EMED Block 4 Flashcards
What type of underlying issues cause visceral pain?
What do PTs present complaining of?
Where will they locate their pain to?
Obstruction Ischemia Inflammation
Stretched unmyelinated fibers innervating organs
Cramp Dull Ache
Steady/Colicky
Localized to spinal cord level
What types of underlying issues cause parietal pain?
PTs will localize pain to?
What happens as this pain develops?
Irritated myelinated fibers innervating peritoneum (anterior wall)
Dermatome above origin
Rigidity/rebound tenderness, still PT
Define Referred Pain
What is an example and why does this happen?
Pain felt distant from origin but on same side
Ureter obstruction w/ ipsilateral testicle pain d/t shared innervation
What two facts are used to determine urgency and approach to PTs w/ abdominal pain?
What type of fluid support is requested for critically ill PTs needing stabilization?
PT acuity, RFs
Emergency release blood
How long does it take for SBP to reflect a loss of blood volume?
? is used to assess volume depletion
This assessment tool is invalid in ? PTs
30-40%
Tachy
Peds- compensated shock
If PTs pulse and BP are WNL but suspected volume depletion is present, what is the next step?
Tachypnea can indicate ? issues may be present
Orthostatic VS
Cardiopulmonary
Axiety
Metabolic acidosis
Panic
What labs are ordered for critically ill PTs w abdominal pain?
What type of blood is ordered if hemorrhage is suspected or transfusions are anticipated
Chem panel- E+ BUN/Cr
CBC w/ platelet
PT/PTT/INR
Type, Ag Screen
Cross-matched
What are the high risk groups of PTs to present w/ abdominal pain?
Cognitive impairment
Lack of communication
Asplenic
Minimal/obscured lab results
Transplant/ImmSupp/Mod
Impaired immune system
Neutropenic
Mild-Mod immune dysfunctions have ? presentations of common dzs
Severe immune dysfunction PTs are more likely to present w/ ?
Delayed/atypical
Opportunistic infections
? is the most important measure of immune competency in AIDS PTs
What level in these PTs are less likely to present w/ opportunistic infections
CD4
> 200
When PTs present w/ acute abdominal pain, what is the abdomen inspected for?
Distension Obvious masses Ecchymoses Scars Stigmata of liver dz
Although non-specific for Dx, what do different bowel sounds mean?
Liver size can be estimated w/ percussion except for when ? is present
What does tympanic sounds indicate?
Dec: Narcotic Infarction Peritonitis Ileus
Inc: Small bowel obstruction
Bowel distension
Dilated loops of bowel
Define Sine qua Non
Peritoneal signs, CMT, uni/bilateral abdominal/pelvic tenderness can suggest ? issues are present
If these S/Sxs are present in males PTs, what exams are needed?
Necessary rebound tenderness for Dx of peritonitis
Pelvic infection
Ectopic pregnancy
Hernia
Testicular
Prostate
What abdominal issues present w/ pain, vomiting and/or rigidity
What abdominal issues present w/ pain, vomiting and distension?
Diabetic gastric paresis
Incarcerated hernia
DKA
Acute pancreatitis
Bowel obstruction
Cecal volvulus
What abdominal issues present w/ pain and/or vomiting?
What abdominal conditions present w/ pain, shock and rigidity
MI Acute diverticulitis Mesenteric ischemia Adnexal torsion Testicular torsion
Perforated appendix, diverticula, ulcer
Ruptured esophagus, spleen
What abdominal issues present w/ distension and/or pain?
When giving opioids for pain to these PTs what is coupled with it?
Bowel obstruction/volvulus
Anti-emetics
What lab result is used to Dx pancreatitis if lipase is unavailable?
What are lactate results used for identifying?
Amylase
Mesenteric ischemia
What are the atypical PTs that need EKGs when presenting w/ abdominal pain?
Radiological evidence of SBO may be present as early as ? before Sxs present
Female Elderly Diabetic
6-12hrs
Plain films have limited benefit for abdominal pain PTs when screening for ?
? is the preferred imaging modality for biliary tracts?
Constipation
Obstructions
Perforation
Sigmoid volvulus
US
What is the next step for suspected cholecystitis/biliary dyskinesia but normal US?
