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EM > EM2 > Flashcards

EM2 Flashcards

1
Q

How to correct hyponatremia + coma/seizures

A

150 mL 3% NS bolus over 5 min (or 1 amp bicarb) (may repeat X 1)

Repeat serum sodium (goal is no more than 6 mmol/6h)

Saline lock IV

Foley –> u/o >100mL/h? –>if yes, 1 mcg DDAVP

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2
Q

Non-severe hyponatremia algorithm

A

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3
Q

Goals of correction of hyponatremia

A

6 in 6 hours for severe symptoms, then no faster than 6 mmol/day (up to 12/day safe by some sources)

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4
Q

Necrotizing Soft Tissue Infections

A
  • Type I: Polymicrobial, most common.
  • Type II: Monomicrobial (MRSA, GAS, clostridium)
  • Type III: V. vulnificus (seawater)
  • Can spread as quickly as 1”/h
  • Pain out of proportion.
  • Pain/edema beyond area of redness
  • Crepitus (30%)
  • Xray shows superficial gas but not deep
  • CT with contrast ~ 90% but 20% false-positive
    • non-enhancing deep tissues
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5
Q

Chance of successful passage of ureteral stone based on size

A

98% stones <5 mm pass within 4 weeks
60% stones 5-7 mm pass within 4 weeks
39% stones >7 mm pass within 4 weeks

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6
Q

Malaria

A

Incubation ~30 days, but with partial chemoprophylaxis and incomplete immunity, can show up even 1 year after travel (~1% cases)

Often periodic fevers preceded by myalgias, headaches, and almost any other symptom. Classically Q48h, but can present very atypically.

Normocytic anemia (hemolysis), may have mild LFT/Cr, WBC elevation or depletion
Dx: thick + thin smear for malaria Q 12-24h for three sets
LP will be nonspecific

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7
Q

Opioid Equivalencies

A

Morphine 5 mg IV = 15 mg PO (MS Contin Q8-12h)
Dilaudid 0.75 mg IV = 3.75 mg PO
Oxycodone 10 mg PO (oxycontin Q8-12h)
Codeine 100 mg PO

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8
Q

Composition of Tylenol #1,2,3,4

A 
T#1 = tylenol 300 mg + codeine 8 mg + caffeine 15 mg
T#2 = tylenol 300 mg + codeine 15 mg + caffeine 15 mg
T#3 = tylenol 300 mg + codeine 30 mg + caffeine 15 mg
T#4 = tylenol 300 mg + codeine 60 mg
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9
Q

Composition of percocet

A

Percocet = 325 mg/5 mg oxycodone

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10
Q

Dosing of Tramadol, Tramacet (composition)

A

Tramadol 50-100 mg PO Q6h or 100 mg ER daily max 300 mg/day, adjust by 100 mg no quicker than q5 days

Tramacet (325 mg Tylenol + 37.5 mg Tramadol) i-ii tabs Q4-6h

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11
Q

ABRS Diagnosis Algorithm

A

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12
Q

ABRS Tx Algorithm

A

Note: IDSA guidelines - Amox/Clav, quinolones, or doxy (not in kids) are first line.

Recommended not to use macrolides, Amoxicillin, TMP-SMX

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13
Q

Sinusitis Steroid Nasal Spray Dosing

A

INCS Mometasone furoate (Nasonex)
50 mcg/spray 17g (120 sprays) per bottle
Age 3-11: 1 spray each nostril once daily
Age >=12: 2 sprays each nostril BID, increase to 4 BID if inadequate response

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14
Q

Oral Candidiasis Treatment

A

Nystatin swish and swallow: 400,000-600,000 units QID X 7-14d (adults & children, different for infants); response within 24-48 hours.
if no response/poorly tolerated then fluconazole 200 mg day 1, then 100 mg daily X 14 d

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15
Q

Apthous Stomatitis Treatment

A

oracort dental paste 0.1% TID X 7-14 days m: 5 g

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16
Q

Insulin Correction Factor

A

100/Total Daily Dose

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17
Q

Antibiotics for acute cholecystitis

A

Flagyl 500 mg IV (Q6h)

Ceftriaxone 1 g IV (Q24h)

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18
Q

3 I’s (causes) of DKA

A

Infection, Infarction, Insulin

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19
Q

Dose of PO morphine for acute pain

A

Morphine, 0.3 milligram/kg PO

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20
Q

Dose of PO Dilaudid for acute pain

A

Hydromorphone, 0.06–0.08 milligram/kg PO

(4-5 mg PO)

