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IPAP > EMED 2 > Flashcards

EMED 2 Flashcards

1
Q

Define Mental Status

Define Delerium

A

Clinical state of emotional and intellectual function

Transient disorder of impaired attention and cognition w/ difficulty shifting/maintaining attention

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2
Q

Define Dementia

Define Coma

A

Failure of content portion of consciousness w/ preserved alerting functions

Failure of arousal and content functions

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3
Q

Define the pathophysiologies for delirium

A

Wide neuron/transmitter dysfunction due to:

Priary intracranial dz (bleed mass stroke)

Systemic dz (pyelonephritis UTI sepsis)

Exogenous toxin (drug poison)

Withdrawal (DTs opiates)

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4
Q

What are the two etiologies of dementia

What causes a stroke?

A

Idiopathic- Alzheimer’s
Vascular- cerebrovascular dz w/ multiple/repeat infarction

Deficiency of glucose/O2 supply

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5
Q

What are the different coma etiology categories?

A

Uncal: medial lobe pushes on brain stem/CN3= ipsilateral pupil dilation, hemiparesis

Central herniaion: cerebral edema of increased ICP causing LoC, loss of brain stem reflexes, decorticate posture, irregular RR

Inc ICP- >15mmHg decreases perfusion leading to ischemia

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6
Q

Define Kellie-Monroe doctrine

What is the equation

A

Increase of one fluid within the brain should cause reciprocal decrease of the other two pressures

CPP= MAP - ICP

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7
Q

How long does it take for delirium to develop?

How does it present

A

Hours to days

Altered thinking, memory and perception
Outbursts Hallucinations HTN Asterexis Tachy Sweat Somnolence/Sun downing

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8
Q

How long does it take for dementia to develop?

Define the characteristic Alzheimer’s onset

A

Slow and insidious onset of hallucinations, repetitive behavior, delusion/depression

Impaired memory/orientation w/ preserved speech/motor ability

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9
Q

What are the two categories of dementia?

How does each present

A

Idiopathic, forgetfulness of-
Early: items, names
Mid: direction reading social
Sev: personality self-care disorientation

Vascular:
Gait abnormality
Extremity weakness
DTRs exaggerated/asymmetric

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10
Q

What are the 3 causes of comas

A

Diffuse- toxic/metabolic
Small reactive pupils, no PE findings

Focal- structural coma
Supratentorial (uncle)- HTN, bradycardia, WPP

Infratentorial- abrupt coma, extensor posture, no pupil reflex/EOMs

Pseudo- faker won’t look at you
+nystagmus w/ caloric test

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11
Q

How is delirium Dx

What labs are ordered

What rads are ordered

A

Hx PE Medication consolidaiton

CBC LP UA E+ HR function

CXR Head CT

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12
Q

How is dementia Dx?

What labs are ordered?

What rads are ordered?

A

Hx PE

LCC STUB CHEF

CT MRI

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13
Q

How is GCS measured

How does opiate syndrome coma present

A

Motor: FLWFEN
Verbal: OCIIN
Eye: SCPN

Hypoventilation
Small pupils

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14
Q

How does cholinergic syndrome coma present?

Asymmetric PE findings in coma PTs means?

Extensor/flexor posturing indicates?

A

Miosis Lacrimation Seizure

Focal CNS lesion

CNS dysfunction

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15
Q

What is the imaging modality of choice for AMS?

How is delirium PTs managed?

A

Non-contrast CT

Tx underlying issue
Haldol/Benzo w/ capnography
B52- Benadryl, Ativan, Haldol

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16
Q

What is the disposition for delirium, dementia, coma?

What are the causes of delirium in elderly PTs

A

Reversible can be d/c
Admit all others

Pneumonia UTI Sepsis Skin infxn
Metabolic/toxin
Drugs
Infection
Neuro
Cardiopulm
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17
Q

What are the DDx for coma

A 
Alcohol Acidosis Arrhythmia
Endocrine E+ Encephalopathy
Infection
O2 OD Opiates
Uremia
Trauma Temp Thiamine
Insulin
Poison Psych
Stroke Seizure Space lesion Shunt malfunction
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18
Q

DDx for delirium

DDx for dementia

A

Non-convulsive/complex partial status epilepticus

Hypothyroid UTI CHF- mild but functional dementia

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19
Q

PT w/ seizure Hx hasn’t woken up after 30min since seizure stopped needs to have ? DDx considered

What is the 5th MC Sx seen in the ED?

