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DIT Level 2 > EM and Surgery > Flashcards

EM and Surgery Flashcards

1
Q

Choking

A

Clinical features:
stridor, coughing, gagging, wheezing

CXR: location of FB
Bronchoscopy - definitive dx and removal

Management:
Monitor pulse ox symmetry - supplemental O2
Encourage actively coughing patients to keep coughing
Heimlich maneuver or emergency tracheotomy - can’t breathe
IV glucocorticoids - reduce bronchial inflammation, aid extraction

Complications: lung abscess, pneumonia

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2
Q

Drowning

A

High risk groups: under 5, Males 15 to 25

Pathophysiology:
Submersion water -> hypoxemia
Reflex laryngospasm -> hypoxemia
Wash out of pulmonary surfactant -> alveolar collapse and ARDS
Hypoxemia -> cerebral ischemia and edema -> elevated ICP
No significant difference between fresh water and saltwater

Features:
Unresponsive or obtunded
Cyanosis and respiratory arrest
Arrhythmias or cardiac arrest
Hypothermia common

Tx:
CPR, intubate, O2
warm
Persistent hypoxia following successful resuscitation suggest underlying lung injury

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3
Q

Cat and dog bites

A

Consequences:
Deep puncture wounds damage nerves and tendons
High risk for abscess:
-Pasturella multocida (cat > dog)
-S. aureus (esp MRSA) - from skin surface

Tx:
Clean surface with iodine, Copious pressure irrigation with NS
-use soft IV catheter to get deep into wound

Suturing:

  • do not close puncture bites and dog bites to hand
  • suture facial wounds - low rate of infection
Ppx abx: 
Amoxicillin-clavulanate "dog-mentin"
Doxy + metronidazole or clindamycin
Rabies ppx if can't observe animal for 10 d or suspected to be rabid
Td if not within 5 yr

F/u psych assessment for PTSD - occurs in more than 50% of children

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4
Q

Human bites

A

Contaminated by S. aureus or Group A strep

Tx:
Irrigate with saline
Debridement as needed

Abx ppx:
Amox-clav
Doxy + metronidazole or clindamycin
Td
Document thoroughly
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5
Q

Black widow spider bite

A

Latrotoxin - neurotoxin that causes ACh release -> muscle pain/spasm, diaphoresis, autonomic stimulation

Tx:
Mild rxn resolve in less than 12 hrs without complications
-wash with soap and water
-ice to reduce inflammation
-Td ppx
-analgesia as needed
-pressure and immobilization to slow the systemic spread of venom
-24 hrs of observation for signs of systemic involvement

Systemic systoms - aka latrodectism
-benzo’s for muscle spasm
Analgesia with acetaminophen +/- opioids
Antivenin within 30 min

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6
Q

Brown recluse spider bite

A

Venom causes LOCAL ulceration, skin necrosis -> full thickness

Usually 1 bite
April - October
Pale center, flat/sunken

Systemic sxs:
Fever
Nausea/vomiting
Malaise
Hemolytic anemia
Rhabdomyolysis

Tx:
If ulceration: wound care with dressing changes and debridement
S/S of infection, cellulitis, abscess - erythromycin or clindamycin or doxycycline or TMP-SMX
Td ppx
consider Dapsone to reduce the extent of local necrosis d/t leukocyte inhibitory properties (r/o G6PD prior)

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7
Q

Ruling out brown recluse spider bite

A

NOT RECLUSE

Numberous
Occurance - not in secluded area
Timing - November to March
Red center
Elevated
Chronic
Large
Ulcerates in less than 7 days
Swollen
Exudative
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8
Q

Indications for tetanus booster in adult

A

Td q10 yr
Tdap at least once between 19-64

Injuries:
If clean, minor, low risk of tetanus - give if more than 10 yrs or if uncertain of last dose or has had less than 3 lifetime doses

Dirty, contaminated, puncture or crush injury that is tetanus prone - give Td if more than 5 yrs since last dose, if unknown last dose or less than 3 life time doses, give Td + tetanus immune globulin at site other than the Td

For those with less than 3 life time doses - complete series

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9
Q

Rule of nines for Burns

A 
Each are 9%
Full head
Chest
Upper back
Abdomen
Lower back and buttock
Full arm
Front of leg
Back of leg

