EM Flashcards
What are the ABCDs of acute management of patients?
Airway Breathing Circulation Disability Exposure
Under what GCS score is intubation indicated?
GSC under 8, intubate!
What is the treatment for hemoperitoneum?
Surgery
What is the role of placing a foley catheter in the hemodynamically unstable patient?
Monitor urine output in those receiving fluids
When is a CT neck/ spine indicated in a trauma patient?
Neck pain / TTP
Neurological findings
Depressed mental status
What are the three main components of the GCS coma scale? How many points are in each category?
Eye opening 4 (EYES)
Verbal response 5 (VOICE)
Motor response 6 (ARM+ LEG)
What are scores for 1-4 for the eye opening portion of the GSC scale?
4 = spontaneous 3 = opens to command 2 = opens to pain 1 = none
What are scores for 1-5 for the verbal response portion of the GSC scale?
5= Oriented 4 = confused speech 3 = inappropriate words 2 = incomprehensible 1 = None
What are scores for 1-6 for the motor response portion of the GSC scale?
6 = follows commands 5 = localized pain 4 = Withdraws to pain 3 = Flexion 2 = extension 1 = none
What is the classic triad for cardiac tamponade?
Muffled heart sounds
JVD
Hypotension
What are the components of circulation management in the trauma / unstable patient?
Assess pulses
Control bleeding
IVFs PRN
What are the components of the disability part of the primary assessment?
GCS score
What are the components of the exposure part of the primary assessment?
Disrobe pt and inspect
Cover pt
A rough estimate of systolic BP (SBP) can be made on the basis of palpated pulses; Carotids correspond roughly to an SBP of what?
60 mmHg
A rough estimate of systolic BP (SBP) can be made on the basis of palpated pulses;Femorals correspond to a rough SBP of what?
70 mmHg
A rough estimate of systolic BP (SBP) can be made on the basis of palpated pulses; Radial correspond to a SBP of what?
80 mmHg
All wounds that penetrate what anatomical structure are considered true penetrating neck trauma?
Platysma
What is indicated in the ABCDEs of patients with penetrating neck traumas?
Intubation before airway is compromised
Immediate surgical exploration of neck wounds is indicated if what?
If shock and active hemorrhage are present
What testing is indicated in the treatment of penetrating neck trauma?
Angiography of the neck
Doppler US
Contrast esophagram
True or false: intubation is indicated in all cases of thoracic trauma with penetrating injuries
True
When is an open thoracotomy indicated to rule out pericardial effusion with penetrating chest trauma?
If patient goes into cardiac arrest in ED or shortly before arrival
If a patient with a chest trauma suddenly becomes hemodynamically unstable, what should be at the top of the differential?
Air embolism
A new diastolic murmur after chest trauma suggests what?
Aortic dissection
Penetrating trauma to areas lower than what anatomic landmark warrants abdominal investigation?
Nipple line
What are the indications for surgical exploration in penetrating stab wounds to the abdomen?
Hemodynamic instability or evisceration
What is the next step in diagnostic evaluation of an abdominal stab wound in the stable patient?
CT a close f/u
What are the first steps in MS injures?
Early wound irrigation
Wound debridement
Tetanus prophylaxis
Vascular injuries usually require what diagnostic evaluation and management?
Arteriography
Nerve injuries usually require what sort of management?
Surgical
What should always be assessed for with blunt head trauma, besides bleeding, fractures, and neuro?
Increased ICP
What is the stabilizing treatment for increased ICP? (3)
Head elevation
Hyperventilation
IV mannitol
What are the CT characteristics of diffuse axonal injuries?
Blurring and punctate hemorrhaging along the gray-white matter junction
Blurring and punctate hemorrhaging along the gray-white matter junction on a head CT indicates what sort of trauma?
Rapid-deceleration injuries leading to diffuse axonal injury
What are the shape of epidural hematomas? Can they cross suture lines?
Lenticular
Cannot cross suture lines
What artery is classically indicated in epidural hematomas?