A

Non-convulsive status epilepticus

HAs

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20
Q

Primary HAs include?

Secondary HAs include?

A

Migraine Cluster

Tumor Meningitis SAH

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21
Q

HA onset during exertion needs to have ? two Dxs considered

HA associated w/ valsalva indicates ? issue?

A

SAH
Arterial dissection of carotid or vertebrobasilar circulation

Intracranial abnormality

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22
Q

? PT population w/ new or worsening HA is high risk

Why is this risk present?

A

> 50y/o w/ new or worsening HAs

Migraine, cluster, and tension HAs decrease w/ age

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23
Q

PTs on what three classes of meds are at increase risk for hemorrhage and automatically get CT scan?

A

Anticoagulants
Antiplatelets
ABX

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24
Q

Define Reversible Cerebral Vasoconstriction Syndrome

Why does this occur

A

Coke/Meth/Amphetamine use increases risk for hemorrhage

Vasospasm and ischemia affects smooth muscles

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25
Q

? renal dz causes PTs to be at risk for intracranial aneurysm

What PE finding indicates an infection or brain hemorrhage?

What PE exam needs to be done?

A

PolyKDz

Meningismus

ENT for OM and sinusitis

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26
Q

? eye issues can present as HA?

Intraocular pressure above ? is abnormal

A

Scleritis
Enophthalmitis
Acute ACG

> 21

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27
Q

If PT is high risk, what labs are drawn for HAs?

What form of imaging is done for these PTs

A

BMP ESR
CBC Coags Culture CSF

NCHCT regardless of Sxs
MRI- arterial dz

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28
Q

What can be diagnostic and therapeutic for HAs?

What part of this is critical?

A

LP

Opening pressure

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29
Q

When can an LP be down w/out prior imaging?

When do HA PTs need to be d/c w/ follow up plans

A

No ImmSupp,
No focal neuro deficit and,
Normal sensorium

High risk- GCA, IIHTN
Chronic HAs

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30
Q

What is the classic presentation of meningitis

When can the head CT be delayed until after LP for these PTs

A

HA (MC) + Triad: fever (2nd MC) AMS stiff neck

Awake/alert
No papilledema, focal neuro deficit, ImmComp or new onset seizure

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31
Q

What are the common pathogens of bacterial meningitis

Where are these pathogens found?

A 
Strep pneumo
GBS
N meningitidis
H influenza
L monocytogenes
SP: penetrating head trauma
NM: dorm, barracks
HI: unvaccinated
LM: alcoholics
Staph A/Strep: post-craniotomy
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32
Q

How is bacterial meningitis Tx

A 
ABCs, labs, cultures
Empiric ABX w/ Dexameth during 1st dose
Non contrast CT
LP
Admit w/ droplet isolation
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33
Q

Why are SAHs so dangerous?

75% of SAHs are caused by ?

A

50% have 30 day survival rate

Ruptured aneurysm

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34
Q

What are the SAH RFs in the AD/Ret population

What is the first step for suspected SAHs

A

FamHx Alcohol Smoking HTN

Non contrast CT
Sens best after Sx onset
Spec best 6-12hrs later

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35
Q

What is the next step for suspected SAH if CT is negative?

Why is this next step so important?

A

LP for RBCs or xanthochromia

Normal CT, no xanthochromia/RBCs= SAH exclusion

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36
Q

When are SAH PTs at the highest risk for re-bleeds?

How is this risk window reduced?

What meds need to be avoided?

A

First 24hrs

BP control- Labetalol/Nicardipine

Nitroprusside
Nitroglycerine

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37
Q

How are all SAH PTs managed?

What PT populations are at risk for non-traumatic intracranial hemorrhage?

A

Neurosurgery consult
Admit to ICU

Elderly
Alcoholic/drug abuse
Anti-platelet/coagulant

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38
Q

PTs presenting w/ ? Sx duo have cerebellar hemorrhage until proven otherwise?

How do brain tumors cause HAs

A

Acute HA
Vestibular Sxs- vertigo/ataxia

CSF flow obstruction
Intracranial HTN

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39
Q

What PE findings suggest brain tumor

What is the preferred imaging modality?

A 
Abnormal neuro exam
Worse w/ valsalva
Mental status change
Awakes from sleep
Recent Ca Dx
Seizures

MRI w/out gadolinium
Non contrast CT is used, but misses small mass

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40
Q

Cerebral venous thrombosis is suspected when PTs present w/ HA and ? Sxs

If PT has abnormal CT, focal neuro deficit or AMS, what is the definitive way to Dx cerebral venous thrombosis

A

Female
Hypercoagulable
Peripartum
Recent SurgHx

MR venography

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41
Q

What PE finding should prompt suspicion of cerebral venous thrombosis

How does Posterior Reversible Encephalopathy
Syndrome present?