Genitalia - 1%

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10
Q

Treatment of severe burns

A

3rd degree >2-3 %, 2nd degree >10%

Admit
Fluid resuscitation
Escharotomy - decreased risk of ischemia or restricted breathing
Extensive burns and facial burns require intubation to protect the airway
Smoke inhalation -> CO poisoning -> treat 100% O2, Monitor for respiratory failure

Td booster

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11
Q

Life threatening complications in burn patients

A 
Hypovolemia -> shock
Inhalation injury
Sepsis - pneumonia or Pseudomonas wound infections
Renal failure
Arrhythmias
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12
Q

Parkland burn formula

A

4ml X kg X % burned

Fluid resuscitation volume for mod-severe burns - not maintenance needs

LR - give half within 8 hrs, 1/2 following 16 hrs

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13
Q

electrical burns

A 
Presentation:
Internal damage worse than external
Arrhythmias
Compartment syndrome
Bony injuries
myoglobinuria
Acidosis
Rhabdomyolysis
Renal failure
Neurologic disturbances

Tx:
Aggressive IVF to prevent myoglobinuria, renal failure, acidosis in face of muscle necrosis
High index of suspicion for compartment syndrome
Obtain an ECG and monitor for arrhythmias

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14
Q

Heat exhaustion

A 
Features:
Tachycardia
Hypotension
Weakness/collapsed
Headache
Muscle cramps
G.I. upset
Profuse sweating
Temperature slightly elevated - 102-104

Tx:
Cool the patient
Hydration - oral or IV
Close monitoring

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15
Q

Heat stroke

A

Features:
Temperature over 104
Brain dysfunction - disorientation, coma, seizures
Features of heat exhaustion

Tx:
Cool patient rapidly - immersion in ice water, spray with water and fan, gastric lavage the cold saline, Cold IV fluids
IV fluids
Monitor labs - ensure not progressing to organ failure
Treat seizures with benzo’s

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16
Q

Mild hypothermia

A

90-95 F

Features:
Tachycardia
Tachypnea
Ataxia
dysarthria
Impaired judgment

ECG: J waves V2-V5

Tx:
External heating - out of wet clothes, underline gets
Possible forced air warming systems

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17
Q

Moderate hypothermia

A

82-90 F

Features:
Bradycardia
CNS depression

ECG: J waves V2-V5

Tx:
Start with the external heating
Internal:
-warm saline 42C or warm humidified O2

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18
Q

Severe hypothermia

A

below 82F

Features:
Hypotension
CV collapse
Unstable arrhythmias - V tach, V fib
Areflexia
coma like state
Tx:
External heating
Warm saline, warm humidified O2
pleural and peritoneal irrigation with warm saline
Extracorporeal heating

Make it parodoxical drop in temperature as cold blood returns to core -> worse condition

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19
Q

Acetaminophen overdose

A

Stage I: 30 min - 24 hr
Nausea, vomiting, diaphoresis, pallor, lethargy, and malaise

Stage II: 24-72 hr
Elevated LFTs, PT, and total bilirubin
RUQ pain and tenderness

Stage III: 72-96 hrs
Peak LFT elevation
Jaundice, hepatic encephalopathy, bleeding, +/- acute renal failure
Possible multisystem organ failure -> death

Stage IV: 4 d-2w
Recovery

Dx: check acetaminophen level

Tx:
Activated charcoal within 4 hours
N-acetylcysteine within 8 hrs - restores hepatic glutathione stores

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20
Q

Theophylline overdose

A

Narrow therapeutic index - 10-20 mg/L

Mild toxicity - hypokalemia, hyperglycemia, vomiting

Severe toxicity: seizures, hypotension, cardiac tachyarrhythmias

Tx:
Supportive - IV hydration, potassium
ACLS protocol for SVT
Benzodiazepines for seizure - no phenytoin
G.I. decontamination
Hemodialysis
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21
Q

Beta blockers and calcium channel blocker overdose

A

Bradycardia
Hypotension
Pulmonary edema
Hypoglycemia

Tx:
IVF
Atropine
GLUCAGON - 1st line antidote for b-blocker toxicity (activates adenylyl cyclase -> elevated Ca2+ level)
Calcium
Insulin and glucose
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22
Q

Anticholinergic overdose (atropine, benadryl)

A 
Hot as a hare - hyperpyrexia
Dry as a bone
Red is a beet
Blind as a bat - cycloplegia, mydriasis
Mad is a hatter - disoriented
Bloated as a toad - constipation and urinary retention
Tachycardia
Decreased or absent bowel sounds