How much radiation exposure comes w/ each abdominal CT?
How does that compare to x-ray images?
Cholescintegraphy
10msV, 10x higher than x-ray
Skull x-ray= 5 CXRs
Lumbar x-ray= 75 CXRs
Head CT= 100 CXR
Abd CT= 400 CXRs
What are two examples of underlying issues that non-contrast CT would be used to image?
? is the preferred imaging modality when searching for kidney/ureteral stones?
Ureteral calculi
Retroperitoneal hematoma
Non-contrast CT
When is PO contrast CT the preferred imaging modality?
When is IV contrast CT procedures preferred?
Perforation
Fistula
GI abscess
Bowel mucosa
Visceral organs
Vascular structures
Sm/Lg bowel obstruction and transition points
? is the initial ToC for suspected AAA rupture or mesenteric ischemia
How are suspected abdominal sepsis and peritonitis Tx
IV contrast CT
Zosyns
How are PID cases Tx
What are high risk PTs that may need to be held overnight for observation prior to surgical Tx
What PTs are not high risk but candidates for admission/observation?
Ceftriaxone Metronidazole Doxy
Non-communicative
ImmComp
Cognitively impaired
Elderly
Non compliant (d/c, f/u)
Ill-appearing
Lack of social support
Intractable pain/vomit
PTs w/ abdominal pain, negative CT and are being d/c have ? f/u orders?
When/why would they need to return to the ER sooner?
Return <12hrs
Inc/different pain
Vomit
Bleeding Fever Syncope
What type of surgical complications are higher in elderly PTs?
? lab result has a low predictive value for surgical dzs
Perforated viscus Strangulated hernia Infarcted bowel Necrotizing pancreatitis Gangrenous gallbladder
WBC
? is the MC surgical entity in elderly PTs w/ abdominal pain
What other entities follow this MC?
What Dx is rare among the elderly and ? presentation of diarrhea may indicate ? Dx
Cholecystitis
SBO
Perferated viscus
Appendicitis
LBO
VGE, Messenteric ischemia
What is the difference in presentation between a proximal and distal obstruction
What type of PE finding suggests a mechanic obstruction
Prox: early emesis, less distension
Dist: later emesis, more distension (feculent emesis)
High pitched sounds
MC cause of mechanical SBO?
What PT populations are more likely to present w/ appendicitis?
Adhesion from prior surgery
F>M 10-19y/o
? is the MC cause of atraumatic abdominal pain in Peds >1y/o
? is the MC non-OB surgical emergency in pregnant PTs
Appendicitis
Appendicitis
Why does appendicitis pain start w/ umbilical pain?
What is the classic location?
Visceral innervation
McBurneys- 1/3 distance between ASIC-umbilicus
What are the causes for atypical appendicitis presentations?
Retrocecal- R flank/pelvic pain
Colo malrotation- LUQ pain
RUQ pain- pregnant, but RLQ still MC
? is a common early sign of appendicitis
What is the next Sx to present after non-specific Sxs
Anorexia
Periumbilical pain (pain then nausea)
What type of urinary tract manifestation indicates appendicitis?
What aggravating/alleviating PE findings can help w/ Dx
Sterile pyuria
Worse w/ deep inspiration
Painful trip w/ bumps
What type of appendicitis will not have TTP in RLQ?
How is this type tested for on PE?
Retrocecal, doesn’t touch anterior parietal peritoneum
DRE
Define Rovsing Sign
Define Psoas Sign
Define Oburator test
Pain at McBurneys w/ palpation w/ palpation of LLQ
Pain w/ extension of R leg at hip w/ PT lays on L side
Pain w/ in/external rotation of flexed R hip
? lab result may be the earliest marker of appendicitis inflammation?
What are the 4 goals of imaging suspected cases?
Inc WBC
Establish Dx
Avoid - appendectomy
ID perforation
Exclude other causes
What type of US findings in pregnant/Peds PTs suggest appendicitis
? PTs are more likely to have unclear US results and what is the next step?