Who does this occur more often in?

A

Inc opening LP pressure

Severe HA
Visual changes
Seizure
Encephalopathy

ImmSupp
Chemo PTs
ESRenal Dz

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42
Q

What is the imaging modality for Posterior Reversible Encephalopathy
Syndrome

How is it Tx

When is this Dx considered

A

MRI
CT will be normal

BP management

Thunderclap HA and SAH is r/o

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43
Q

What is the characteristic of Posterior Reversible Encephalopathy
Syndrome etiology?

How do PTs w/ GCA present

What needs to be measured and r/o

A

Cerebral vasospasm from cocaine/amphetamines

>50y/o
Fatigue Fever 
Proximal muscle weakness
Jaw claudication
Transient vision loss

IOP to r/o glaucoma

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44
Q

How is Temporal Arteritis Dx

How is Temporal Arteritis Tx

A 
3 of: 
\+50y/o 
New HA
Abnormal artery/biopsy
ESR >50mm

Prednisone 60mg PO
Consult w/ Rheum/Ophthal

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45
Q

What are the MC auras to occur w/ migraines

What med is used as first line abortive therapy?

How are these initially Tx?

A

Scotoma- light headed
Scintillations- vision changes

Triptans

IV hydration NSAIDs anti-emetic/histamine
Steroids to reduce re-occurrence after d/c

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46
Q

What meds can and cannot be used for migraine Tx during pregnancy

A

Triptans, Ergotamines (caffeine/isometheptene combo)- c/i

Acetaminophen, Opioids, CCS Metoclopramide- ok
NSAIDs until 3rd-T

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47
Q

What needs to be given to migraine PTs upon d/c?

II-HTN is AKA and is MC in ?

A

Abortive meds

Pseudotumor Cerebri
Obese women 20-44y/o

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48
Q

What are the prominent Sxs of II-HTN?

Why does this Dx need to be ID’d fast?

A

HA
Transient visual obscurations
Back pain
Pulsatile tinnitus

Permanent visual impairment

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49
Q

What is the Dx criteria for II-HTN

What is necessary to complete/confirm Dx

A

Papilledema w/ normal neuro exam
Inc opening pressure on LP (>25mm)
Normal CSF, images

LP- can be Dx and Thx

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50
Q

How is II-HTN Dx if there is no papilledema or abducens palsy?

What medication can be used to help lower ICP for these PTs?

A 
Need 3 of:
Empty sella
Flat posterior globe
Distended perioptic subarachnoid space
Transverse venous sinus stenosis

Acetazolamide

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51
Q

What criteria needs to be met in order to Dx cluster HAs

What is the first line Tx for cluster HAs?

A

5 attacks that are:
Severe Unilateral 15-180min and Circadian w/ one ipsilateral:
Ptosis Edema Miosis Congestion Injection Lacrimatoin

100% O2 12L/min NRB
Sumatriptan

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52
Q

Define Stroke

What are the 3 categories and types of stroke

A

Dz process that interrupts blood/substrate flow
Injury causing edema/mass effects to brain

Ischemic- thrombotic hypoperfusion embolic

Hemorrhagic- intracerebral subarachnoid

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53
Q

What is the mechanism of thrombotic strokes?

What are these a common cause of?

A

Narrowing of damaged lumen by in situ process (clot formation)

Gradual waxing/waning Sxs
Common cause of TIAs

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54
Q

What is the mechanism of embolic strokes?

How do these present and what do they account for?

A

Obstruction of normal lumen by material from remote source

Sudden onset, 20% of ischemic strokes

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55
Q

What is the mechanism of hypoperfusion strokes?

How do these present

A

Low blood flow

Injury to water shed areas w/ wax/wane Sxs

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56
Q

What is the mechanism of hemorrhagic strokes?

Where are these more common?

A

Intraparenchymal hemorrhage from weakened arterioles
Inc ICP causes damage, constriction changes perfusion

Asians/Africans

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57
Q

What is the mechanism of non-traumatic subarachnoid strokes?

How are these types of strokes foreshadowed?

A

Hemorrhage into subarachnoid space

Preceded by sentinal HA (warning leak)

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58
Q

What are the general Sxs of strokes?

