EM3 Flashcards
MC area for mesenteric ischemia lesion?
The superior mesenteric artery (SMA) is at highest risk because of its large caliber and small angle of takeoff from the aorta.
Which medication places patients at risk for mesenteric ischemia?
Digoxin
Jammed finger and now unable to extend DIP? To?
Mallet finger. distal interphalangeal joint should be splinted in slight hyperextension while allowing full range of motion at the proximal interphalangeal joint.
What is a boutonniere (buttonhole) deformity?
Extension of the MCP and DIP joints with flexion of the PIP joint. It occurs as a result of central extensor tendon disruption.
Menieres disease triad?
Sensorineural hearing loss, episodic vertigo, tinnitus
Tx pseudotumor cerebri (3)
acetazolamide, serial LPs, weight loss
Which steroid to use in myxedema coma?
Hydrocortisone is typically administered because adrenal crisis occurs frequently along with myxedema coma and lab results are not immediately available.
Type of abdominal incision in perimortem C-section? Must be done within?
Midline vertical. Do within 5 minutes of maternal loss of pulses
Indications for perimortem c-section?
Loss of maternal pulses and >24 weeks
Tx of TTP?
Plasmapheresis
negatively birefringent crystals
Gout
Pediatric dextrose administration rule?
Neonates and infants should be given 10% dextrose at 5 mL/kg IV bolus, toddlers and children (1-8) should receive 25% dextrose at 2 mL/kg IV bolus, and adolescents (8+) can be given 50% dextrose at 1 mL/kg IV bolus. Maintenance dextrose should the be started with 10% dextrose at 6–8 mL/kg/hr IV. For patients without IV access, glucagon can be given at 0.3 mg/kg intramuscularly.
Sulfonylurea OD Tx? (4)
Observe 24 hours, dextrose, charcoal and octreotide if bad
Loss of red color vision? Ass with?
Optic neuritis. Multiple sclerosis
acute hemarthroses after a sports-related knee injury
ACL tear
Which Med to give if primate bite?
Acyclovir (high transmission rate of herpesvirus)
Tx of WPW?
Procainamide
PaO2:FiO2 < 300 mm Hg
ARDS
Hypoxemia refractory to O2
ARDS
PA wedge pressure and A-a gradient in ARDS?
PA wedge pressure < 18
↑ A-a gradient
Tx ARDS? (2)
Rx: high PEEP, low TVs (6 mL/kg)
Flumazenil only works if?
BZD naive patient
First step in tx of NEC?
First NGT decompression
THEN IV ABx
child less than two years of age complaining of a rash that started after the fever went away
Roseola
Kid <2 PE will show blanching macular or maculopapular rash with a distribution that begins at the neck and trunk region and spreads to the face and extremities
Roseola
Hemolytic uremic syndrome? (3)
microangiopathic hemolytic anemia, thrombocytopenia, and renal failure
What is the optimal location for placement of a 14-gauge catheter for needle decompression of a pneumothorax?
2nd intercostal space in the midclavicular line.
What is the dose and route of administration of epinephrine for anaphylaxis in children?
0.01 mg/kg IM (max 0.3-0.5 mg) with an intravenous infusion at 0.1-0.3 mcg/kg/min (max 1 mcg/min) if needed.
Which patients with rib fractures should be admitted? (3)
Patients with flail chest, more than three rib fractures and older patients (>50) or those with multiple comorbidities/lung dz . These patients are at increased risk of developing pneumonia after rib fractures.
Most commonly fractured:
ribs 4-9
Weakest point of ribs
posterolateral angle
1st/2nd rib fractures ass with:
severe trauma
9-12 rib fractures ass with:
liver/spleen injuries
Nurse aids elbow reduction techniques (2)
Supination and flexion or hyperpronation
Vesicular lesions on the tip of the nose (Hutchinson’s sign) may indicate herpetic infection involving which nerve?
Nasociliary branch of the ophthalmic nerve.
Pericarditis pain pattern?
Pain may be improved with sitting forward and exacerbated when supine.
Tx NSAID OD?
Activated charcoal if within 2 hours of ingestion, otherwise supportive
Define pulmonary hypertension
Mean pulmonary artery pressure > 25mmHg
Tx of umbilical cord prolapse? (5)
Treatment is emergent c-section
If cesarean not possible: Trendelenburg position, knee-chest position, bladder filling, manual replacement of the cord
Of the clinical features of generalized tetanus, which usually appears first?
Trismus (“lockjaw”).
Magical thoughts and beliefs is characteristic of ?
schizotypal personality disorder.
Splitting among providers is typical of ?
borderline personality disorder.
Social seclusion and withdrawal is characteristic of ?
schizoid personality disorder.
Chlamydia conjunctivitis tx?
Oral erythromycin x14 days
Diff between SJS and TEN?
