EM extras Flashcards
what is the heart score used for?
ED scoring system that predicts likelihood of a person to have a major adverse cardiac event when the patient presents with chest pain
heart score system
Hx
highly suspicious 2
Moderately suspicious 1
slightly or non suspicious 0
ECG
significant ST depression 2
nonspecific repol disturbance 1
normal 0
Age
> 65 yr 2
45-65 1
<45 0
risk factors
>3 risk factors or hx of atherosclerotic dz 2
1 or 2 risk factors 1
no risk factors 0
troponin- one time*
>3x normal limit 2
1-3x normal limit 1
< normal limit 0
low risk 0-3 (1.7%)
moderate risk 4-6 (16.6%)
high risk 7-10 (50.1%)
life threatening differentials of chest pain (6)
PETMAC Pulmonary embolism esophageal rupture tension pneumo MI aortic dissection cardiac tamponade
some differentials of chest pain (not as emergent)
Gastroesophageal Reflux Herpes Zoster Thoracic Root Compression Panic Disorder Aortic Stenosis Mediastinal Mass Biliary Disease Costochondritis Pneumonia Rib Fracture Pleurisy Pneumothorax Pericarditis Lung Cancer Pneumomediastinum Splenic Infarction
most predictive signs of ACS? (4)
vomiting, diaphoresis, dyspnea, and radiation to both arms
all the lab tests automatically ordered for chest pain?
IV EKG cardiac monitoring chest x-ray CBC BMP/CMP troponin \+/- lipase
what meds do we give chest pt patients?
1) . aspirin 324 mg PO
2) . nitro 0.4ml SL every 5 mins up to 3 doses
3) . analgesia
4) . O2 if needed
treatment of STEMI
PCI is preferred
- CABG if occlusion >3 vessels, L main coronary occlusion, or low ejection fraction
- thrombolytic therapy if cant transfer pt to a PCI facility within 90 mins
what ED anticoagulation is used for pts with STEMI or NSTEMI
unfractionated heparin
aortic dissection symptoms (6)
tearing/ripping chest pain radiating to back pain dec peripheral pulses HTN new murmur (aortic regurg) neuro deficits
how to diagnose aortic dissection?
chest pain workup plus CTA chest
tx of aortic dissection
urgent surgery (unless distal dissection without complications- then medical management)
what are the ED goals for HR and BP (aortic dissection)? what meds to use?
HR- less than 60BPM -- esmolol BP- systolic BP 100-120 -- nicardipine **helps decrease shearing force on aorta
what triad is seen with cardiac tamponade?
beck’s:
muffled heart sounds +
increased jugular venous pressure +
hypotension +
signs and symptoms of cardiac tamponade?
dyspnea, fatigue, peripheral edema, shock
BECK’s TRIAD
how to diagnose and treat cardiac tamponade?
dx: beside US
tx: pericardiocentesis and then surgery
what is ACS?
acute plaque rupture and coronary artery occlusion causing myocardial ischemia
women, DM, and elderly patients might present with these ACS symptoms
weakness, abdominal pain, jaw pain, or dyspnea WITHOUT chest pain
ACS: ischemic EKG vs elevated troponin tells you what?
ischemic EKG = STEMI
high trop = NSTEMI
ACS EKG changes
STEMI- ST elevation
what are the two categories of mental status that can be altered?
1). content of consciousness- ORIENTATION
Or
2). level of consciousness- AROUSAL
types of orientation AMS and what are they?
confusion- alteration in content
delirium- acute alteration in content
dementia- chronic alteration in content
types of arousal AMS
sleepy, lethargic, obtunded, unconscious/coma
GCS
“red flag” high risk HA symptoms
AMS, seizures, fever, neuro symptoms, visual changes, neck stiffness, papilledema
Primary vs secondary brain injury (plus types)
primary- immediate and permanent damage to brain tissue by a traumatic event
*skull laceration, fractures, contusions, cerebral lacerations, ICH
secondary- response to initial mechanical trauma (maybe preventable and reversible)
*increased ICP, hypotension, hypoxia, hypothermia, electrolyte probs
signs and symptoms of epiglottitis?
Hot potato voice, respiratory distress, cherry red epiglottis (gentle visualization of epiglottis)
how to diagnose epiglottitis?
looking (GENTLY) or lateral neck film in extension and during inspiration
epiglottitis treatment?
1) . humidified O2, airway supplies, IV access
2) . Call ENT
3) . start empiric ABX (ceftriaxone)
4) . admit to ICU for ABX and airway management
presentation of tension pneumothorax?
- tracheal and great vessels deviation from affected side
- hyperresonance of affected side
- distended neck veins
- unequal breath sounds
- dyspnea
- tachycardic
- hypotensive
how to diagnose pneumothorax?
clinical diagnosis but can use US to confirm after decompression! see the barcode sign instead of the seashore
how to treat tension pneumothorax?
immediate needle decompression and chest tube placement plus
admit
treatment of small pneumothorax (15- 20% collapse)
if patient is stable then give O2 and observe. repeat CXR in 6 hours. If not getting worse, they can go home & be checked on
treatment for large pneumothorax?
chest tube placement and admit
hemothorax treatment
put a chest tube in and drain the blood, admit
CXR signs of a spontaneous pneumothorax?