What is used to grade the PTs Sxs

A

General: Facial droop Arm drift Abnormal speech
Subtle: weak, light headed, vague sensory changes

Cincinnati pre-hospital scale

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59
Q

Traditional stroke Sx women present with?

Non-traditional Sx they present w/ ?

What is an odd non-traditional Sx

A

AMS

General weakness

Hiccups

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60
Q

Embolic/hemorrhagic strokes present as?

Thrombotic/hypoperfusion strokes present as ?

? type of stroke is suspected when HA w/ valsalva or lifting?

A

Sudden onset Sxs

Wax/wane Sxs
Stuttering

Cerebral aneurysm rupture

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61
Q

? type of injury can present after neck trauma or manipulation?

RFs for thrombus stroke and how it will be seen on PE

A

Cervical artery dissection

HTN DM Atherosclerosis
Transient neuro deficits in SAME vascular distribution

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62
Q

RFs for embolus stroke and what will be seen on PE

When are stroke Sx onset calculated?

A

A-fib
Valve replacement
Recent MI
Transient neuro deficits in DIFFERENT vascular distributions

Time of last known baseline/normal

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63
Q

Inclusion criteria for rtPA during strokes?

A

Measureable Dx: >22 poor
Sx onset <3hrs
18 or older

64
Q

Exclusion criteria for rtPA use during strokes?

A 
Head trauma/stroke <3mon
SAH Sxs
Arterial puncture <7days
Hx ICH
Intracranial Ca/AV-mal/aneurysm
Cranial/spine surgery recent
Active internal bleeds
Platelets <100K
Heparin use <48hrs and prolonged aPTT
INR >1.7
PTT >15s
Current direct thrombin inhibitor/Factor Xa use
Glucose <50
CT shows multi-lobular infarct
65
Q

What is done during a PE for stroke

How many categories are in NIHSS scale and what is the score range

A

ABCs
Confirm/exclude immitators
ID comorbidity
Evaluate cardiac/vascular dzs

11 categories
0-42pts
<4= minor
5-15= mod
16-20= mod to sev
\+21= sev stroke
66
Q

What vessel is MC involved in ischemic strokes?

How do these strokes present?

A

Mid cerebral artery infarction

Hemiparesis
Facial plegia (Face>LE)
Contralateral sensory loss

67
Q

What is the difference in MCA infarctions if it affects dominant or non-dominant side?

What will be seen regardless of hemisphere involvement?

A

Dom: aphasia
Non-dom: neglect apraxia dysarthria inattention

Homonymous hemianopsia and gaze preference TOWARD infarcted side

68
Q

How do posterior cerebral artery infarct present?

What are common presenting sxs?

A

Classic: ataxia nystagmus AMS and vertigo
Ipsilateral CN deficits
Contralateral motor weakness

Dizzy
HA
Dysarthria
Visual field deficit
Unilateral limb weakness
Gait ataxia
CN7 signs
Lethargy
Sensory deficit
69
Q

What PE finding is specific for distal posterior circulation stroke?

What other Sxs may be seen?

A

Contralateral homonymous hemianopsia and unilateral cortical blindness

CN3 palsy
Hemiballismus

70
Q

How do basilar artery infarcts present

A 
Unilateral limb weakness
Dizzy
Dysarthria
Diplopia
HA
MC:
Unilateral limb weakness
CN7 Sxs
Dysarthria
Babinski
71
Q

What unique PE finding can be seen in basilar artery infarction?

Why is this finding dangerous?

A

Locked in syndrome from bilateral pontine ischemia

High risk of death

72
Q

Define Lacunar infarction

What can cause these?

Why would this type of stroke be preferred?

A

Pure motor/sensory deficit from infarction of small arteries

Chronic HTN
Inc age

More favorable prognosis

73
Q

What are the RFs for carotid/vertebral artery dissection

What is the first presenting Sx?

If PT has new onset HA/neck pain of unclear etiology, what imaging is ordered?

A

Judy chop
Chiropractor

Unilateral HA in frontotemporal region

CT angiogram of neck vessels

74
Q

What PE finding may be seen if PT has carotid artery dissection

What type of HA is localized to occipital area

A

Partial Horner’s

Vertebral artery dissection

75
Q

What imaging modalities are preferred for carotid/vertebral artery dissections

What types of strokes have higher MnM

A

CT angiography followed by MRA

Intracerebral

76
Q

What Sxs usually precede neurological deficits during intracerebral hemorrhages?

