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EM > EM 3 > Flashcards

EM 3 Flashcards

1
Q

Dosing of Diltiazem

A
  • 0.25 mg/kg over 2 min, may repeat at 0.35 mg/kg
    • infusion at 5-15 mg/h (increase by 5 mg/h)
  • 5 mg/h drip = 60 mg PO Q6h
  • 10 mg/h drip = 90 mg PO Q6h
  • 15 mg/h drip = 120 mg PO Q6h
  • DC IV drip 2-3 h after oral dose given
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2
Q

Verapamil Dosing

A
  • 2.5-5 mg IV over 2 min
    • if no response after 15 min give 5-10 mg
    • max total dose 30 mg
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3
Q

IV Digoxin Load (AF)

A
  • 8 to 12 mcg/kg total loading dose, give 50% IV over 5 min, then 25% of dose x 2 at 4-8hr intervals
  • i.e. 0.25 mg IV then 0.125 mg IV Q8h x 2 then check levels
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4
Q

Dopamine

A
  • a1, b1, b2
  • increases SVR, HR, BP, CO
  • more beta at lower doses (5-10 mcgs/kg/min)
  • more alpha at higher doses (>15 mcgs/kg/min)
  • 2-20 mcgs/kg/min
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5
Q

Epineprhine (pressor)

A
  • nonselective alpha + beta agonist
  • 0.1 - 2 mcg/kg/min (7-140 mcg/min)
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6
Q

Norepinephrine

A
  • a1, b1 agonist
  • 0.1-2 mcg/kg/min (7-140 mcg/min)
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7
Q

Phenylephrine

A
  • pure alpha-1 agonist
  • may cause reflex bradycardia
  • 100 mcg - 500 mcg bolus Q 10-15 min or
  • infusion 50-200 mcg/min
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8
Q

Dobutamine

A
  • synthetic dopamine analog
  • B1>B2>alpha
  • increased HR + contractility, neutral on BP
  • 2 mcg/kg/min-40 mcg/kg/min (max 20 mcg/kg/min in septic shock)
  • avoid in AF, aortic stenosis
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9
Q

Milrinone

A
  • inotrope with vasodilator properties (inodilator)
  • increased CO, decreased SVR
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10
Q

Dose of Bicarb in Arrest

A

1-1.5 mEq/kg IV, repeat at 50% dose in 10-15 min PRN

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11
Q

Pulsus Paradoxus

A
  • exaggeration of normal physiology
  • stroke volume decreases during inspiration because of RV filling and pushing on LV to make it smaller
  • exaggerated when pericardium is constrained (e.g. pericarditis, tamponade, hyperinflation of asthma)
  • > 10 mm Hg difference in SBP between inspiration and expiration is +ve
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12
Q

Normal 2-point discrimination on fingerpads

A

< 6 mm

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13
Q

DDx for short QTc

A
  • hypercalcemia
  • digoxin toxicity
  • congenital short QT
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14
Q

DDx for ST elevation

A
  • AMI
  • Vasospasm
  • Early Repolarization
  • Myo/pericarditis
  • Ventricular aneurysm
  • LVH/high voltage
  • LBBB/Pacemaker
  • PE
  • HyperK
  • Brugada
  • Hypothermia
  • Post-cardioversion
  • Tako tsubo
  • Intracranial abnormalities
  • Spiked Helmet Sign
  • Hypercalcemia
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15
Q

Bacteria from dog bites responsible for life-threatening infections in immunocompromised patients.

A
  • Capnocytophaga canimorsus
    • slow-growing GNR
    • dogs, cats
    • responds to Augmentin
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16
Q

Cat-scratch Disease

A
  • bartonella henselae
  • low-grade fever
  • painful, fluctuant LAN
  • sometimes multi-organ involvement
  • usually resolved spontaneously 2-5 months
  • Z-pack for painful LAN
  • Cipro for immunocompromised
  • may aspirate lymph nodes for relief but do not I&D (scarring, fistula formation)
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17
Q

UHF Bolus + Infusion Dose

A
  • 60 units/kg bolus (max 4, 000 units)
  • infusion 12 units/kg/h (max 1, 000 units/h)
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18
Q

Blood supply to cardiac conduction system

A
  • LAD (septal perforating branch)
  • RCA (AV branch)
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19
Q

Dose of Plavix ACS

A
  • NSTEMI/Fibrinolysis STEMI
    • Age < 75: 300 mg then 75 mg daily
    • Age >= 75: 75 mg daily
  • STEMI for PCI
    • 600 mg (all ages)
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20
Q

