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Senoir 21-2 > EM Block II > Flashcards

EM Block II Flashcards

1
Q

Describe visceral pain

A

Obstruction, ischemia, or inflammation can cause stretching of unmyelinated fibers that innervate the walls or capsules of organs, resulting in visceral pain

Visceral pain is often described as “crampy, dull, or achy,” and it can be either steady or intermittent (colicky)
(Think obstruction).

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2
Q

Describe parietal pain

A

Parietal (somatic) abdominal pain is caused by irritation of myelinated fibers that innervate the parietal peritoneum, usually the portion covering the anterior abdominal wall.

This may be caused by continued inflammation from an obstructed organ or chemical irritants

Parietal afferent signals: specific area of peritoneum! Parietal pain can be localized to the dermatome superficial to the site of the painful stimulus.

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3
Q

If you think you need blood later on then what should you order

A

Type and Screen

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4
Q

If you need blood now, what should you order

A

Type and Cross

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5
Q

Who is it most common to have appendicitis

A

Acute appendicitis is most common in patients age 10 to 19 years, remains the most frequent cause of atraumatic abdominal pain in children >1 year old, and is the most common non-obstetric surgical emergency in pregnancy, complicating up to 1 in 1500 pregnancies.

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6
Q

What is the traditional cause of appendicitis

A

Luminal obstruction of the vermiform appendix, typically by a fecalith,(poop stone) is considered the traditional cause of appendicitis.

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7
Q

What is the location of McBurney’s point

A

located one third of the distance from the anterior superior iliac spine to the umbilicus.

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8
Q

What is the initial pain sensation of appendicitis

A

unenervated visceral pain fibers

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9
Q

What is rovsings sign

A

Rebound referred pain from contra lateral compression of the abdomen that is a sign of appendicitis

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10
Q

What kind of pyuria is present is appendicitis

A

Sterile pyuria

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11
Q

In appendicitis in pregnant or child pts

What is the imaging modality of choice

A

US ! First

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12
Q

What is the imaging for Appendicitis in the majority of pts

A

Non con ct

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13
Q

What is the tx for appendicitis

A

Immediate surg consult
NPO immediately
Maintenance fluids and pain meds

ABX as appropriate
Ampicillin/Sulbactam
Pipercillin/ Tazobactam
Cefetoxin

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14
Q

What is the flow of ducts through the pancreas

A

Bile flows out of the liver through the left and right hepatic ducts, which come together to form the common hepatic duct. This duct then joins with a duct connected to the gallbladder, called the cystic duct, to form the common bile duct. The common bile duct enters the small intestine at the sphincter of Oddi (a ring-shaped muscle), located a few inches below the stomach.

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15
Q

How does pancreatitis general resolve

A

Generally resolves with only supportive care

IV Fluids, pain control, bowel rest etc etc..

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16
Q

What are the common pancreatitis presentation in men vs women

A

Alcohol is more common in men

Gall stones more common in women

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17
Q

What surgery has a 5% incidence rate for pancreatitis

A

ERCP ( gall stone removal)

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18
Q

What enzyme is responsible for auto digestion of the pancreas

A

Trypsin

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19
Q

What is the criteria to Dz pancreatitis

A

(1) clinical presentation consistent with acute pancreatitis
(2) serum lipase or amylase elevated above the upper limit of normal (X3)

(3) imaging findings characteristic of acute pancreatitis
(IV contrast CT, MRI, or transabdominal US)

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20
Q

How elevated with the amylase or lipase be in pancreatitis

A

3x ULN

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21
Q

ALT elevated above 150 means..

A

An alanine aminotransferase of >150 U/L within the first 48 hours of symptoms predicts gallstone pancreatitis

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22
Q

When does pancreatitis show up on CT

A

72 hours of onset

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23
Q

What is the SIRS criteria for severe acute pancreatitis

A

Patient characteristics:
>55 years, obesity, AMS, comorbidities
Labs:
BUN >20 or rising; hematocrit >44% or rising; ↑creatinine- DEHYDRATION!

