EM2 M4 Flashcards
guideline ETT tube depth at lip line adult male vs female
22-24cm adult male
21-23cm adult female
asthma epidemiology
prevalence in 1980’s vs 1990’s
male vs female
white vs black
asthma epidemiology
inc prevalence in 1980’s vs dip in 1990’s
more male peds vs more female adults
more black than white
inhaled vs IV steroids for acute asthma exacerbation?
IV because may have difficulty with inhaled/oral in acute asthma exacerbation
otherwise equally efficacious routes
which is most beneficial in an acute COPD exacerbation, steroids or beta agonist?
beta agonist is most beneficial in an acute COPD exacerbation
TF
in CAP, co-infection with multiple bacteria such as chlamydia and strep pneumo commonly occurs
T
in CAP, co-infection with multiple bacteria such as chlamydia and strep pneumo commonly occurs
TF
cigarrette smoke is a risk for strep pneumo pneumonia
F
^65, alcoholism, dm, cardiovascular disease, splenectomy, scd, malignancy, immunosuppresion are risks for strep pneumo cap
not smoking
TF
Varicell Zoster virus infection can present as pneumonia, more commonly in kids than adults
T
Varicell Zoster virus infection can present as pneumonia, more commonly in kids than adults
TF
CMV does not usually cause pneumonia in immunocompetent adults
T
CMV does not usually cause pneumonia in immunocompetent adults
TB facts
- rank on deadlist bugs list
- % world pop infected with TB
- % US pop infected with TB
- incidence trend in US
- incidence trend of MDR TB
TB facts
- # 1 rank on deadlist bugs list
- 33% world pop infected with TB
- 4-6% US pop infected with TB
- incidence trend in US v in 1950s from public health advancements, ^ since 1980s espec in low SES
- incidence trend of MDR TB ^ espec in AIDS pts
why can klebsiella pna cause currant-jelly sputum
klebsiella pna can cause severe necrotizing hemorrhagic pna which causes the currant-jelly sputum, especially in elderly or debilitated… also often complicated by abscess, empyema, bacteremia, and high mortality
5 most common pathogens causing cavitary lung lesion
TB anaerobic bacteria (aspiration pna) aerobic gnrs staph aureus fungal disease
strongest consideration for whether to admit pt for pneumonia… age? comorbidities? vitals?
comorbidities vs Elderly
clinical decision…
which part of the right lung is most likely to become atelectatic after food aspiration
right middle lobe most likely to become atelectatic from aspiration – lobar bronchus to right middle lobehas acute takeoff and poor collateral ventilation
What does Heliox do
Heliox (mixed helium and oxygen) decreases turbulence of air flow to facilitate air movement into the airways
- Pulseless electrical activity in Emergency Department cardiac arrest victims is associated with PE in __%
- Up to ___ of patients with PE have no symptoms of DVT. PE is also found in about ___ of patients who have DVT but who do not have symptoms of PE. Thus, the presence or absence of DVT or symptoms of DVT does or does not? correlate well with the finding of PE.
- Pulseless electrical activity in Emergency Department cardiac arrest victims is associated with PE in 33%
- Up to 2/3s of patients with PE have no symptoms of DVT. PE is also found in about 1/2 of patients who have DVT but who do not have symptoms of PE. Thus, the presence or absence of DVT or symptoms of DVT does or does not? correlate well with the finding of PE.
__% of PE patients without identifiable risk factors are diagnosed with cancer within __ years
So…
25% of PE patients without identifiable risk factors are diagnosed with cancer within 2 years
So development of PE without any identifiable risk factors warrants a search for an underlying malignancy.
High vs low risk cancers for PE
esophageal and laryngeal cancer, as well as leukemia and lymphoma have a low incidence of PE, whereas those with ovarian or colon cancers are at higher risk for developing PE
TF
Hematologic cancers such as leukemia have higher risk of PE
F
esophageal and laryngeal cancer, as well as leukemia and lymphoma have a low incidence of PE, whereas those with ovarian or colon cancers are at higher risk for developing PE
development of PE without any identifiable risk factors warrants a search for…
Development of PE without any identifiable risk factors warrants a search for an underlying malignancy
Because 25% of PE patients without identifiable risk factors are diagnosed with cancer within 2 years
EKG changes with PE
Tachycardia and non-specific ST-segment and T-wave abnormalities are the most common findings on EKG of patients with PE; however up to 25% will have EKGs unchanged from their baselines. An S1-Q3-T3 pattern is suggestive but not diagnostic of PE. Right bundle branch block may also be seen in PE, but does not indicate pulmonary infarction or severity of PE. Diffuse PR depression is typically seen in pericarditis
____ is a common cause of pneumonia in young adults. It is classically associated with bullous myringitis
Mycoplasma pneumoniae is a common cause of pneumonia in young adults. It is classically associated with bullous myringitis
____ is the most common cause of community- acquired pneumonia. ____ is the second most common cause.
Streptococcus pneumoniae is the most common cause of community- acquired pneumonia. Viral is the second most common cause.