Antidote: physostigmine

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23
Q

Digoxin toxicity

A 
Yellow vision
Fatigue
Blurred vision
Anorexia
Nausea/vomiting
Diarrhea
Abdominal pain
Headache
Dizziness
Confusion
Delirium

ECG changes:

  • prolonged PR interval, “scooping” ST segments - at therapeutic levels
  • bradycardia
  • PVCs
  • atrial tachycardia with AV block (4:1 or 6:1)

Labs: hyperkalemia - indicates severity
Elevated serum digoxin levels

Tx:
Digoxin antibody fragments for: 
-V tach, V fib, asystole, complete heart block Mobitz II, symptomatic bradycardia
-Hyperkalemia
-end organ dysfunction

Activated charcoal
Atropine is bradycardia present

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24
Q

Aspirin overdose

A

Tinnitus
Hyperthermia - uncouples mitochondrial oxidative phosphorylation
Alkalosis (hyperventilation) -> mixed respiratory alkalosis and metabolic acidosis with elevated anion gap
-tachypnea - stimulated medullary respiratory center
-acidosis
N/V, dehydration, AMS

Tx:
Charcoal
Dialysis
Sodium bicarb

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25
Heparin toxicity sxs
Easy bruising/bleeding | Gross hematuria
26
isoniazid toxicity sxs
peripheral neuropathy | hepatotoxicity
27
TCA toxicity sxs
``` Tachycardia Dry mouth Anti-cholinergic affects Urinary retention Seizures ECG: QRS widening >100 ```
28
Warfarin toxicity
Excessive bleeding - nose bleed, hematuria, intracranial bleed INR less than 5: decrease dose INR > 5 - oral vit K, adjust dose INR >20 or serious bleeding - IV vit K, FFP Alternatives: prothrombin complex concentrate, recombinant human factor VIIa isntead of FFP
29
Methanol and ethylene glycol
Methanol - antifreeze - smells like ethanol, -> blindness Ethylene glycol - antifreeze - sweet -> vomiting, hyperventilation, slurred speech, metabolic acidosis, kidney failure Dx: hx and elevated anion gap Tx: Sodium bicarb - correct acidosis, limit penetration of toxic metabolites into tissues (retina) Fomepizole or ethanol Dialysis for severe metabolic acidosis or organ damage
30
caustics (acid and alkali) ingestion
``` Sxs: Oropharyngeal and gastric irritation or burns Drooling odynophagia Abdominal pain Gastric perforation ``` DO NOT give emetics, a neutralizing agent, or attempt to place NG tube Supportive care in ICU Endoscopy in first 24 hrs Complications: esophageal strictures, 1000 fold increase in esophageal squamous cell carcinoma (lye ingestion)
31
organophosphate poisoning
Insecticides and fertilizers ``` DUMBBELSS: Diarrhea Urination Miosis Bronchospasm Bradycardia Emesis and excitation of skeletal muscles Lacrimation Sweating Salivation - drooling ``` Tx: Atropine (anticholinergic) Pralidoxime (reactivates acetylcholinesterase)
32
Iron toxicity
GI phase: 30min - 6 hrs -abdominal pain, vomiting, diarrhea (often bloody), hematemesis, melena, lethargy -> shock latent/stable phase: 6-24 hrs Shock and metabolic acidosis: 6-72 hr - widespread cellular destruction - Multi systems organ failure, G.I. bleeding and or perforation, pulmonary dysfunction, coagulopathy, renal dysfunction, neurologic dysfunction - Core outcome hepatotoxicity/hepatic necrosis 12-96 hr Bowel obstruction 2-8 wks -G.I. scarring, gastric outlet XR - radioopaque pills Tx: deferoxamine, gastric lavage
33
Lead toxicity
paint chips, house older than 1950s ``` Presentation: asx vomiting cognitive impairment language delay hearing loss behavior problems at low levels abdominal pain anemia seizures renal insufficiency encephalopathy ``` Pediatric mod tox: 45-69 - succimer Ped severe tox over 70 - dimercaprol AND calcium disodium edetate Adults - succimer
34
Cyanide poisoning
domestic fires, mining, plastic manufacturing, nitroprusside inhibits cytochrome c oxidase Rapidly lethal ``` Presentation: tachycardia and hypertension - early bradycarida and hypotension - late headache confusion seizures coma flushing almond-scented breath ``` Tx: sodium thiosulfate - converts to thiocynate - renally excreted Hydroxocobalamin (B12 precursor) - forms cyanocobalamin - excreted in urine -causes reddish discoloration to skin, mucous membranes, urine Amyl nitrite and sodium nitrite -induce methemoglobin -> cyanomethemoglobin -don't give methylene blue - releases free cyanide
