A

Spurunk

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112
Q

What are the most common STIs from sexual assault?

A
  • Trich
  • BV
  • gonorrhea
  • chlamydia
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113
Q

What do you give for gonorrhea prophylaxis?

A

ceftriaxone IM

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114
Q

What do you give for chlamydia prophylaxis?

A

Azithromycin PO single dose

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115
Q

What do you give for trich and BV prophylaxis?

A

flagyl PO ince

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116
Q

What do you have to instruct patient when prescirbing flagly?

A

Don’t take if have dranken etoh w/n 24hrs, and don’t drink alcohol for at least48 hrs after

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117
Q

What do you do for HBV prophylaxis?

A
  • immunized: no tx
  • non-immunized: vaccine now, 1-2 months, 4-6 months
  • high risk: IgG and vaccine
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118
Q

When should PEP be contemplated?

A
  • unprotected vaginal/anal intercourse
  • oral receipt of fluids/blood
  • victim who is going to be compliant/finish course
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119
Q

How soon does PEP need to be started?

A

w/n 72hrs

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120
Q

What are common SE’s of PEP drugs?

A
  • hepatoxicity
  • naseau
  • fatigue
  • myalgias
  • rash
  • bone marrow suppression
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121
Q

Why do most patients stop PEP?

A

SE

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122
Q

What baseline labs should be gotten before starting PEP?

A
  • HIV now, 3 months, 6 months (with counseling)
  • CBC
  • CMP
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123
Q

What medications are used for PEP?

A

Truvada and Kaletra (2 tabs BID for 4 weeks)

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124
Q

What is the most common cause of abdominal pain in children?

A

constipation

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125
Q

A person presents with ABRUPT, localized pain that is increased with swallowing. The onset was preceded by violent emesis.

A

Perforated esophagus

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126
Q

What is a complication of perforated esophagus?

A

SubQ emphysema present

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127
Q

What are common causes of a perforated esophagus?

A
  • 50-60percent iatrogenic
  • 15 percent Boerhaavens (alcoholics, bulimics)
  • 10-15 percent FB
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128
Q

What are risk factors for gastric ulcers? (3)

A
  • heavy NSAID/ASA use
  • ETOH
  • smoking
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129
Q

How do you tx gastric ulcers?

A
  • GI cocktail
  • IV
  • PPI/H2 blocker
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130
Q

What is a mallory-weiss tear?

A

partial thickness tear of esophagogastric junction

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131
Q

How do you dx mallory-weiss tear?

A

EGD

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132
Q

How do you treat mallory-weiss tear?

A

conservative managment

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133
Q

Patient presents with RUQ pain after fatty meals that radiates to right shoulder/scapula?

A

colelithiasis

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134
Q

How do you dx cholelithiasis?

A

transabdominal US

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135
Q

Patient presents with chills, fever and severe post-meals that radiates to right shoulder and has a positive Murphys sign

A

Acute cholecystitis

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136
Q

How do you dx acute cholecystitis?

A

US (thickened GB, pericholecystic fluid)

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137
Q

How do you treat acute cholecystitis?

A
  • surgery is definitive tx (keep pt NPO)

- IV mefoxin, nausea meds, pain meds

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138
Q

Patient presents with intermittent, colicky pain radiating to back with fever/chills, jaundice and pancreatitis/sepsis

A

choledocholithiasis

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139
Q

What is the most common cause of acute cholecystitis?

A

gallstones

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140
Q

How do you dx and tx choledocholithiasis?

A

ERCP (and IV abx)

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141
Q

What is the most common cause of pancreatitis?

A

gallstones (then ETOH)

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142
Q

What are complications of pancreatitis?

A
  • abscesses

- necrotic pancreas

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143
Q

Patient presents with severe, unrelenting pain radiating to back. The pain is worse lying down and better sitting slumped forward with decreased/absent bowel sounds?

A

acute pancreatitis

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144
Q

What lab findings do you expect to find with acute pancreatitis?