What imaging is used to differentiate between hemorrhage and ischemic strokes?

A

HA, N/V

NCHCT

77
Q

How are cerebellar hemorrhages Dx on images?

How what are the S/Sxs of SAH strokes

A

NCHCT but has low sensitivity
MRI w/ diffusion weighted images

Occipital/nuchal HA w/ recent onset of max intensity HA

78
Q

What is the time frame from presentation to imaging and Tx decision for stroke PTs

How is a stroke Dx?

A

Image: <20min
Dx/Tx: 60min from PTs arrival

EMS
Code team
H/P
Inclusion/exclusion criteria
CT
79
Q

When are stroke CTs interpreted?

What is the only imaging study necessary prior to giving rtPA?

A

W/in 45min of arrival by radiologist>neurologist or ASAP after completion

NCHCT

80
Q

How are ischemic strokes Tx

If PT is not candidate for thrombolytics or reperfusion, how are they managed?

A

Fluids
Maintain SPo2 >94%
IV acetaminophen
Maintain glucose 140-180

Permissive HTN, don’t lower unless:
BP >220/>120
Condition reqs lower BP
Reduce x 10-20% in first 24hrs

81
Q

What is the BP goal for stroke PTs that are reperfusion candidates?

What if this goal can’t be met?

A

<185/110

No longer candidate for rtPA therapy

82
Q

? metabolic condition is common in acute strokes?

NIHSS score of ? is commonly used as criteria for rtPA therapy

A

Hyperglycemia from release of cortisol/NorEpi

4-22

83
Q

? lab result is required prior to administering rtPA?

Why are TIAs such a big deal?

A

Glucose

1/3 of PTs will have stroke in 30 days

84
Q

How are TIA Dx scored

A 
ABCD2
Age 60+
BP >140/90
Clinical features
Duration
DM
85
Q

How are TIAs Tx

What is the MC cause of ischemic stroke in kids

How is this MC cause Tx

A

ASA
ASA + Dipyridamole
Warfarin if no Afib

Sickle cell

O2

86
Q

When are pregnant PTs at highest risk for all types of strokes?

Can you use rtPA during pregnancy?

A

6wk post-partum

Yes, doesn’t cross placenta

87
Q

What is the MC precipitating factor to a seizure?

What presenting PE findings suggest a previously unwitness/unrecognized seizure

A

Missed dose of anti-epileptic

Unexplained injury
Nocturnal tongue biting
Enuresis

88
Q

Seizure PT w/ persistent/severe HA suggests?

What does a PE for suspected seizure include?

What are 3 common post-seizure sequelaes?

A

Intracranial pathology

VS
POC glucose
Head/spine assessment
Post shoulder dislocation

Tongue lac/dental fx/pulmonary aspiration

89
Q

Define Todd’s Paralysis

What needs to be monitored closely in PTs post-seizure?

A

Transient focal deficit, usually unilateral, following simple/complex focal seizures
Resolve in 48hrs

Loc/mentation to avoid missing non-convulsant status epilepticus

90
Q

Most seizures are followed by period of postictal confusion or lethargy except for ?

Syncope presents w/ ? prodome Sx

A

Simple absence
Simple partial seizure

Light headed
Diaphoresis
Nausea
Tunnel vision

91
Q

? form of syncope has no prodrome?

What are the characteristic movements of pseudoseizures?

What are two uncommon events

A

Cardiac

Side to side head thrash
Rhythmic pelvic thrusts
Clonic extremity motions that alternate

Incontinence
Injury

92
Q

What lab result proves pseudoseizure and an actual seizure was less likely?

What are the only two labs needed to be drawn for a PT w/ known epilepsy Hx

What labs are drawn for a first seizure

A

No lactic acidosis
No elevated prolactin

Glucose
Anti-convulsant med levels

Glucose
BMP
Lactate
Ca+ Mg
hCG
Toxicology
93
Q

Seizures can cause the body to acquire ? metabolic state?

What is the first imaging ordered for first time seizure?

What other images may be considered?

A

Lactate driven wide anion gap metabolic acidosis

CT to r/o structural lesion

Head/neck CT
CXR
Shoulder x-rays

94
Q

When would an LP be ordered for a seizure PT

If the rare/odd PT needs an EEG in the ER, what is the f/u fate of this PT?

A

Febrile
ImmComp
SAH suspected w/ normal NCHCT

Admit w/ neuro consult

95
Q

What steps are taken for PT protection during seizure?

