EM M4 Flashcards
TF
Vitals are often normal in appendicitis
What % have fever at time of perf
T
Vitals often normal in appendicitis
Only 40% have Low grade fever at time of perf (low grade is 37-38… 98.6-100.4)
TF
Pain prior to N/V suggests a surgical etiology
T
eg SBO
TF
Female with appendicitis often has cervical motion tenderness
T
25% female appendicitis has cervical motion tenderness
Why does peptic ulcer pain awaken pts at night but gone when waking in the morning
Gastric acid secretion peaks at ~2am and nadirs at awaking
TF
Unrelenting pain over weeks to months suggests peptic ulcer disease
F
PUD pain usually exacerbating and remitting
Hypertrophic pyloric stenosis typically presents At what age In what gender With what eating pattern What classic exam finding What diagnostic test
Hypertrophic pyloric stenosis age 2-6 wks of life gender 4x more male than female Vigorous appetitie but projectile non-bilious vom classic exam finding olive shaped mass diagnostic test ultrasound
Intussusception typical age of presentation
5-12 months
Intussusception typical age of presentation
Vomiting with apoendicitis?
Not usually, but can present atypically in young kids and elderly
KUB detects what % of renal calculi
Helical CT is how sensitive and specific
What about ultrasound
60-70%
Renal calculi detected with KUB
Helical CT ^95% sns and sps for renal calculi *best test
Ultrasound not good for stones but good for hydronephrosis
TF
Renal insufficiency contraindicates intravenous pyelogram
T
Describe diverticulosis
“Sac-like protrusions of colonic mucosa through the muscularis”
Old guy with mild diverticular pain and tenderness in the ED, no fever… discharge home on fiber and stool softeners or antibiotics? (And follow up with pcm)
If mild can treat as diverticulosis — fiber and stool softeners
If more severe and/or with fever or leukocytosis can treat as diverticuliis — 7-10 day abx, bowel rest and analgesia
TF
Crohn’s often involves the rectum
F
Can involve any gi tract but rarely rectum
How much do UC and Crohn’s increase the risk of colon cancer
UC x30 fold
Crohn’s only mildly
TF
UC NEVER involves the small intestine
T
Acute cholecystitis WBC Left shift? Transaminases Bili
WBC elevated with or without left shift
Transaminases and Bili typically normal
Scapular pain common with what intraabdominal process
Acute cholecystitis
TF
Increased parity is a risk for cholecystitis
T
Female fat forty fertilemultiparous fnative american
2 most common causes of pancreatitis in usa
some other causes
TF alcoholic pancreatitis only in chronic alcoholics
1 gallstone pancreatitis 2 alcoholic pancreatitis - old or young, chronic or sporadic abuse Hypertriglyceridemia Pregnancy Trauma Cancer Atherosclerotic emboli Scorpion bite
Cecal volvulus
Pathophys
Age of presentation
Marathon running a risk why?
Cecal volvulus
Abnormal fixation of right colon, cecum mobile to twist mesenteric axis
25-35 yo most common presentstion
Marsthon runners skinny with thin flexible mesentery for more mobility… (thin plus jostly i think)
TF
Constipation predisposes to cecal volvulus
F 25-35yo Preg Prior surgery Marathon... not constipation...
Causes of hepatic abscess
Anaerobes, gram negatives, entamoeba hystolytica
bacteroides, E. coli, Klebsiella, Pseudomonas, Enterococcus, anaerobic Streptococci, and E. histolytica
Hepatic abscess Typrical causes Labs Cxr Tx
ypically caused by gram negatives, anaerobic Streptococci or Entameoba histolytica. Laboratory findings include elevations of WBC, bilirubin, alkaline phosphatase and serum aminotransferases. CXR may demonstrate a right-sided effusion and elevation of the right hemidiaphragm. Treatment with triple coverage antibiotics such as gentamicin, metronidazole and ampicillin should be instituted immediately, however consultation with a general surgeon, interventional radiologist, or gastroenterologist is necessary for definitive treatment, which is drainage of the abscess.
TF
Age is a factor when considering admission for mild diverticulitis vs dispo home (abx bowel rest analgesia)
T
Consider admitting elderly for mild diverticulitis, hogher risk of complications
Most common causes and sites of esophageal perforation
1 iatrogenic — proximal pharyngoesophagela junction or distal ge junction
2 spontaneous — distal esophagus (90%)
Foreign body
Caustic ingestion
Blunt or penetrating trauma
Carcinoma
Foreign body impaction in esophagus a greater airway risk via edema or perf/mediastinitis risk?
Other complications
Air trapping?