Middle meningeal artery
What type of hematoma is characterized by a lucid interval”?
Epidural
What is the shape of subdural hematomas? Can these cross suture lines?
Follow the curve of the skull (crescentic)
Cross suture lines
What is/are the artery/arteries that are implicated in subdural hematomas?
Briding veins
Tracheobronchial disruption is most often caused by what sort of trauma?
Deceleration shearing forces
What are the PE findings of tracheobronchial disruptions?
Respiratory distress
Hemoptysis
Sternal TTP
Subcutaneous emphysema
Blunt cardiac injury may manifest how on an EKG?
New BBB
Ectopy
Dysrhythmia
True or false: blunt cardiac injury rarely requires intervention
True
What is the pathophysiology of pulmonary contusion?
Damage to capillaries and leakage of intra and extravascular fluid, causing hypoxic
What is the mainstay of treatment for pulmonary contusion?
Diuretics and fluid restriction, and airway support
What will a CXR show with pulmonary contusion?
Patchy alveolar opacities
What is the classic cause of aortic disruption?
Rapid-deceleration injury
Aortic disruption is often associated with what bony fractures? (4)
- 1st rib
- Second rib
- Scapular
- Sternal
What causes the hoarse voice that may appear with an aortic disruption?
Pressure on the recurrent laryngeal nerve
What causes a flail chest (physically)?
Three or more adjacent ribs, fractured at two points
What is the treatment for a flail chest?
O2, narcotic analgesia
What is the major complication of a flail chest?
Respiratory compromise
What is the most common solid organ to be traumatized in the abdomen? Second most common?
Spleen
Liver
What is Kehr’s sign?
Referred pain to the shoulder from peritoneal irritation
What is the duodenum susceptible to traumatic injury?
Sits right in front of the spine
What are the radiographic findings of a diaphragmatic rupture?
Elevated hemidiaphragm
What is the most commonly injured GU organ?
Kidneys
True or false: hemodynamically unstable patients with blunt abdominal trauma should undergo immediate exploratory lap
True
What is the immediate treatment for a pelvic fracture?
External binder
What is the treatment for a pelvic fracture?
Early resuscitation
Angiography with embolization of bleeding vessels
Why do pelvic fractures tend to occur in multiple places?
Ring-like structure
What are the exam findings of a urethral injury?
High riding prostate
Blood at the urethral meatus/scrotum
Non-palpable prostate
What test is needed to r/o a urethral injury prior to catheter placement?
Retrograde urethrogram
What are the 5 H’s of PEA?
Hypothermia Hypovolemia Hypoxia H+ Hyper/hyp K
What are the 5 T’s of PEA?
Tablets: drug overdose, ingestion Tamponade: cardiac Tension pneumothorax Thrombosis: coronary Thrombosis: pulmonary embolism
What Joules is used when shocking v-fib/pulseless v-tach?
120-200 J (biphasic)
What is the treatment for unstable SVT?
Shock
What is the treatment for stable SVT?
Adenosine, then beta blockers/CCBs
How many hours in a-fib is a contraindication to cardioversion?
48 hours
What is the treatment for symptomatic bradycardia?
Atropine
Dopamine
Epi
Transcutaneous pacing
Sudden onset abdominal pain with rigidity = ?
Perforated bowel
How can pneumonia cause upper abdominal pain?
Diaphragmatic irritation
A ⊕ β-human chorionic gonadotropin (β-hCG) in the setting of shock is what until proven otherwise.
Ruptured ectopic pregnancy
True or false: peritoneal signs warrant surgical exploration
True
What are the two exam that are needed with abdominal pain?
Rectal
Pelvic
What is the classic presentation of a fat embolism?
fever, tachypnea, tachycardia, conjunctival hemorrhage, and upper extremity petechiae after a patient suffers longbone fractures.
When is an NG tube needed for decompression of the stomach?
In the setting of bowel obstruction
What is the diagnostic work-up for appendicitis?