A
  • 3x elevated LIPASE

- 3x elevated ALT

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145
Q

What is Ranson’s Criteria?

A

prognosis for acute pancreatitis

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146
Q

What is tx for acute pancreatitis?

A
  • NPO
  • IV hydration with LARGE amounts of fluids
  • IV nausea/pain meds
  • abx controversial but likely helpful
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147
Q

What are risk factors for AAA?

A
  • old age
  • HTN
  • family hx
  • atherosclerosis
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148
Q

How much does an AAA grow every year?

A

1-1.5 cm/year

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149
Q

What is the PE exam of AAA?

A

palpable, pulsatile, non-tender mass on abd palpation

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150
Q

When do you not need to operate on AAA?

A

asymptomatic and under 5cm

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151
Q

Patient with periumbilical pain out of proportion to exam?

A

ischemic bowel

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152
Q

Where does ischemic bowel usually happen?

A

“watershed” areas of intersecting circulation (splenic flexure, rectosigmoid junction, ascending colon)

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153
Q

What are risk factors for ischemic bowel?

A
  • Over 60yo
  • afib
  • hypercoagable
  • vasculitis
  • sickle cell
  • TPP
  • recent AAA surgery
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154
Q

How do you dx ischemic bowel?

A

CT w/ oral and IV contrast

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155
Q

How do you treat ischemic bowel?

A
  • surgery (NPO)
  • broad spectrum abx (zosyn)
  • NG tube
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156
Q

What is mesenteric adenitis?

A

inflammation of lymph nodes located in intestines/abd wall

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157
Q

Who is mesenteric adenitis most common in?

A

children/young adults with periumbilical pain

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158
Q

What is the most common cause of mesenteric adenitis?

A

infection

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159
Q

How do you treat mesenteric adenitis?

A

Supportive (self-limited)

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160
Q

Who is appendicitis rare in?

A

under 5yo

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161
Q

What are complications of appendicitis?

A

-perforation and diffuse peritonitis

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162
Q

When is appendicitis difficult to dx?

A

PG

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163
Q

How do you dx appendicitis?

A
  • US in children

- CT scan w/PO and IV contrast

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164
Q

Where do most diverticulitis happen?

A

sigmoid colon (90 percent)

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165
Q

What is NOT a clear risk factor of diverticulitis?

A

DIET

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166
Q

What causes invasion of colonic bacteria in diverticulum?

A

fecolith

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167
Q

What are complications of diverticulitis?

A
  • mural abscess

- micro-perforation

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168
Q

How do you treat diverticulitis?

A

ABX (CIPRO AND FLAGYL)

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169
Q

How do you dx diverticulitis?

A

CT with PO and IV contrast

170
Q

Patient presents with N/V, hyperactive bowel sounds, pencil stools (diarrhea), distended abd?

A

small bowel obstruction

171
Q

What are etiologies of bowel obstructions?

A
  • adhesions
  • neoplasms
  • Bezoars
  • intussception
  • volvulus
172
Q

How do you dx bowel obstruction?

A

KUB w/ upright abdomen (air-fluid levels)

173
Q

How do you treat bowel obstruction?

A
  • NG tube
  • surgery (NPO)
  • pain meds
174
Q

What is Grey-Turner sign?

A

Bruising on side of abdomen

175
Q

What is Cullens sign?

A

bruising around the belly button

176
Q

Patient presents with bloody, mucous diarrhea?

177
Q

What does tenting indicate on PE?

A

broken clavicle

178
Q

What part of the clavicle is usually broken?

A

distal 1/3

179
Q

What should you check for with a broken clavicle?

A

pain at SC joint (if there is that is sign for sternal fracture, and deeper injury)

180
Q

How do you treat broken clavicle?

A

sling dat shit

suggest sleeping upright

181
Q

Patient presents with point tenderness and bump at AC joint and NO sulcus sign?

A

AC separation

182
Q

How do you treat AC separation?

A

sling dat shit

183
Q

What is actually broken in a shoulder fracture?

A

humeral head

184
Q

Who are shoulder fractures common in?