Thick/non-compressible >6mm in diameter
Possible hyperemia
Adult male/non-preg female
Ab/pelvic CT w/out contrast
What CT findings suggest an appendicitis
When would the preferred MRI imaging of pregnant PTs be removed
Dilated >6mm w/ thick wall
Periappendiceal inflammation
Visualizing fecolith/abscess
2nd/3rd trimester
Alcohol associated pancreatitis is morecommon in ? while gallstone induced is more common in?
What are the RFs for this condition
Alcohol- men
Gall- women
Smoking Obese DM
PTs tend to develop pancreatitis <30 days after having ? procedure
How do PTs w/ pancreatitis present
ERCP
Severe persistent pain in epigastrium w/ N/V anorexia and dec PO intake
Worse laying, inhale
Better sitting/knee flexed
Define Cullen’s Sign
Define Grey-Turner Sign
Blue discolor around umbilicus, indicates hemoperitoneum
Red-brown discolor along flanks, indicates retroperitoneal blood/extravasation
Pancreatitis Dx requires two of what three criteria
Lipase is the key for Dx but what other non-pancreatis issues can cause inc lipase?
Consistent presentation
Inc lipase/amylase x3
Images (contrast CT/MRI/US)
DM
Renal Dz
Appendicitis
Cholecystitis
Lipase levels during pacreatitis is more sensitive in ? PTs/presentations
What labs are drawn w/ lipase during work ups?
HyperTG
Alcohol induced
Delayed
CHEM w/ LFT Glucose CBC- Belly Labs
? criteria is used for predicting severity/outcome of pancreatitis
If PTs meet clinical presentation Dx criteria, what is not needed?
Ransons criteria
CT
If doubtful- CT w/ contrast= inflammation, necrosis, fluids or pseudocyst seen
How is pancreatitis Tx
What is avoided
Fluid resuscitation: 2.5-4L total w/ 1/3 given in first 24hrs
IV opioids
ABX/anti-fungals
What defines mod-sev pancreatitis?
What defines a severe dz?
Transient organ failure <48hrs
Local/systemic complications
One or more complications
Organ failure >48hrs
Besides SIRS, what other clinical findings are associated w/ severe pancreatitis at initial assessment?
> 55y/o Comorbid Obese AMS
BUN >20
Hct >44%
Inc Creatinine
Extrapancreatic fluid collection
Pleural effusion
Pulmonary infiltrates
When do PTs w/ pancreatitis need to be considered for admission?
First pancreatitis Biliary- surg consult, cholecystectomy Pain meds IV Inc pain Abnormal VS NPO d/t vomit Organ insufficiency
? is MC cause of progression from acute to chronic pancreatitis
How are these PTs care for upon presentation
Alcohol
Hydrate
Pain/nausea control
? has lower mortality risk, chronic or acute pancreatitis
Why?
? is the MC complication of gallstone dz
Acute>chronic
Acute can progress to necrosis/gangrenous
Biliary colic x few hrs, self resolves when stone moves from obstructing
Define emphysematous cholecystitis
Define Choledocholithiasis and the two types
Inflammed gallbladder infected w/ gas producing organisms (Clostridium, E Coli, Klebsiella)
Gallstone in CBD-
Primary- arises w/in bile duct
Secondary- MC, forms in gallbladder then moves to CBD
Define Cholangitis
This complication can further complicate ? issues
Infection of biliary tree
Choledocholithiasis
Stricture/tumor obstruction
? causes chronic cholecystitis
? is a rare but life threatening sequelae that can develop?
Define Biliary sludge
Prolonged gallbladder inflammation from recurrent cystic duct obstructions
Gallbladder perf
Microlithiasis composed of cholesterol crystals, Ca bilirubinate/salts
Define Acute Acalculous cholecystitis
What are RFs
No gallstones, from Sepsis Burns Trauma Surgery
DM ImmSupp Age
When/how does cholecystitis induced colic present
What tradition is not reliable for this Dx
Epigastric/RUQ pain at midnight from circadian rhythm
Fatty food intake induced pain
How does cholecystitis biliary colic and acute cholecystitis pain differ?
What are the classic presentations of biliary cholic and acute cholecystitis?
