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
? 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?
PolyKDz Meningismus ENT for OM and sinusitis
26
? eye issues can present as HA? Intraocular pressure above ? is abnormal
Scleritis Enophthalmitis Acute ACG >21
27
If PT is high risk, what labs are drawn for HAs? What form of imaging is done for these PTs
BMP ESR CBC Coags Culture CSF NCHCT regardless of Sxs MRI- arterial dz
28
What can be diagnostic and therapeutic for HAs? What part of this is critical?
LP Opening pressure
29
When can an LP be down w/out prior imaging? When do HA PTs need to be d/c w/ follow up plans
No ImmSupp, No focal neuro deficit and, Normal sensorium High risk- GCA, IIHTN Chronic HAs
30
What is the classic presentation of meningitis When can the head CT be delayed until after LP for these PTs
HA (MC) + Triad: fever (2nd MC) AMS stiff neck Awake/alert No papilledema, focal neuro deficit, ImmComp or new onset seizure
31
What are the common pathogens of bacterial meningitis Where are these pathogens found?
``` 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 ```
32
How is bacterial meningitis Tx
``` ABCs, labs, cultures Empiric ABX w/ Dexameth during 1st dose Non contrast CT LP Admit w/ droplet isolation ```
33
Why are SAHs so dangerous? 75% of SAHs are caused by ?
50% have 30 day survival rate Ruptured aneurysm
34
What are the SAH RFs in the AD/Ret population What is the first step for suspected SAHs
FamHx Alcohol Smoking HTN Non contrast CT Sens best after Sx onset Spec best 6-12hrs later
35
What is the next step for suspected SAH if CT is negative? Why is this next step so important?
LP for RBCs or xanthochromia Normal CT, no xanthochromia/RBCs= SAH exclusion
36
When are SAH PTs at the highest risk for re-bleeds? How is this risk window reduced? What meds need to be avoided?
First 24hrs BP control- Labetalol/Nicardipine Nitroprusside Nitroglycerine
37
How are all SAH PTs managed? What PT populations are at risk for non-traumatic intracranial hemorrhage?
Neurosurgery consult Admit to ICU Elderly Alcoholic/drug abuse Anti-platelet/coagulant
38
PTs presenting w/ ? Sx duo have cerebellar hemorrhage until proven otherwise? How do brain tumors cause HAs
Acute HA Vestibular Sxs- vertigo/ataxia CSF flow obstruction Intracranial HTN
39
What PE findings suggest brain tumor What is the preferred imaging modality?
``` 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
40
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
Female Hypercoagulable Peripartum Recent SurgHx MR venography
41
What PE finding should prompt suspicion of cerebral venous thrombosis How does Posterior Reversible Encephalopathy Syndrome present? Who does this occur more often in?
Inc opening LP pressure Severe HA Visual changes Seizure Encephalopathy ImmSupp Chemo PTs ESRenal Dz
42
What is the imaging modality for Posterior Reversible Encephalopathy Syndrome How is it Tx When is this Dx considered
MRI CT will be normal BP management Thunderclap HA and SAH is r/o
43
What is the characteristic of Posterior Reversible Encephalopathy Syndrome etiology? How do PTs w/ GCA present What needs to be measured and r/o
Cerebral vasospasm from cocaine/amphetamines ``` >50y/o Fatigue Fever Proximal muscle weakness Jaw claudication Transient vision loss ``` IOP to r/o glaucoma
44
How is Temporal Arteritis Dx How is Temporal Arteritis Tx
``` 3 of: +50y/o New HA Abnormal artery/biopsy ESR >50mm ``` Prednisone 60mg PO Consult w/ Rheum/Ophthal
45
What are the MC auras to occur w/ migraines What med is used as first line abortive therapy? How are these initially Tx?