185
Q

How do you treat shoulder fracture?

A

sling dat shit and refer to ortho

186
Q

What is the most common direction of shoulder dislocation?

187
Q

What causes posterior dislocations?

A

seizure, electrocution

188
Q

What is the most common MOI of shoulder dislocations?

189
Q

What is a common PE finding of someone with a shoulder dislocation?

A

sulcus sign (right under AC joint)

190
Q

What is a Hill-Sachs deformity?

A

Notch on humeral head (seen on xray)

Makes reduction difficult

191
Q

What are neurovascular findings of someone with shoulder dislocation?

A
  • may have tingling in fingers

- vascular should be NORMAL

192
Q

What should you ask in PMH with someone with shoulder dislocation?

A
  • prior dislocations

- how long has shoulder been out?

193
Q

What xrays do you need to dx dislocation/reduction?

A

PA AND LATERAL (y-view)

194
Q

What shouldn’t a patient with a recently reduced shoulder do?

A

externally rotate and ABduct (aka brush hair)

195
Q

What should be done once the shoulder is reduced?

A
  • post–reduction films
  • check neurovascular
  • shoulder immobilizer
  • ortho f/u!!
196
Q

What is the key PE finding in rotator cuff tears?

A

limited ROM

197
Q

How do you treat rotator cuff tear?

A

Sling dat shit and refer to ortho

198
Q

What is a bad type of elbow fracture?

A

supracondylar (do not heal well– need ortho referral ASAP!)

199
Q

What is an anterior fat pad sign?

A

Always present but usually flush with bone–> if fracture SAIL SIGN

200
Q

What is posterior fat pad?

A

Pathognomic for fracture (only present if fracture present)

201
Q

What should you be concerned with for any elbow injury?

A

neurovascular injury

202
Q

What should you always do when someone has a wrist fracture?

A

palpate anatomic snuffbox

203
Q

What should you do if you suspect a scaphoid fracture?

A

spica cast

204
Q

Patient presents with pain with motion of thumb?

A

Dequervains tenosynovitis

205
Q

How do you diagnose Dequervains?

A

Finkelstein’s

206
Q

How do you treat Dequervains?

A
  • NSAIDs
  • splints
  • cortisone injection
  • surgery- fasiotomy
207
Q

How do you dx carpal tunnel?

A
  • Tinnels (tapping)

- Phalens (reverse praying)

208
Q

What don’t you want to miss with a wrist fracture?

A
  • Monteggia

- Galiazzi

209
Q

What is a Monteggia fracture?

A

fracture of proximal 1/3rd of ULNA w/dislocation of head of radius (end to wrist fracture)

210
Q

What is Galiazzi fracture?

A

fracture distal radius w/distal radioulnar joint and intact ulna (2nd to wrist fracture)

211
Q

What are most common bones to fracture/dislocate?

212
Q

Patient presents with instability of MCP (thumb) joint with weakness of pinch grasp and ecchymosis of thenar eminence

A

Gamekeeper’s thumb

213
Q

What is a gamekeeper’s thumb?

A

Ulnar collateral ligament (UCL) torn

214
Q

How do you treat gamekeepers thumb?

A

spica splint and ortho referral

215
Q

What is the only stable type of pelvic fracture?

216
Q

What is common presentation of pelvic fracture?

A

elderly fall and can’t walk

217
Q

How do you treat unstable pelvic fractures?

218
Q

Patient presents with leg shortened and externally rotated?

A

hip fracture

219
Q

Patient presents with leg shortened and internally rotated?

A

hip dislocation

220
Q

What is actually broken in a hip fracture?

A

femoral head

221
Q

What is garden classification used for?

A

hip fractures

222
Q

What are the classification levels of hip fractures?

A

1: incomplete
2: complete with no dislocation
3: complete w/ partial dislocation
4: complete w/ full dislocation

223
Q

What should you watch out for with hip fracture?

A

acetabular fx

224
Q

How do you treat hip fracture?

