EMED 2 Cram Flashcards
What gender is more likely to present to ER w/ vague Sxs of stroke?
What is the first lab drawn during suspected stroke or AMS work up?
Women- weak, light headed, fatigue
Glucose
What type of seizure mimics a stroke w/ transient focal unilateral deficits that is normally self resolving after 48hrs?
What vessel is MC affected in strokes?
Todd’s paralysis
Middle cerebral artery
What type of stroke has complete muscle paralysis, no communication or movement except for ability to do upward gaze and blinking?
PT presents w/ acute onset of HA, stroke type Sxs, partial Horner’s and hears ‘whooshing’ noises?
Basilar artery infarction
Carotid artery dissection
What image modality is not used for posterior infarcts/hemorrhages?
If PT is allergic to bees, are they allergic to wasps?
NCHCT- can’t see through bone window
Yes, w/ common Sx of swelling
What is the first line of Tx for Hymenoptera stings and/or anaphylaxis?
What is the MC manifestation of a Loxosceles bite?
Epi IM, repeat q5-10min
Red White and Blue
PT presents w/ Crotalinae bite to extremities, what needs to be monitored for development?
What are the 3 P’s of DKA?
Compartment syndrome
Poly-dipsia, uria, phagia
What is the sequence of Tx DKA
What are the 5 things needed for DKA Dx
Fluids then check K+
Widened gap Acidosis Low bicarb Ketones DM
What is the criteria for DKA Tx
Define Dementia
Glucose under 200 and two of:
Bicarb >18
pH >7.3
Normal gap
Failure of content portion of consciousness w/ preserved alertness
What are the 3 MC causes of AMS in elderly PTs beside strokes?
What are the 3 meds and dosages contained within a B52?
Hypoglycemia
Infection- PUSS
Meds
Benadryl 50mg
Ativan 2mg
Haloperidol 5mg
How are alcoholics going through withdrawals Tx?
Why would a PT w/ dementia suddenly have declining mental status?
Diazepam
CHF
UTI
Hypothyroid
What type of syncope presents w/ flushed, warm and nauseous?
What type of syncope has a fast/slow onset
Vasovagal
Fast- cardiac
Slow- vasovagal
PT passes out while decorating Christmas tree, what is a DDx?
MC cause of death in young adults/teens?
Sub-clavian steal syndrome
HOCM
Anaphylaxis presenting w/ ? needs immediate intubation
What is the MOA of Epi used during these cases?
Angioedema
A1 activation= dec edema, corrects HOTN
B1 activation= inc HR/strength
B2 activation= bronchodilation, dec mediator responses
How are PTs w/ anaphylaxis but on BBs Tx?
What is the s/e of this Tx step?
Glucagon reverses BB
Epi IM
Refractory= IV Epi
N/V from glucagon administration
Anaphylaxis is ? type of shock, meaning ? is used during Tx?
What meds are used for second-line therapy?
Distributive
IV crystalloids 20mg/kg
CCS Antihistamines B2 bronchodilator Glucagon Vasopressors
What is the disposition for anaphylactic PTs
Which ones need to be observed for longer times?
Healthy PT ASx x 1-6hrs post Tx= d/c
Hx of severe reactions
Use of BBs
PTs that are d/c after severe allergic reactions or anaphylaxis are given ? on the way out?
Hymenoptera venom contains ? components?
Antihistamines
CCSs
Epi auto injectors x 2
Histamine
Melittin- baso/mast degranulation
Phospholipase
Hyaluronidase
What is the MC response to a Hymenoptera sting?
How are these stings Tx?
Transient local reaction w/ spontaneous resolution
Stinger removal
Cold compress
PO CCS Antihistamine NSAIDs
How is Hymenoptera anaphylaxis Tx?