Scotoma- light headed Scintillations- vision changes Triptans IV hydration NSAIDs anti-emetic/histamine Steroids to reduce re-occurrence after d/c
46
What meds can and cannot be used for migraine Tx during pregnancy
Triptans, Ergotamines (caffeine/isometheptene combo)- c/i Acetaminophen, Opioids, CCS Metoclopramide- ok NSAIDs until 3rd-T
47
What needs to be given to migraine PTs upon d/c? II-HTN is AKA and is MC in ?
Abortive meds Pseudotumor Cerebri Obese women 20-44y/o
48
What are the prominent Sxs of II-HTN? Why does this Dx need to be ID'd fast?
HA Transient visual obscurations Back pain Pulsatile tinnitus Permanent visual impairment
49
What is the Dx criteria for II-HTN What is necessary to complete/confirm Dx
Papilledema w/ normal neuro exam Inc opening pressure on LP (>25mm) Normal CSF, images LP- can be Dx and Thx
50
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?
``` Need 3 of: Empty sella Flat posterior globe Distended perioptic subarachnoid space Transverse venous sinus stenosis ``` Acetazolamide
51
What criteria needs to be met in order to Dx cluster HAs What is the first line Tx for cluster HAs?
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
52
# Define Stroke What are the 3 categories and types of stroke
Dz process that interrupts blood/substrate flow Injury causing edema/mass effects to brain Ischemic- thrombotic hypoperfusion embolic Hemorrhagic- intracerebral subarachnoid
53
What is the mechanism of thrombotic strokes? What are these a common cause of?
Narrowing of damaged lumen by in situ process (clot formation) Gradual waxing/waning Sxs Common cause of TIAs
54
What is the mechanism of embolic strokes? How do these present and what do they account for?
Obstruction of normal lumen by material from remote source Sudden onset, 20% of ischemic strokes
55
What is the mechanism of hypoperfusion strokes? How do these present
Low blood flow Injury to water shed areas w/ wax/wane Sxs
56
What is the mechanism of hemorrhagic strokes? Where are these more common?
Intraparenchymal hemorrhage from weakened arterioles Inc ICP causes damage, constriction changes perfusion Asians/Africans
57
What is the mechanism of non-traumatic subarachnoid strokes? How are these types of strokes foreshadowed?
Hemorrhage into subarachnoid space Preceded by sentinal HA (warning leak)
58
What are the general Sxs of strokes? What is used to grade the PTs Sxs
General: Facial droop Arm drift Abnormal speech Subtle: weak, light headed, vague sensory changes Cincinnati pre-hospital scale
59
Traditional stroke Sx women present with? Non-traditional Sx they present w/ ? What is an odd non-traditional Sx
AMS General weakness Hiccups
60
Embolic/hemorrhagic strokes present as? Thrombotic/hypoperfusion strokes present as ? ? type of stroke is suspected when HA w/ valsalva or lifting?
Sudden onset Sxs Wax/wane Sxs Stuttering Cerebral aneurysm rupture
61
? type of injury can present after neck trauma or manipulation? RFs for thrombus stroke and how it will be seen on PE
Cervical artery dissection HTN DM Atherosclerosis Transient neuro deficits in SAME vascular distribution
62
RFs for embolus stroke and what will be seen on PE When are stroke Sx onset calculated?
A-fib Valve replacement Recent MI Transient neuro deficits in DIFFERENT vascular distributions Time of last known baseline/normal
63
Inclusion criteria for rtPA during strokes?
Measureable Dx: >22 poor Sx onset <3hrs 18 or older
64
Exclusion criteria for rtPA use during strokes?
``` 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
What is done during a PE for stroke How many categories are in NIHSS scale and what is the score range
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
What vessel is MC involved in ischemic strokes? How do these strokes present?
Mid cerebral artery infarction Hemiparesis Facial plegia (Face>LE) Contralateral sensory loss
67
What is the difference in MCA infarctions if it affects dominant or non-dominant side? What will be seen regardless of hemisphere involvement?
Dom: aphasia Non-dom: neglect apraxia dysarthria inattention Homonymous hemianopsia and gaze preference TOWARD infarcted side
68
How do posterior cerebral artery infarct present? What are common presenting sxs?