When to give second antiplatelet agent in ACS

A
  • 2/3 CCS criteria
    • ST changes
    • +ve biomarkers
    • any of
      • age >60
      • DM
      • hx CV disease
      • 2 or 3 vessel CAD
      • CrCl < 60
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21
Q

Plavix vs. Ticagrelor in ACS

A
  • OAC/NOAC, Afib, Hx ICH, 2nd/3rd deg AVB?
    • Plavix
  • None of above?
    • Ticagrelor 180 mg then 90 mg BID
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22
Q

Doses of Fonda, Enox for ACS

A
  • Fondaparinux - 2.5 mg subcut
  • Enoxaparin - 1 mg/kg subcut
  • use UFH if eGFR < 30
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23
Q

Pulmonary Hypertension (Read Through)

A
  • Definition: mean pulmonary arterial pressure >25 mm Hg at rest or >30 mm Hg on exertion
  • Not from left heart failure: PCWP < 15 mm Hg
  • From left heart failure: PCWP > 15 mm Hg
  • Categories
    • Group 1: Pulmonary Arterial
      • idiopathic, generic, drug/toxin, HIV, liver disease
    • Group 2: Pulmonary Venous (Left Heart Disease)
      • most common
      • systolic or diastolic dysfunction
      • mitral or aortic valve disease
    • Group 3: Chronic Hypoxemic Lung Disease
      • COPD, ILD (IPF), OSA, chronic high altitude
    • Group 4: Embolic Disease
    • Group 5: Misc
      • lymphatic obstruction, myeloproliferative, sarcoidosis, metabolic disorders
  • Normal Pulmonary Arterial Pressures
    • Systolic Pressure: 15-30 mm Hg
    • Diastolic Pressure: 4-12 mm Hg
  • Signs/Symptoms
    • early: dyspnea, syncope, anorexia
    • late: R side heart failure
    • RCA ischemia (RCA perfusion depends on Aorto-pulmonary artery gradient)
    • RAD, RVH, RBBB
  • Treatment
    • careful with PPV/intubation and fluids
    • Dobutamine 2-10 mcgs/kg/min (higher may cause low BP)
    • Milrinone 0.375-0.75 mcgs/kg/min (higher may cause low BP)
    • Norepi 0.05 mcgs/kg/min for RCA perfusion
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24
Q

Grading of Heart Murmurs

A
  • 1 - Faint, may not be heard in all positions
  • 2 - Quiet, but heard immediately with stethoscope placed on chest wall
  • 3 - moderately loud
  • 4 - loud
  • 5 - Heard with stethoscope partially off chest wall
  • 6 - Heard with stethoscope completely off chest wall
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25
Q

Mitral Stenosis

A
  • RHD most common cause
  • nonrheumatic mitral annular calcification, slow progression, common in elderly
  • SOBOE, LAE, orthopnea, PAC’s, Afib, pulmonary HTN, hemoptysis
  • mid-diastolic rumble at apex
26
Q

Mitral Regurg

A
  • acute: dyspnea, flash CHF, harsh apical systolic murmur loudest in early/mid systole
  • nitro (improves forward flow), BiPap, sx
  • chronic: MVP or old age, high-pitched holosystolic murmur radiating to axilla, S3, Afib, LAE, LVH
  • MVP: mid-systolic click, can occur with or without regurg, refer for echo/cards
27
Q

Aortic Stenosis

A
  • dyspnea + CP + syncope
  • usually from HTN, calcification, smoking, bicuspid aortic valve
  • late peaking systolic murmur RSB 2nd ICS rad to carotids, carotid pulsus parvus et tardus, narrowed pulse pressure, brachioradial delay, LVH
  • caution with nitro, BB, may need to cardiovert afib as ++ preload dependent
  • if symptomatic, admit (40-50% mortality within 1 year)
28
Q

Aortic Regurg

A
  • chronic: (with ao stenosis, RHD, IE, bicuspid Ao valve)
  • SOBOE, ischemic CP
  • acute: AAD, aortitis
  • high-pitched, blowing diastolic murmur LSB 2nd ICS, waterhammer pulse
  • de Musset sign: pulsatile head bobbing
  • LVH
  • avoid BB (need tachycardia to compensate)
29
Q