ABCs
IM Epi
IV crystalloids, antihistamine, steroids
Brown Recluse bites
Loxosceles
Venom contains:
Hyaluronidase
Sphingomyelinase D- necrosis
Painless bite
Red White Blue sign
ABX
Dapsone- leukocyte inhibitor
Serial wound f/u w/ PCM
Latrodectus
Black Widow
Painful bite
Venom= A-latrotoxin- release Ach/NorEpi (muscle/cardiac)
Abdominal cramping/pain
HTN/Tachy
Tx- IV Ca Opioid Benzo Anti-V
Centruroides Sculpturatus
Bark Scorpion
Opens Na channels= seizure like movements d/t prolonged depolarization
CV toxicity= Tachy HTN Pulm edema, cardiogenic shock
Peripheral NS toxicity-
Abnormal eye, pharyngeal, tongue control (Hyper salivation- CN 5 7 9)
Systemic/CN Sxs= admit
Crotaline
Rattlesnake
Tissue/hematology destruction
Early Sxs: N/V PO numbness
Systemic= Tachy Tachy HOTN
Dry bite Dz= ASx x 8-12hrs
Tx mainstay= IV/IO FabAV
Isotonic fluid/vasopressor
Elapid
Red on yellow, kill fellow
Red on black, venom lack
Tx- 3-5 vials IM/IO Antivenin (M Fulvius)
Observe x 12hrs
What lab result is used as prognostic for PTs w/ sepsis
What body process creates this lab result for tracking?
Serum lactate
Anaerobic metabolism secondary to tissue hypoperfusion
What are two independent predictors of mortality during sepsis?
How does one of these predictors response to Tx determine mortality?
Lactate elevation
HOTN
Failure to dec lactate by 10% in first few hrs= inc mortality
What causes Sepsis
What two events occur
Immune response fails to control/over reacts to pathogen
Abnormal inflammatory response
Imbalanced pro/anticoagulant function
PTs suffering from septic shock are at increased risk of developing ?
What Sxs indicate an underlying sepsis issue?
DIC- clots, impaired perfusion, thrombosis
Fever
HOTN
Tachy
What type of shock does sepsis create?
What areas of the body can be injured by the sepsis inflammation process?
Distributive
Cholestatic jaundice Thrombocytopenia AKI Ileus Lungs- ARDS
What 3 parts of the body are examined for suspected sepsis?
What is needed to Dx sepsis?
Skin (erysipelas) Urine CXR
SBP <90 after fluids
Evidence of hypoperfusion
What is the only reliable method to obtain temps in PTs that are septic?
What is a late Sx of sepsis on Peds?
Rectal temps
HOTN
What two extra labs are drawn in septic PTs that are HOTN/anemic?
What labs are drawn if they have DIC?
Type/screen
Fibrinogen aPTT PTT D-dimer
What are the goals of resuscitation when Tx sepsis?
If PT is not improving after 20cc/kg fluid push, what is added to Tx in order?
Improvement of:
Preload O2 delivery Perfusion
NorEpi Vasopressin Epi
What is the ABX delivery time frame recommended for septic PTs?
What are 4 examples of cardiac syncope etiology?
1hr of recognition
3hrs from triage
Aortic stenosis
HCM- MC cause of death
PE
MI
What are three forms of dysrhythmias that can cause cardiac syncope?
How do these types of syncope present?
Brugada
Long/short Qtc
Catecholamine PVTachy
Sudden w/out prodome
Why do vasovagal/neuro reflex syncopes occur?
What are the preceding Sxs?
What is different/unique about this type of syncope?
Inappropriate dilation/brady
Light headed
Nausea
Pallor
Sweat/warmth
Slow/progressive onset
What type of syncope is a situational syncope?
What causes this type?
Vasovagal/neuro reflex
Post cough, micturition, defecation or swallowing
How does carotid sinus hypersensitivity cause V/N reflex syncope?
When is this form of syncope a possible Dx?
Abnormal vagal response leads to brady and asystole >3sec
Sometimes BP dec x 50mm
Older PT w/ recurrent syncope and negative cardiac exams
What causes OHOTN sycope
What are the two MC underlying psych issues in PTs who have psych syncope?