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24
Q

What is the treatment appraoch to biliary pancreatitis

A

Early surgical consult! ERCP

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25
Q

In a female, fat, fertile over 40

Think of what d/o

A

Cholecystitis

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26
Q

What is the most common complication of gallstone dz

A

Biliary colic

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27
Q

Define emphysemic cholecystitis

A

inflamed gallbladder becomes infected with gas-producing organisms

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28
Q

Define choleodocolithiasis

A

gallstones within the common bile duct

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29
Q

Define Cholangitis

A

Infection of the biliary tree

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30
Q

What is billary sludge

A

Biliary sludge is microlithiasis composed of cholesterol crystals, calcium bilirubinate pigment, and other calcium salts

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31
Q

Define acute acalculus cholesytisis

A

Occurs in the setting of critical illness such as septic shock, burns, & major trauma or surgery

Old age, DM, and immunosuppression are also risk factors

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32
Q

A pt that presents with N/V and back pain that happens around midnight

Think

A

Cholecystitis and biliary colic

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33
Q

Jaundice in the setting of biliary tract stone disease implies:

A

Obstruction of the CBD from choledocholithiasis

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34
Q

What is the Dx criteria for Acute cholecystitis

A

+ Murphys
RUQ pain
Fever, Elevated CRP And WBC

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35
Q

What is Charcots triad

A

Fever
RUQ abdominal pain
Jaundice

Dx cholangitis

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36
Q

What is Reynolds pentad

A

Fever
RUQ abdominal pain
Jaundice

+ AMS and Shock

For cholangitis

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37
Q

What is the most sensitive serum marker for choledocholithiasis

A

GGT

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38
Q

What is the normal measurement for the common bile duct

A

Less than 5cm

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39
Q

If youre looking for choledocholithiasis

What should you order

A

ERCP

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40
Q

What is the perferred initial imaging for cholecystitis

A

US

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41
Q

How do we tx biliary colic

A

Elective cholecystectomy is occasionally recommended for those at high risk for gallstone complications

  • Sickle cell disease
  • Planned organ transplantation
  • Ethnic groups at high risk for GB cancer

ED managment of biliary colic:
NSAIDs 1st line, Antiemetics, analgesics

Referal to outpt or to general surgery

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42
Q

What is the tx approach to acute cholecytsis

A

Laparotomy/ scopy

Analgesics 
Antiemits 
NPA 
Fluids 
And ABX
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43
Q

What is a gallstone ileus

A

Gallstone ileus —>mechanical SBO caused by an ectopic gallstone that has reached the intestinal lumen via a biliary-enteric fistula

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44
Q

What is riglers triad

A

Diagnosed on plain films or with CT (usually) for gallstone ileus

Rigler’s triad: small bowel obstruction, pneumobilia, and an ectopic gallstone.

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45
Q

What separates upper and lower GI bleed

A

Ligament of tritz

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46
Q

What is the most common cause of GI bleeding

A

PUD

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47
Q

What is responsible for maintingin the gastric mucosal barrier

A

Prostaglandins

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48
Q

What is the major cause of varicela bleeding

A

Cirrhotics

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49
Q

What are the S/s of an underlying GI bleed

A

Hypotension, tachycardia, angina, syncope, weakness, confusion, or cardiac arrest

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50
Q

What is the most reliable way to Dx Upper GI bleed

A

Visual inspection of the vomitus

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51
Q

Spider angiomas, palmar erythema, jaundice, and gynecomastia suggest

A

Liver Dz

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52
Q

What is the single most important lab test for a signifigant bleed

A

Cross and match

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53
Q

What is the BUN level be in an upper GI bleed

A

Elevated

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54
Q

An elevated lactate level is a sentinel sign of…

A

Severe illness

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55
Q

Can pts with GI bleeds get barium studies

A

Barium contrast studies are contraindicated because barium may hinder subsequent endoscopy or angiography- don’t do them