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
What PE finding is specific for distal posterior circulation stroke? What other Sxs may be seen?
Contralateral homonymous hemianopsia and unilateral cortical blindness CN3 palsy Hemiballismus
70
How do basilar artery infarcts present
``` Unilateral limb weakness Dizzy Dysarthria Diplopia HA ``` ``` MC: Unilateral limb weakness CN7 Sxs Dysarthria Babinski ```
71
What unique PE finding can be seen in basilar artery infarction? Why is this finding dangerous?
Locked in syndrome from bilateral pontine ischemia High risk of death
72
# Define Lacunar infarction What can cause these? Why would this type of stroke be preferred?
Pure motor/sensory deficit from infarction of small arteries Chronic HTN Inc age More favorable prognosis
73
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?
Judy chop Chiropractor Unilateral HA in frontotemporal region CT angiogram of neck vessels
74
What PE finding may be seen if PT has carotid artery dissection What type of HA is localized to occipital area
Partial Horner's Vertebral artery dissection
75
What imaging modalities are preferred for carotid/vertebral artery dissections What types of strokes have higher MnM
CT angiography followed by MRA Intracerebral
76
What Sxs usually precede neurological deficits during intracerebral hemorrhages? What imaging is used to differentiate between hemorrhage and ischemic strokes?
HA, N/V NCHCT
77
How are cerebellar hemorrhages Dx on images? How what are the S/Sxs of SAH strokes
NCHCT but has low sensitivity MRI w/ diffusion weighted images Occipital/nuchal HA w/ recent onset of max intensity HA
78
What is the time frame from presentation to imaging and Tx decision for stroke PTs How is a stroke Dx?
Image: <20min Dx/Tx: 60min from PTs arrival ``` EMS Code team H/P Inclusion/exclusion criteria CT ```
79
When are stroke CTs interpreted? What is the only imaging study necessary prior to giving rtPA?
W/in 45min of arrival by radiologist>neurologist or ASAP after completion NCHCT
80
How are ischemic strokes Tx If PT is not candidate for thrombolytics or reperfusion, how are they managed?
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
What is the BP goal for stroke PTs that are reperfusion candidates? What if this goal can't be met?
<185/110 No longer candidate for rtPA therapy
82
? metabolic condition is common in acute strokes? NIHSS score of ? is commonly used as criteria for rtPA therapy
Hyperglycemia from release of cortisol/NorEpi 4-22
83
? lab result is required prior to administering rtPA? Why are TIAs such a big deal?
Glucose 1/3 of PTs will have stroke in 30 days
84
How are TIA Dx scored
``` ABCD2 Age 60+ BP >140/90 Clinical features Duration DM ```
85
How are TIAs Tx What is the MC cause of ischemic stroke in kids How is this MC cause Tx
ASA ASA + Dipyridamole Warfarin if no Afib Sickle cell O2
86
When are pregnant PTs at highest risk for all types of strokes? Can you use rtPA during pregnancy?
6wk post-partum Yes, doesn't cross placenta
87
What is the MC precipitating factor to a seizure? What presenting PE findings suggest a previously unwitness/unrecognized seizure
Missed dose of anti-epileptic Unexplained injury Nocturnal tongue biting Enuresis
88
Seizure PT w/ persistent/severe HA suggests? What does a PE for suspected seizure include? What are 3 common post-seizure sequelaes?
Intracranial pathology VS POC glucose Head/spine assessment Post shoulder dislocation Tongue lac/dental fx/pulmonary aspiration
89
# Define Todd's Paralysis What needs to be monitored closely in PTs post-seizure?
Transient focal deficit, usually unilateral, following simple/complex focal seizures Resolve in 48hrs Loc/mentation to avoid missing non-convulsant status epilepticus
90
Most seizures are followed by period of postictal confusion or lethargy except for ? Syncope presents w/ ? prodome Sx
Simple absence Simple partial seizure Light headed Diaphoresis Nausea Tunnel vision
91
? form of syncope has no prodrome? What are the characteristic movements of pseudoseizures? What are two uncommon events
Cardiac Side to side head thrash Rhythmic pelvic thrusts Clonic extremity motions that alternate Incontinence Injury
92
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
No lactic acidosis No elevated prolactin Glucose Anti-convulsant med levels ``` Glucose BMP Lactate Ca+ Mg hCG Toxicology ```
93
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?