Dec volume
Poor tone d/t a-receptor d/o or meds
GAD, MDD
Why is neurological syncope no a true syncope?
The LoC is usually preceded by ? Sxs?
LoC w/ persistent neuro deficit/AMS
Diplopia
Vertigo
Focal neuro deficit
Nausea
What type of syncope is Sublclavian Steal syndrome?
What causes this?
How is it ID’d on PE?
Neuro
Blood stolen from vertebrobasilar to subclavian artery, usually on L side
Dec pulse/BP on affected arm
What medications can lead to syncope?
Sudden events w/out warning and events associated w/ exertion raises suspicion for ? Dxs
BB/CCBs- blunts HR after orthostatic stress
Diuretics- depleted volume
Laxatives
Cardiac dysrhythmia
Cardiopulmonary lesion
What 4 precipitating issues cause concern for immediate life threatening Dxs after syncope?
PT w/ more than 5 syncope episodes w/in 1 yr are likely to have ? Dx
Chest pain
HA
Abdominal pain
Palpitations
Vasovagal
Psych dx
What is the MC Dx mistaken for syncope?
What physical appearance may present with any form of syncope?
Seizure
Convulsive syncope
Post-syncope PE needs to be focused on what two system?
What is the criteria for OHOTN?
Cardiovascular
Neurological
Dec >20mm w/ Sxs
SBP <90mm
What is the most important part of Dx syncope?
What EKG findings post-syncope are linked with higher morbidity
Hx
LBBB
Non-sinus rhythms
What post-syncope lab result would indicate PT is at risk for morbidity?
When are head CTs/MRIs not needed for syncope work ups?
Inc BNP
ASx PT
Isolated event
Atraumatic event
What type of syncope means PT is admitted?
If pregnant PT has syncope, first two Dxs are ?
Cardiac
Neurologic
Ectopic pregnancy
PE
What PTs usually suffer from DKA?
What PT population does DKA have higher mortality?
DMT-1
Newly Dx DMT-2, esp AfAm/Hispanic
Elderly- Renal dz Infection Coma HOTN
What catabolic hormones are released during DKA?
DKA occurs in response to ?
Glucagon GH
Catecholamine Cortisol
Cellular starvation
During DKA, the lack of insulin and presence of catabolic hormones results in what 5 issues?
Why do DKA PTs experience N/V?
Why does their breath smell fruity?
Pre-renal azotemia Osmotic diuresis Wide gap acidosis Hyperglycemia Ketone formation
Prostaglandin release
Acetone production
Clinical manifestations of DKA are directly related to what 3 things?
Why can DKA PTs develop AMS?
Hyperglycemia
Acidosis
Depleted volume
Dec K= inc acidosis
Hyperosmolarity*
Low ECF volume
Poor hyemodynamics
What odd VS may be seen in DKA?
How is DKA Dx
Hypothermia from peripheral dilation
Glucose >250 Anion gap >10 pH <7.3 BiCarb <15 Ketonuria/emia
What are the DDx for DKA?
What type of fluid is used during DKA Tx
Renal failure
Alcohol/starvation ketoacidosis
Ingestion- MES
Lactic acidosis
NS 25mg/kg
Once glucose reaches 250mg, switch to D5W and .45NS
What is the most life threatening adverse reaction DKA PTs can have during Tx?
What K+ ranges dictate holding/giving K or insulin?
HypoK
Norm range- give FKI
<3.3- give FK, no I
>5.2- give FI, no K
How are DKA PTs w/ insulin pump malfunctions Tx?
What is the leading cause of fetal loss during pregnancy?
What Sxs may precede a DKA episode?
D/c and turn off pump
Tx like normal PT
DKA
Vomit/UTI
DKA will be triggered at lower glucose level
What is the MC cause of seizures?
What PE findings suggest an unwitnessed/unrecognized seizure?
Missed Rx dose in young adult/teens
Unexplained injury
Nocturnal tongue bite/enuresis
What is suspected in post-seizure PT w/ persistent/severe HA?