CT with PO and IV contrast or US
What is the treatment for a rupture appendix?
Abx until afebrile
What is the treatment for a psoas abscess?
Broad spectrum abx and percutaneous drainage
What are the rule of 9’s relating to burns and surface areas?
Head and each arm = 9%, each
Back and chest each = 18%
Each leg = 18%
Perineum = 1%
*Patient’s palm (including fingers) represents about 1% of total BSA in adults and children.
What is the parkland formula for calculating IVFs needed in burn patients?
Fluids for the first 24 hours = 4 × patient’s weight in kg × % BSA.
Give 50% of fluids over the first 8 hours and the remaining 50% over the following 16 hours.
What are first degree burns?
BUrns that only involve the epidermis
What are second degree burns?
Burns that involve epidermis and dermis
What are third degree burns?
Burns that involve dermis, epidermis, and SQ tissue
What type of burns have blisters?
2nd degree
What is the appearance of third degree burns?
Painless, white, and charred
If there is evidence of airway involvement with burn patients, what needs to be done?
Intubate
What are the 6 w’s of post operative fever?
Wind: pneumonia Water: UTI Wounds: Walking: DVT Wonder drugs: rxn Womb: Endometritis
What topical antimicrobial can be used to treat burns?
Silver sulfadiazine
What cause compartment syndrome from burns?
Circumferential burns causing stricture
What is the implicated organism in shock from burns?
Pseudomonas
What is the first sign of shock?
Tachycardia
What should be given first: pressors or IVFs
IVFs
What is the treatment for neuroleptic malignant syndrome? Malignant hyperthermia?
IV dantrolene
What usually causes immediate shock?
Drugs, malignant hyperthemia
What is the definition of acute shock, and what usually causes it?
Within 1st week post op
Infections
What is the definition of subacute shock, and what usually causes it?
Onset 1-4 weeks post op
Wounds, DVT
What is the definition of delayed shock, and what usually causes it?
Onset more than 1 month
Viral infection
indolent bacterial infx
How long should domestic animals be kept after biting a human to r/o rabies?
10 days
What happens to the following in hypovolemic shock:
- Cardiac output
- PCWP
- PVR
- Cardiac output = decreased
- PCWP = decreased
- PVR = increased
What happens to the following in cardiogenic shock:
- Cardiac output
- PCWP
- PVR
- Cardiac output = Decreased
- PCWP = Increased
- PVR = increased
What happens to the following in obstructive shock:
- Cardiac output
- PCWP
- PVR
- Cardiac output = Decreased
- PCWP = increased
- PVR = Increased
What happens to the following in distributive shock:
- Cardiac output
- PCWP
- PVR
- Cardiac output = Increased
- PCWP = Decreased
- PVR = Decreased
What is the treatment for neurogenic shock?
Pressors and IVFs
What is the treatment for hypovolemic shock
fluids:blood in a 3:1 ratio
What is the definition of hypothermia?
Temp less than 35 C or 95 F
What are the three major endocrine abnormalities that can cause hypothermia?
Hypothyroidism
Hypoadrenalism
Hypoglycemia
What is the classic EKG finding associated with hypothermia?
J (osborne) wave
True or false: never stop resuscitation efforts on a hypothermic patient until they have been rewarmed
True
What is the treatment for unstable, hypothermic patients?
Core rewarming:
- NG or bladder lavage
- Cardiac bypass
What is the definition of hyperthermia?
More than 40 C or 104 F
Should deep bites be sutured closed?
No
What is the treatment for hyperthermia?
Cold water, wet blankets, ice
Benzo to prevent shivering
What are the s/sx of chronic CO poisoning?
ILI
What is the classic electrolyte abnormality with spider bites?
Hypocalcemia
What are the s/sx of scorpion bites?
Cranial nerve dysfunction
Respiratory compromise
What is the treatment for scorpion bites?
