EM COMAT Flashcards
What is the mnemonic for remembering the 5 types of Salter-Harris fractures?
I - S = Slip II - A = Above III - L = Lower IV = TE = Through Everything V = R = Rammed
Describe a type I Salter-Harris fracture
I - S = Slip, Straight across the cartilage of the growth plate
Describe a type II Salter-Harris fracture
II - A = Above, a fracture of the growth plate and metaphysis, Above and Away from the physis
Describe a type III Salter-Harris fracture
III - L = Lower, a fracture of the growth plate and epiphysis, below the physis
Describe a type IV Salter-Harris fracture
IV - TE = Through Everything, a fracture of the growth plate, the metaphysis and the epiphysis
Describe a type V Salter-Harris fracture
V - R = Rammed, a crush fracture of the physis
What is the most common cause of traveler’s diarrhea?
enterotoxigenic E. coli (caused by heat labile enterotoxin and heat-stable enterotoxin
Slipped capital femoral epiphysis
patient, pathology, sx,
obese males age 10-16
femoral head remains within the acetabulum but is displaced posteriorly and inferiorly in relation to the femoral neck
gradually worsening pain and gait abnormalities but patient remains able to ambulate
drug of choice for ICP secondary to brain neoplasm
dexamethasone
blood gas in salicylate poisoning (3 Phases)
Phase 1 (up to 24 hours) - primary respiratory alkalosis with elevated pH and decreased PaCO2 due to hyperventilation from direct respiratory center stimulation
Phase 2 - compensation for phase 1 leads to KHCO3 and NaHCO3 leaving in urine. When enough K+ has been lost, you get paradoxical aciduria
Phase 3 - lactic acidosis due to inhibition of citric acid cycle and uncoupling oxidative phosphorylation
ABG pH 7.24, PaCO2 48, HCO3- 22 - disorder?
acute primary respiratory acidosis - can occur in respiratory depression due to opioid intoxication
ABG pH 7.39, PaCO2 48, HCO3- 30 - disorder?
primary metabolic alkalosis (because HCO3- is increased) with compensatory respiratory acidosis (because PaCO2 is increased and pH is normal) - this can occur with patients taking thiazide diuretics
ABG pH 7.41, PaCO2 41, HCO3- 23 - disorder?
none, this is normal. learn your normal values, Mik
ABG pH 7.50, PaCO2 44, HCO3- 30 - disorder?
uncompensated metabolic alkalosis - copious vomiting can cause this picture
prinzmetal angina sx and tx
sx - cardiac chest pain that occurs at rest due to coronary artery vasospasm
tx - CCB (amlodipine) for prevention
ANC calculation and cut off for neutropenia
ANC = WBC x (% neutrophils + % bands) neutropenia = ANC <1500, high risk = ANC <500
What is recommended with ANC < 100?
broad spectrum Abx therapy with piperacillin-tazobactam, cefepime, meropenem, or imimpenem-cilastatin
Where is a tube thoracotomy placed?
fifth intercostal space at mid-axillary line
What test diagnoses acute Hep A?
Hepatitis A IgM antibody
What medications are known to cause Stephens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN)?
sulfonamide antibiotics, allopurinol, carbamazepine, lamotrigine, phenobarbital, and piroxicam
(mycoplasma pneumonia and viral infections can also cause these, and HIV infection is a risk factor)
What is the treatment for SJS/TEN?
discontinuing offending medication, IV fluids, electrolyte management, pain management, and wound care
Contrast the crystals found in gout vs. pseudogout
gout - negatively birefringent urate crystals (needle-shaped)
pseudo gout - positively birefringent calcium pyrophosphate crystals (rhomboid shaped)
Tx of PEA?
epinephrine (inotrope) 1 mg q3-5 minutes. The first or second dose of epinephrine can be replaced by vasopressin 40 units
What are the reversible causes of cardiac arrest?