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56
Q

When should you order tagged red blood cells

A

In babies or in pts with C/i for endoscopy

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57
Q

What procedure is both Dx and Tx for a GI bleed

A

NG placement and aspiration are diagnostic and therapeutic

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58
Q

What is the threshold for blood transfusion in a GI bleed

A

Transfusion is less than 7 or less than 9 in older pts

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59
Q

What is the ABX for prophylaxis in Upper GI bleed

A

Ciprofloxacin 400 mg

Or Ceftriaxone 1 gram IV

Only really need for pts with cirrhosis

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60
Q

What is a concerning INR in a pt with a GI bleed

A

INR ≥1.5 is a significant predictor of mortality in UGIB pts who are receiving anticoagulants! They are thin!!!

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61
Q

What is octreotide used for in an Upper GI Bleed

A

Octreotide is a long-acting analog of somatostatin that elicits several actions in patients with UGIB

Inhibits the secretion of gastric acid- good

Reduces blood flow to the gastroduodenal mucosa- also good

Causes splanchnic vasoconstriction- Mixed..

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62
Q

If a pt has an allergy to ciprofloxacin what is the ABX to be used

A

Ceftriaxone

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63
Q

When should we use ABX in a Upper GI Bleed

A

Patients with cirrhosis have an impaired immune system and have an increased risk of gut bacterial translocation during an acute bleeding episode

Prophylactic antibiotics

  • Reduce infectious complications
  • May decrease mortality
  • Start ASAP
  • Ciprofloxacin 400 mg IV or ceftriaxone 1 gram IV
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64
Q

What is the Dx study of choice in a Uppe GI bleed

A

UGI endoscopy is the diagnostic study of choice for bleeding- Why?

Allows visualization of bleeding source (in most cases) & administration of hemostatic therapy- two in one!

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65
Q

What is the most common cause of Lower GI bleed

A

diverticular disease

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66
Q

Define hematochezia

A

bright red or maroon-colored rectal bleeding

Originating from a UGI source—> brisk UGIB

May be accompanied by hematemesis & hemodynamic instability

~10% of hematochezia episodes may be associated with UGIB

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67
Q

Define Melena

A

Melena—> dark or black-colored stools

Usually represents bleeding from a UGI source

May also represent slow bleeding from an LGI source along with slow colonic transit or constipation..

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68
Q

Is bleeding from diverticulosis painful?

A

Usually painless

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69
Q

Describe Vascular ectasia

A

Incl. arteriovenous malformations & angiodysplasias of the colon

Can also be present in the small bowel

Development in the large bowel —> chronic process & increases with age

Valvular heart disease is a risk factor for developing bleeding vascular ectasias

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70
Q

What is the most common cause of intestinal ischemia

A

Ischemic colitis

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71
Q

What are the pts for high index for ischemia and Mesenteric ischemia

A

> 60 years old

Atrial fibrillation

Congestive heart failure

Recent myocardial infarction

Postprandial abdominal pain

Unexplained weight loss

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72
Q

What is the Dx study of choice for Ischemic and Mesenteric ischemia

A

Angiography

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73
Q

Describe meckels diverticulum

A

Consists of embryonic tissue

Most commonly found in the terminal ileum

More than half of lesions contain ectopic gastric tissue

Can secrete gastric enzymes, eroding the mucosal wall & cause bleeding

Rare but important condition, esp in the younger population!

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74
Q

Bleeding and a non tender abdomen is a sign of..

