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Royal College: Emergency Medicine flashcards
1
Q

Abdominal pain associated with hypotension =

A

Vascular emergency!

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2
Q

ED Safety net

A

2 large bore (14 or 16) IV lines, NS resuscitation, cardiac monitoring, supplemental O2

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3
Q

True AAA

A

dilation of all 3 layers of arterial wall

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4
Q

Definition of aorta diamter for aneurysm

A

3cm or greater

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5
Q

Most AAAs involve

A

infrarenal aorta

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6
Q

Major AAA risk factors

A

atherosclerosis, PVD, first deg relative w/ AAA (10x higher risk)

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7
Q

Ruptured AAA triad

A

Abdominal pain, hypotension, syncope

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8
Q

AAA rupture more likely w/ what diameter

A

> 5.5 cm

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9
Q

AAA Diagnostic tools

A

US, CT ; No place for Angiography or MRI in emergency eval

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10
Q

Surgical mortality of ruptured vs. elective AAA repair

A

50% if ruptured, 5% if elective

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11
Q

Intestinal blood supply (4)

A

Cardiac plexus, SMA, IMA, internal iliac

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12
Q

Most acute mesenteric ischemia due to occlusion of

A

SMA or IMA

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13
Q

Embolic mesenteric ischemia most often etiology

A

just distal to origin of middle colic artery of SMA

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14
Q

Thrombotic mesenteric ishcemia most common arterial and venous etiologies

A

arterial: origin of SMA; venous: venous arcades to SMV

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15
Q

Typically see non-occlusive mesenteric ischemia in

A

elderly, debilitated, critically ill pts

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16
Q

KUB “thumb printing” shows

A

thickened bowel wall

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17
Q

Gold standard for dx of mesenteric ischemia

A

Angiography

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18
Q

Tx of occlusive mesenteric ischemia

A

Heparin, Glucagon (if angiography not done), intraarterial papaverine, laparotomy usually necessary

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19
Q

Tx of non-occlusive mesenteric ischemia

A

correct underlying conditions; vasodilation, anticoagulants, mesenteric regional blockade, intraarterial papverine (lap only necessary if dead bowel)

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20
Q

Tx of mesenteric venous thrombosis

A

Heparain, IV thrombolytics, throbectomy occasionally

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21
Q

Top cause of upper GI bleed

A

Peptic ulcer disease

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22
Q

Most common presentation of PUD

A

melena

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23
Q

For NG lavage, most people use what solution

A

tap water at room tempereature

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24
Q

Relative contraindication to placing NG tube

A

Patients w/ prior gastric bypass surgery

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25
Q

Tx of Upper GI bleed

A

Octreotide or somatostatin to reduce splanchnic blood flow, PPI, Sengstaken-Blakemore tube for intractable hemorrhage (very rare); Endoscopy

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26
Q

Has endoscopy reduced mortality for upper GI bleeds?

A

No

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27
Q

If lower GI bleed, from where can you see melena?

A

right side colonic bleeds

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28
Q

Most common cause of lower GI bleeding

A

diverticulosis

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29
Q

Tx of lower GI bleed

A

embolization, intraarterial vasopressin, surgery

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30
Q

AVPU

A

Alert/Awake, Voice, Pain, Unresponsive

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31
Q

GCS points by category

A

Eye Opening (4), Verbal Response (5), Motor Response (6)

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32
Q

Tx for Hypoglycemia rule of 50

A

Infants: D5 x 10ml/kg; Toddlers D10 x5 ml/kg; Kids D10 or D25 2ml/kg; Adults 1-2 amps D50

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33
Q

Opioid antagonist (OD tx), dose

A

Naoloxone ; 0.4-2mg, double q2-3min till desired effect (IV onset l/t 1min, half life 30-60min)