H’s:
Hypovolemia, Hypoxia, Hydrogen ions (acidosis), Hypo/Hyperkalemia, Hypoglycemia, and Hypothermia) and T’s: Toxins, cardiac Tamponade, Tension pneumothorax, and Thrombosis (MI or PE)
When can atropine be used in PEA?
if the underlying electrical rhythm is slower than 60 bpm (dose = 1 mg q5 minutes up to 3 doses)
Acute phenytoin toxicity sx
nystagmus and ataxia, uncommonly cardiac arrhythmia can occur with rapid IV administration of phenytoin
What does chronic phenytoin use cause?
decreased folate -> megaloblastic anemia, gingival hyperplasia
What drug-drug interactions should you remember with phenytoin?
isoniazid, fluconazole, sulfonamides, and trimethoprim
What are the most common causes of methemoglobinemia?
exposure to oxidizing agents, most commonly local anesthetic agents (prilocaine and benzocaine) and dapsone (can also be caused by congenital enzyme deficiencies)
What are the symptoms of decreased serum pyridoxine (Vitamin B6) levels?
dermatitis, glossitis, AMS, peripheral neuropathy, sideroblastic anemia
What changes can you see in blood cells in lead poisoning? What are the symptoms?
blood cells - basophilic stippling and ringed sideroblasts (RBC precursors with nuclei surrounded by mitochondria containing iron granules)
Sx - anemia, neurotoxicity, and GI toxicity; in acute poisoning, CNS symptoms may predominant, esp visual disturbances
What are the two shockable rhythms?
V tach and V fib
What are the most common causes of v tach?
Hx of acute or chronic infarction, ischemia, myocardial scar, ventricular hypertrophy, cardiac conduction abnormalities, or QT interval prolongation
Electrical abnormalities (hypokalemia, hypocalcemia, and hypomagnesemia)
Medications (digoxin, methamphetamine, and cocaine)
Class I Hemorrhage
involves up to 15% of blood volume. These patients typically do not have detectable hemodynamic changes
Class II Hemorrhage
involves 15-30% of blood volume. These patients typically have tachycardia (100-120 bpm) and narrowed pulse pressure
Class III Hemorrhage
Involves 30-40% of blood volume. These patients typically have tachycardia (120-140 bpm), hypotension with decreased pulse pressure, and tachypnea. They exhibit signs of end-organ hypo perfusion (AMS and oliguria)
Class IV Hemorrhage
involves over 40% of blood volume. These patients have tachycardia (>140 bpm), significant hypotension, and tachypnea above 35 breaths per minute. They exhibit end-organ hypo perfusion with confusion/stupor and negligible urine output
TRALI cause and sx
caused by donor antibodies targeted against recipient WBCs
Sx - occurs in the first 6 hours (usually within 2 hours), picture similar to ARDS with dyspnea, hypotension, and hypoxemia
TRALI will NOT show signs of circulatory volume overload and will be unresponsive to diuretics
Tx for snake bites?
Snake venoms cause injury due to destructive enzymatic proteins.
Tx = antivenom (or antivenin), which consists of antibodies (or antibody fragments) against snake venom that are derived from the serum of the host animal, typically horse or sheep
Empiric tx of CAP for those at risk of multi-drug resistant infections
cover for pseudomonas
w/o requiring hospitalization = respiratory fluoroquinolone, such as levofloxacin or moxifloxacin
requiring hospitalization = respiratory fluoroquinolone or pip-tazo plus a macrolide (commonly azithromycin or clarithromycin)
What bleeding parameter does warfarin affect?
prothrombin time (PT) and INR (WEPT = Warfarin Extrinsic PT)
drugs that can affect warfarin levels: amiodarone, simvastatin, fluconazole, macrolides, fluoroquinolones, Bactrim, mirtazapine, metronidazole, St Johns Wort, SSRIs (and tamoxifen is contraindicated)
What bleeding parameter does heparin affect?
partial thromboplastin time (PTT)
mechanism of botulinum toxin?
prevents the release of acetylcholine from axons at the neuromuscular junction, leading to flaccid paralysis
mechanism of organophosphate poisoning?