A

Nontender abdomen (predictive of severe bleeding)

LGIB, a lack of abdominal tenderness suggests bleeding from disorders involving the vasculature (diverticulosis or angiodysplasia)

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75
Q

What is the BUN in a upper or lower GI bleed

A

Bleeding from a source higher in the GI tract may elevate blood urea nitrogen levels through digestion & absorption of hemoglobin

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76
Q

Which is more sensitive for a bleed in the GI

Scintigraphy or angiography

A

Scintigraphy appears more sensitive than angiography and can localize the site of bleeding at as low a rate as 0.1 mL/min

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77
Q

What is the role of multi detector CT angiography

A

Multidetector CT angiography has a sensitivity up to 100% and specificity of up to 99% for detecting active or recent GI bleeding

~93% accurate in determining the site of bleeding

Useful tool prior to treatment with conventional angiography

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78
Q

What is the tole or flexible sig

A

Can evaluate possible distal colonic & rectal sources of bleeding

Cannot identify more proximal sources of bleeding

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79
Q

If colonoscopy fails to determine the source of bleeding—>consider…

A

onsider upper endoscopy to evaluate for a UGI source

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80
Q

Describe diverticulitis

A

Incidental finding

small herniations at sites where the vasculature (vasa recta) penetrates the circular muscle layer of the colon

True diverticula involve all layers of the colon wall

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81
Q

What are the common bacterial pathogens in diverticulitis

A 
Bacteroides
 Peptostreptococcus
 Clostridium
 Fusobacterium 
 Gram-negative rods, such as Escherichia coli
82
Q

What causes diverticula formation

A

Altered bowel motility —>high intraluminal colonic pressures lead to diverticula formation

Smoking & obesity increase risk for diverticulitis

83
Q

Is diverticula on the left or right abdomen?

A

LEFT ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !

84
Q

A pt presents with LLQ pain, +/- fever, and leukocytosis

Think

A

Diverticular Dz

Can present with a change in bowel (diarrhea or constipation)

85
Q

When is imaging required in diverticular dz

A

If a prior diagnosis has not been confirmed

or

the current episode differs from the past episode:

Diagnostic imaging is required to exclude other intra-abdominal pathology and to evaluate for complications

86
Q

What is the preferred imaging modality for Diverticular Dz

A

Contrast abd/pelvis CT

87
Q

What is the treatment for uncomplicated diverticulitis

A

bowel rest (liquid diet) and oral antibiotics

Dietary restriction/modification (efficacy is not clear)

No advantage of IV antibiotics over oral antibiotics

Admission is not necessary unless there are serious comorbidities or obstacles to outpatient care

Confirmed with CT—>success rate of ambulatory treatment is about 98%

88
Q

What is the tx for complicated diverticulitis

A

diverticulitis generally requires admission

Bowel rest and IV antibiotics

Specific treatments are directed to complications

89
Q

What is stage 1 hínchey classification

A

Stage 1 is small, confined pericolic or mesenteric abscesses

90
Q

Stage II hínchey classification

A

Stage 2 is larger abscesses, extending to the pelvis

91
Q

Stage III hínchey classification

A

Stage 3 is perforated diverticulitis and purulent peritonitis

92
Q

What is stage IV hínchey classification

A

Stage 4 is free perforation with fecal contamination of the peritoneal cavity

93
Q

What is a phlegmon

A

Phlegmon is inflammation and infection of tissue without abscess- but causes pus, so not walled off.

94
Q

What is the ED D/c approach for uncomplicated diverticulitis

A

F/u in 2-3 days

Or go to the ER if worsening

95
Q

What is defined as failure of Tx in diverticulitis

A

Failure of outpatient therapy= symptoms or worsening radiographic imaging within 6 weeks of the initial episode

96
Q

What are the most common sites for kidney stone obstruction

A

The most common sites of obstruction include:
-Ureteropelvic junction, where the 1-cm pelvis constricts into the 2- to 3-mm ureter

  • Pelvic brim, where the ureter courses over both the pelvis and the iliac vessels
  • Ureterovesical junction, because this is the most constricted site of the ureter due to the muscular coat of the bladder.
97
Q

Where do distal ureter stones usually present

A

Distal ureter stone, which is where 75% of stones are diagnosed, refers pain to the groin.