A
  • all get admitted

- foley catheter

225
Q

What is the usual cause behind hip dislocations?

A

hip replacements

226
Q

What do you need to do with hip dislocation?

A

check vascular flow!!

227
Q

What is classic PE finding of hip dislocation?

A

leg shortened and INTERNALLY rotated

228
Q

What is the hallmark of treatment for femur fractures in the ED?

A

traction (hare) splint

229
Q

What is the most common meniscus to be torn?

A

medial meniscus (because connected to MCL)

230
Q

What are PE findings of someone with a meniscus tear?

A
  • joint line tenderness

- Apley’s

231
Q

xray shows fracture on of knee on side of patella

A

tibial plateau fracture

232
Q

Why are tibial plateau fractures high risk?

A

poor healing

233
Q

How do you treat knee dislocation?

A

DO NOT REDUCE WITHOUT ORTHO

234
Q

What should you always check with ankle injuries?

A

check mortise alignment

235
Q

What is the classic fibular fx?

A

lateral malleoulus fx

236
Q

What should you watch for with bi/tri malleolar fx?

A

compartment syndrome!

237
Q

What is the PE test for an achilles rupture?

A

Thompsons test

238
Q

How do you treat an achilles rupture?

A

splint in full plantar flexion

239
Q

What is the usual MOI for calcaneal injuries?

A

Jump from height

240
Q

What should you do if you have a calcaneal fracture?

A

check other side!! (usually bilateral)

241
Q

What else should you do if you have a calcaneal fracture?

A

Examine spine!!!

242
Q

Patient presents with upward displacement of tongue, trismus, drooling and dyspnea

A

Ludwig’s angina

243
Q

What are risk factors for Ludwig Angina?

A
  • poor dentition

- immunocompromised

244
Q

What is Ludwig’s angina?

A

soft tissue infection of submandibular region of anterior neck

245
Q

How do you treat Ludwig’s Angina?

A
  • EARLY airway management

- PCN G IV + flagyl IV

246
Q

Patient presents with “hot potato” voice, tripod position and drooling but oral exam reveals nothing

A

Retropharyngeal Abscess

247
Q

What is the most common cause of retropharyngeal absecesses?

A

Heamfluenza (hib vaccine)

248
Q

How do you dx retropharyngeal abscess?

A

soft tissue lateral neck xray

249
Q

What are you looking for on xray of retropharyngeal abscess?

A

swelling between trachea and anterior spine

250
Q

How do you treat retropharyngeal abscesses?

A

Penicillinase resistant PCN (Oxacillin, cephalosporin)

251
Q

Patient presents with sore throat, trismus and hot potato voice

A

epiglottitis

252
Q

What do you look for on xray to dx epiglottitis?

A

Thumb sign

253
Q

How do you treat epiglottitis?

A
  • cefuroxine, ceftriaxone, bactrim

- steroids

254
Q

Who is at risk of getting epiglottitis?

A

unimmunized

255
Q

Patient presents with uvula deviation, trismus, stridor and drooling

A

peritonsillar absecess

256
Q

How do you treat peritonsillar abscess?

A
  • Needle I and D
  • IM Pen VK
  • recheck in 24hrs
257
Q

How should you treat dental pain in ED?

A
  • dental block (preiapical, infraorbital, inferior alveolar)
  • temporary dental filling
  • abx
  • pain management
  • dentist referral
258
Q

What should you check if you have a dental abscess?

A

check teeth and neck

259
Q

How do you treat dental abscess?

A
  • DON’T DRAIN
  • refer to oral surgery ASAP
  • cover with abx
260
Q

Patient presents with red/bulging TM and a normal canal

A

acute otitis media

261
Q

What shouldn’t you do if TM ruptures?

A

give oto-toxic drugs

262
Q

What should you always do if someone presents with AOM?

A

examine/percuss mastoid

263
Q

What are common pathogens of otitis externa?

A
  • P. aeruginosa
  • S. aureus
  • often polymicrobial
264
Q

What are common pathogens of mastoiditis?