Tricuspid Valve Disease

A
  • common in normal people
  • severe, acute in IE
  • regurg: soft, blowing, holosystolic @ LLSB, increases with inspiration
  • stenosis: crescendo-decrescendo diastolic rumble @ LLSB, increases with inspiration
30
Q

Pulmonic Valve Disease

A
  • mostly congenital
  • stenosis: harsh systolic murmur LUSB
  • regurg: high-pitched blowing diastolic murmur LUSB
31
Q

Murmur of HOCM

A
  • LLSB or apical systolic murmur
  • louder with decreased LV filling or stronger LV contractions
    • straining on Valsalva, standing
  • quieter with increased LV filling
    • squatting, passive leg raise, hand grip
32
Q

Paradoxical Embolism Syndrome

A
  • 20% patients have PFO
  • PE embolizes through PFO causing TIA/myelopathies/shower emboli type symptoms
33
Q

Enoxaparin Dose VTE Tx

A
  • 1 mg/kg SC Q12h
    • or
  • 1.5 mg/kg SC daily
  • Actual body weight, eGFR >30
34
Q

Rivaroxaban (Xarelto) VTE Tx Dose

A
  • 15 mg BID for 21 days then 20 mg daily with food
35
Q

Superficial vs. Deep Veins (Upper + Lower Extremity)

A
  • superficial veins
    • greater + short saphenous veins, perforating veins; cephalic, basilic
  • deep veins
    • calf (distal DVT): anterior tibial, posterior tibial, peroneal veins
    • popliteal vein –>femoral (superficial femoral) vein –> joins with deep femoral to make common femoral –> iliac vein
    • axillary vein
36
Q

Superficial Venous Thrombophlebitis Treatment

A
  • NSAIDS, heat, 30-40 mm Hg compression stockings
  • repeat US in 2-5 d
    • if progressing, anticoagulate x 10 d and repeat US
  • If risk factors or > 7 cm, upper half of thigh, may anticoagulate right away.
37
Q

Calf DVT Treatment

A
  • ECASA 325 mg daily —> repeat US in 2-5 days
  • anticoagulate if:
    • all 3 deep veins involved
    • clot close to popliteal vein
    • severe symptoms
    • clot > 5 cm

previous VTE

* +ve Ddimer
* progression of clot on repeat imaging
38
Q

Massive PE

(definition, indications for thrombolysis, contraindications, dosing)

A
  • SBP < 90 mm Hg x 15 min, SBP < 100 mm Hg with Hx HTN, or 40% reduction in baseline BP
  • best evidence for fibrinolysis is for PE +
    • cardiac arrest
    • hypotension
    • hypoxemia <90% on max O2 + increased WOB
    • evidence of R heart strain on echo, elevated Trop, or both
  • major contraindications to thrombolysis
    • intracranial disease
    • uncontrolled HTN at presentation
    • recent major surgery/trauma (3 weeks)
    • if trauma from syncope from PE, CT Head to r/o bleed before thrombolysis
    • metastatic cancer

Alteplase: 15 mg IV bolus, then 85 mg over 2h, after complete start UFH 80 u/kg bolus + 18 u/kg/h, goal apTT<120s

39
Q

Submassive PE

Definition

A
  • PE with evidence of R heart strain, elevated Trop or BNP
  • consider thrombolysis if young, consult with cards first
40
Q

DVT Dx Algorithm

A

See Evernote DVT/PE

41
Q

BP Targets for Hypertensive Emergencies

A
  • AAD: SBP 100-120, HR <60
  • APE: 20% reduction
  • AMI: 20% reduction
  • AKI: 20% reduction
  • Hypertensive encephalopathy: 20% reduction
  • SAH/ICH: SBP 120-160
  • Ischemic CVA, tPA candidate: tx if BP >180/110 on 3 separate readings target SBP 140-150
  • Ischemic CVA, non-tPA candidate: tx if BP >220/120 on 3rd of 3 measurements, 15 min apart, tx to 10-15% reduction in first 24h
42
Q

Stanford and DeBakey Classifications of AAD

A

Stanford

  • Type A — Involves ascending aorta. Can extend distally ad infinitum. Surgery usually indicated.
  • Type B — Involves aorta beyond left subclavian artery only. Often managed medically with BP control.