____ is not a common cause of community-acquired pneumonia. It generally occurs in the elderly, smokers, alcoholics, and those with other co-morbidities. It is classically associated with a bulging fissure on chest X-ray and …
Klebsiella is not a common cause of community-acquired pneumonia. It generally occurs in the elderly, smokers, alcoholics, and those with other co-morbidities. It is classically associated with a bulging fissure on chest X-ray and currant jelly sputum.
_____ is an atypical pathogen commonly causing pneumonia. It is often found in the elderly or others with co-morbid illnesses. It is classically associated with GI symptoms and relative bradycardia
Legionella is an atypical pathogen commonly causing pneumonia. It is often found in the elderly or others with co-morbid illnesses. It is classically associated with GI symptoms and relative bradycardia
Treat torsades
Mag
Then cardioversion if persisting
(Unlikely to respond to cardioversion without adjunctive therapy like mag)
In PEA, in addition to providing effective cardiopulmonary resuscitation, what management step is most likely to result in survival?
Identification and treatment of a reversible underlying etiology (H’s and T’s)
Unstable VT is treated by…
Unstable VT is treated by a series of three stacked shocks, before medications. Early defibrillation is the key to successful resuscitation
Many resuscitation drugs can be given via endotracheal tube. When this method is used, what (if any) change in dosing is recommended?
2-2.5x the IV dose when given endotracheally
Epi dose in ACLS
1 milligram IV or IO of a 1:10,000 solution every 3 to 5 minutes. Doses >1 milligram are not recommended and may be harmful.”
Treat asystole
The treatment of choice for asystole is
epinephrine or vasopressin and atropine
It is important to check that the monitor is working and to check
a second lead to rule out very fine ventricular fibrillation.
Treat complete av block type III
Permanent pacing usually
Brady ventricular rate
TF
The chin-lift maneuver risks spinal injury due to its employment of neck extension.
T
In many patients in the Emergency Department, the inability to rule-out cervical spine injury negates the option to use the chin-lift maneuver, since this method of airway opening can exacerbate C-spine injury.
blood Ph, bicarb level in DKA vs HHNC?
patients with DKA typically have profound metabolic acidosis with serum bicarbonate < 10mEq,
acidosis is typically absent in patients with HHNC and serum bicarbonate is usually > 15 mEq
ketones glucose BUN levels in DKA vs HHNC?
Serum ketones are present in patients with DKA but not usually in patients with HHNC.
Patients with HHNC typically have blood glucose > 700 mg/dL, whereas patients with DKA have blood glucose > 350 mg/dL.
BUN is elevated more in patients with HHNC (>50 mg/dL) than in patients with DKA (25-50 mg/dL).
Hydration status and Na K Mag Phos status of pt in DKA
Patients with DKA are typically severely dehydrated with a total body water deficit of approximately 70-80 mL/kg, in addition to being total body depleted of potassium, magnesium, and phosphorous despite initially normal serum levels of these electrolytes.
Correct sodium about +2 for every 100 glucose over 100
____ is contraindicated in patients with HHNC as it may impair endogenous insulin release and is often ineffective in the management of seizures associated with HHNC
Phenytoin (Dilantin) is contraindicated in patients with HHNC as it may impair endogenous insulin release and is often ineffective in the management of seizures associated with HHNC
Phenytoin (Dilantin) is contraindicated in patients with HHNC as it may impair endogenous ____ release and is often ineffective in the management of ____ associated with HHNC
Phenytoin (Dilantin) is contraindicated in patients with HHNC as it may impair endogenous insulin release and is often ineffective in the management of seizures associated with HHNC
In HHNC managment:
____ is contraindicated as it may impair endogenous insulin release and is often ineffective in the management of seizures associated with HHNC. ____ of the fluid deficit should be replaced over the first __ hours, and the remainder over the ensuing __ hours. ____ must be tightly monitored as fluid resuscitation alone may normalize serum ____ or precipitate ____ in aggressive fluid resuscitation. Too-rapid correction of hyperosmolality may result in development of ____, especially in ____. ____ should be considered in patients with severe dehydration due to increased risk of thrombosis from ____ and ____
Phenytoin (Dilantin) is contraindicated in patients with HHNC as it may impair endogenous insulin release and is often ineffective in the management of seizures associated with HHNC. Half of the fluid deficit should be replaced over the first 8 hours, and the remainder over the ensuing 24 hours. Glucose must be tightly monitored as fluid resuscitation alone may normalize serum glucose or precipitate hypoglycemia in aggressive fluid resuscitation. Too-rapid correction of hyperosmolarity may result in development of cerebral edema, especially in children. Subcutaneous heparin should be considered in patients with severe dehydration due to increased risk of thrombosis from hypovolemia and hyperviscosity
Regarding the development of cerebral edema in patients being treated for DKA:
Patients with serum glucose below __ mg/dL still being treated with ____ are most likely to develop clinically evident cerebral edema. Cerebral edema typically occurs __ hours following onset of treatment. ____ have a higher incidence of cerebral edema. Mortality of patients developing cerebral edema is __%. ____ __ mg/kg should be administered upon any change in mental status of ____ being treated for DKA as they are at high risk for developing ____ especially when being treated with ____ and serum ____ is below __ mg/dL…. steroids for cerebral edema?