35
Carbon monoxide poisoning
car fumes, smoke, paint thinner, house fire displaces O2 from hemoglobin ``` Features: headache dizziness nausea myalgias cherry-red lips AMS hypotension ``` Increased carboxyhemoglobin -> normal pulse oximetry Tx: 100% O2, hyperbaric oxygen therapy
36
Body packing -> OD
Tx: polyethylene glycol - Golightly | reversal agent if know substance
37
Initial management for femur fracture
Close reduction via manual traction then stabilize with traction brace
38
Initial management of open fractures
Remove any gross debris -> NS pressure wash X 5L -> cover with Kerlex Meds: abx, analgesics, tetanus shot Consult surg/ortho Document, talk with family
39
Glasgow coma scale
``` Eye response 1-4 4 Open spontaneously 3 Opened to voice 2 opened pain 1 none ``` ``` Verbal response 1-5 5 oriented 4 confused 3 inappropriate words 2 incomprehensible sounds 1 no verbal response ``` ``` Motor response 1-6 6 obeys commands 5 localizes the pain 4 withdrawal from pain 3 abnormal flexion with pain - decorticate 2 extension to pain - decerebrate 1 no movement with pain ``` GCS 8 or less - intubate
40
Cushing triad
Hypertension Bradycardia bradypnea
41
Signs of increased ICP
``` Hypertension Bradycardia Bradypnea Papilledema AMS pupil asymmetry ```
42
Basilar skull fracture
Bruising around eyes - raccoon eyes Bruising over mastoid process - Battle sign Blood behind TMs CSF rhinorrhea or otorrhea
43
Interventions to lower ICP in head injury
HOB at 30 pretreat with lidocaine before intubation (minimize ICP elevations) IV mannitol q6h - check serum Na and osmolarity q6 - hold mannitol if Na >152 or osmolarity >305 Intubate and hyperventilate until pCO2 25-30 on ABG - decreasing pCO2 by 5-10 will lower ICP by 20-30 - temporary Decompressive craniectomy Ventriculostomy bariturate coma paralysis
44
Treatment for anterior spinal cord syndrome following traumatic injury
ABCs - keep spine stabilized hypotension - aggressive bolus fluids, limit fluids once normotensive to avoid cord swelling +/- high dose IV steroids 3-8 hrs of injury (controversial) CT/MRI of spinal cord Decompression via closed reduction (halo) or surgical intervention once stabilized
45
Neck zone 1
clavicle -> cricoid cartilage ``` Structures: Great vessels Aortic arch Trachea Esophagus lung apices Cervical spine Spinal cord Cervical nerve roots ``` Evaluation: CT angio Triple endoscopy - EGD, bronchoscopy, laryngoscopy
46
Neck zone 2
Cricoid cartilage -> angle of mandible ``` Structures: Carotid arteries Vertebral arteries Jugular veins Pharynx Larynx Trachea Esophagus Cervical spine Spinal cord ``` Evaulation: Surgical exploration
47
Neck zone 3
Angle of the mandible -> base of skull ``` Structures: Salivary glands Parotid glands Esophagus Trachea Cervical spine Carotid arteries Jugular veins Major cranial nerves ``` Evaluation: CT angio
48
CXR findings indicating ruptured thoracic aorta
Widened mediastinum Loss of aortic knob Pleural cap Deviation of the trachea in esophagus to the right Depression of the left main stem bronchus
49
Tension pneumothorax
Absent breath sounds and hyperresonance to percussion (hollow sound) on the affected side Distended neck veins Hypotension Tx: Immediate chest tube placement If delayed - needle decompression -2nd or 3rd intercostal space at midclavicular line 5th intercostal space midaxillary line - preferred site of tube thoracostomy
50
Intraperitoneal vs extraperitoneal bladder rupture
Intra: blunt force injury to the lower abdomen with full bladder -> dome rupture, urine in peritoneal space Extra: pelvic fracture, anterior or anterolateral wall of bladder ``` Dx: IV pyelogram retrograde urethrogram pelvic XR CT scan ``` Tx: penetrating injury -> ex lap Cystoscopy w/ repair - urethral, intraperitoneal, renal pelvis injury
51
Flail chest