Esophageal fb a greater perf/mediastinal risk
complications of esophageal foreign bodies are rare but serious. They include esophageal Erosion and Perforation, Mediastinitis, esophagus-to-trachea or esophagus-to-vasculature Fistula formation, Stricture formation, Diverticuli formation, and tracheal Compression (from both the esophageal foreign body and resultant edema or infection)….. Air trapping is a sign of a foreign body of the Airway. Rarely, airway foreign bodies act as one-way valves that could cause hyperinflation of a lung segment, with resultant bleb rupture and pneumothorax formation.
Tardive dyskinesia results from prolongued use of
Tardive dyskinesia results from prolongued use of antipsychotics
Features of neuroleptic malignant syndrome
Elevated temperature , lead pipe muscle rigidity, altered mental status, choreoathetosis, tremor, autonomic dysfunction — diaphoresis, labile blood pressure, dysrhythmia, incontinence
Temp over ___ is most likely not infectious
Temp over 105 is most likely not infectious
4 neurologic complications of antipsychotic use
Neuroleptic malignant syndrome
Tardive dyskinesia
Dystonia
Akithesia
EKG complication of haloperidol
Long qt
Potential side effects of haloperidol
Potential side effects of haloperidol include acute dystonia, prolonged QT interval, Parkinsonism, and akathisia.
What recreational drugs cause
Dilated pupils
Pinpoint pupils
Vertical nystsgmus
Dilated pupils - sympathomimetics like cocaine and amphetamines
Pinpoint pupils - opiods
Vertical nystsgmus - phencyclidine pcp
Best antipsychotic for severe agitaion
And dosing
And time to peak serum level
Haloperidou - Best antipsychotic for severe agitaion… high potency highly studied… no resp depression negligible anticholinergic rare hypotension which are all side effects of throdazine, and benzos can cause respiratory depression
5-10 mg IM q 10-30 minutes dosing
30 minutes time to peak serum level
Which of the following are/are not associated with violent agitation? DM Hypothyroid COPD Alcohol abuse
Hypothyroid can cause agitation but not violence like the others
Why chemically in addition to physically restrain the especially violent patient? Specific complications of restraints, which is life-threatening
Circulatory obstruction
Asphyxia
Rhabdomyolysis
Life-threatening metabolic acidosis from struggle against restraints can lead to cardiovascular collapse
First line chemical restraint for cobative patient? Why? If elderly?
5 mg of haloperidol (antipsychotic) IV/IM with 2 mg of lorazepam (benzodiazepine) IV/IM, repeated every 30 minutes as needed, is recommended for the combative patient who does not have contraindications to these medications.
Drugs with a relatively short half-life allowing for more careful monitoring of chemically restrained patients. Patients may be given multiple administrations of the restraining agent as needed.
Half doses should be used in the elderly.
Flumazenil can be used to temporarily reverse the ____ caused by ____ but also carries with it the risk of precipitating ____ and ____ in chronic ____ users. As a result, it is not recommended for routine use in patients with ____
Flumazenil can be used to temporarily reverse the Respiratory Depression caused by Benzodiazepines but also carries with it the risk of precipitating Withdrawal and uncontrollable Seizures in chronic benzodiazepine users. As a result, it is not recommended for routine use in patients with Altered mental status.
mnemonic can be used to recall the common causes of an increased anion gap metabolic acidosis:
CAT MUDPILES; C - cyanide A - alcoholic ketoacidosis T - toluene M - methanol U - uremia D - diabetic ketoacidosis P - paraldehyde I - isoniazid/iron L - lactate E - ethylene glycol S - salicylates
Alcoholic presents agitated vomiting and altered with no detectable etoh and non gap metabolic acidosis, what is the likely agent
Isopropyl alcohol is metabolized via alcohol dehydrogenase to acetone which accumulates and causes significant ketosis but not an anion gap. Other toxic alcohols such as methanol and ethylene glycol are ultimately metabolized to formic and glycolic acids which cause toxic effects and an anion gap metabolic acidosis.
Hepatitis from alcoholic liver disease in ED Vitamin to give Electrolyte to replete Comprbidity to check for Assess nutrition with attention to... Treatment is primarily...
Thiamine before glucose, Mag, check and treat gastritis, assess nutrition with attention to possible protein restriction, managment mostly supportive with fluids and electrolytes
Alcoholics often have low thiamine levels due to poor nutrition, and low glucose levels due to the suppression of gluconeogenesis by alcohol. Thiamine should always be replaced prior to glucose to avoid the potential complication of precipitating Wernicke’s encephalopathy. Magnesium levels may appear normal on laboratory testing, but alcoholics typically have low magnesium stores and should be given magnesium empirically unless contraindications for magnesium exist. Alcoholics should also be evaluated for gastritis and overall nutritional status and should be referred appropriately.