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34
Q

Indication for administration of naloxone

A

Opioid OD, insufficient respiratory drive

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35
Q

Target for naloxone administration

A

Sufficient respiratory drive, NOT normalization of mental status

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36
Q

biggest problem w/ naloxone

A

it wears off before opiate agent does

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37
Q

Conjugated eye deviation in stroke vs. seizure

A

Stroke deviates towards lesion, seizure away from lesion

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38
Q

Drug therapy for agitated pts w/ unknown cause

A

benzodiazepines (Lorazepam 1-2mg IV, Midazolam 2.5-5mg IM)

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39
Q

Haloperidol used cautiously in which patients

A

prolonged QT

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40
Q

When to treat agitated delirium

A

Presence of excited delirium or continued max struggle despite attempts at maximal restraint

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41
Q

For sympathomimetic toxidorme tx, avoid

A

Beta blockers

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42
Q

Duration of CK-MB vs. Trop I vs. Trop T

A

2d vs 5-10d vs 5-14d

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43
Q

ACS Tx

A

Aspirin, Nitrates, Beta blockers, Fibrinolysis/PCI; consider heparin/enoxaprain, antiplatelet agents, GIIb/IIIa inhibitors

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44
Q

Aspirin mechanism

A

Inhibits thromboxane A2 (decreases platelet aggregation)

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45
Q

Nitrates mechanism

A

Dec preload and afterload, inc coronary perfusion in obstructed vessels

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46
Q

Indications for fibrinolysis

A

ST elev in 2 or more contiguous leads or new LBB, time to therapy l/t 12 hrs

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47
Q

Tx for Cocaine related CP

A

Benzodiazepines, avoid beta blockers

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48
Q

Aortic dissection pathophys

A

intimal tear –> dissection b/w intima and adventitia –> blood into media

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49
Q

1 site for aortic dissection

A

ascending aorta at ligamentum arteriosum

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50
Q

Stanford Classification for aortic dissection

A

A: involves Ascending aorta (80%), B: descending aorta only

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51
Q

High risk pts for aortic dissections

A

> 50 yo w/ HTN; younger pt w/ Marfan’s, Ehler-Danos, pregnant

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52
Q

Mortality for Type A aortic dissection

A

untreated 75%, sugically treated 15-20%

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53
Q

CXR findings for aortic dissection

A

widened mediastinum, L pleural effusion, indistinct aortic knob, displaced calcified intima

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54
Q

Tx of aortic dissection

A

[nitroprusside + esmolol] OR labetalol; goal SBP 100-110 mmHg, HR 60-80; early CT surg involvement

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55
Q

PE mortality

A

2-10% if dx and tx; 30% if undiagnosed

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56
Q

Source of PE in 80-90% of cases

A

Lower extremity DVT

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57
Q

Virchow’s triad

A

Venous stasis, hypercoagulability, Endothelial damage

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58
Q

1 risk factor for PE

A

prior DVT/PE

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59
Q

Classic PE triad

A

Dyspnea, pleuritic CP, hemoptysis

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60
Q

Classic (thought unusual) PE ECG finding

A

S1Q3T3

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61
Q

Hamptom’s Hump

A

Pleural based wedge shaped infiltrate

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62
Q

Tx if high pretest probability for PE

A

1) anticoagulate w/ heparin, 2) then order study; can consider thrombolytics if unstable

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63
Q

Heparin mechanism

A

activates antithrombin III –> inactivates thrombin and Xa

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64
Q

“Big 5” Life threatening causes of CP

A

ACS, Aortic dissection, PE, tension pneumothorax, esophageal rupture

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65
Q

EMS curriculum set by

A

Federal Dpt of Transportation

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66
Q

Order of Emergency Providers from Least to Most Training

A

EM dispatcher -> EM Responder (certified first responder) -> EMT-B -> EMT-I ->EMT-Paramedic -> EMS Physician

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67
Q

Most common pelvic infection

A

Chlamydia trachomatis

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68
Q

Recommended tx for chlamydia

A

Azithromycin 1g PO single dose OR doxycycline 100mg PO 2x/d for 7d

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69
Q

Whiff test

A

for bacterial vaginosis - “fishy” odor on wet mount w/ KOH

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70
Q

Tx for bacterial vaginosis

A

Metronidazole 500mg PO BID x 7d

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71
Q

strawberry cervix

A

trichomonas

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72
Q

PID CDC diagnostic guidelines

A

low abd pain w/o other cause + at least 1 of uterine, adnexal, or cervical motion tenderness