Regarding the development of cerebral edema in patients being treated for DKA:
Patients with serum glucose below 250 mg/dL still being treated with insulin are most likely to develop clinically evident cerebral edema. Cerebral edema typically occurs 6-10 hours following onset of treatment. Children have a higher incidence of cerebral edema. Mortality of patients developing cerebral edema is 90%. Mannitol .25-.5 mg/kg should be administered upon any change in mental status of children being treated for DKA as they are at high risk for developing cerebral edema especially when being treated with insulin and serum glucose is below 250 mg/dL…. Steroids are not indicated for treatment of cerebral edema and may actually worsen DKA
Hyperkalemia with EKG changes is treated with ____ in order to ____. It works quickly and is relatively safe unless patients are ____. Other treatments for acute hyperkalemia include ____ and ____.
Hyperkalemia with EKG changes is treated with calcium to stabilize cardiac membranes. Calcium works quickly and is relatively safe unless patients are digitalized. Other treatments for acute hyperkalemia include sodium bicarbonate and insulin/glucose.
An EKG showing signs of hyperkalemia is characterized by ____. Other EKG changes include ____ and ____. The heart rate may be ____, with ____ and ____ as the terminal events. Acute myocardial ischemia can be represented by ____ as well, but in these cases…
An EKG showing signs of hyperkalemia is characterized by diffuse peaked T waves. Other EKG changes include widening of the QRS complex and biphasic QRS-T segments. The heart rate may be slow, with ventricular fibrillation and cardiac arrest as the terminal events. Acute myocardial ischemia can be represented by hyperacute T waves as well, but in these cases the T wave changes are more likely to be focal (i.e. in an anatomical distribution corresponding to the area of threatened myocardium).
In managing hypoglycemia:
Glucagon is ineffective in patients …. , as would be expected in ____. Further, glucagon can precipitate ____ in patients with ____ diseases and therefore should not be used in ____ with hypoglycemia of unknown etiology. Typical symptoms of hypoglycemia include ….. . Symptoms should not be attributed to hypoglycemia unless the level falls below __ mg/dL. Type 1 diabetics practicing strict control of serum glucose are at high risk for hypoglycemic episodes precipitated by ____, or by ____ or ____ . Due to the ____ of the oral hypoglycemic agents, hospitalization and __ hours observation (at minimum) are the typical management for overdose of these agents.
Glucagon is ineffective in patients without adequate glycogen stores, as would be expected in alcoholics. Further, glucagon can precipitate a severe lactic acidosis in patients with glycogen storage diseases and therefore should not be used in children with hypoglycemia of unknown etiology. Typical symptoms of hypoglycemia include sweating, tachycardia, nervousness, hunger, and neurologic symptoms (virtually any neurologic deficit). Symptoms should not be attributed to hypoglycemia unless the level falls below 40-50 mg/dL. Type 1 diabetics practicing strict control of serum glucose are at high risk for hypoglycemic episodes precipitated by skipping a meal, or by increasing energy output or insulin dose. Due to the extended half-lives of the oral hypoglycemic agents, hospitalization and 24-hour observation (at minimum) are the typical management for overdose of these agents.
TF
Hypoglycemia can present with virtually any neurological deficit
T
Hypoglycemia can present with virtually any neurological deficit
Temperature range, mental status, shivers, heart rate, respiratory rate in patient with moderate hypothermia
Moderate hypothermia is associated with temperatures of 28-32 C. Shivering ceases at about 32 degrees Celsius. Moderate hypothermia is associated with altered mental status, absence of shivering, bradycardia, and bradypnea.