What is the time limit of concern?

A

Protect
Roll on side

> 5min= more interventions
Considered status epilepticus

96
Q

How are PTs managed after their first unprovoked seizure?

How are PTs managed after provoked seizure d/t an identifiable underlying cause?

A

As long as PT returns to baseline, do not:
Admit
Initiate anticonvulsant meds
Safe to d/c

Admit and medicated

97
Q

How are HIV PTs that have a seizure managed?

A

NCHCT shows now lesions,
No evidence of inc ICP,
do LP
No explanations= contrast CT/MRI

98
Q

When are pregnancy related seizures Dx as eclampsia?

How are these seizures Tx?

A

> 20wks w/ HTN, edema, proteinuria

MgSulfate

99
Q

How are alcohol withdrawal seizures managed?

What is the criteria for Status Epilepticus

A

Benzos

Single seizure lasting 5m or more
2 or more seizures w/out recovery of consciousness

100
Q

What short acting paralytic is used to intubate these PTs and which one is avoided?

What type of fluid is used and what anti-epileptic drug is d/t this fluid administration

A

Succinylcholine
Not Rocuronium

NS
Phenytoin, not compatible w/ glucose solutions

101
Q

What serial monitoring occurs in Status Epilepticus Pts afte paralytic agents are administered?

What Dx lab test is avoided in status epilepticus PTs

What transient lab result may be seen?

A

EEG

LPs

Peripheral leuckocytosis
Mild CSF pleocytosis

102
Q

What drugs are most often used during status epilepticus

What two drugs may be given by neurologist for d/c PTs

A

IV Lorazepam- first choice
Fos/Phenytoin

Levetiracetam
Lacosamide

103
Q

What is the criteria for refractory status epilepticus

What 3 drugs may be pushed at this time?

A

Persistent seizure activity despite two antiepileptic agents and
Exceeds 60min

1st: Propofol
2nd: Midazolam
3rd: Barbitals, Ketamine

104
Q

Define Syncope

This can be due to lack of circulation supplying ? parts of the brain?

A

Brief LoC w/ inability to maintain postural tone that spontaneously resolves w/out medical intervention

Cerebral cortices
Brainstem

105
Q

How are cerebral perfusion and consciousness restored after a syncope?

What is the MC cause

A

Supine
Autonomic autoregulation
Perfusing cardiac rhythm

Vasovagal (reflex mediated)

106
Q

Of all the causes of syncope, what is the only one that has no increased risk of death when compared to GenPop?

What 4 cardiac conditions can lead to cardiac syncope?

A

Vasovagal

Hypertrophic myopathy- MC
Aortic stenosis
PE
MI

107
Q

When do situational syncope tend to occur?

How does carotid sinus hypersensitivity present?

A

Micturition
Coughing
Defecation
Swallowing

Brady or HOTN
MC- abdominal vagal response causing brady and asystole >3seconds
Less common- vasodepressor response- BP dec >50mm

108
Q

When is carotid sinus hypersensitivity considered as a Dx?

What two psych d/os are associated w/ psychiatric syncope?

A

Older PTs w/ recurrent syncope and negative cardiac evals

General anxiety
MDD

109
Q

Define Subclavian Steal Syndrome

What will be seen on PE?

A

Abnormal narrowing of subclavian artery proximal to vertebral artery origin, MC on L side

Dec pulse volume/BP on affected arm

110
Q

What medications are the MC cause of orthostasis?

What meds have pro-arrhythmic properties?

A

BBs/CCBs- dec HR response
Diuretics- deplete volume

Anti fungal
Anti emetics
ABX

111
Q

What type of syncope prodrome Sxs are concerns for immediate life threatening Dx

What type of presentation indicates cardiac dysrhythmia or structural lesion?

A

Chest pain
HA
Abd pain
Palpitations

Sudden w/out warning
Associated w/ exertion
SAH

112
Q

What Dx is the MC event mistake as a syncope

? type of PT presentation indicates a sudden event w/out warning?

A

Seizure

Trauma w/out defensive injuries

113
Q

Post-syncope PE needs to focus on what two thing?

What assessment must be done for these PTs?

A

Cardio
Neuro

BP on both arms

114
Q

What steps are done to Dx orthostatic HOTN

What two EKG findings are linked w/ higher morbidity?

A

Dec of SBP >20mm
SBP <90 w/ Sxs

New LBBB
Non-sinus rhythms

115
Q

What is the only lab needed to be ordered for syncope?