98
Q

What is the Rx most commonly used for medical expulsion therapy

A

tamsulosin

99
Q

Pregnancy in a patient with prior tubal surgery for sterilization is assumed to be

A

Ectopic pregnancy UPO

100
Q

Define the discriminatory zone for a trans vaginal vs trans abdominal US in pregnancy pts

A

With transvaginal scanning, the discriminatory zone is often considered to be 1500 mIU/mL.

For transabdominal scanning, an IUP should be detectable when the β-hCG level reaches about 6000 mIU/mL.

101
Q

Slide 20 Ectopic Pregnancy

A
102
Q

What is the most common Rx for Ectopic pregnancy

A

Methotrexate

103
Q

What are the managment options for stable pts with a HCG below that ediscrimanatoy zone

A

Management options for stable patients with a β-hCG level below the discriminatory zone and indeterminate US include consultation in the ED or discharge for follow-up in 2 days for reexamination and repeat β-hCG levels.

104
Q

What does AEIOU TIPS stand for

A 
Alcohol/ Acidosis/ Alkalosis
Endocrine. Electrolytes.
Insulin 
Opiates 
Uremia

Trauma
ICP/ Infection
Poisoning/ Psych
SZR. Syncope

105
Q

What is the threshold for dialysis

A

Acidosis <7.1

Electrolytes: K >6.5

Intoxications: SLIME

  • salicylates
  • lithium
  • isopropanol
  • ethylene glycol

Overload: volume

uremia: uremic syndrome

106
Q

If a child has an unexpected postive Tox screen

What should you do

A

Notify CPS

107
Q

Drugs that widen the QRS

A

Diphenhydramine

Antipsychotics:

  • Risperidone
  • Quetiapine

TCAs;

  • amitryptyline
  • imipramine
  • nortriptyline
108
Q

What does the acronym sludge mean

A 
S-alivation
L-acrimation
U-rination
D-iaphoresis
G-astrointestinal
E-mesis
109
Q

What is the only poising that you get the antidote before you do ABCs

A

Cyanide

110
Q

What is the treatment for Hypogl in OD

A

IV dextrose

111
Q

If a pt has an IV lipid emulsion

What is the tx

A

management of cardiac arrest in bupivacaine toxicity.

112
Q

What is a DONT cocktail

A

Dextrose
O2
Naloxone
Thiamine

For Coma

113
Q

How do you decon someone’s eyes

A

Eyes: Copious Irrigation w/ NS or LR 1-2L per eye followed by ph testing

114
Q

How do you decon the GI system

A

GI Decon: NG Lavage w/ Charcoal & Cathartic

115
Q

What anesthetic is used in eye washouts

A

Tetracaine

116
Q

If alkaline gets in the eye what should you do

A

Wash out maybe 1-2 hours
And refer to ophthalmology

Ten minutes after irrigation (allowing equilibration of crystalloid and conjunctival sac pH), conjunctival sac pH is tested.

Irrigation continues until pH is between 7.2 and 7.4.

117
Q

What is the role of polyethylene glycol (Mira lax)

A

Whole bowel irrigation

118
Q

How do we alkalinize the urine

A

Bicarb

(Used for aspirin OD)

Infused over 1 hr

Urine goal 7.5-8.5

119
Q

If an OD doesn’t respond to Tx

What should you do

A

Hemodialysis or Hemoperfusion

120
Q

What is the Admission length for an OD

A

Admission -persistent and/or severe toxic effects or will require a prolonged course of treatment.

Typically 6-hour observation period is sufficient to exclude the development of serious toxicity and change in condition of the patient.

In the developed world, toxicity will resolve within 24 hours in most poisoned patients requiring noncritical care inpatient management unless unstable or requires intensivists care.

121
Q

What are the toxins that can be removed with dialysis

A

Remember SLIME

Salicylates 
Lithium 
Isopropanolol 
Methanol 
Ethylene Gylcol
122
Q

A pt presents with an volume overload status and a ph less than 7.1 with unexplained decline in mental status..