DeBakey

  • 1 – entire aorta affected
  • 2 – confined to the ascending aorta
  • 3 – descending aorta affected distal to subclavian artery
43
Q

ABI

A
  • <0.9 is abnormal
  • <0.5 critical limb ischemia likely
  • >1.3 calcified vessel, unreliable
44
Q

AAA size

A
  • Dx: AA >= 3 cm
  • Sx: >= 5 cm
45
Q

Signs of agranulocytosis on tapazole

A

Fever, sore throat

46
Q

Light’s Criteria

A
  • does not apply to patients with CHF treated with diuretics
  • effusion is exudative if one of the following present:
    • pleural/serum fluid protein ratio >0.5
    • pleural/serum fluid LDH ratio >0.6
    • pleural fluid LDH level >2/3 upper limit of normal for serum LDH
47
Q

CAP vs. HAP vs. HCAP vs. VAP

A
  • CAP: > 2 wks since hospitalization
  • HAP: >48h since admission
  • VAP: >48h since intubation
  • HCAP:
    • hospitalized 2 or more days within past 90 days
    • LTC
    • Home IV Abx
    • Chronic Wound Care
    • Dialysis, chemo, immunocompromise
48
Q

Pertussis

A
  • bordetella pertussis
  • treat with z-pack
  • only really effective in 1st week
49
Q

Atypical Pneumonia

A
  • h. influenzae
  • moraxella catarrhalis
  • legionella
  • lack a cell wall, respond to quinolones and macrolides
50
Q

Bells Palsy Treatment

A
  • prednisone 60-80 mg PO daily x 7 d
  • valtrex 1 g TID x 7 d
51
Q

Causes of Mono Syndrome

A
  • HHV 4 (EBV)
  • CMV
  • HHV 6
  • Toxoplasma
52
Q

Infectious Mononucleosis Clinical Signs

Infectivity

A
  • Fever
  • Exudative pharyngotonsillitis
  • Lymphadenopathy (usually posterior chain)
  • Fatigue
  • Older = more symptomatic
  • Infects B Cells. Mostly college-high school kids through kissing. Incubation can be as long as 4-6 weeks. Pharyngeal excretion can persist for >1yr.
  • 95% young adults have abnormal LFTs, 4% have jaundice. Hepatosplenomegaly common (50%).
  • Resolves 1-3 weeks. Malaise and fatigue rarely for months. Splenic rupture rare (~1/1000) but consider if LUQ + decreasing Hct

Often morbilliform rash if treated with Pen/Amoxil

53
Q

Mono BW

A
  • Lymphocytosis (>50% total WBC)
  • Monospot test (elevation in heterophil antibodies), +ve in 90% (25% false neg in 1st week, 5% week 2, 5% week 3) Very specific, but can persist at low levels for up to 1 year.
  • Abnormal lymphocytes on peripheral smear
  • if mono picture but -ve monospot & preg
    • draw CMV titres and contact obs/gyn
54
Q

PEF in Asthma

A
  • 1h post treatment
    • > 70% mild
    • 40-69% moderate, decide clinically
    • < 40% admit
    • <25% intubate, ICU
55
Q

COPD Spirometry Definition and staging

A
  • FEV1/FVC <0.7
  • FEV1 < 0.8
    • mild: FEV1 > 80%
    • moderate: FEV1 50-80%
    • severe: FEV1 30-50%
    • very severe: FEV1 < 30%
56
Q

COPD Criteria for Home O2

A
  • PaO2 <= 55
    • or <=59 with pul HTN, cor pulmonale, or polycythemia
  • SaO2 <= 88%
  • goal is PaO2 >= 60 mm Hg or SpO2 >=90% at rest
  • long-term O2 therapy reduces mortality
57
Q

COPD Rate of Progression (FEV1 loss)

A
  • ~40-60 cc/year in smokers, ~20-30 in those who quit
58
Q

When to get ABG in COPD for Home O2 consideration

A
  • FEV1 < 40%
59
Q

Low vs. high risk AECOPD and abx choice

A
  • low risk: FEV1 > 50% and no co-morbidities
    • z-pack, septra, amoxil, doxy, biaxin
  • high risk: FEV1 < 50% or co-morbidities, age >65, > 3 exacerbations/year, abx within past 3 months
    • clavulin, levaquin, moxi
60
Q

Dieulafoi Lesion

A
  • Gastric artery protruding into stomach
  • Sometimes multiple negative endoscopies
61
Q

Dose of octreotide for cirrhotic UGI

A
  • 50 mcg bolus + 50 mcgs/h
  • 50% dose for elderly
62
Q

Meckel’s Diverticulum

A
  • embrionic vestige in terminal ileum
  • contains gastric mucosa cells and causes erosions and GI bleeds in young patients

EM (27 decks)

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