What lab result is predictive for PTs w/ higher risk of morbidity

A

hCG

BNP

116
Q

When are CT/MRI images not needed in syncope PTs

What is the disposition for PTs that had cardiac/neurological syncope?

A

ASx w/ isolate event w/out head trauma

Admit

117
Q

What are the first Dxs considered in pregnant women w/ syncope?

DKA usually occurs in ? types

A

Ectopic pregnancy
PE

DMT-1
Newly Dx DMT-2 AfAm/Hispanics

118
Q

What is the process leading to DKA?

What hormones are involved in this process?

A

Cellular starvation due to insulin deficiency and counter-regulatory response

Glucagon GH
Catecholamines Cortisol

119
Q

What metabolic issues develop during DKA

Clinical manifestations of DKA are directly related to ?

A 
Hyperglycemia
Osmotic diuresis
Prerenal azotemia
Ketones
Wide gap acidosis

Hyperglycemia
Acidosis
Volume depleion

120
Q

What are the 3 Ps of DKA

Why do these PTs experience N/V?

A

Polydipsia Polyuria Polyphagia

Prostaglandins

121
Q

Why do DKA PTs have AMS?

? PE finding correlates to the level of acidosis?

A

Inc serum osmolality

Abd pain/tenderness

122
Q

How is DKA Dx

DDx for DKA

A 
pH <7.3
Ketonuria/emia
BiCarb <15
Anion gap >10
Glucose >250
Renal failure
Alcholic ketoacidosis
Ingestion (salicylate ethylene methanol)
Lactic acidosis
Starvation
123
Q

What labs are ordered for DKA PTs

What is the goal and sequence of Tx

A 
Glucose
VBG
CBC CMP
Anion gap
ABG if critical

Fluid repletion w/ NS, 20mL/kg/hr for first hr
Correct K+
Insulin

124
Q

What serial monitoring occurs on DKA PTs during treatment effort?

What are the criteria for a DKA PT to be ‘treated’?

A

MS Out/INs VS E

Glucose <200 and 2:
BiCarb 18 or higher
pH >7.3
Normal anion gap

125
Q

When is Dextrose added to DKA Tx regime

What adverse outcome can develop if too much fluid is pushed too quickly in these PTs?

A

250mg, 5%D in 0.45%NS

ARDS
Cerebral edema

126
Q

What is the most life threatening part of DKA?

A

Severe HypoK

127
Q

Tx sequence for DKA if K is >3.3-<5.2

Tx sequence if K+ is <3.3

Tx sequence if K+ is >5.2

A

Fluids, K+, Insulin

Fluid K, no insulin

Fluid, no K, insulin

128
Q

What is the disposition for DKA PTs

DKA is the leading cause of death in ?

A

ICU if critical
Gen/Med surg if AG <25/glucose <600 and no comorbidity

Fetus

129
Q

What is unique about DKA in pregnancy?

What two Sxs can precede and episode of DKA?

A

Triggered at lower sugar levels

Vomit/UTI

130
Q

What is used for prognostic indicator in PTs w/ sepsis?

What has this traditionally bee attributed to

A

Serum lactate
Failure to red x 10% in first hrs, higher mortality

Anaerobic metabolism secondary to tissue hypoperfusion

131
Q

What are the two events that occur during sepsis

What series of Sxs are hints for sepsis

A

Abnormal inflammatory response
Imbalanced pro/anticoagulants= DIC

Fever HOTN and/or tachy

132
Q

What type of shock is sepsis

What sequelae injury is common during sepsis

What findings hint towards this issue

A

Distributive

Acute lung injury- ARDS
AKI- azotemia, a/oliguria

Refractory hypoxemia
Non-compliant lungs w/ mechanical ventilation
CXR showing bilateral infiltrates

133
Q

What is the MC live abnormality to occur due to sepsis

What is the MC GI manifestation of sepsis

A

Cholestatic jaundice

Ileus

134
Q

What can develop as a result of DIC in sepsis

What skin presentation can indicate sepsis

A

Thrombocytopenia

Erysipelas

135
Q

How is sepsis Dx in ER?

What is the only accurate method to get temp in septic PT?