Lactate driven wide anion gap metabolic acidosis CT to r/o structural lesion Head/neck CT CXR Shoulder x-rays
94
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?
Febrile ImmComp SAH suspected w/ normal NCHCT Admit w/ neuro consult
95
What steps are taken for PT protection during seizure? What is the time limit of concern?
Protect Roll on side >5min= more interventions Considered status epilepticus
96
How are PTs managed after their first unprovoked seizure? How are PTs managed after provoked seizure d/t an identifiable underlying cause?
As long as PT returns to baseline, do not: Admit Initiate anticonvulsant meds Safe to d/c Admit and medicated
97
How are HIV PTs that have a seizure managed?
NCHCT shows now lesions, No evidence of inc ICP, do LP No explanations= contrast CT/MRI
98
When are pregnancy related seizures Dx as eclampsia? How are these seizures Tx?
>20wks w/ HTN, edema, proteinuria MgSulfate
99
How are alcohol withdrawal seizures managed? What is the criteria for Status Epilepticus
Benzos Single seizure lasting 5m or more 2 or more seizures w/out recovery of consciousness
100
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
Succinylcholine Not Rocuronium NS Phenytoin, not compatible w/ glucose solutions
101
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?
EEG LPs Peripheral leuckocytosis Mild CSF pleocytosis
102
What drugs are most often used during status epilepticus What two drugs may be given by neurologist for d/c PTs
IV Lorazepam- first choice Fos/Phenytoin Levetiracetam Lacosamide
103
What is the criteria for refractory status epilepticus What 3 drugs may be pushed at this time?
Persistent seizure activity despite two antiepileptic agents and Exceeds 60min 1st: Propofol 2nd: Midazolam 3rd: Barbitals, Ketamine
104
# Define Syncope This can be due to lack of circulation supplying ? parts of the brain?
Brief LoC w/ inability to maintain postural tone that spontaneously resolves w/out medical intervention Cerebral cortices Brainstem
105
How are cerebral perfusion and consciousness restored after a syncope? What is the MC cause
Supine Autonomic autoregulation Perfusing cardiac rhythm Vasovagal (reflex mediated)
106
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?
Vasovagal Hypertrophic myopathy- MC Aortic stenosis PE MI
107
When do situational syncope tend to occur? How does carotid sinus hypersensitivity present?
Micturition Coughing Defecation Swallowing Brady or HOTN MC- abdominal vagal response causing brady and asystole >3seconds Less common- vasodepressor response- BP dec >50mm
108
When is carotid sinus hypersensitivity considered as a Dx? What two psych d/os are associated w/ psychiatric syncope?
Older PTs w/ recurrent syncope and negative cardiac evals General anxiety MDD
109
# Define Subclavian Steal Syndrome What will be seen on PE?
Abnormal narrowing of subclavian artery proximal to vertebral artery origin, MC on L side Dec pulse volume/BP on affected arm
110
What medications are the MC cause of orthostasis? What meds have pro-arrhythmic properties?
BBs/CCBs- dec HR response Diuretics- deplete volume Anti fungal Anti emetics ABX
111
What type of syncope prodrome Sxs are concerns for immediate life threatening Dx What type of presentation indicates cardiac dysrhythmia or structural lesion?
Chest pain HA Abd pain Palpitations Sudden w/out warning Associated w/ exertion SAH
112
What Dx is the MC event mistake as a syncope ? type of PT presentation indicates a sudden event w/out warning?
Seizure Trauma w/out defensive injuries
113
Post-syncope PE needs to focus on what two thing? What assessment must be done for these PTs?