What are 3 common sequelaes of seizures?
Intracranial pathology
Tongue lacs
Aspiraiton
Dental Fx
What are the first 4 things checked in suspected seizure PT?
What needs to be done after the PT assessment?
VS
Glucose
Head/C-spine
Shoulders
Monitor LoC/mentation
What type of seizures don’t have postictal state?
How do pseudoseizures present
Simple absence/partial
Head side to side
Pelvic thrusts
Extremity cogwheel
How are movement d/os different from seizures?
What is an inconsistent d/o associated w/ seizures?
Consciousness always preserved
Temp suppressible on command
Active movement d/os
What are the only two labs needed for seizure Hx PTs w/ repeat seizures?
What are two lab results that can prove seizure was fake?
Medication levels
Glucose
Lactate
Prolactin
What is the image ordered for first time seizure or change in baseline seizure Hx?
What are the 3 indications to do LP in setting of an acute seizure?
CT
Febrile
ImmComp
Suspected SAH w/ normal NCHCT
Seizures lasting longer than 5min are considered ?
How are first time/unprovoked seizures Tx?
How are PTs w/ provoked/secondary seizures Tx?
Status epilepticus- more than 5min or two seizures w/out regaining consciousness
Return to baseline
Do not admit/medicate
Admit/medicate
What are the criteria for eclampsia Dx?
How are these seizures Tx?
> 20wks w/ seizure and:
HTN Edema Proteinuria
MgSO4
Criteria for non-convulsive status epilepticus?
What Tx step is take for status epilepticus immediately after paralytic agents are given?
What drugs are used for Tx?
Fluctuating mental status
Long postictal after general seizure
Unexplained stupor/confusion
Subtle motor signs
Continuous EEG monitoring
Loraz*/Diazepam
Fospheny- IM loading dose if PT doesn’t have IV
Phenytoin
What is the criteria for refractory status epilepticus?
What meds are used for this type?
> 60min after two anti-epileptic drugs
Propofol*
Midazolam
Ketamine/Barbituates-Pento/Phenobarbital
What causes a syncope
How is consciousness restored?
10sec of complete blockage of blood/substrates
Reduced perfusion x 35-50%
Supine
Autonomic autoregulators
Perfusing cardiac rhythms
What is the MC type of syncope
What type of syncope has no increased risk of death when compared to GenPop?
Vasovagal
Vasovagal
Define Stroke
What are the two categories of stroke and the types within each category
Dz that interrupts blood flow
Injury related to loss of oxygen/glucose
Injury d/t mediators of injury
Ischemic- thrombotic hypoperfusion embolic
Hemorrhagic- intracerebral subarachnoid
How do thrombotic strokes develop?
How do the Sxs present?
These are the MC cause of ?
Narrowing of damaged lumen by clot formation
Gradual onset/wax and wane
TIAs
How do embolic strokes develop?
How do the Sxs present?
Obstruction of normal lumen by material from remote source
Sudden, account for 20% of ischemic strokes
How do the Sxs of hypoperfusion strokes present?
How do intracerebral hemorrhages develop?
Who is more likely to have this type
Diffuse injury in water shed areas w/ wax/waning sxs
Parenchymal hemorrhage from weakened arterioles
Asian/AfAm
What can cause non-traumatic subarachnoid strokes?
How does these get foreshadowed?
Berry aneurysm
Vascular malformation rupture
Warning leak (sentinal HA)
What are the general Sxs of strokes?
What are the subtle Sxs?
Face Arm Speech
Weak Light Vague sensory AMS
Traditional stroke Sx for women?
Non-traditional stroke Sx for women?
AMS
Weakness
Hemorrhage/embolic strokes have ? onset
Hypo/thrombotic strokes have ? onset
Sudden
Wax/wane
How could a cerebral aneurysm rupture be provoked during PE?