A

SBP <90 after fluids
Evidenced poor perfusion

Rectal Temps

136
Q

What is the last Sx to present in Peds w/ sepsis

What are the 3 cornerstones of sepsis Tx

A

HOTN

Early recognition
Reversal of hemodynamics
Early infection control

137
Q

Sepsis rescuscitation efforts are based on ? 3 things

The goals of Tx are to improve ? 3 things

A

Fluids
Adjunct therapies
Response

Preload
Perfusion
O2 delivery

138
Q

How is sepsis Tx

What is the next step if PTs are not responding to this first Tx step

What is added to Tx w/in ?time frame

A

Cyrstalloid bolus 20mg/kg

NorEpi/Epi
Vasopressin

ABX w/in 1hr or 3hrs of triage

139
Q

Anaphylaxis is a ? dependent process

Anaphylaxis is a more severe/end result of ?

A

IgE

Hypersensitivity

140
Q

What are the MC provoking factors of anaphylaxis reactions

Anaphylaxis starts with the activation of ?

What substances are released

A

Foods
Meds
Stings
Injections

Mast cells, Basophils

Histamine
Tryptase
Carboxy A
Proteoglycans

141
Q

What is the sequence of events during an anaphylaxis reaction

A 
Allergen
igE forms
IgE and mast cells link
Release of THCP
Dilation/inc permeability
Inc HR, contraction, glandular secretion
142
Q

Classic presentation of anaphylaxis includes ? 3

What presenting Sx is indicator of life threatening issue

A

Pruritis Urticaria Flushing

Lump in throat
Hoarseness

143
Q

How fast do anaphylaxis Sxs present

When are these PTs at risk for recurrence?

A

<60min
Faster Sxs= worse reaction

3-4hrs later, peaks 8-11hrs later

144
Q

How is anaphylaxis Tx

What is used in PTs on BBs and have anaphylaxis?

A

ABCs
IV access w/ crystalloids
O2 therapy
IM Epi q5-10min

Glucagon reverses BB

145
Q

What are the 5 second line therapies for anaphylaxis Tx

What are PTs dispositions after Tx

A 
CCS
Antihistamine- Diphen/Ranitidine
Vasopressors
Glucagon
B2 bronchodilators

ASx x 6hrs= d/c

146
Q

Bees/wasps belong to ? group

What is the MC response to one of these stings?

A

Hymenoptera

Transient local reaction, spontaneously resolves from 15m-6hrs

147
Q

What is the important principle of Hymenoptera stings

What meds can be used for Sx relief

A

Immediate removal
Wash w/ soap and water

CCS
Antihistamines
NSAIDs

148
Q

How is Hymenoptera anaphylaxis Tx

What are these PTs d/c home w/?

A

Antihistamines/CCS
Crystalloids
Epi

Steroid Antihistamine
Epi Pen

149
Q

How do Loxoscele bites present

What med is used for Tx

What follow on Tx is needed

A

Recluse- red white blue sign

Dapsone

Skin grafts after necrosis heals into schar

150
Q

Black Widows belong to ? class

What is the most active component of it’s venom and what does this component cause to be released

A

Lactrodectus

A-lactrotoxin-
Ach- neuromuscular manifestations
NorEpi- cardiac manifestation

151
Q

What is the difference between the brown recluse and black widow bite

How are BW bites Tx

A

Brown- painless
Black- pinprick, abdominal wall cramping, HTN, tachy

IV Ca+
Opioids/benzos
Antivenom

152
Q

What type of scorpion can cause systemic toxicity

What happens in the body if stung?

A

C sculpturatus- Bark scorpion

Opens Na channels= prolong/excessive depolarization= seizure-like activty

153
Q

What would be seen on PE of a scorpion sting

When do these PTs need to be admitted?

A

Hypersalivation
CN5 7 9 dysfunction
Eye, pharyngeal, tongue control issues

Systemic Sxs
CN impairment

154
Q

Crotalinae includes ?

What does their venom cause

What would be the early indications of poisoning since 25% are dry bites

A

Rattle snakes

Tissue/hematological toxins by fibrinogen/platelet consumption

N/V
Weak
PO numbness/tingles
Local swelling

155
Q

What are the systemic effects of a Crotalinae bite

How is a snake bite Dx

How is snake envenomation Dx

How is a dry bite Dx

A

Tachy Tachy HOTN

Fang marks and Hx

Fang marks and tissue injury

ASx x 8-12hrs

156
Q

What is the mainstay of Crotalinae therapy?

Difference between Coral and Milk snake

A

FabAntivenom- IV/IO
Do not give IM if finger bite

Red on yellow- kills fellow
Red on black, venom lacks

157
Q

How are coral snake bites Tx

What group do they belong to

A

3-5 vials of Antivenin IV or IO

Elapid

IPAP (212 decks)

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