What is the treatment approach

A

Indications for dialysis

123
Q

What are the drugs that can be picked up on Tox Screen

A 
Benzo 
Cocaine 
PCP 
Barbituates 
Opiods 
Amphetamines
124
Q

What are the drugs that can not be found with a Tox Screen

A

Rohypnol
Methadone or Meperidine
MDMA

125
Q

What can the Toxicologist handshake tell you

A

absence of palpated axillary sweat-anticholinergic

or presence- sympathomimetic or cholinergic.

126
Q

Define a wide QRS

A

Any duration greater than 100 ms is abnormal

127
Q

A pt presents wtih mydriasis, dry flushed skin, urinary retention, decreased bowel sounds, hyperthermia, dry mucos membranes, SZR, and possible Rhabo

Think?

A

Mad as a hatter

Atropine, antihistamines, antipsychotics

ANTICHOLINERGICS

128
Q

A pt presents with salivation, lacrimation, diaphoresis, vomiting, urination, defecation, bronchorrhea, muscle fasiculations, weakness, miosis/ mydriasis, Brady cardia and SZR

Think

A

SLUDGE

Cholinergic
Organophosphate poison
Sarin
Insecticides

129
Q

A pt presents with AMS, diaphoresis, tachycardia, HTN , dysarthria, behavioral changes, and SZR

Think

A

HOgl

Sulfonylreas or Insulin

130
Q

A pt presents with miosis, rr depression, CNS depression, Hypothermia, bradycardia

Think

A

Opiod!

Cocaine, heroin, morphine

131
Q

A pt has AMS, resp Alky met acid, and tinnitus

Think

A

Aspirin! (Salicylates)

132
Q

A pt presents wtih CNS depression, Ataqxia, dysarthria, Bradycardia, and RR depression

Think

A

Sedative/ Hyponotic

Benzos and barbituates

133
Q

sodium channel blocker toxicity with cardiovascular complications, such as wide QRS complex tachydysrhythmias
Is treated with…

A

Sodium Bicarb

134
Q

How do you treat agitation in the ED

A

Benzos

135
Q

What is in a cyanide rescue kit

A

Amyl nitrate
Sodium Nitrate
Sodium Thiosulfate

Can also use hydroxocobalamin

136
Q

What is the antidote to Beta Blockers

A

Glucagon

137
Q

What is the antidote to CCB

A

Calcium chloride/ gluconate

+/- glucagon

138
Q

What do you use methylene blue for

A

Nitrates, benzocaine, Sulfonamides

over doses

139
Q

Antidote for Isonazid

A

Pyridoxine

140
Q

What is the antidote for a pt in wernickes syndrome

A

Thiamine

141
Q

How do you decon the blood or urine

A

Urine alkalization or hemodialysis/ perfusion

142
Q

During eye irrigation when is the conjunctival sac ph tested

A

Ten minutes after irrigation
(allowing equilibration of crystalloid and conjunctival sac pH), conjunctival sac pH is tested.

Irrigation continues until pH is between 7.2 and 7.4.

143
Q

What drugs can multi dose active char be used for

A 
Theophylline (Theo-Dur)
Carbamazepine (Tegretol)
Phenobarbital
Quinine
Dapsone
144
Q

What are the indications to use míralax in the ED

A

Indications for WBI:
Sustained or delayed-release pills
-Iron, lithium, lead, and drugs in body: stuffers/packers

Contraindications: Substances causing diarrhea, bowel obstruction

145
Q

Pts that intentionally intox themselves need what Referal before D/c

A

Psych

146
Q

A pt presents with a possible ectopic

The B-hCG level is 500

The qualitative and Quanitative test is pos

Think?

A

Ectopic preg

Consult with OBGYN

147
Q

Where is hCG made

A

hCG is a hormone produced by the trophoblast. Intact hCG consists of the α and β subunits.

148
Q

Where is the common site for an ectopic preg

A

In the ampullary segment of the Fallopian tubes

149
Q

What is the most often pathology that leads to ectopic pregs

A

The underlying cause is most often damage to the tubal mucosa from previous infection, preventing transport of the ovum to the uterus.