BC- Sxs last few hrs
AC- loca RUQ pain, inc w/ peritoneal irritation
BC: Mild RUQ tenderness, afebrile, no peritoneal signs
AC: severe tenderness, possible fever, rare jaundice
What PE maneuver is done during acute cholecystitis
What does jaundice on PE suggest?
Murphys- cessation of inspiration from fingers touching inflamed gallbladder
Choledocholithiasis obstruction in CBD
Mirizzis Syndrome- compressed duct from impacted cystic duct/gallstone
Define Charcot’s Triad
What S/Sxs are added for it to become Reynolds Pentad
Cholangitis presentation:
Jaundice RUQ pain Fever
AMS Shock
What lab results will be seen in acute cholecystitis results?
What lab result is most sensitive and specific for choledocholithiasis?
Leukocytosis
Inc CRP
Normal LFTs
Abnormal y-glutamyl transpeptidase
? is imaging modality of choice for acute cholecystitis
W/ this image, ? Dx test can be done
Abdominal/RUQ US
Sonographic Murphys
? combo of results is indirect evidence of choledocholithiasis?
When is an elective cholecystectomy recommended?
Gallstone + CBD dilation
Sickle cell
Planned organ transplant
Ethnic groups w/ high risk for GB Ca
What is first line therapy for cholecystitis biliary colic?
How are these PTs managed?
NSAIDs
Anti-emetics Analgesic Volume/E+ ABX NPO
GenSurg- laparascopic cholecystectomy
When can cholecystitis PTs be d/c from ED?
Define Post-Cholecystectomy Syndrome
Colic Sx control
Persistent Sxs after GB removal
Early- concern for bile leak
? is a common cause of post-cholecystectomy pain
? is the landmark separating upper from lower GI bleeds
Choledocholithiasis
Ligament of Treitz
MC cause of UGI bleeds
What are common predisposing factors?
Peptic ulcer dz, H Pylori
Alcohol Salicylates Anticoags NSAIDs Glucocorticoids
Stress related mucosal Dzs occur in PTs w/ ?
What causes esophageal and gastric varices?
Sepsis
Trauma
Respiratory failure requiring mechanical ventilation
PHTN
Most often- alcoholic liver dz
Define Mallory Weiss Syndrome
What is the classic history leading to this condition?
What predisposing factors can it also be associated with?
Bleeding secondary to longitudinal tear a GE junction
Repeat vomit leading to bright read hematemesis
Binge drinking
DKA
Chemo
Why are NSAIDs so hard on the stomach?
Ingestion of what two things can present/mimic melena?
Inhibit prostaglandin formation for protective barrier of stomach
Fe/Bismuth
? is the most reliable method to Dx UGI bleeds in ED
What is the most important test to order if significant bleeding is present?
Visual inspection of vomit
Type and Cross match
What effect does UGIB have on BUN levels?
? lab result is a sentinel sign of severe illness?
Increases
Elevated lactate
? Dx/image study is c/i for suspected GI bleeds?
What tests can be ordered if endoscopic methods are unavailable?
Barium contrast
Tagged red-cell scintigraphy
Visceral angiography
? procedure is Dx and Thx for GI bleeds?
What does this result mean if there is not Hx of hematemesis?
NG intubation and aspiration w/ visual inspection
Strong evidence for UGI source of bleeding
If bright red blood or clots are seen on NG aspirate, what is the next step?
What resuscitative step is done w/ caution in these PTs?
Gatric lavage w/ room temp water
Intubate
What is the Hgb threshold used for deciding to blood transfuse a PT or not
What are two c/i to reversing anticoagulation in PTs on therapy w/ GI bleeds
Hgb <7, <9 if older PT w/ comorbidities
Cardiac/vascular stents
INR of ? is significant predictor of mortality in UGIB PTs on anticoagulants
What are PPIs important for non-variceal bleeds
> 1.5 or more
Clots from platelet aggregation require pH >6
Omeprazole 80mg IV bolus w/ infusion 8mg/h
What is the trifecta benefit of using PPIs in peptic ulcer bleeds
What is Octerotide and its benefits
Reduce need for surgery
Dec hospital stays
Reduce signs of bleeding
Long acting somatostatin analog
Inhibits gastric acid secretion
Reduced blood flow to mucosa
Induces spanchnic constriction
? drug is preferred over Octreotide, why?