Benzos and analgesics
Atropine for hypersalivation and respiratory distress
What is the treatment for snake bites? (3)
- Antivenom
- Keep affected limb below the heart
- Compression bands, but NOT tourniquets
Do rodents carry rabies? Treatment?
Not known to
Just local wound care
When is ipecac syrup indicated?
Never–makes matters worse with emesis
What is the treatment for rabies infx?
1 dose of human rabies immunoglobin
4 doses of rabies vaccine / 14 days
When should tetanus immunoglobulin be given?
If patient has had less than 3 lifetime toxoid vaccines and wound is major/dirty
When is orogastric lavage (“pumping stomach”) indicated?
Life-threatening intoxications less than 1 hours after ingestion
What are the p450 inducing agents?
Barbs St. John's wort Phenytoin Rifampin Griseofulvin Carbamazepine
“Barbara Steals Phen-phen and Refuses Greasy Carbs.”
What are the p450 inhibitors?
Acute alcohol abuse Ritonavir Amiodarone Cimetidine/cipro Ketoconazole Sulfonamides INH Grapefruit juice Quinidine Macrolides
“AAA RACKS IN GQ Magazine”
What are the four major substrates of the p450 enzymes?
Anti-epileptics
Theophylline
Warfarin
OCPs
What are the drugs that can cause pulmonary fibrosis? (“My Nose Cannot BReathe BAd Air)
Methotrexate Nitrofurantoin Carmustine Bleomycin Busulfan Amiodarone
What are the sulfa drugs? (“scary sulfa Pharm FACTS”
Sulfonamide Sulfasalazine Probenecid Furosemide Acetazolamide Celecoxib Thiazides Sulfonylureas
What drugs cause photosensitivity (“SAT For Photo”)
Sulfonamides
Amiodarone
Tetracyclines
5-FU
What are the drugs that can cause gynecomastia (“Some Drugs Create Awesome Knockers”)?
Spironolactone Digitalis Cimetidine Alcohol Ketoconazole
What is the treatment for acetaminophen poisoning?
N-acetylcysteine
What is the treatment for acid/alkali poisoning?
Upper endoscopy to evaluate for stricutes
What is the treatment for anticholinesterase /organophosphates poisoning?
Atropine
Pralidoxime
What is the treatment for anticholinergic poisoning?
Physostigmine
What is the treatment for Arsenic poisoning?
Succimer
Dimercaprol
What is the treatment for Hg poisoning?
Succimer
Dimercaprol
What is the treatment for Au poisoning?
Succimer
Dimercaprol
What is the treatment for beta-blocker poisoning?
Glucagon
What is the treatment for Barbiturate poisoning?
Urine alkalinization
Dialysis
What is the treatment for benzo poisoning?
Flumazenil
What is the treatment for black widow spider bite?
Ca-gluconate
What is the treatment for Cu poisoning?
Penicillamine
What is the treatment for Pb poisoning?
Penicillamine
Dimercaperol
What is the treatment for cyanide poisoning?
Hydroxocobalamin
Sodium nitrate
What is the treatment for digitalis poisoning?
Normalize K+
Digibind
What is the treatment for heparin poisoning?
Protamine sulfate
What is the treatment for INH poisoning?
Pyridoxine
What is the treatment for Fe poisoning?
Deferoxamine
What is the treatment for Methanol poisoning?
EtOH
Fomepizole
What is the treatment for methemoglobinemia?
Methylene blue
What is the treatment for opioid poisoning?
Naloxone
What is the treatment for salicylate poisoning?
Urine alkalinization
What is the treatment for TCA poisoning?
Na2CO3
What is the treatment for theophylline poisoning?
Activated charcoal
What is the treatment for tPA poisoning?
Aminocaproic acid
What is the classic side effect of amantadine?
Livedo reticularis
What is the classic side effect of aminoglycosides?
Ototoxicity
What is the classic side effect of amphotericin?