1) . loss of lung markings in the periphery
2) . pleural line runs parallel to the chest wall (deep sulcus sign/deep lateral costophrenic angle)
difference between tension pneumo and cardiac tamponade on PE?
cardiac tamponade will have BILATERAL breath sounds present (TP will also have hyper resonance on percussion)
EKG sign of cardiac tamponade?
electrical alternans- alternating QRS amplitude seen in any or all leads with no changes to conduction pathway
Adult GCS system: categories and scoring
1) . eye opening
- spontaneous = 4
- to speech = 3
- to pain = 2
- no response = 1
2) . Verbal response
- A x O = 5
- disoriented conversation = 4
- speaking but non sensical = 3
- moans, weird sounds = 2
- no response = 1
3) . Motor Response
- follows commands = 6
- localizes pain = 5
- moves or withdraws to pain = 4
- decorticate flexion = 3
- decerebrate extension = 2
- no response
scoring 3-15
“T” after score means intubation
when ICP is increasing (due to an injury, etc), what happens to the CPP?
cerebral perfusion pressure must decrease (MAP increases to compensate for decreased perfusion pressure)
what are the two intracranial contents that can most adapt to decreased volume due to increased ICP?
intracranial blood (venous esp) and CSF
what is cushing’s triad?
HTN, bradycardia, irregular breathing (herniation soon) in a patient with increased ICP
*mechanism to help try to save brain perfusion, more common in children
best imaging modality for patients with acute TBI?
Head CT scan without contrast
NEXUS II- Head CT is not required if a patient doesn’t have these characteristics
age >65 yrs evidence of skull fracture scalp hematoma neuro deficit altered level of alertness abnormal behavior coagulopathy recurrent or forceful vomiting
what is an uncal herniation? what S/S does it cause?
uncus of temporal lobe pushed into brainstem (midbrain)
S/S: coma, pupil dilation same side, hemiparesis/posturing opposite side
what is a cerebellar tonsillar herniation? what does this cause?
tonsils of cerebellum slide through foramen magnum against medulla
causes sudden death
S/S of progressive deterioration/impending herniation?
1) . decreasing GCS
2) . pupillary changes
3) . paralysis/posturing
head trauma treatment and management (5)
1) . ABCs
- PaCO2 35-45
- PaO2 >60
- MAP above systolic 100-110
2) . Neuro exam
3) . neurosurgical consult
4) . reversal of anticoags
5) . seizure prophylaxis (Keppra)
Immediate action of lowering ICP after head trauma
- elevate head of bed (30 degrees)
- keep head and neck in neutral position
- maintain cerebral perfusion (if MAP <80, then CPP < 60)
- hyperosmolar therapy: hypertonic saline/mannitol
what is an epidural hematoma and what is a common cause of this bleed?
blood collects between skull and dura due to middle meningeal artery tear
**blunt trauma to temporal or tempoparietal region (high association with skull fractures)
what is the “lucid interval” for an epidural hematoma?
**only happens in 20-50%
momentary LOC at injury time and then improve (up to 2 days) and then back to LOC and neuro deficit
CT sign of epidural hematoma? how do you differentiate from a subdural?
lens-shaped/lemon-shaped
blood WILL NOT cross suture line (unlike subdural)
any patient with injury at C5 or above should have what procedure done?
airway secured by endotracheal intubation
what is a subdural hematoma and what are some causes?
bleed that pools between dura and arachnoid
**commonly seen in alcoholics and elderly, MC from sudden acceleration/deceleration injury (slower onset so worse damage)
CT findings of subdural
crescent shaped
two weeks from injury, the lesion becomes isodense with brain tissue so turns darker
what is a traumatic SAH? compare it to an atraumatic or spontaneous SAH?
traumatic is shearing of blood vessels in the subarachnoid space (tends to be in the periphery of brain) whereas spontaneous is central collection of blood from artery rupture
what is the worst headache of your life a sign of?
SAH
risk factors of SAH?
family hx HTN smoking excessive alcohol coarctation of aorta Marfan's/Ehler's danlos alpha 1 antitrypsin deficiency
Ottawa SAH rule: what is it for and how do you score someone?
used to rule out SAH for a person with a HA (helps determine if further SAH eval/imaging is needed) 1- point if you have it, 0- if you don't - >40 yrs old - neck pain/stiffness -witnessed LOC -onset during exertion -thunderclap HA -limited neck flexion 0 points- significant rule out
subarachnoid hemorrhage treatment
medical management: BP control, pain control, antiemetics
neurosurgery consult
what are some risk factors for intracranial hemorrhage? (4)
1) . ANTICOAGULATION (warfarin)
2) . African America
3) . sympathomimetic drugs
4) . arterial aneurysm
splenic injury MOI and presentation
MOI: MVC, falls, sports, assault
- usually blunt trauma
- Kehr’s sign: pain in left shoulder that worsens with inspiration (irritating the phrenic nerve)
Liver injury MOI and presentation
hx of trauma to abdomen, RUQ, right rib cage, right flank or chest (associated with chest injury the most)
-pres: pain of RUQ, generalized abd pain
intestinal injury MOI and presentation
MOI: blunt trauma due to deceleration injuries causing tearing (seat belt signs)
- unrestrained drivers in frontal-impact MVC, bicycle handlebars
pelvic trauma MOI and presentation
high energy blunt trauma
-widening of pubic symphysis is indicative of open book fracture
traumatic aortic rupture MOI and presentation
common with deceleration (MVC)
-symptoms are commonly absent but survivors often have hematoma formation that is preventing death
toxemia in pregnancy is characterized by what three things?