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73
Q

PID outpatient tx

A

Ceftraixone 250mg IM once PLUS doxy 100mg BID x 14d w/ or w/o metronidazole 500mg BID x 14d (ALTERNATE: cftx + azithro)

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74
Q

most common ultrasonographic finding in women w/ ovarian torsion

A

ovarian enlargement

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75
Q

strongest predictor of ectopic pregnancy

A

prior ectopic

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76
Q

most common risk factor for ectopic pregnancy

A

hx of PID

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77
Q

When can you see IUP on US?

A

transvaginal: B-HCG>1500; transabdominal: B-HCG>4000

78
Q

Medical mgt of ectopic

A

methotrexate

79
Q

Pre-eclampsia & Severe Pre-eclampsia criteria

A

BP >140/90 or inc in SBP>20 or DBP>10 over baseline AFTER 20wks gestation and 6hrs apart; severe: SBP 160 or higher, DBP 110 or higher 6hrs apart, proteinuria >5g/24hr

80
Q

Pre-eclampsia mgt

A

definitive tx delivery, magnesium sulfate (titrate to reflexes) for seizure prophylaxis in severe cases, anti-hypertensives (hydralazine / labetalol), fluids

81
Q

Antidote to mg toxicity

A

calcium gluconate

82
Q

Eclampsia

A

pre-eclampsia + seizure (up to 4 wks postpartum)

83
Q

HELLP syndrome

A

Severe pre-eclampsia variant: Hemolysis, Elevated Liver enzymes, Low Platelets + epigastric/RUQ pain

84
Q

Tx of urosepsis

A

Abx, aggressive IVF (rivers protocol), admit

85
Q

leading cause of long term disability in US

A

acute ischemic stroke

86
Q

acute ischemic stroke most commonly caused by

A

embolus (usually from heart) or thombus (usually at site of atherosclerotic plaque)

87
Q

Todd’s paralysis

A

post-ictal transient paralysis

88
Q

Menier’es Disease

A

Inner ear disorder (endolymphatic hydrops); vertigo + fluctuating sensorineural hearing loss + tinnitus

89
Q

Classic presentation of middle cerebral artery (MCA) stroke

A

Aphasia (Broac’s & Wernicke’s usually on L), R hemiparesis & sensory loss, L hemianopsia (L visual field cut), gaze preference to L

90
Q

Window for thrombolytics in acute ischemic stroke

A

4 hrs, longer for posterior circulation strokes

91
Q

FDA-approved thrombolytic for ischemic stroke; dose

A

Tissue Plasminogen Activator (tPA); 0.9mg/kg (max 90mg), 10% IV bolus, 90% infusion over 60min; can give 6hrs post sx in some pts

92
Q

Causative oganisms in g/t 80% of acute meningitis cases

A

Strep pneumoniae, Neisseria meningitidis

93
Q

Causative organisms in 25% of meningitis cases in pt g/t 60yo

A

Listeria

94
Q

Classic 4 sx of acute bacterial meningitis

A

headache, neck stiffness, fever, altered MS

95
Q

CSF findings in bacterial meningitis

A

Elevated opening pressure (often g/t 40), WBC g/t 5, Elevated protein, Low glucose, Organism on gram stain

96
Q

Tx of bacterial meningitis

A

Abx PRIOR to CT/LP (Vanc + 3rd gen cephalosporin pts l/t 50, +ampicillin pts g/t 50), IV Dexamethasone (esp Pneumococcal), stabilization/resuscitation

97
Q

Indications for meningococcal meningitis and penumoccal meningitis prophylaxis

A

household member Rifampin or Cipro q12hrs x 4 doses; HC workers only if interacted w/ secretions; No ppx for pneumococcal

