EMED 2 Cram Flashcards by brandon lovin

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

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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

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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

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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

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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

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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

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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

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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

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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

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How are alcoholics going through withdrawals Tx?

Why would a PT w/ dementia suddenly have declining mental status?

Diazepam

CHF
UTI
Hypothyroid

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What type of syncope presents w/ flushed, warm and nauseous?

What type of syncope has a fast/slow onset

Vasovagal

Fast- cardiac
Slow- vasovagal

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PT passes out while decorating Christmas tree, what is a DDx?

MC cause of death in young adults/teens?

Sub-clavian steal syndrome

HOCM

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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

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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

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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

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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

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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

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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

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How is Hymenoptera anaphylaxis Tx?

ABCs
IM Epi
IV crystalloids, antihistamine, steroids

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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

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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

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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

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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

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Elapid

Red on yellow, kill fellow
Red on black, venom lack

Tx- 3-5 vials IM/IO Antivenin (M Fulvius)
Observe x 12hrs

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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)