SJS <10% BSA
TEN >30% BSA
Perilunate dislocation?
dorsal dislocation of the capitate and carpus relative to the lunate
3 C’s on lateral wrist film?
The radius (the saucer) holds the lunate (the cup), and this cup contains the capitate (the apple).
Diff between perilunate dislocation and lunate dislocation?
In a perilunate dislocation, the radiolunate articulation is maintained, but the capitate is not sitting within the distal articular “cup” of the lunate. In a lunate dislocation, on the other hand, the radiolunate articulation is disrupted and the lunate is tipped towards the palm, which is known as the “spilled teacup” sign.
Perilunate dislocation associated with what other injury? (2)
60% also have scaphoid fx. Also medial nerve palsy
Tx of perilunate dislocation
Ortho emergency! Immediate closed reduction or OR if cant
TRALI? (5)
Within 6 hours of blood transfusion develop:
Hypoxemia
BL pulm infiltrates
Fever, hypotension, tachycardia
Above what serum salicylate level should you consider hemodialysis in acute and chronic aspirin toxicity?
Acute toxicity > 100 mg/dL and chronic toxicity > 60 mg/dL.
Dx of SBP? (3)
- ascitic neutrophil count (PMN) > 250 cells.
OR - serum-ascites albumin gradient > 1.1 g/dL
- WBC count > 1,000 cells/mm3
Anterior knee dislocation ass with what other injuries? (3)
Popliteal artery injury, ligamentous injury, common peroneal nerve injury (loss of eversion, dorsiflexion, sensory of medial dorsum of foot)
TM rupture tx?
D/c with ENT follow up if no infxn. PO amox if infxn.
What is the most common cause of minor hemoptysis in the emergency department?
Bronchitis
What is the classic appearance of the blood in a patient with methemoglobinemia?
Chocolate brown
Tx of impetigo?
Mupurocin or retapamulin x 5 days
What post-infectious sequelae are associated with impetigo? (2)
Rheumatic fever and poststreptococcal glomerulonephritis (in GAS-associated impetigo).
elevated alkaline phosphatase out of proportion to the transaminases
cirrhosis
Laboratory values that suggest DIC ? (5)
PT high, platelet low, PTT high, D-dimer high, and fibrinogen low
What laboratory differences will be seen in disseminated intravascular coagulation (DIC) versus thrombotic thrombocytopenic purpura (TTP)?
Coagulation studies will be abnormal in DIC and not TTP. PT, PTT, and D-dimer will be elevated and fibrinogen will be low in DIC and normal or near normal in TTP.
SC ends where in adults vs infants?
Adults - L1
Infants- L3
BL Bells Palsy (2)
Lyme and infectious mononucleosis
Tx epiglottis?
Ceftriaxone
MC cx of alcohol cirrhosis
Ascites
Tx sulfonylurea OD?
Dextrose, octreotide, 24hr obs for refractory hypoglycemia
Glipizide vs glyburide?
Both sulfonylureas but glipizide is short acting Vs glyburide is long acting
Steps for cric?
1) Prepare the skin with antiseptic solution; 2) Locate cricothyroid membrane; 3) Make a vertical incision in the midline through the skin and subcutaneous tissues; 4) Dilate the cricothyroid membrane; 5) Place a 6.0 cuffed endotracheal tube or tracheostomy tube and inflate.
Tx Raynaud’s phenomena
Rewarming, CaCB
Tx neuroleptic malignant syndrome (4)
discontinue, supportive, Benzos. Bromocriptine/dantroline if severe
What develops first in salicylate toxicity?
Resp alkalosis
oxygen saturation 85% that does not improve with O2 administration
Methemoglobinemia
Tx for methemoglobinemia?
Methylene blue
ITP tx? (2)
Steroids, IVIG
IgA vasculitis AKA?
Henosch Shonlein Purpura
HSP + abd pain?
Intussusception
HSP triad?
Arthralgias + palpable purpura + kidney involvement
ED Tx hypercalcemia?
IVF
Tx hyperviscosity syndromes?
Temporizing measures for leukemias include leukapheresis, patients with elevated proteins require plasmapheresis, and patients with polycythemia vera require phlebotomy.
Hemodialysis is generally indicated for lithium when? (5)
When the lithium level is greater than 5 mEq/L, when the lithium level is greater than 4 mEq/L in the setting of renal insufficiency, and in patients who present with altered mental status, seizures or life-threatening complications regardless of their lithium level.
Cyanide toxicity tx? (3)
Hydroxocobalam, sodium thiosulfate, amyl nitrite
2 poisonings from fire?
Carbon monoxide and cyanide (burning plastics)
Coma + anion gap metabolic acidosis + increased lactate after fire
Cyanide toxicity
Tx CMV esophagitis?
Ganciclovor
Tx delirium in elderly
Haldol
What maneuver is used to attempt to move an otolith within the semicircular canals causing peripheral vertigo?