Manage frostbitten extremity
expected symptoms
Immersion of the affected extremity is the mainstay of treatment for patients with frostbite. Numbness of the affected area is the most common initial symptom and severe pain is frequently encountered after rewarming. Tetanus prophylaxis and debridement is indicated , but is not the most appropriate initial step in the management of patients with frostbite
TF Free T4 and TSH levels are typically low in secondary and tertiary hypothyroidism
TF Free thyroxine (T4) is always depressed in hypothyroid states.
TF Serum thyroid-stimulating hormone (TSH) is the most sensitive test to diagnose primary hypothyroidism
TF T3 level may be normal in hypothyroid states.
TF Total thyroxine levels may be normal due to elevated thyroxine-binding globulin (TBG) levels.
T Free T4 and TSH levels are typically low in secondary and tertiary hypothyroidism.
F Free thyroxine (T4) is NOT always depressed in hypothyroid states… Free T4 may be normal in early stages of hypothyroidism due to physiologic compensation from elevated TSH levels.
T Serum thyroid-stimulating hormone (TSH) is the most sensitive test to diagnose primary hypothyroidism
T T3 level may be normal in hypothyroid states.
T Total thyroxine levels may be normal due to elevated thyroxine-binding globulin (TBG) levels.
How does hypothyroidism affect glucose sodium cholesterol blood count acid/base status?
Hyperglycemia is not typically associated with hypothyroidism. Hypoglycemia may be present, but is unusual, and may suggest hypothalamic-pituitary involvement. Hyponatremia is common and corrects with thyroid replacement. Hypercholesterolemia to over 250 mg/dL is typical. A mild normochromic, normocytic anemia may be present, in addition to respiratory acidosis from hypoventilation.
Azotemia is…
Azotemia is an elevation of blood urea nitrogen (BUN) and serum creatinine levels. The reference range for BUN is 8-20 mg/dL, and the normal range for serum creatinine is 0.7-1.4 mg/dL.
How does adrenal insufficiency affect K Na glucose calcium bun Cr hematocrit?
Hyperkalemia is seen in approximately 64% of patients with adrenal failure. Typically this is because of aldosterone production failure that normally enhances potassium excretion. Even more common is hyponatremia, present in 88% of patients. Hypoglycemia is present in two-thirds of patients and is a significant cause of morbidity and mortality associated with adrenal failure. Hypercalcemia is seen in 6 to 33% for unclear reasons; azotemia (elevated BUN and Cr) and increased hematocrit from hypovolemia may also be present.
Manage suspected adrenal insufficiency
Dexamthasone is the treatment of choice in suspected but not confirmed adrenal insufficiency. It will not affect the serum cortisol level; therefore, it will not interfere with the diagnosis of adrenal insufficiency using the ACTH stimulation test. Administering cosyntropin, a synthetic form of ACTH, and measuring the serum cortisol levels typically perform the ACTH stimulation test. In confirmed adrenal insufficiency, hydrocortisone IV or cortisone IM are the treatments of choice.
How does secondary adrenal insufficiency affect… weight strength appetite skin pigmentation
Weight loss, weakness, anorexia and nausea and vomiting, normal skin pigmentation:
Hyperpigmentation is seen in greater than 90% of Primary adrenal insufficiency. It is a result of compensatory adrenocorticotropic hormone (ACTH) and melanocyte-stimulating hormone (MSH) secretion. The secretion is a feedback mechanism that is not activated in secondary adrenal insufficiency, for example, adrenal insufficiency from pituitary infarction or hypothalamic insufficiency.
Hyperpigmentation is seen in greater than 90% of ____ adrenal insufficiency. It is a result of compensatory ____ and ____ secretion
Hyperpigmentation is seen in greater than 90% of Primary adrenal insufficiency. It is a result of compensatory adrenocorticotropic hormone (ACTH) and melanocyte-stimulating hormone (MSH) secretion
4 contraindications to hyperbaric oxygen therapy
Untreated pneumothorax is an absolute contraindication to HBO therapy. The reason is concern that it can progress to tension pneumothorax, especially during the decompression phase of therapy….. The COPD patient with a large bleb represents a relative contraindication for similar reasons….. Treatment with doxorubicin, and many other drugs – such as cisplatin (Cisplatinum®), bleomycin (Blenoxane®), disulfiram (Antabuse®), and mafenide acetate (Sulfamylon®) – contraindicates HBO therapy because of potentially toxic effects when combined with HBO….. URI illnesses such as otitis media are relative contraindications, due to the potential for tympanic membrane rupture secondary to inability of the ears to equalize pressure during therapy. This can be addressed through myringotomy with placement of tubes (in cases where multiple HBO treatments are anticipated).