PTs w/ ? liver Dz are ImmComp and have inc risk for bacterial infections?
Terlipressin- only drug Tx associated w/ reduced mortality
Cirrhosis- Tx w/ Cipro/Ceftriax
What are two pro-motility agents used for GI bleeds that can aid visualization during procedures
? is the Dx study of choice for UGI bleeds and why is this preferred and w/in ? time frame?
Erythromycin
Metroclopramide
Endoscopy- visualization and administration of hemostatic therapy, <24hrs
What procedure is done during endoscopy for Tx of visceral bleeds
What procedure is done during endoscopy for Tx of ulcerative lesions
Variceal ligation and sclerotherapy
Clips
Thermocoagulation
Sclerosant injections w/ Epi
What drugs are used for endoscopy prep?
What drugs are used if PT is unstable?
Fentanyl
Versed/Propofol
Ketamine Etomidate
What is an effective short term solution for GI bleed Tx
What is the MC source for all bleeds detect in LGI system
Balloon tamponade after intubation
Upper GI bleeds
? is the MC cause of LGI bleeds
How does this MC present
Diverticular Dz
Colitis Adenomatous polyps Malignancy (apple core lesion)
Painless gross bleeding from L sided lesion but lesions on R side more likely to bleed
? is a RF for developing bleeding vascular ectasis
? is the MC cause of intestinal ischemia and a common RF
Valvular heart dz
Ischemic colitis
Prolonged strenuous exercise
? causes messenteric ischemia
What is a presenting clue of this condition?
Clot in SMA
Pain OOP on exam
? is the Dx study of choice for ischemic and mesenteric ischemia
Why is this Dx dangerous
Angiography
50% survival if Dx <24hrs
Where are Meckels MC found
More than half will contain ?
Terminal ileum
Ectopic gastric tissue
What are the initial Dx procedures of choice for lower GI bleeds
What image has the highest sens/spec for detection?
Angiography Scintography
Endoscopy
Multi-detector CT angiography
Define Diverticula
What is the criteria for a true diverticula
Define false diverticula
Herniation where vasculature penetrate muscular layer of colon
All layers of colon wall involved
Only sub/mucosal layers
What microbes can cause diverticulitis
Fusobacterium Gram neg rods- E coli Bacteroides Clostridium Peptostreptococcus
What are two major RFs for diverticuli
What is a protective fact
Smoking
Obesity
Active life style
Where is diverticular dz almost exclusively found in the US
What is the classic presentation for this dz
L sided dz in descending/sigmoid colon
LLQ pain w/ change in bowel type/habits
Fever
Leukocytosis
Why do PTs presenting w/ diverticuli dz have urinary Sxs
What is the next step for presenting PTs that have Hx and Dx of diverticulitis and an acute presentation?
Inflammation effect
Do not scan, no further evaluation required
What type of image is ordered for PTs presenting w/ first acute flare of diverticulitis
What findings are indicative of Dx
Abd/Pelvis CT w/ IV and PO contrast
Thickening >4mm
Phlegmon- inflammation of soft tissue spreading under skin/in body
What are the two severity categories for diverticulitis
Uncomplicated: isolated to inflammation of diverticula w/ or w/out phlegmon
Complicated: diverticula inflammation w/ abscess, stricture, obstruction, fistula or perforation
How is uncomplicated diverticulitis Tx
? are the MC complications from this dz process
Bowel rest, liquid diet
PO ABX
Abscess
Phlegmon
Diverticulitis PTs w/ abscess that measure ? size and ? are admitted
How are these PTs Tx
<4cm and phlegmon
IV ABX, no percutaneous drainage
? PT populations w/ diverticulitis have inc risk for morbidity and mortality
What is the criteria for failed OutPT therapy
ImmComp
Chronic steroids
Sxs/worsening radiographic images w/in 6wks of initial episode
Define Apiploic Appendagitis
How is it Dx
How is it Tx
Fat filled sacs near lining of colon that inflame due to torsion/thrombosis
CT
Benign/self limiting
Pain management w/ f/u in 7 days
What causes kidney stones to hurt so much?