Cardio Neuro BP on both arms
114
What steps are done to Dx orthostatic HOTN What two EKG findings are linked w/ higher morbidity?
Dec of SBP >20mm SBP <90 w/ Sxs New LBBB Non-sinus rhythms
115
What is the only lab needed to be ordered for syncope? What lab result is predictive for PTs w/ higher risk of morbidity
hCG BNP
116
When are CT/MRI images not needed in syncope PTs What is the disposition for PTs that had cardiac/neurological syncope?
ASx w/ isolate event w/out head trauma Admit
117
What are the first Dxs considered in pregnant women w/ syncope? DKA usually occurs in ? types
Ectopic pregnancy PE DMT-1 Newly Dx DMT-2 AfAm/Hispanics
118
What is the process leading to DKA? What hormones are involved in this process?
Cellular starvation due to insulin deficiency and counter-regulatory response Glucagon GH Catecholamines Cortisol
119
What metabolic issues develop during DKA Clinical manifestations of DKA are directly related to ?
``` Hyperglycemia Osmotic diuresis Prerenal azotemia Ketones Wide gap acidosis ``` Hyperglycemia Acidosis Volume depleion
120
What are the 3 Ps of DKA Why do these PTs experience N/V?
Polydipsia Polyuria Polyphagia Prostaglandins
121
Why do DKA PTs have AMS? ? PE finding correlates to the level of acidosis?
Inc serum osmolality Abd pain/tenderness
122
How is DKA Dx DDx for DKA
``` pH <7.3 Ketonuria/emia BiCarb <15 Anion gap >10 Glucose >250 ``` ``` Renal failure Alcholic ketoacidosis Ingestion (salicylate ethylene methanol) Lactic acidosis Starvation ```
123
What labs are ordered for DKA PTs What is the goal and sequence of Tx
``` Glucose VBG CBC CMP Anion gap ABG if critical ``` Fluid repletion w/ NS, 20mL/kg/hr for first hr Correct K+ Insulin
124
What serial monitoring occurs on DKA PTs during treatment effort? What are the criteria for a DKA PT to be 'treated'?
MS Out/INs VS E Glucose <200 and 2: BiCarb 18 or higher pH >7.3 Normal anion gap
125
When is Dextrose added to DKA Tx regime What adverse outcome can develop if too much fluid is pushed too quickly in these PTs?
250mg, 5%D in 0.45%NS ARDS Cerebral edema
126
What is the most life threatening part of DKA?
Severe HypoK
127
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
Fluids, K+, Insulin Fluid K, no insulin Fluid, no K, insulin
128
What is the disposition for DKA PTs DKA is the leading cause of death in ?
ICU if critical Gen/Med surg if AG <25/glucose <600 and no comorbidity Fetus
129
What is unique about DKA in pregnancy? What two Sxs can precede and episode of DKA?
Triggered at lower sugar levels Vomit/UTI
130
What is used for prognostic indicator in PTs w/ sepsis? What has this traditionally bee attributed to
Serum lactate Failure to red x 10% in first hrs, higher mortality Anaerobic metabolism secondary to tissue hypoperfusion
131
What are the two events that occur during sepsis What series of Sxs are hints for sepsis
Abnormal inflammatory response Imbalanced pro/anticoagulants= DIC Fever HOTN and/or tachy
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What type of shock is sepsis What sequelae injury is common during sepsis What findings hint towards this issue
Distributive Acute lung injury- ARDS AKI- azotemia, a/oliguria Refractory hypoxemia Non-compliant lungs w/ mechanical ventilation CXR showing bilateral infiltrates
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What is the MC live abnormality to occur due to sepsis What is the MC GI manifestation of sepsis
Cholestatic jaundice Ileus
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What can develop as a result of DIC in sepsis What skin presentation can indicate sepsis
Thrombocytopenia Erysipelas
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How is sepsis Dx in ER? What is the only accurate method to get temp in septic PT?