A
  • S. pneumo
  • Group A strep
  • S. aureus
  • M. catarhallis
265
Q

Why is mastoiditis so concerning?

A

COMPLICATIONS:

  • MENINGITIS
  • brain abscess
  • epidural abscess
266
Q

What can mastoiditis present with?

A

CN VI, VII, V palsy

267
Q

How do you dx mastoiditis?

A

CT mastoid bone (swiss cheese appearance)

268
Q

How do you treat mastoiditis?

A
  • ENT for hearing analysis
  • non-toxic–> treat like AOM
  • Toxic–> zosyn, recephin, clinda
269
Q

What should you always check for in someone who presents with nasal trauma?

A

septal hematoma

270
Q

What is complication of septal hematoma?

A

septum will breakdown and cause disfiguration

271
Q

How do you treat septal hematoma?

A

ENT referral

272
Q

What is the common place to get epitaxis?

A

Kiesselbach’s Plexus (anterior)

273
Q

What is the clinical presentation of a posterior nose bleed?

A

blood in back of throat

274
Q

What is treatment of epitaxis?

A
  • mechanical
  • vasoconstrictors (cocaine)
  • inserter devices (caution TSS)
  • cautery
275
Q

Patient presents with posterior LAD

276
Q

What abx do you want to avoid with mono?

A

amoxicillin (rash)

277
Q

What is the centaur criteria?

A

criteria to ID bacterial infection

278
Q

What are the 4 centaur criteria?

A
  • hx fever
  • tonsillar exudates
  • tender ANTERIOR cervical adenopathy
  • absence of cough
279
Q

What should you do with a centaur score of 0-1

A

no abx or culture

280
Q

What should you do with a centaur score of 2-3 points?

A

culture and abx until find out result of culture

281
Q

What should you do if centaur score is 4?

A

abx, no culture needed

282
Q

Patient presents with pain over parotid gland and duct blockage?

A

parotiditis

283
Q

How do you treat parotiditis?

A
  • salivary agents

- dicloxicillan if concern for infection

284
Q

Patient presents with inspiratory stridor, sealbark cough, and resp. distress

A

croup (laryngotracheatis)

285
Q

When is croup most common?

A

fall, early winter

286
Q

What is the most usual pathogen of croup?

A

Parainfluenza type 1

287
Q

How do you dx croup?

A

Steeple sign on xray

288
Q

How do you treat croup?

A
  • single dose decadron

- mod-severe: racemic epi, o2, IV fluids

289
Q

What drugs have narrow therapeutic indexes?

A
  • digoxin
  • TCA
  • lithium
  • warfarin
  • theophylline
290
Q

What blood test is most likely to change initially in overdoses?

291
Q

Who should you have a high suspicion for overdoses in?

A

elderly (polypharm)

292
Q

What are the 4 EKG changes you are looking for in an overdose?

A
  1. QT prolongation
  2. Wide QRS (>100ms)
  3. Terminal R-wave aVR
  4. high-grade block
293
Q

What is the ddx for metabolic acidosis w/widening anion gap?

294
Q

What are MUDPILES?

A 
M- methanol
U- uremia
D- DKA
P- propylene glycol
I- infection/isoniazid
L- lactic acidosis
E- ethylene glycol
S- salicylates
295
Q

Patient presents with Kussmals breathing, tinnitus, pulmonary edema and hypotension

A

ASA overdose

296
Q

What is the M-M prediction of ASA?

A

under 150mg/kg: non-toxic-mild
150-300 mg/kg: mild-moderate
300-500 mg/kg: serious toxicity
Over 500 mg/kg: potentially life-threatening

297
Q

What labs will change first in an ASA overdose?

298
Q

When should you get serum salicylate?

A

Repeat q2hrs for first 6hrs

299
Q

What should you be careful of with salicylate serum levels?

A

careful when under first 6hrs

300
Q

What do you want to monitor with an ASA overdose?

301
Q

What do you want to keep urine pH at with an ASA overdose?