98
Q

Risk factors for subarachnoid hemorrhage / intracranial aneurysm rupture

A

tobacco, alcohol, cocaine, HTN, family hx (polycystic kidney ds, ehlers-danlos, etc)

99
Q

Pseudotumor cerebrii

A

Idiopathic intracranial HTN

100
Q

Tx of SAH

A

SBP less than 140, analgesia, nimodipine (in aneurysmal SAH), seizure prophylaxis, correct hyperglyceima & hyperthermia

101
Q

In SOB pt, breathing goal is:

A

paO2>60 or sO2>90%

102
Q

Wells’ Criteria

A

For PE; clinical signs/sx of DVT, PE #1 dx, HR g/t 100, Immobilization at least 3d or surg in previous 4 wks, previous PE/DVT, Hemoptysis, malignnacy w/ tx w/in 6mo or palliative

103
Q

PERC rules

A

for PE; Age over 50, HR over 100, O2 on RA less than 95%, Prior VTE, Trauma/Surg w/in 4wks, hemoptysis, exogenous estrogen, unilateral leg swelling

104
Q

TIMI Risk Score

A

for UA/NSTEMI mortality; Age>65, 3+ risk factors, known CAD (stenosis >50%), ASA use in past 7d, severe angina (2+ episodes in 24hrs), EKG ST changes>0.5mm, positive cardiac marker

105
Q

What is Grace score for?

A

ACS risk

106
Q

Approach to poisoning

A

ABCs, D (Dextrostick, details, decontaminate), E (EKG, evaluate toxidrome)

107
Q

QRS/ST segment with hockey stick scoop?

A

Digitalis effect

108
Q

EKG finding for cyclic antidepressants

A

RAD (look at R in AVR)

109
Q

QRS>100msec suggests what poisoning agents (e.g. wide complex tachy)

A

TCA, quinidine, diphenhydramine, cocaine

110
Q

QT prolongation suggests what type of poisoning agents

A

antipsychotics, hypocalcemia (risk for torsade de points)

111
Q

Indications for whole bowel irrigation

A

SR drugs (CCBs, lithium), drug packets (body packers)

112
Q

opioid (=narcotic, opiate) toxidrome

A

pinpoint pupils, respiratory depression, latheargy to coma, bradycardia, hypothermia, borderline hypotension

113
Q

common opioids

A

morphine, heroin, codeine, meperidine, propoxyphene, fentanyl, hyrdocodone, methadone

114
Q

“opioid like” agents

A

clonidine, imidazolidines, tramadol

115
Q

anticholinergic toxidrome

A

tachy, elevated temp, AMS, delirium, mydriasis, dry mouth/skin, flushing, decreased bs, urinary retention

116
Q

anticholinergic toxidrome rhyme

A

mad as a hatter, blnd as a bat, red as a beet ,hot as a hare, dry as a bone, full as a tick

117
Q

common anticholinergics

A

diphenhydramine, antiparkinson/anticholinergic meds (benztropine), misidentified plant/herbal products

118
Q

sympathomimetic toxidorme

A

tachy, elevated bp, hyperthermia, dilated pupils, hyperactive bowels, diaphoresis

119
Q

sympathomimetics

A

cocaine, amphetamines, anorectics, otc stimulants, “herbal” stimulants

120
Q

cholinergic toxidorme

A

AMS, excess secretions, fasciculations, weakness; DUMBBELS

121
Q

DUMBBELS

A

cholinergic toxidorme: diarrhea/diaphoresis, urination, miosis, bradycardia, bronchorrhea, emesis, lacrimation, salivation/seizures

122
Q

cholinergic agents

A

organophsophates/carbamate pesticides, carbamate medicinals (donepezil, physostigmine, pyridostigmine), nerve gas agents

123
Q

Wadell Triad

A

(pediatric trauma - e.g. hit by car) closed head injury, intraabdominal injury, mid-shaft femur fracture

124
Q

AMPLE History

A

Allergies, medicatins, PMHx, last meal, event

125
Q

What is an independent predictor if ICI?