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21
Q

MI & LBBB

A

Doesn’t matter if new or old.
If CHF or HD instability –> cath/lytic
If stable, apply Sgarbossa criteria

A. Concordant STE 1 mm in any lead (~90% accurate, take to cath)
B. Concordant STD 1 mm in V1-V3, only need 1 lead (~90%, take to cath)
Modified C (Smith’s). ST discordance >25% (cath)

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22
Q

MI & Pacemaker (LBBB pattern)

A

Doesn’t matter if new or old.
If CHF or HD instability –> cath/lytic
If stable, apply Sgarbossa criteria

A. Concordant STE 1 mm in any lead (~90% accurate, take to cath)
B. Concordant STD 1 mm in V1-V3, only need 1 lead (~90%, take to cath)
C. Discordant STE >5 mm any lead (~60%, consider other factors, speak with cardio) applies also and is even more specific than other criteria.

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23
Q

sTE aVR

A

STE in aVR + aVL = 95% specific for LMCA stenosis
STE in aVR + V1 = LMCA or prox. LAD stenosis
If STE in aVR > STE in V1 then LMCA stenosis
If STE in aVR > 1.5 mm then >75% mortality
LMCA stenosis has 70% mortality, no medical therapy is effective, time to cath is crucial, PCI decreases mortality to 40%

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24
Q

Diagnosis of Acute Pericarditis

A

Two of:

  • Chest pain consistent with pericarditis (pleuritic, worse with lying down, relieved with leaning forward)
  • Pericardial friction rub
  • Typical ECG changes
  • Pericardial effusion of more than trivial size
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25
Q

Treatment of Acute Pericarditis

A

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26
Q

Disposition of Acute Pericarditis

A

Consider admission if:

  • temp >38.5, trauma, troponin (myopericarditis), OAC, immunosuppressed, or large effusion
  • Competitive athletes: no sports until 3 months (6 months for myopericarditis) after resolution symptoms and cleared by MD
  • Regular athletes: no sports until resolution symptoms
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27
Q

Flomax Dosing, precautions

A

Tamsulosin 0.4 mg PO daily (may increase to 0.8 mg daily after 2-4 weeks if poor response).

Watch for hypotension with first dose and after interrupting therapy.

Do not start if planned eye surgery (floppy iris syndrome).

Avoid with severe sulfa allergy.

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28
Q

Tuberculosis

A
  • assume infectious –> airborne isolation, negative pressure, N95 for visitors, surgical mask for patient outside of room, call IPAC
  • outpatient: home isolation pending lab results + call PH
  • active TB –> specialist referral
  • CXR
  • sputum X 3 for TB (AFB smear - 24h), NAAT (48h), and culture (1-4 weeks). May collect sputum on same day 1h apart.
  • If CAP but suspecting TB, use Amox/Clav, do not use quinolones (they are active against TB and may mask test results)
  • test for HIV if +ve
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29
Q

HIV Testing

A

HIV Ab test
95% sensitive within 30 days
5% will take up to 3 months

HIV Ag/Ab Combo EIA
reduces time to detection to 0-20 days, lab dependent

INSTI POC test
Sens/Spec 99.8%/99.5% at 3 months post-exposure

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30
Q

Workup for fever in the returning traveler

A

CBC, diff, malaria thick/thin Q12-24h X 3, LFT’s, culture everything for typhoid, NP swab for influenza, urinalysis, CXR, serology (hold red top or specify for dengue, chikungunya, Rickettsia, etc.)

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31
Q

QTc Calculation

A

Qt (ms)/square root of preceding r-r (ms)

Lead II or V5 best

32
Q

CAUTI Definition

A

Catheter in more than 2 days (or intermittent catheterization) and change in symptoms/condition + positive urine culture

33
Q

When to change catheter for suspected CAUTI

A
  • Do not remove catheters placed post-op for GU surgery or for GU trauma
  • If catheter has been in >2 weeks, take it out, replace it, and draw culture from new catheter
34
Q

How long to treat CAUTI for?

35
Q

Adult dose of Atarax (hydroxyzine)

36
Q

Scabies Treatment

A

Permethrin 5% Cream from neck down (or whole body for immune compromise/kids)

m: 30 g

Apply at bedtime, wash off in morning. Wash linens + clothes in hot water in AM, treat all household contacts.

or

Ivermectin 200 mcgs/kg PO, repeat X 1 in 2 weeks

plus

Atarax, Hydrocortisone 1 or 2.5% 60 g

Itching may last up to 6 weeks but should progressively get better.