302
Q

How do you change urine pH?

303
Q

What other tests should you get during an ASA overdose?

A
  • ABG (metabolic acidosis common)
  • EKG
  • CXR
304
Q

How do you treat ASA overdose?

305
Q

What is the most widely used OTC med?

306
Q

What is the max daily dose of tylenol in adults?

A

4g/day (90 mg/kg)

307
Q

What is the most common cause of ACUTE liver failure in the US?

A

Tylenol overdose

308
Q

Who has a better chance of surviving an acetaminophen overdose?

A

Under 5yo (more glutathione)

309
Q

What is a really important thing to remember with tylenol toxicity?

A

DELAYED TOXICITY

310
Q

What worsens a tylenol overdose?

A

co-ingestion with ALCOHOL

311
Q

Why does alcohol make it worse?

A

Glutatione exhausted more quickly and NAPQI is made instead, which ruins liver

312
Q

What are the 3 phases of tylenol overdose?

A
  1. 0-24hrs (asymptomatic, N/V, subclinical LFT’s)
  2. 18-72hrs (RUQ pain, continue rise LFTs)
  3. 72-96hrs (jaundiced, coagulopathy, fatality, liver necrosis, renal failure)
313
Q

What is the timing of drawing serum tylenol levels?

A

draw initial and then post-4 hrs

314
Q

What can be used to predict prognosis of tylenol overdose?

A

Rumack-Matthew nomogram

315
Q

Why is glucose a good thing to check during tylenol overdose?

316
Q

What does lactate level check for?

317
Q

What is TOC for tylenol overdose?

318
Q

What is the time you want to give NAC w/n?

A

8hrs post-ingestion (anytime if PG)

319
Q

What are the criteria for a liver transplant? (4)

A
  1. pH under 7.3
  2. grade 3 plus encephalopathic
  3. PT over 100
  4. Cr over 3.4
320
Q

What are psych med overdoses hard to dx?

A

They present similar to psyc illness

321
Q

Why are psych meds overdosed on frequently?

A

low therapeutic index

322
Q

What are common psych meds that are overdosed on?

A
  • amitriptyline

- lithium

323
Q

What meds can you commonly get levels on?

A
  • lithium
  • tegretol (carbamazepine)
  • depakote
324
Q

Patinet presents with agitation, tremor ridigity, sweating, hyper-reflexia, ataxia?

A

serotonin syndrome

325
Q

What is the anticholinergic toxidrome?

A
  • Hot as a hare
  • Blind as a bat
  • Dry as a bone
  • Mad as a hatter
  • Red as a beet
326
Q

What should you look for in someone with an overdose of psych meds?

A

look for rhabdo

327
Q

How do you treat psych med overdose?

A
  • Benzos
  • BP control
  • Cooling
328
Q

How long does an opiate take if taken IV?

329
Q

How long dose an opiate take if taken IM?

330
Q

How long dose an opiate take if taken PO?

331
Q

How long does opiate take if taken transdermal?

332
Q

What do you have to be careful of with narcan and heroin?

A

Narcan half-life shorter than heroin half-life

333
Q

What should you do if there was an oral opiate overdose?

A

GI decontamination

334
Q

If patient is still altered after narcan what should you consider?

A
  • other ingestion

- anoxic brain injury

335
Q

What are the classic EKG findings in someone with a TCA overdose?

A
  • wide QRS

- terminal R-wave in aVR

336
Q

Who should you not prescribe TCA’s to?

A
  • uncontrolled mental illness

- hx suidice attempts

337
Q

What are TCA’s usually prescribed for?

A
  • sleep
  • enuresis
  • OCD
  • ADD
  • anxiety
338
Q

When is peak absorption of TCAs?

339
Q

What is the toxic dose of TCA’s?

A

10-20 mg/kg

340
Q

How do you treat TCA overdose?

A
  • O2, IV, monitor
  • bicarb (even if not acidotic)
  • intubation is key if severe OD
  • seizure precautions
  • gastric lavage/charcoal
341
Q

Why is ethylene glycol poisonous?