A

Seizures (not LOC when adjusted for mental status)

126
Q

Leading cause of death in kids

A

Trauma; TBI leading cause of trauma death/disability

127
Q

Clinically important TBI linked to what signs/sx (pt more than 2 yrs and less than 2yo)

A

more than 2: AMS, signs of basial skull fracture, less than 2: AMS, parietal/temporal scalp hematoma, palpable skull fracture

128
Q

Salter-Harris Classification

A

Pediatric fractures: S (straight across), A (above), L (lower/Below), T (Two/through), ER (erasure of growth plate or crush)

129
Q

most common pediatric elbow fx, often due to

A

supracondylar fracture, fall on outstretched hand

130
Q

Most common avulsion fractures in pelvis in kids

A

Ischial tuberosity, anterior superior iliac spine

131
Q

Toddler’s Fracture

A

spiral or oblique fx through distal 3rd of tibia, non-displaced

132
Q

Philadelphia Criteria

A

29-56d old, T g/t 38.2; low-risk criteria: PE no infxn, Labs (CSF wnl, neg gram stain), WBC l/t 15k, Band/neutrophil l/t 0.2, UA l/t 8 wbc/hpf, CXR no infiltrate), social good observer, car, phone

133
Q

Workup/tx for FYI l/t 4 wks old

A

full sepsis w/u, hospitalized, empiric abx

134
Q

Which protocol for FYI doesn’t use CSF to define low-risk?

A

Rochester 1994 (applies to FYI l/t 60d)

135
Q

role for coticosteroids in meningitis for 29-56do infants?

A

No proven role

136
Q

Most common three bacterial pathogens for ?meningitis (in order)

A

E coli (56%), GBS, S aureus

137
Q

Neonatal HSV distribution

A

1/3 SEM, 1/3 CNS, 1/3 disseminated

138
Q

Indication for empiric HSV testing/tx w/ acyclovir

A

Any one criteria: hx (l/t 21d old, mom w/ active primary HSV at delivery), exam (vesicles, seizure), lab (CSF pleocytosis, inc liver enzymes)

139
Q

FYI 29-56d old who meet all low risk criteria - mgt?

A

CBC w/ diff, blood culture, enhanced UA and urine cx (vs. full eval for sepsis + LP is fail to meet any criteria)

140
Q

Heptavalent Pneumococcal Vaccine - how many serotypes and when to give?

A

7 serotypes (cause 85% of IPD in kids), give at 2,4,6, 12-15mo

141
Q

Risk factors for pyelonephritis in infants

A

Screen if 2 or more: F:l/t 12mo, white, T g/t 39, F g/t 2d, no other source; M; l/t 6mo, uncircumcised

142
Q

Is 1 dose of HPV7 effective?

A

Yes, esp if given after 12mo

143
Q

Leading cause of inpatient hospitilization fo rinfants

A

bronchiolitis

144
Q

most common chronic pediatrician-treated disease

A

asthma

145
Q

Ipratropium bromide

A

synthetic derivative of atropine, reduces bronchospasm (atrovent, given w/ albuterol up front for asthma attack)

146
Q

Terbutaline

A

systemic beta agonist (IV/SubQ then drip)

147
Q

Magnesium mechanism for asthma

A

smooth muscle relaxer

148
Q

Bronchiolitis

A

lower airway infection/inflamation - VIRAL (RSV most common)

149
Q

PNA etiology in neonates

A

Group B strep, GN enterics

150
Q

PNA tx for infants

A

amoxicillin, 3rd gen cephalosporins, macrolides (azithromycin), supportive care (antitussives NOT indicated)

151
Q

Croup

A

upper airway inflammation due to viral infection, then stridor

152
Q

Croup tx

A

airway first; decadron IM/PO, racemic epi neb +/- humidified air or heliox, possibly epi pen

153
Q

Foreign body in infants triad

A

wheeze, cough, decreased breath sounds

154
Q

CXR indicated for foreign body aspiration?