38
Q

Name for bees, wasps, ants.

A

Hymenoptera

39
Q

Name for Poison Ivy

A

Toxicodendron

40
Q

de Winter T waves

A

Proximal LAD occlusion –> STEMI equivalent, call cath lab

41
Q

When to treat influenza in pregnant women.

A
  • treat all pregnant and postpartum women (up to 2 weeks) on spec with oseltamivir 75 mg PO BID x 5 days
  • rapid testing not sufficiently sensitive to rule out
42
Q

Treatment for epiglottitis

A

Ceftriaxone 2 g IV

Solu-medrol 125 mg IV

Humidified O2

43
Q

DDx of Altered LOC

A
  • A — Alcohol/Acidosis
  • E — Endocrine
    • Epilepsy
    • Electrolytes
    • Encephalopathy
  • I — Infection
  • O — Opiates, Overdose
  • U — Uremia
  • T — Trauma
  • I — Insulin
  • P — Poisoning/Psychosis
  • S — Stroke/Seizure/syncope
44
Q

How many primary teeth?

45
Q

When do primary teeth erupt?

A

8-33 months

46
Q

How many permanent teeth?

47
Q

When do permanent teeth erupt?

A

7-13 years (wisdom up to early 20’s)

48
Q

When do primary teeth fall out?

49
Q

How to tell a primary tooth from a permanent tooth?

A

Permanent teeth have

  • longer roots
  • yellow colour
  • mamelons (ridges –> later wear down)
50
Q

Spectrum of disease in dental caries

A

Caries –> reversible pulpitis –> irreversible pulipits –> pulpal necrosis/death –> dental abscess

51
Q

Name for dental abscess fistulizing through gingival wall

52
Q

Abx Choice for Ludwig’s Angina

A

PipTazo

or

Clinda + Ceftriaxone

53
Q

TXA solution for post-extraction dental bleeding

A
  • 500 mg tab in 10-20 mL sterile water or
  • 5 mL 100 mg/mL solution in 5 mL sterile water
54
Q

Mouthwas for ANUG

A

Chlorhexidine 0.1% BID

55
Q

Herpes Simplex (secondary infection) Treatment

A

Acyclovir 400 mg 5x/day X 5 days

or

Valacyclovir 2 g PO BID x 1 day

Helps during prodromal phase

56
Q

How to estimate Uosm from Urinalysis

A
  • Urine SG, take hundredths and thousandths spot as whole numbers and multiply by 35: (e.g. 1.005 = 5x35 = 175)
57
Q

Diabetes Insipidus

A
  • Central (damage to ADH producing neurons) or Nephrogenic (receptors to ADH)
  • Acquired of congenital
  • Hypernatremia
  • Water-deprivation testing/ADH testing, not in ED
58
Q

Goal of correction for hypernatremia

Danger of overcorrection

A
  • <48h (acute hypernatremia): 1 mEq/L/h
  • >48h (chronic hypernatremia): 0.5 mEq/L/h
  • risk of cerebral edema and herniation with rapid overcorrection
59
Q

K+ Replacement

A
  • Central line: KCl 20 mEq/L in 100 mL NS over 1 h
  • Peripheral line: KCl 10 mEq/L in 100 mL NS over 1 h, repeat x 3
  • PO
    • KCl Elixir 20 mEq/15 mL PO
    • Slow-K 600 mg = 8 mEq
    • Micro-K (slow-release capsule) 600 mg = 8 mEq
    • K-lyte effervescent tablet = 25 mEq
    • K-Dur (20 mEq tab)
  • Daily max = 240 mEq/day
  • *supplement Mg as well
60
Q

Mg+ Replacement

A
  • Mg Rougier 15-30mL po tid-qid
  • Mg gluconate 1-2 tabs po tid-qid; 1 tab
  • Mg sulfate 5 g in 250mL NS (or D5W) iv over 5h or 2 g in 100 mL over 1h
61
Q

ED Treatment Hyperkalemia

A
  • Calcium chloride 10% 5-10 mL IV (repeat up to 4x/h)
  • Calcium gluconate 10% 10-20 mL IV (repeat up to 4x/h)
  • NaHCO3 50-150 mEq IV
  • Ventolin Neb
  • Insulin 10 units regular (Humulin R) + 25 g D50W
  • Lasix 40-80 mg IV + 1-2 L NS bolus
  • Kayxelate 25-50 g PO/PR
62
Q