TF
Pregnancy contraindicates hyperbaric oxygen therapy
F
In pregnant patients, HBO therapy has been shown to be safe for the fetus when given at appropriate levels and “doses” (durations). In fact, pregnancy lowers the threshold for HBO treatment of carbon monoxide-exposed pregnant patients. This is due to the high affinity of fetal hemoglobin for CO.
6 indications for hyperbaric oxygen therapy… necrotizing enterocolitis?
carbon monoxide poisoning decompression sickness air or gas embolism crush injury compartment syndrome necrotizing fasciitis NEC FAC
Not necrotizing enterocolitis
advise/manage a novice mountain climber suffering from mild but worsening headache and nausea. Can he go on climbing with some medications?
The syndrome of high altitude illness ranges from mild AMS (Acute Mountain Sickness) to life threatening conditions of HAPE (High Altitude Pulmonary Edema) and HACE (High Altitude Cerebral Edema). This patient is experiencing mild AMS. After the symptoms of altitude illness occur, further ascent to a higher sleeping altitude is contraindicated. Halting ascent or activity to allow further acclimatization may reverse symptoms….. Acetazolamide is a carbonic anhhydrase inhibitor that induces a renal bicarbonate diuresis, causing a metabolic acidosis and thereby increasing ventilation and arterial oxygenation….. Supplemental oxygen addresses the hypoxic insult of high altitude exposure….. Ibuprofen is useful for the treatment of his headache….. Dexamethasone can help with the symptoms of AMS, but does not play a role in acclimatization.
Which endocrine abnormality is the most likely cause of a-fib
How to treat a-fib… pace?
Hyperthyroidism can cause a-fib
AF’s many treatment options include calcium channel blockers, beta blockers, amiodarone, quinidine, and cardioversion. Pacing is not a treatment option.
Thyroid storm… straightforward dx? Can it be diagnosed in the absence of tered mental status? When to start treatment? How to screen?
diagnosis of thyroid storm in the emergency department may be challenging due to the relatively infrequent occurrence of the disease and its typically nonspecific signs and symptoms…. may be mistaken for psychiatric illness, heat stroke, sympathomimetic toxidromes, hypoglycemia and withdrawal syndromes, among others….. Altered mental status, though frequently present, is not a prerequisite for diagnosis….. Treatment should be initiated in a timely fashion in any patient suspected of having thyroid storm due to the potential lethality of this disease…… Immediate laboratory testing is typically not available to confirm clinically suspected cases, although thyroxine (T4) radioimmunoassay and free T4 index are good screening tests for hyperthyroidism.
Symptoms of thyrotoxicosis
Fever, nervousness, weight loss, thyrotoxic stare, thyromegaly, palpitations, tachycardia, congestive heart failure, wide pulse pressure, tremor
How to give iodine for thyroid storm
Iodine inhibits preformed thyroid hormone release and should be administered at least one hour after treatment with PTU to prevent organification of iodine. A typical dose is potassium iodide (SSKI) 5 drops every 6 hours PO or NG, or sodium iodide 1 gm slow IV drip every 8 to 12 hours. Iodine should not be administered to patients with known iodine allergy.
Common components of supportive treatment of thyroid storm… amiodarone for afib? aspirin for antipyrexia?
oxygen corticosteriods acetaminophen to manage hyperpyrexia diuretics to treat congestive heart failure propanolol
Not amiodarone… amiodarone is an iodine-rich antidysrhythmic with poorly-defined effects on thyroid function that has been associated with both hyperthyroidism and hypothyroidism. It should therefore be avoided in the management of thyroid disease. Propranolol is standard therapy in thyroid storm and, in addition to its effects of adrenergic blockade, also may reduce dysrhythmias….. Of note, aspirin should be avoided in the treatment of hyperpyrexia as it may increase the level of active thyroid hormone by displacing thyroid hormone from thyroglobulin.
Symptoms of Scorpion envenomnation… who is most affected… treatment…prognosis…
Most scorpion envenomations are mild, limited to pain and paresthesias at the site of envenomation. Children are affected more severely than adults: restlessness, jerking movements of the limbs, roving eye movements, and drooling are seen in severe cases. Anaphylaxis can also occur….. Intubation is required rarely….. Most envenomations require analgesics only; ….. antivenom is indicated for severe reactions and anaphylaxis. Antivenom treatment is not without complications – serum sickness, and immediate and delayed hypersensitivity reactions occur….. Without antivenom treatment, symptoms usually last for 1-2 days.