A

Yes

155
Q

FAST scan suprapubic space

A

retrovescular/pouch of douglas

156
Q

RUQ/LUQ spaces on FAST scan

A

pleural, subphrenic, hepatorenal/splenorenal, infrarenal

157
Q

US findings for pneumothorax

A

absence of pleural sliding, leading edge sign

158
Q

heat stroke definition

A

core temp g/t 40 w/ CNS dysfunction in setting of environment heat load

159
Q

drugs that can cause heat stroke

A

cocaine, ecstasy, diphenhydramine/anticholinergics, phenothiazoines/dopamine blockers, ethanol, diuretics

160
Q

most sensitive tissues to hyperthermia

A

vascular endothelium, hepatocytes, neural tissue

161
Q

UA dip +blood but none on micro suggests

A

myoglobinuria

162
Q

Hypothermia definition

A

core temp l/t 35 (severe l/t 28)

163
Q

Osborne J waves

A

Seen in severe hypothermia; can be accompanied by afib, bradycardia, prolonged QT/QTc

164
Q

Electrolyte abnormality to watch for in ED mgt of hypothermia

A

Hyperkalemia

165
Q

TCA overdose tx to consider for hypotension, prolonged qrs, etc

A

sodium bicarb

166
Q

cardinal features of shock

A

hypotension g/t 20min, oliguria, HR g/t 100, RR g/t 20 or PaCO2 l/t 32, ill appearing/AMS, metabolic acidosis

167
Q

SIRS

A

2 or more of: T g/t 38 or l/t 36, HR g/t 90, RR g/t 20 or PaCO2 l/t 32, or wBC g/t 12k or l/t 4k or 10% bands

168
Q

Sepsis

A

SIRS + hypotension or organ dysfunction

169
Q

Septic shock

A

SIRS + hypotension despite fluid resuscitation

170
Q

Most common organisms for 0-56d febrile infant

A

e. coli, GSB, Listeria (

171
Q

occult UTI bugs in febrile young child 2-36mo old

A

E. coli or GN enterics, enterococcus

172
Q

Tx for gram - enterics in febrile young child w/ UTI

A

cefixime, TMP-SMX

173
Q

tx for meningitis: community acquired and brain abscess

A

CA: ceftriaxone IV +/- vanc/ampicillin; Brain: ceftriaxone IV +/- metronidazole

174
Q

Sinusitis tx: acute vs chronic

A

3 wks tmp/smz

175
Q

tx of acute bacterial pharyngitis

A

penicillin V PO, amoxicillin

176
Q

acute bronchitis tx

A

no abx

177
Q

copd/chronic bronchitis tx

A

doxy or tmp-smx or azithro

178
Q

CAP tx

A

azithro + PCN/dox depending, if multiple lobes levofloxacin

179
Q

tx for urethritis (c. trachomatis + n. gonorrhea) or cervicitis

A

Ceftriaxone 125mg IM x1 + Azithro 1g PO or 100mg BID x 7d

180
Q

trichomoniasis tx

A

metronidazole

181
Q

Scope of EMS practice set by

A

each state, no uniform regulation

182
Q

Length of training minimums for EMS set by

A

DOT, overseen by states

183
Q

Who verifies paramedic’s authority to provide care?

A

In PA, physician medical director anually

184
Q

migraine tx

A

reglan or compazine, serotonin agonists (triptans), narcotics

185
Q

tx of cluster headache

A

100% o2, intranasal lidocaine, NSAIDs

186
Q

for early goal directed therapy of shock, what is first line vasopressor to get MAP to 65-90?

A

norepinephrine

187
Q

in evaluating delirium, what element of GCS does the prognosis lie most heavily on?

A

motor response

188
Q

For pt with disequilibrium, what to avoid?

A

no medications! e.g. sedation can worsen sx

189
Q

for aortic dissection, what tx to get to goal SBP of 90-100 and goal HR 60-80?

A

IV nitroprusside + esmolol or labetolol

190
Q

tx for cocaine related chest pain

A

benzodiazepines, AVOID beta blockers

Emergency Med (1 decks)

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