PO Replacement of Phosphate

A

Phosphate Novartis 1-2 tabs po bid-tid

63
Q

ED Treatment Hypercalcemia

A
  • 1L NS/h for 2-4 hours, 3-4 L over first 24 hours
  • Lasix 20-40 mg IV, target UO 150-200 mL/h
  • For corrected Ca2+ >3.0-3.5
  • zolendronic acid 4 mg IV over 15 min
64
Q

ECG features favouring V-tach vs. SVT

A
  • regular
  • AV dissociation
  • Capture/fusion beats
  • QRS > 160 ms
  • -ve concordance (V1-V6)
65
Q

Vereckei Criteria for Vtach vs SVT

A
  • any of these +ve in aVR = Vtach
    • initial R wave
    • initial R or Q wave > 40 ms
    • notch present on initial descending limb of predominantly negative QRS
    • ratio of vertical distance travelled during initial 40 ms of QRS : distal 40 ms < 1
  • SVTAC if none of the above are +ve
66
Q

Pava criteria for Vtach vs SVT

A
  • VT if time from isoelectric line to peak of R wave in lead II is > 50 ms
  • SVTAC if not
67
Q

Vaughan-Williams Classification of Antiarrhythmic Medications

A
  • Class I: Fast Na+ Channel Blockers
    • Ia (moderate) - procainamide
    • Ib (weak) - Lidocaine, phenytoin
    • Ic (strong) - flecainide, propafenone
  • Class II: beta-blockers
    • esmolol, labetalol, metoprolol, propranolol
  • Class III: K+ Channel Blockers
    • Amiodarone, ibutilide, sotalol (also a BB)
  • Class IV: CCB’s
    • diltiazem, verapamil
  • Unclassified
    • digoxin, adenosine, atropine, isoproterenol, magnesium
68
Q

Dose of Procainamide

A
  • 20-50 mg/min until arrhythmia controlled, hypotension occurs, QRS widens by > 50 % original width, or 17 mg/kg is given (20 min-60 min for 70 kg patient).
  • Practically: 1 g at 20-50 mg/min
  • Maintenance: 1-4 mg/min
69
Q

Beta 1 vs Beta 2 receptors

A
  • beta 1: heart muscle
  • beta 2: bronchi + vascular smooth muscle
70
Q

Esmolol

A
  • Cardioselective BB
  • Onset 2-10 min, duration 10-30 min
  • 500 mcg/kg bolus over 1 min then 50 mcg/kg/min infusion, increase by 50 mcg/kg/min Q4 min, max 200 mcg/kg/min
  • may give two additional 500 mcg/kg boluses before increasing from 50 mcg/kg/min to 100 and from 100 to 150
  • try not to discontinue abruptly
71
Q

Labetalol

A
  • combined a1 and non-selective beta blocker
  • beta > alpha ~3:1 oral and 7:1 IV
  • 20 mg IVP over 2 min
    • 40-80 mg IV q 10 min (total 300 mg)
  • 2 mg/min infusion (total 300 mg)
  • PO
    • 200 mg PO, repeat in 6- 12 h, then 400-2400 mg /day (Q6-8h)
72
Q

Metoprolol

A
  • cardioselective BB
  • 1.25 - 5 mg Q 5min IV, max 15 mg
  • 25-50 mg PO BID
73
Q

Bisoprolol

A
  • cardioselective BB
  • 2.5-20 mg PO daily
74
Q

Amiodarone

A
  • Class III but has properties of all 4 classes
  • lipophilic, large loading doses needed to saturate tissues until serum levels are maintained
  • long half-life (55 days)
  • max 30 mg/min, 2.2 g/day
  • ACLS
    • Pulseless Vtach/VF
      • 300 mg IV rapid bolus, repeat 150 mg x 1 PRN
  • Stable monomorphic VT, or polymorphic VT with normal QTc or SVT
    • 150 mg IV over 10 min then 1 mg/min for 6h then 0.5 mg/min for 18h
75
Q

Dihydropyridine vs. nondihydropyridine CCB’s

A
  • nondihydropyridine (Diltiazem, Verapamil) are cardioselective and good for rate control
  • dihydropyridine (amlodipine, nicardipine) are vascular selective and used for HTN

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