SBP <90 after fluids Evidenced poor perfusion Rectal Temps
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What is the last Sx to present in Peds w/ sepsis What are the 3 cornerstones of sepsis Tx
HOTN Early recognition Reversal of hemodynamics Early infection control
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Sepsis rescuscitation efforts are based on ? 3 things The goals of Tx are to improve ? 3 things
Fluids Adjunct therapies Response Preload Perfusion O2 delivery
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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
Cyrstalloid bolus 20mg/kg NorEpi/Epi Vasopressin ABX w/in 1hr or 3hrs of triage
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Anaphylaxis is a ? dependent process Anaphylaxis is a more severe/end result of ?
IgE Hypersensitivity
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What are the MC provoking factors of anaphylaxis reactions Anaphylaxis starts with the activation of ? What substances are released
Foods Meds Stings Injections Mast cells, Basophils Histamine Tryptase Carboxy A Proteoglycans
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What is the sequence of events during an anaphylaxis reaction
``` Allergen igE forms IgE and mast cells link Release of THCP Dilation/inc permeability Inc HR, contraction, glandular secretion ```
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Classic presentation of anaphylaxis includes ? 3 What presenting Sx is indicator of life threatening issue
Pruritis Urticaria Flushing Lump in throat Hoarseness
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How fast do anaphylaxis Sxs present When are these PTs at risk for recurrence?
<60min Faster Sxs= worse reaction 3-4hrs later, peaks 8-11hrs later
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How is anaphylaxis Tx What is used in PTs on BBs and have anaphylaxis?
ABCs IV access w/ crystalloids O2 therapy IM Epi q5-10min Glucagon reverses BB
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What are the 5 second line therapies for anaphylaxis Tx What are PTs dispositions after Tx
``` CCS Antihistamine- Diphen/Ranitidine Vasopressors Glucagon B2 bronchodilators ``` ASx x 6hrs= d/c
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Bees/wasps belong to ? group What is the MC response to one of these stings?
Hymenoptera Transient local reaction, spontaneously resolves from 15m-6hrs
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What is the important principle of Hymenoptera stings What meds can be used for Sx relief
Immediate removal Wash w/ soap and water CCS Antihistamines NSAIDs
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How is Hymenoptera anaphylaxis Tx What are these PTs d/c home w/?
Antihistamines/CCS Crystalloids Epi Steroid Antihistamine Epi Pen
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How do Loxoscele bites present What med is used for Tx What follow on Tx is needed
Recluse- red white blue sign Dapsone Skin grafts after necrosis heals into schar
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Black Widows belong to ? class What is the most active component of it's venom and what does this component cause to be released
Lactrodectus A-lactrotoxin- Ach- neuromuscular manifestations NorEpi- cardiac manifestation
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What is the difference between the brown recluse and black widow bite How are BW bites Tx
Brown- painless Black- pinprick, abdominal wall cramping, HTN, tachy IV Ca+ Opioids/benzos Antivenom
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What type of scorpion can cause systemic toxicity What happens in the body if stung?
C sculpturatus- Bark scorpion Opens Na channels= prolong/excessive depolarization= seizure-like activty
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What would be seen on PE of a scorpion sting When do these PTs need to be admitted?
Hypersalivation CN5 7 9 dysfunction Eye, pharyngeal, tongue control issues Systemic Sxs CN impairment
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Crotalinae includes ? What does their venom cause What would be the early indications of poisoning since 25% are dry bites
Rattle snakes Tissue/hematological toxins by fibrinogen/platelet consumption N/V Weak PO numbness/tingles Local swelling
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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
Tachy Tachy HOTN Fang marks and Hx Fang marks and tissue injury ASx x 8-12hrs
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What is the mainstay of Crotalinae therapy? Difference between Coral and Milk snake
FabAntivenom- IV/IO Do not give IM if finger bite Red on yellow- kills fellow Red on black, venom lacks
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How are coral snake bites Tx What group do they belong to
3-5 vials of Antivenin IV or IO Elapid