prevents neurotransmitter degradation, irreversibly inhibiting acetylcholine esterase resulting in increased concentrations of ACh at synapses and neuromuscular junctions
Sx of HIV infection
sore throat, myalgias, diarrhea, arthralgias, rash, and mucocutaneous ulcerations
Anterior cord syndrome path and Sx
path - interruption of the anterior spinal artery
Sx - loss of motor function and sensation of pain and temp below the level of injury (retention of touch, proprioception and vibratory sensation)
Brown-Sequard syndrome path and sx
path - injury to one half of the spinal cord, typically due to penetrating injury
Sx - ipsilateral upper motor neuron signs below the level of the lesion due to corticospinal tract damage as well as ipsilateral loss of tactile, vibration, proprioception sense below the level of the lesion due to dorsal column damage. And ipsilateral loss of all sensation at the level of the lesion and ipsilateral lower motor neuron signs (flaccid paralysis) at the level of the lesion. Loss of pain and temp occurs on the contralateral side below the level of the lesion due to damage of the spinothalamic tract
Central cord syndrome path and sx
path - trauma to the cervial spine
Sx - decreased motor function and sensation in both upper extremities with less severe symptoms in both lower extremities
coccidioidomycosis path, sx, labs, complication
path - inhalation of airborne spores of coccidioides species of soil fungus, most commonly encountered in the southwestern US
Sx - primarily pulmonary symptoms
labs - elevated eosinophils
Complication - cavitary lung disease
Fat embolism syndrome path, sx, dx
path - release of fat emboli into the systemic circulation, most commonly following long bone fracture
Sx - petechial rash, respiratory decompensation, and change in level of consciousness
Dx - macrophages with lipid inclusions on bronchoalveolar lavage
Most common causes of orbital cellulitis
staph aureus, strep pneumo, beta-hemolytic strep
blunt chest trauma with hypotension and diminished pulses in the lower extremities and possibly left upper extremity - dx?
thoracic aortic transection
Imaging of nephrolithiasis?
U/S or CT scan show the stone and proximal ureteral dilation and/or hydronephrosis in the case of an obstructing stone
When does nephrolithiasis require urologic consult and intervention?
obstructing renal stones in an infected collecting system, failure of stones to pass spontaneously, and large-sized stones (>10mm)
local anesthetic toxicity (injection intravascularly) sx
CNS or cardiovascular toxicity
CNS - circumoral or tongue numbness, metallic taste, lightheadedness, dizziness, and disorientation before progressing to unconsciousness or seizures
CV - chest pain, dyspnea, or palpitations that can lead to prolonged PR, QRS, and QT intervals
What features of a seizure suggest PNES (pyogenic non-epileptic seizures)?
long duration, fluctuating course, closed eyes, ictal crying, and memory recall
Tx of suspected rabies
wound cleansing and debridement, administration of human rabies immunoglobulin (administered at the site of injury), and inactivated rabies vaccine (administered as a series of four doses over 14 days)
Hunter criteria for diagnosis of serotonin syndrome
must meet one of the following:
- spontaneous clonus or
- inducible clonus plus agitation or diaphoresis or
- ocular clonus plus agitation or diaphoresis, or
- tremor plus hyperreflexia or
- hypertonism plus temp greater than 38 degrees celsius (100.4)
ECG and Tx of Wolff-Parkinson-White (WPW)
ECG - short PR interval (less than 120 ms), a slurred upstroke of the QRS complex (delta wave), and a widened QRS complex (greater than 120 ms).
Tx - procainamide 1st line, amiodarone and propafenone 2nd line (definitive tx = radiofrequency ablation)
Medications that slow AV node conduction (CCB, beta-blockers, adenosine) may lead to ventricular arrhythmia in WPW
characteristics of empyema
purulent fluid with a positive gram stain and/or bacterial culture, pH less than 7.2, glucose less than 60 mg/dL
Light’s criteria
pleural effusion is likely exudative if:
- the ratio of pleural fluid protein to serum protein is > 0.5
- the ratio of pleural fluid LDH to serum LDH > 0.6
- pleural fluid LDH is greater than 0.6 times the upper limit of normal for serum LDH
Wernicke encephalopathy triad
confusion, ataxia, and ophthalmoplegia
mechanism of PCP
NMDA receptor antagonist
What is a key symptom of inferior wall myocardial infarction, and what leads will be affected?
referred pain to the epigastrium. Dx based on ECG changes in leads II, III, aVF
Sx of right sided MI, and affected leads?
hypotension, distended neck veins, clear lung fields with ECG findings of ST elevation in II, III, and aVR
Pre-load dependent, so avoid nitrates and opioids
Most common cause of malignant otitis external? Treatment?