A

EG itself is not toxic, but is metabolized using ADH and converted to glycolic acid

342
Q

How do you treat ethylene glycol overdose?

A

give alcohol (takes up ADH)

343
Q

How does someone with an ethylene glycol OD present?

A
  • Kussmals breathing
  • tachypnea
  • AMS
344
Q

How do you work up ethylene glycol OD?

A
  • obtain serum level

- calculate serum osmolarity

345
Q

What are the conversion factors for serum osmolarity

A

ethylene glycol: 6.2
Methanol: 3.2
Ethanol: 4.6

346
Q

What is TOC of ethylene glycol?

A

Fomepizide (expensive, hard to get)

347
Q

Patient presents with bradycardia and severe hypotension

348
Q

What is a toxic level of verapamil?

349
Q

What are dx findings of someone with verapamil OD?

A

high-grade blocks on EKG

350
Q

What is TOC for verpamil OD?

A

10 percent CaCl (pressor support)

351
Q

What is the legal limit for alcohol?

352
Q

What do you have to keep in mind with face trauma?

A

Appearance of wound does NOT correlate to severity of injury (may be asymptomatic at first)

353
Q

What are the borders of the anterior triangle?

A

Scm, midline of neck, mandible

354
Q

What are the borders of the posterior triangle?

A

Scm, trapezius, clavicle

355
Q

Where is zone 1 of neck?

A

base of neck

356
Q

Where is zone 2 of neck?

A

middle of neck

357
Q

Where is zone 3 of neck?

A

superior aspect of neck

358
Q

Which zone has carotid/vertebral arteries, jugular vein, larynx and C-spine?

359
Q

Which zone has trachea, vertebrae bodies, catodies, jugular and CN IX-XII?

360
Q

Which zone has subclavian, aortic arch, trachea and C-spine roots?

361
Q

What is the most common cause of penetrating traumas?

362
Q

Which caliber weapon causes the most damage?

A

LOW CALIBER (low velocity, SHREDS)

363
Q

What are PE findings of penetrating trauma?

A
  • expanding hematoma
  • pulsatile bleeding
  • signs of CVA
  • shock unresponsive to fluids
  • bruit/thrill
364
Q

Does presence of pulse exclude vascular injury?

365
Q

What are signs of underlying injury from blunt trauma?

A
  • hematemesis
  • odynophagia
  • SubQ emphysema
366
Q

What should you do it there is injury to platysma?

A

Don’t wait to image, ASAP trauma surgery!

367
Q

What is the best imaging to pick up c-spine fractures?

368
Q

What should you do to avoid air embolus?

A

trendenlenburg position

369
Q

What do you have to consider if there is a neuro deficit?

A

carotid/vertebral artery injury

370
Q

What imaging should you get if someone has had blunt trauma?

371
Q

What is the usual MOI of a frontal bone fx?

A

blow to head

372
Q

What else can happen with a frontal bone fx?

A

can involve sinuses

373
Q

What is the weakest aspect of the skull?

A

orbital floor

374
Q

What are complications of orbital floor fractures?

A
  • hernation of orbital contents

- entraps inferior rectus muscle

375
Q

What imaging should you get to see orbital floor fracture?

A

non-contrast CT

376
Q

What do you want to look for with a nasal bridge fracture?

A

septal hematoma

377
Q

What can nasoethmoidal fx cause damage to?

A
  • medial canthus
  • lacrimal gland
  • basofrontal duct
  • cribiform plate
378
Q

What can you see on PE with nasoethmoidal fx?

A
  • telecanthus

- CSF rhinorrhea

379
Q

What is important to know in nasoethmoidal fx?

A
  • mechanism
  • exam
  • gestault
380
Q

What does PE of zygomatic arch fx look like?

A
  • tender
  • crepitus
  • decreased mandible ROM
381
Q

What are the Lefort classifications of Maxillary fx?