RFs and distribution for thrombotic strokes
Valsalva worsens it
HTN Atherosclerosis DM
Transient neuro deficits in same vascular distribution
Epidural bleed
Subdural bleed
Subarachnoid hemorrhage
E: blood out of dura, concave shape
S: blood under dura, crescent shape
SAH: blood in brain, compressing ventricles
rtPA inclusion criteria
rtPA exclusion criteria
Measurable Dx
Onset <3hrs
>18y/o
Platelets <100K Heparin <48hrs aPTT elevated Direct thrombin/Xa inhibitors Glucose <50 INR >1.7 Multi-lobe infarct PTT >15s
What is the MC vessel involved in ischemic strokes
How does this type present
MCA
Hemiparesis
Facial plegia
Contralateral sensory loss
How does MCA infarct on dominant side present?
How does it present if it’s on the non-dominant side?
Dom= aphasia
Non-dom= DIANE Dysarthria Inattention Apraxia- 2D/3D Neglect Extinction on double stime
What eye clue develops during MCA infarcts?
What are the presenting issues w/ PCA infarct?
Homo Hemi
Gaze preference to infarcted side
Ipsi CN
Contra motor
V7 GULS:
Vision CN7 Gait Unilateral weak/ataxia Lethargy Sensory
What PE finding is specific for a PCA infarct?
What other PE findings may be seen?
Hemi Homo and Unilateral blindness
CN3 palsy
Hemiballismus, chorea type
No reading/naming colors
How does a BA infarct present
CN7 signs Babinski Locked in syndrome Unilateral limb weakness Dysarthria
Define Lacunar infarction
RFs for Carotid/vertebral artery dissection
Pure motor/sensory loss d/t HTN/age
Chiro/Chop/CT dz
Migraine Hx
Vessel arteriopathies
HTN
What is the first presenting Sx of Carotid/Vertebral artery dissection?
What other unique PE finding may be seen?
What is the first image ordered?
Unialteral HA in frontoremporal region
Partial Horner’s
CTA then MRA
How does Vertebral Artery Dissection present
What is the first and second image ordered for cerebellar hemorrhages?
Occipital HA and neck pain
1st- NCHCT
2nd: MRI diffusion weighted images
Stoke evaluation and Tx decision needs to occur w/in ?mins?
They need to be imaged w/in ?min
60min of arrival at ED
20min of arrival at ED, read w/in 45min/ASAP
What is the only image needed prior to giving rtPA?
What is the only lab result needed prior to administration?
NCHCT
Glucose
Ischemic Tx gaols
SPO2 >94% Glucose 140-180 IV Acetaminophen Only lower BP if: >220/120, condition reqs Reduce x 20% over 24hrs w/ Labetalol/Nicardipine Reperfusion candidate: <185/110
What metabolic condition is common during acute strokes?
NIHSS score commonly indicates rtPA use
Hyperglycemia d/t cortisol/NEpi release
4-22
Stroked due to ? vessel involvement are not candidates for rtPA therapy?
What is c/i during hemorrhagic strokes?
MCA
Thrombolytics
How are TIAs scored?
How are these Tx
ABCD2, 0-7pts Age >60 BP >140/90 Clinical Duration DM
ASA/ASA + Dipyridamole
Warfarin for non-vascular Afib/TIAs
When are pregnant PTs at highest risk for any type of stroke?
It’s recommended to give ASA w/in ?hrs of stroke onset?
6wks post partum
24-48hrs
What are the 3 locations stimulation w/ valsalva appears?
What causes RCVS?
Brain tumor
Intracranial abnormality
Cerebral aneurysm rupture
Uppers causing constriction of smooth muscles- ischemia
What is an important PE finding that indicates underlying bleeding or infection in the CNS?
What f/u exam is needed?
Meningismus
ENT for OM/sinusitis
What two issues can cause asymmetric pupil/ptosis issues?
Define meningitis
CN3 compression d/t PCS aneurysm or brain stem herniation
HA + Triad (fever Neck stiffness AMS)
? + ? is a cerebellar hemorrhage until proven otherwise?
Acute HA + vestibular Sxs (vertigo, ataxia)