Pseudomonas
can use an Abx with pseudomonas coverage, such as IV ciprofloxacin. If this therapy fails to improve symptoms, patient should be treated with a broad spectrum beta-lactam, such as pip-tazo, ceftazidime, and cefepime
When can you not use FENa for evaluation of kidney injury? What should be used instead?
You cannot use FENa in the case of a patient on diuretics in which case the kidneys’ ability to retain sodium is impaired. You have to use FEUrea instead
FEUrea = 100% * [(Urine urea)(Serum creatinine)]/[(Blood urea nitrogen)(Urine creatinine)]
FEUrea below 35% suggests prerenal acute kidney injury
What is the complication of infection with vibrio vulnificus, and what is the treatment?
Complication - sepsis or necrotizing fasciitis
Treatment - doxycycline and ceftazidime
Definition of a prolonged QT?
QTC > 480 ms
QTc = (QT interval)/(square root of RR interval)
Sx of Fournier gangrene, what are predisposing conditions?
(usually preceded by anorectal, urogenital, or dermatologic infection)
Sx - exquisite pain and tenderness often preceded by a prodrome of fever and lethargy. As tissue necrosis occurs, there is increasing pain and erythema that progresses to a dusky skin appearance. Ultimately, causes crepitus, purulent drainage, and gangrene of the genitals
predisposing conditions - diabetes, morbid obesity, liver disease (alcoholic hepatitis or cirrhosis), and other causes of immune dysfunction (HIV, immunosuppressive meds)
What is the treatment for benzo withdrawal?
long half-life benzos, typically diazepam or chlordiazepoxide
triad of acute cholangitis and tx?
fever, RUQ pain, jaundice
Tx = IV zosyn
Sx of neuroleptic malignant syndrome (NMS)
fever, muscular rigidity, AMS, and autonomic dysfunction
Sx of acute cholecystitis?
postprandial RUQ pain, fever, leukocytosis, positive Murphy’s sign
What is the immediate management of Boerhaave syndrome?
NPO status, IV PPI, and IV broad-spectrum Abx
EGD shouldn’t be done if presenting >48 hours after symptoms or if clinical signs of sepsis are present
Dx and Tx of acute chest syndrome
(pulmonary manifestation of sickle cell disease)
Dx - new infiltrate on CXR in combo with at least one clinical sign or symptom (chest pain, cough, wheezing, tachypnea, fever)
Tx - if patient doesn’t improve with symptomatic treatment, exchange transfusion is indicated
Sx of malaria and prophylaxis against
Sx - periodic fevers, hepatosplenomegaly, hemolytic anemia, and jaundice
prophylaxis: atovaquone/proguanil, doxycycline, or mefloquine
Lemierre syndrome cause, sx, and complication?
cause - F. necrophorum bacteria most commonly
Sx - pharyngitis, fever, sepsis
Complication - bacterial thrombophlebitis of the internal jugular vein
presentation of a hemolytic transfusion reaction
acute onset of fever, flank pain, and red/brown urine that begins soon after a transfusion is initiated
Sx of acute intermittent porphyria (AIP)
abdominal pain, followed by psychiatric symptoms and peripheral neuropathies (which are predominantly motor). Less common CNS effects are seizures, delirium, cortical blindness, and coma
Gamma-hydroxybutyric acid (GHB) drug effects, MOA, complications
causes AMS, unconsciousness, and impaired recall
known as a date rape drug
GABAB receptor agonist
Complications include respiratory depression and convulsions
3,4-methylenedioxymethamphetamine (MDMA) street name, effects, adverse effects
ectasy
causes euphoria and heightened sensations
Adverse effects - hyperthermia and dehydration
Lysergic acid diethylamide street name, effects, adverse effects
LSD
AMS and hallucinations
Adverse effects - severe anxiety/panic attacks (“bad trip”)
CSF analysis in bacterial meningitis?
elevated opening pressure, elevated WBC (predominantly neutrophils), elevated protein, and decreased glucose