A

1: facial edema, mobility of palate and teeth
2: telecanthus, mobility of maxilla, epitaxis, CSF rhinorrhea
3: facial elongation/flattening, movement of facial bones, CSF rhinorrhea

382
Q

What type of mandible fx is commonly overlooked?

A

condyle fx

383
Q

What PE exam can you do to test for mandible fx?

A

tongue blade test

384
Q

How many adult teeth are there?

385
Q

How should you store avulsed tooth?

A

-in milk! Do not scrub tooth!

386
Q

How do you tx dental fx?

A

-temp dental filling/dental block

387
Q

What should you check for in someone with trauma?

A
  • coumadin

- alcohol

388
Q

What should you do if there is a fx through the siinuses?

A

prescribe abx

389
Q

Why type of facial fx needs neurosurgery?

A

nasoethmoidal

390
Q

What type of facial fx needs mandatory opth consult?

A

orbital blowout

391
Q

What are etiologies of subconjunctival hemorrhage?

A
  • trauma
  • valsalva
  • spontaneous
392
Q

What is tx of subconjunctival hemorrhage?

A

none, will heal on own in 2 weeks

393
Q

What shoudl ou always do when someone presents with a corneal abrasion?

A

document lids everted

394
Q

What should you always ask in patient with corneal abrasion?

A

Contact lenses (can’t wear while healing)

395
Q

How do you dx corneal abrasion?

A

flourescin dye w/ woods lamp

396
Q

how do you tx corneal abrasion?

A

E-mycin ointment, pain meds

opth referral

397
Q

How do you remove FB from eye?

A
  • cotton tip applicator
  • 18g needle
  • algar brush (vibrator)
398
Q

When should you NOT attempt to remove FB?

A
  • Rust
  • Full-thickness FB
  • Over pupil (risk of scarring)
399
Q

What must you r/o if there has been blunt trauma around the eyes?

A

ruptured globe

400
Q

What should you look for with blunt trauma to the eyes?

A
  • Flatness of anterior chamber
  • hyphema
  • EOM’s
401
Q

What is the vessel that causes hyphemas usually?

A

Iris root vessel

402
Q

what do you need to do to see a hyphema?

A

elevate head of bed and allow blood to settle

403
Q

What should you do if there is a hyphema?

A

-measure and control IOP (tono pen)

404
Q

How do you treat hyphema?

A

MANDATORY opth referral

405
Q

What is an elevated IOP?

406
Q

Where is the most common spot to have a blowout fracture?

A

orbital floor

407
Q

What imaging do you need to get to see blow out fracture?

408
Q

What should you not do if you suspect a ruptured globe?

A

measure IOP

409
Q

How do you tx ruptured globe?

A
  • Stat optho referral

- IV cephalosporin and patch eye

410
Q

Patient presents with superficial punctate keratitis?

A

flash burn

411
Q

When does flash burn typically present?

A

6-12hrs after injury

412
Q

How do you dx flash burn?

A

floursecin with slit-lamp

413
Q

How do you treat flash burn?

A
  • E-mycin oitment
  • pain meds
  • cycloplegics
414
Q

Is bacterial or viral conjunctivits more common?

415
Q

What is the most common cause of blindness in the Western World?

A

Herpes Keratitis

416
Q

How do you treat herpes keratitis?

A

NO STEROIDS

mandatory opth consult

417
Q

Patient presents with eye pain, HA, and STEAMY pupil?

A

Acute angle closure glaucoma

418
Q

What are sxs of acute glaucoma?

A
  • eye pain
  • redness
  • blurred vision
  • N/V
  • intermittent halos
419
Q

What are signs of acute glaucoma?

A
  • IOP over 21
  • conjunctival infection
  • corneal epitherlial edema
  • mid-dilated, nonreactive pupil
420
Q

How do you treat acute glaucoma?

A

RAPID decreased IOP (acetazolamide, BB (timolol), apraclonide/brimonidine)

ASAP opth referra

421
Q

How do you dx acute glaucoma?

A

2 sxs, 3 signs

Emergency Medicine (3 decks)

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