pregnancy induced HTN, proteinuria and seizures when severe
symptoms of toxemia are so variable that every pregnant female in 3rd trimester who goes to the ED gets what two tests?
BP check and UA
most cases of toxemia occur within ___ hrs of delivery
48 hrs
what is important to remember about blood pressure in pregnancy?
it is LOWER
rising BP in relation to normal BP is a relevant sign of toxemia!
supportive lab findings of toxemia (pregnancy)
dec urine output higher BUN/Cr dec creatinine clearance proteinuria evidence of DIC
Mild preeclampsia vs mod to severe (PLUS TREATMENT)
mild: diastolic BP under 105, 1+ proteinuria, good urinary output (TX: patient rests at home and followed)
mod/severe: proteinuria >2+, diastolic BP >105, seizures, anuria, severe edema
(TX: Magnesium plus hydralazine if HTN persists)
what is PID and how does it present?
PID: infection of upper genital tract and reproductive organs in females
- exam: marked cervical motion tenderness (chandelier sign), adnexal tenderness (unilateral might be ruptured tubo-ovarian abscess), lower abd tenderness (can have temp > 101, abnormal discharge too)
most common sexually transmitted infection? how to treat?
chlamydia; azithromycin
if you are treating gonorrhea then you also treat?
for chlamydia
ceftriaxone plus azitrhomycin
major cause of recurrent genital lesions?
HERPES- vesicular lesions
what is important about initial herpes infection?
initial infection tends to be the most severe
tx of genital herpes
antiviral drug, warm compresses
what happens in pregnancy if mom has trichomonas infection?
possible premature rupture of membranes, premature birth, and low birth weight infants
trichomonas symptoms and treatment
green frothy discharge
tx: flagyl
if pregnant- avoid breast feeding for 24 hrs after last dose of flaygl
test for what STI if patient has syphilis
HIV
treatment of syphilis
penicillin, or doxycycline if allergic to penicillin
primary, secondary, and tertiary stages of syphilis
primary: painless chancre with depressed center and rolled up edges
secondary: 4 weeks after chancre, non pruritic rash (thorax, abd, extremities)
* latent in between*
tertiary: destructive lesions of aorta, CNS, skeletal structures and skin
abnormal vaginal bleeding signs in non-pregnant female
heavy menses: soaking pad or tampon more than every 2hrs or volume that interferes with daily activites
large clots in blood
changing pads/tampons at night
anemia
how to treat abnormal vaginal bleeding in non pregnant person
1) . vital signs- think of systemic things (hypotensive, tachycardic- FIRST THING)
2) . treat shock
3) . IV access, type and cross, preg test, fluid replacement
4) . determine cause of bleeding and stop it
any patient with vaginal bleeding that results in abnormal hemodynamics or anemia should be ___________
hospitalized
ruptured ovarian cyst diagnosis essentials
SUDDEN unilateral pelvic pain
lack of systemic signs of infection
negative preg test
significant hemorrhage on US
ovarian torsion presentation
extremes of age
gradual OR sudden symptoms
pain with sex or pooping
US detects decreased or absent blood flow
1st trimester bleeding causes
1) . ectopic pregnancy
2) . miscarriage- MOST COMMON NON TRAUMATIC CAUSE
3) . implantation of pregnancy
4) . cervical/vaginal/uterine pathology
S/S miscarriage
typical symptoms of being pregnant and then uterine cramps/bleeding and then passage of fetal/placental tissue
most common presenting complaint of ectopic pregnancy? where does implantation occur?
vaginal bleeding; occurs in fallopian tube 96% of the time
acute ruptured ectopic s/s
sudden, persistent abdominal pain, rapid uterine bleeding, unstable vitals, feeling faint
presentation and treatment of hyperemesis gravidarum?
within 1st trimester
persistent vomiting, dizziness, presyncope, dehydration
tx: correct hypovolemia with IV fluids and possibly antiemetics
most common causes of 2nd and 3rd trimester bleeding
miscarriage, placenta previa or abruptio placentae
indication of placenta previa?
painless bleeding in small volumes that occur regularly for a short period of time
**can hemorrhage ANYTIME
indication of abruptio placenta
severe abd pain associated with hemorrhage into subplacental space (premature separation of placenta)
*increase in contractions may occur
how to treat 2nd and 3rd trimester bleeding
1) . emergent OB consult
2) . evaluate hypovolemia and correct
3) . collect blood through IV
4) . monitor fetal heart tones
5) . UDS and check placenta with US
6) . hospitalize pt immediately