150
Q

Is amenorrhea common in ectopic pregnancy

A

Amenorrhea from 4 to 12 weeks after the last normal period is reported in 70% of ectopic pregnancy cases.. Meaning it was missed or late…

151
Q

A woman presents with sudden sharp and severe lateralized abdominal pain

Think

A

Ectopic preg

152
Q

What is a corpus luteum cyst

A

a 3- to 11-cm, thin-walled, unilocular cyst seen after ovulation that can cause pain and tenderness on exam as well as menstrual irregularities, mimicking an ectopic pregnancy. (differential diagnosis.. Image that!)

153
Q

What is Chadwicks sign

A

Chadwick sign is a bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow.

It can be observed as early as 6 to 8 weeks after conception, and its presence is an early sign of pregnancy.

154
Q

What is the primary goal of US in early pregnancy

A

The primary goal of US in early pregnancy is determination of a viable IUP and exclusion of ectopic pregnancy

155
Q

What is a Dx and Tx for suspected ectopic preg with a non Dx US

A

Laparoscopy

156
Q

What is the tx approach to u ruptured ectopic pregnancy

A

Either srgical laparoscopy or methotrexate

157
Q

What is the MOA of methotrexate

A

Methotrexate is a folic acid antagonist that inhibits dihydrofolate reductase, causing depletion of cofactors needed for DNA and RNA synthesis.

158
Q

What is the HIV drug that can lead to increased kidney stone formation

A

The protease inhibitor indinavir sulfate, used to treat the human immunodeficiency virus, is associated with a 4% to 10% incidence of symptomatic urolithiasis.

159
Q

Why do kidneys stones cause pain

A

Pain associated with kidney stones is due to obstruction of a hollow viscus organ (ureter) and subsequent hydronephrosis creating pressure against Gerota’s fascia, causing flank pain.

160
Q

What is the most constricted site of the ureter

A

Ureterovesical junction, because this is the most constricted site of the ureter due to the muscular coat of the bladder.

161
Q

Ureterovesical junction can mimic a urinary tract infection by causing frequency, urgency, and dysuria.

A

Just know that

162
Q

What are the 2 DDx to consider in renal stone/ flank pain

A

Abdominal aortic aneurysm

Renal artery infarction

163
Q

How many layers does diverticulitis effect?

A

True diverticula involve all layers of the colon wall
Most acquired diverticula are considered false diverticula
Involves only the mucosal and submucosal layers

164
Q

What measurement of abscess requires drainage in diverticulitis

A

Greater than 3 cm or Hínchey stage greater than 1

165
Q

When should you admit a pt with diverticulitis

A

If immuno comped or taking chronic steroids

Or if failed outpt tx

166
Q

A pt presents with a crunching sound upon auscultation of the heart due to pneumomediastium
With coughing up blood

Think

A

Boerhaves syndrome

167
Q

If bright red blood or clots are found in the NG aspirate, perform…

A

gentle gastric lavage with room temp water

168
Q

What is the one label Rx for ulcer bleeds

A

Omeprazole

169
Q

Octreotide is unlabeled use for what type of bleeding

A

Varices

170
Q

What must the pH be for clot formation

A

Has to be higher than 6

171
Q

What is the role of PPI in PUD

A

In patients with peptic ulcer bleeding, PPIs reduce the need for surgery, the length of stay in the hospital, and signs of bleeding

172
Q

What are the three things octreotide does for a pt with PUD

A

Inhibits the secretion of gastric acid- good
Reduces blood flow to the gastroduodenal mucosa- also good
Causes splanchnic vasoconstriction- Mixed..