Epley maneuver
Which antibiotics are most commonly recommended in patients admitted with fever and severe neutropenia?
Cefepime or piperacillin/tazobactam.
Hyperoxia test
When placed on 100% oxygen, the infant with a congenital heart defect will fail to increase their oxygen saturation, whereas those with respiratory causes will likely respond.
Eisenmenger’s syndrome?
Eisenmenger’s syndrome is defined by the reversal of a long-standing left-to-right shunt in congenital heart lesions to a right-to-left shunt.
Digoxin/digital is toxicity? (3)
Tx? (2)
Bradydysrhythmias/AV Blocks acute), VT/VF (chronic), hyperkalemia. Salvador Dalí mustache on ECG
Tx= immediate sodium bicarb, digoxin bonding antibodies
Adrenal insufficiency? (2)
decreased levels of mineralocorticoids resulting in hyponatremia and hyperkalemia
Signs of tumor lysis syndrome? (3)
Hyperkalemia, hyperphosphatemia and hypocalcemia
What viral illness of early childhood commonly presents with high fever for three to five days and a delayed rash after defervescence?
Roseola infantum
Carbon monoxide levels indicating hyperbaric oxygen?
carboxyhemoglobin level >25% in nonpregnant patients or >15% in pregnant patients
Janeway lesions?
Nontender macules on palms/soles (endocarditis)
Roth spots?
Retinal hemorrhages (endocarditis)
Osler nodes?
Painful palpable nodules on the fingertips
Isolated third nerve palsy?
PCA aneurism
Tetrad of Ménière’s disease?
vertigo, tinnitus, hearing loss and aural fullness
sudden, often profound, prolonged vertigo without hearing impairment in an otherwise healthy patient
Vestibular neuritis
Venom of black widow vs brown recluse?
black widow- neurotoxin. Muscle cramping + CNS excitation (Ach + NE). +antivenom
Brown recluse- cytotoxin. Local tissue destruction. No antivenom
Peds blood transfusion?
10cc/kg
Trousseau sign?
Carpopedal spasm after inflating BP cuff (hypocalcemia)
MC presenting sx of hypertrophic CMY?
Dyspnea
methylene blue is indicated in any symptomatic patient or those with methemoglobin over __%.
20%
Pruritus After warm shower
Polycythemia Vera
Risk of having ANOTHER febrile seizure? Epilepsy?
Children who have a febrile seizure have a 30% chance of having another febrile seizure at some point in the future.
The prevalence of epilepsy is slightly higher at 1-2% as opposed to the 0.5-1% of the general population.
Classic triad of intussusception?
Vomiting, colicky abdominal pain, currant jelly stool
TCA OD Sx? 3
- QRS Widening and terminal R wave in aVR
- Looks like anticholinergic
- Seizures + AMS
Normal vs abnl Head Impulse rest suggests?
A patient with central vertigo will have a normal head impulse test, characterized by the patient’s eyes remaining on the target. In a patient with a peripheral cause of vertigo, the eyes are dragged off the target followed by a corrective saccade. This is considered an abnormal head impulse test and is reassuring for vestibular neuritis.
Interpretation of nystagmus on HINTS exam?
Evaluation of nystagmus is the second component of the HINTS exam. A patient with peripheral vertigo will have unidirectional, horizontal nystagmus while a patient with a central cause will have bidirectional nystagmus (i.e., the fast component of nystagmus beats in the same direction as the gaze).
Interpretation of test of skew on HINTS exam?
Patients with peripheral vertigo will have absent skew deviation with alternate eye covering while vertical ocular misalignment is concerning for brainstem stroke.
preferred pressors in cardiogenic shock? (2) if unresponsive?
dobutamine/dopa, levophed
if unresponsive- IABP
morning stiffness that improves throughout the day?
RA
affects MCPs + PIPs
RA
leading cause of poisoning morbidity and mortality in the United States
carbon monoxide
dry cough with rapid progression to shock, coagulopathy, BL pulmonary edema, dysrhythmia, and death
hantavirus from rodent feces exposure
hard signs of neck trauma? (7) tx?
airway obs hematemesis active heavy bleeding bubbling expanding or pulsatile hematoma bruit/thrill HDUS
immediate surgical exploration (if soft sign –> further testing)
joint pain worse w/ use
OA
Heberden’s nodes
OA
hard bony swelling of DIPs
OA
Is a glucose level of 40 mg/dL atypical in a newborn at two hours old?
No, as a newborn transitions from continuous glucose supply from the placenta to intermittent feeding, glucose normally drops to about 40 mg/dL at two hours, before stabilizing at four to six hours of life.
ezcema worse w/?
cold temps, stress, inc body heat (exercise)
3 MC sites of FB obstruction?
C6 > T4 > T11