Free-floating portion of the chest wall that moves paradoxically to the rest of the chest wall -three or more sequential rib fractures Presentation: Muscle splinting due to pain - conceals motion Direct impact or crush injury Tx: O2 Close monitoring for early signs of respiratory compromise BiPAP or ET intubation with vent Analgesia - improve breathing, prevent hypoxia
52
Initial management of abdominal stab wound
ABCs - hypotensive -> surgical exploration Abd exam: - signs of peritonitis -> ex lap - penetrates anterior fascia -> ex lap - no penetration or unable to asses - admit for serial 24 hr exams -> ex lap if develops peritonitis or hemodynamically unstability NG tube - decompress stomach and rule out blood In stomach Urinary catheter Diagnostic peritoneal lavage upright CXR - hemo/pneumothorax and/or intraperitoneal air US - identify hemoperitoneum Abd CT with con Dx: laparoscopy
53
Mangement of blunt abdominal trauma with stable V/S
``` ABC's Establish IV access - two large bore IVs NG tube and Foley CT abd/pelvis H&H +/- type and cross ```
54
Management of blunt abdominal trauma with unstable V/S
ABCs Assessed for and manage pelvic fracture, focused assessment with sonography for trauma (FAST) - blood -> emergent laparotomy - no blood in pelvis - possible retroperitoneal hemorrhage - get angiography with possible embolization -FAST inconclusive -> diagnostic peritoneal lavage If no blood in pelvis and angio normal -> CT abd/pelvis + observation +/- admission R/O other causes of hypotension
55
Treatment for retroperitoneal hematoma
penetrating injury or exsanguination into abdomen -> ex lap and repair Blunt trauma without blood in abd - follow H&H -if hemodynamically unstable or falling H&H -> angiography with possible embolization
56
Immediate treatment for pelvic fracture
ABCs + thorough neurovascular exam IVF +/- blood FAST - no fluid in pelvis + unstable -> diagnostic peritoneal lavage to detect bleeding missed by FAST - blood -> emergent ex lap - no blood, unstable - consider retroperitoneal hemorrhage -> angiography with possible embolization Use a pelvic binder until external fixator placed - assessed for bladder and urethral injury with retrograde cystourethrogram - Extraperitoneal bladder rupture - Foley x10-14 d - Intraperitoneal bladder rupture - urgent ex lap repair
57
Sites a significant blood loss of more than 1.5 L
``` At injury scene Pleural cavity Intra-abdominal Pelvic into thigh ```
58
Antibiotic ppx for rape vicitms
Ceftriaxone 125 mg IM (gonorrhea) Azithromycin 1 g PO x1 or doxy 100 mg BID x7 days (chlamydia) Metronidazole 2 g PO (trichomoniasis) Hep B vaccine 1 of 3 if not vaccinated +/- Hep B IG HIV ppx x 3-7 days Antiemetics - promethazine for nausea caused by HIV meds and pregnancy ppx Levonorestrel 0.75 mg PO, repeat 12 hrs (or both doses at same time)
59
Postop fever
Ws Wind - pneumonia >3 days Water - UTI 3-5 d Walking - DVT and PE Wound - infection 5-8 d Wonder drugs - antimicrobials, heparin, SSRIs Wein - thrombophlebitis, IV or central line infection Other: sinusitis (NG tube), MI, stroke, transfusion reaction
60
Most common postop fever causes in cardiovascular surgery
Pneumonia, sternum wound infection
61
Most common postop fever causes in neurosurgery
Meningitis, DVT, UTI
62
Most common postop fever causes in abdominal surgery
Deep abdomen abscess, pancreatitis
63
Most common postop fever causes after C/S
endometritis
64
Most common postop fever causes in ortho surgeries
DVT | infected prosthesis
65
Malignant hyperthermia
halothane and/or succinylcholine Within one hour of anesthesia induction ``` Presentation: Unexplained rise in end tidal carbon dioxide Muscle rigidity (should be limp) Hyperthermia Cyanosis Tachycardia Autonomic problems Arrhythmias DIC Acidosis ``` Labs: Mixed metabolic and respiratory acidosis Hyperkalemia, elevated urine myoglobin, elevated serum creatinine kinase - due to muscle cell breakdown ``` Tx: 100% O2, increase ventilation rate Stop agents - change to propofol Dantrolene Cool body ```

DIT Level 2 (49 decks)

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