173
Q

What are two examples of promotility agents in the tx of GI bleeds

A

Erythromycin and metoclopramide are examples of promotility agents used to enhance endoscopic visualization

Not recommended for routine use

May consider if the patient is undergoing endoscopy in the ED and suspect large amounts of blood in the UGI tract

174
Q

How id endoscopy used in treating GI bleeds

A

Variceal Ligation and sclerotherappy

Can allow access for clips, thermoregulation, and injections

PRETREAT WITH ANTIEMETIC!
(Ondansetron)

Use Fentanyl and Versed/ Propofol

175
Q

What should be considered for unstable pts prior to endoscopy for a UGIB

A

Unstable patients—> consider using cardiovascular stable agents such as etomidate or ketamine

176
Q

What is an effective short term tx for GI bleeds

A

Balloon Tamp

Strongly consider intubation prior to Balloon Tamp

177
Q

What is the SRGY options for a UGIB

A

If a pt is non responsive to meds or endoscopy then send for emergent SRGY

For a shunt (TIPS) or for junction devasc

178
Q

If a pt has uncontrolled bleeding what is the approach

A

Airway>Stabilize>Emergent surgical consultation

179
Q

What is the most common cause of anorectal bleeding

A

Hemorrhoids

180
Q

A pt with a hx of aortic graft, and a GI bleed think..

A

possibility of an aortoenteric fistula

181
Q

What are the imaging procedures of choice for a LGIB

A

Initial diagnostic procedure of choice—angiography, scintigraphy, or endoscopy—depends upon resource ability and consultant preference

182
Q

What is a useful tool with 100% sensitivity for detecting a GI bleed prior to angiography

A

Multidetector CT angiography

183
Q

Can flexible sigmoidoscopy detect proximal sources of bleeding

A

NO!

184
Q

What should be done If colonoscopy fails to locate a source of bleeding

A

consider upper endoscopy to evaluate for a UGI source

185
Q

A pt presents with acute severe abdominal pain
With N/V and anorexia and decreased oral intake

With pain in both the R and L Upper quads

Think

A

Acute pancreatitis

186
Q

What is the palpation/ provocation for pancreatitis

A

Pain may worsen with oral intake or laying supine

Pain may improve with sitting up with the knees flexed

187
Q

What is the most common cause of pancreatitis

A

Gallstones

188
Q

If you are unsure of if a pt has acute pancreatitis,… what image should you order

A

Abd ct with IV CON

189
Q

What is ranson criteria at admission

A

Age over 55

WBC elevated

BG above 200

Serum LDH above 350

AST above 250

190
Q

Ranson criteria at 48 hours

A

Decreased HCT

Increased BUN

Calcium less than 8

PaO2 less than 60

Base Def greater than 4

Fluid sequestered 6,000

191
Q

A ranson score above 6 means

A

Mortality 40%

192
Q

What time of day does biliary colic present

A

Midnight

193
Q

What are the definitive Dx for Choledocolithisis

A

magnetic resonance cholangiopancreatography
endoscopic US
endoscopic retrograde cholangiopancreatography (ERCP)

194
Q

When should elective cholecystectomy recommend

A

Elective cholecystectomy is occasionally recommended for those at high risk for gallstone complications

  • Sickle cell disease
  • Planned organ transplantation
  • Ethnic groups at high risk for GB cancer
195
Q

What Dz is emphysema cholecystisis associated with

A

DM and the elderly

From gas producing bacteria like C Diff, e. Coli, Klebsiella

196
Q

What is the Tx for emphysema cholecystisis

A

ABX
SRGY
REFER

197
Q

When should you think acalc cholecysitis

A

Most often occurs as inpatients with critical illness

May be seen in the ED (immunocompromised)

Diagnostic challenge - variable clinical presentation and no test result is pathognomonic

198
Q

What is the common cause of post cholecystectomy pain

A

Choledocholithiasis

199
Q

Where do visceral fibers of the appendix enter the spinal cord

A

T10

200
Q

What is the most important measure of immune competency in pts with HIV/ AIDs

A

CD4 count

201
Q

If you measure an aorta greater than 2.5 cm what should you do

A

Addition testing for AAA

202
Q

Acute appendicitis is most common in what age group

A

10-19

Senoir 21-2 (77 decks)

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