What type of hallucination suggests more functional ams than organic
Auditory hallucinations more functional
Tactile visual auditory can be organic
2 most common causes of dementia
1 alzheimers
2 vascular
Key difference between delirium and dementia
Altered consciousness with delirium
Top 4 nutritional/metabolic abnormalities to consider initially for ams
An acute confusional state can also be one of the protean manifestations of a metabolic or nutritional abnormality, including hepatic encephalopathy, acute renal failure, and diabetic ketoacidosis or hyperosmolarity.
Electrolyte disturbances that can cause altered mental status
Hypoglycemia
Hyper or hypo natremia
Hyper calcemia
Some key history to differentiate between functional and organic altered consciousness
Acuity, vitals, fluctuation, trauma, focal neurologic deficits, delusions illusions
Characteristics of organic causes include acute onset, abnormal vital signs, fluctuating level of consciousness, possibly signs of trauma, and/or focal neurologic signs.
Inorganic (functional) causes commonly illustrate chronic onset, stable vital signs, absence of trauma or focal neurologic symptoms, and/or delusions and illusions.
Hypertensive encephalopathy can cause coma and death in what time frame
Hypertensive encephalopathy can cause coma and death over hours… it is a medical emergency
When to give antihypertensiv meds to preggy with eclampsia
If diastolic bp ^110 after seizures controlled with Mag… don’t want to lower too much or too rapidly because uterine hypoperfusion
febrile seizure Age generalized tonic clonic activity? Duration? Post ictal state?
febrile seizure
Age 3mos to 5years
generalized tonic clonic activity? Sure
Duration? v15 min… think intracranial mass lesion or infection if longer
Post ictal state? No, think intracranial mass lesion or infection if not rapid regain of normal consciousness when seizure ends
How can alcohol affect seizure disorder
Can directly cause seizures via neurotixicity of itself and metabolites
Can predispose via head trauma, metabolic disturbance, and lower threshold
Can precipitate seizures with withdrawal
TF
Delirium can be agitated and combative or calm and quiet
T
Delirium swings both ways
Most common causes of delirium in elderly
Why minimize stimuli
Meds
Infectious
Metabolic
Minimize stimuli because difficulty processing stimuli
Dystonic reaction to neuroleptic medication
Incidence
Time to onset
Treat
Most common adverse effect of neuroleptics, 5%
Up to 48 hours after goven in ED or anytime during long term neuroleptic therapy
Dystonic reactions should be treated with IM or IV benztropine anticholinergic (Cogentin®), 1 to 2 mg, or diphenhydramine antihistamine (Benadryl®), 25 to 50 mg. Intravenous administration usually results in near-immediate reversal of symptoms. Patients should receive oral therapy with the same medication for 48 to 72 hours to prevent recurrent symptoms.
Manage Ellis II (enamel and dentin, yellowish tinge to fracture bed) and Ellis III (pinkish pulp and often blood exposed) tooth fractures in the ED
Immediate dental consult to avoid abscess formation
Guy punched in nose jas no ocular or maxillary issues, just nose deformity with A swollen, ecchymotic, tender nasal septum. Most appropriate initial step?
Incision and drainage of the sepatal hematoma followed by nasal packing
Pt hit in eye with racquet ball, now with diplopia with upward gaze deficit in affected eye… why?
Orbital floor fracture and entrapment
Normal body temperature
Febrile body temperature
Normal 36-37 97-99
Febrile 38 100.4
Tension pneumo… needle decompression or chest tube?
Needle decompression first and fastest
Chest tube after
Most sensitive test for nerve injury from finger trauma
And what is the O’Rain wrinkle test
Two point descrimination is most sensitive test for finger nerve injury
O’Rain wrinkle test involves putting finger in warm water and looking for reflex wrinkling of digital pulp indicating intact nerve
Ottowa ankle rules
What are they
Who are they for
For ADULTS
Inability to walk 4 steps at time of injury or in ED
tenderness over medial or lateral malleoli and posterior superior aspect
tenderness over navicular or base of 5th metatarsal
Any of above consider xray for ankle injury
What are the 2 site options for needle decompression of tension pneumo and which has lower risk of parenchymal injury
Anterior mid clavicular line 2nd intercostal space — less risk of parenchymal injury
Lateral mid axillary line 4th or 5th intercostal space — higher risk of parenchymal injury