Nephrotoxicity
Myelosuppression
What is the classic side effect of azoles?
p450 inhibition
What is the classic side effect of AZT
Thrombocytopenia
Megaloblastic anemia
What is the classic side effect of beta blockers
Asthma exacerbation
Masking hypoglycemic symptoms
What is the classic side effect of Bile acid resins
GI upset
What is the classic side effect of carbamazepine
Agranulocytosis
What is the classic side effect of CCBs
Peripheral edema
What is the classic side effect of Chloramphenicol
Gray baby syndrome
What is the classic side effect of cisplatin
Nephrotoxicity
Acoustic nerve damage
What is the classic side effect of clonidine
Severe rebound HA and HTN
alpha 2 agonist
What is the classic side effect of Clozapine
Agranulocytosis
What is the classic side effect of cyclophisphamide
Hemorrhagic cystitis
What is the classic side effect of Digoxin
Yellow visual changes and arrhythmias
What is the classic side effect of doxorubicin
Dilated cardiomyopathy
What is the classic side effect of furosemide
Ototoxic
What is the classic side effect of gemfibrozil?
Myositis, increased LFTs
What is the classic side effect of Halothans
Malignant hyperthermia
Hepatotoxic
What is the classic side effect of HCTZ
Hypokalemia
Hyponatremia
Hyper everything else
What is the classic side effect of hydralazine
Drug induced SLE
What is the classic side effect of hydroxychloroquine
Retinopathy
What is the classic side effect of INH
Peripheral neuropathy 2/2 loss of B6
What is the classic side effect of MAOIs
Hypertensive tyramine rxn
Serotonin syndrome
What is the classic side effect of methanol
Blindness
Anion gap metabolic acidosis
What is the classic side effect of Methotrexate
hepatic fibrosis
Pneumonitis
What is the classic side effect of methyldopa
+coombs test
Drug induced SLE
What is the classic side effect of metronidazole
Disulfiram
Metallic taste
What is the classic side effect of penicillamine
SLE
What is the classic side effect of phenytoin
Gingival hyperplasia
What is the classic side effect of prazosin
First dose hypotension
What is the classic side effect of procainamide
SLE
What is the classic side effect of PTU
Agranulocytosis
What is the classic side effect of Quinidine
Cinchonism
Tdp
What is the classic side effect of resperpine
Depression
What is the classic side effect of rifampin
Orange-red body secretions
What is the classic side effect of salicylates
Respiratory alkalosis and metabolic acidosis
What is the classic side effect of SSRIs
Sexual dysfunction
What is the classic side effect of Succinylcholine
Malignant hyperthermia
What is the classic side effect of TCAs
QRS prolongation
What is the classic side effect of tetracyclines
Tooth discoloration
What is the classic side effect of trimethoprim
megaloblastic anemia
What is the classic side effect of valproic acid
NTDs
What is the classic side effect of vancomycine
Red man syndrome
What is the classic side effect of vinblastine
Severe myelosuppression
What is the classic side effect of vincristine
Peripheral neuropathy
What is the treatment for benzo or barb withdrawal
Benzo taper
What are the s/sx of deficiency in vitamin A
Night blindness
What are the s/sx of deficiency in Vitamin B1
BeriBeri (polyneuritis, dilated cardiomyopathy)
What are the s/sx of deficiency in B2 (riboflavin)
Angular stomatitis
Corneal vascularization
What are the s/sx of deficiency in B3 (niacin)
Pellagra (diarrhea, dermatitis, dementia, death)
What are the s/sx of deficiency in B5 (pantothenate)
Dermatitis
Enteritis
Alopecia
What are the s/sx of deficiency in B6 pyridoxine
Convulsions
Hyperirritability
What are the s/sx of deficiency in Vit E
Fragile RBCs
What are the s/sx of deficiency in biotin
Dermatitis and enteritis
What is the vitamin deficiency that is seen with the consumption of raw eggs?
Biotin
What is the most common vitamin deficiency in the US?
Folate
What are the s/sx of deficiency in Mg?
Weakness
Muscle cramps
What are the s/sx of deficiency in selenium
Keshan disease (cardiomyopathy)