What type of lab results will be seen indicating a stone is likely?
Pressure against Gerota’s fascia
SrCr increase
What are the 3 most likely sites for kidney stones to become obstructed
Stones smaller than ? will almost always pass alone
Ureteropelvic junction
Pelvic brim
Ureterovesical junction- most constricted site of ureter
<5mm w/in 4wks
How do PTs w/ stones present?
What body compensation mechanism will have PTs presenting w/ additional Sxs
Sudden onset flank pain w/out peritoneal Sxs
Adrenergic response= Tachy HTN Diaphoresis
What are 3 important Hx questions asked during kidney stone interviews?
What are two DDx/risks that have to be r/o?
RFs for stone development
Prior stone related outcomes
Important mimickers
AAA
Renal artery infarction
? is the MC mis-Dx given to PTs w/ ruptured AAA
How is this mis-Dx differentiated
Nephrolithiasis
Absent in men >60y/o
No HOTN, ever
Why/how do renal artery stenosis present w/ hematuria similar to stones?
? test has to be ordered on all renal stone PTs that are female and reproductive age?
Infarcted kidney swells
hCG
Why do PTs w/ kidney stones have an elevated WBC w/out fever/systemic illnesses?
When are scans recommended for these PTs?
Stress demargination
All first time stones
What IV pain meds can be used for kidney stones if NSAIDs are not working?
What med is the only antiemetic proven in Tx of renal colic
Ketorolac
Metoclopramide
What ABX are given for PTs w/ kidney stones and signs of fever, renal insufficiency or systemic signs?
What drugs can be used for expulsion therapy?
What Tx class is avoided?
Cipro*
Piper-Tazo
Genta/Tobra +Amp
Ticarcillin-Clavulanic acid
A-blockers: Alfu/Tamsulosin
Steroids
What are the absolute indications to admit PTs w/ kidney stones?
What are the relative indications?
Intractable pain/vomit Urosepsis Single/transplant kidney w/ obstruction Acute RF HyperCa crisis Comorbidities/inc age
Fever Single/transplant kidney w/out obstruction Obstructing stones w/ signs of infection Urinary extravasation Comorbidities Large stone above pelvic brim
When can kidney stone PTs be discharged?
Give these PTs a strainer and they’ll probably catch stones that are ? size w/in ? days
Smaller stones
No infection
Pain controlled w/ PO meds
5-6mm in 7-3 days
What are the d/c orders for PTs w/ kidney stones
When/why would no further Tx be needed in these PTs
Return if fever, vomit, uncontrolled pain
F/u w/ urologist <7days
Stone passes in ED
How are pregnant PTs w/ kidney stones Tx
How are kidney stones in Peds Tx
No NSAIDs, use opioids
A-blockers
Pain/nausea control
US eval
No expulsive therapy
? is the leading cause of maternal death during the first trimester
What hormone imbalances can increase risks for this?
Ectopic pregnancy leading to maternal exsanguination after tubal rupture
Inc estradiol/progesterone, inhibit tubal migration
PTs w/ ? SurgHx have ectopic pregnancy until proven other wise?
? PT population are at high risk for ectopic pregnancy after procedures?
Tubal surgery for sterilization
Laparoscopic partial salpingectomy
Electrodestruction tubal ligation
Either <28y/o
Woman of child bearing age w/ ? SurgHx is excluded from ectopic pregnancy
? is the MC presenting Sx of ectopic pregnancy
Hysterectomy w/ oophorectomy
Abdominal pain from tubal distension
How do PTs present if they’ve had ruptured ectopic pregnancy
What PE finding should not be seen in ectopic PTs?
Shoulder pain from diaphragm irritation
Fever
How is a definitive Dx of ectopic pregnancy made?
What is the primary goal of US during early pregnancy
US
Laparoscopic visualization
Surgery
Viable IUP determination
Exclude ectopic pregnancy
How is GI decontamination accomplished
How is blood/tissue decon accomplished
NG lavage w/ charcoal and Cathartic
Urine alkalinization
Hemodialysis
How do surgical Tx for ectopic pregnancy differ if PTs is hemodynamic un/stable?
MC route of poisoning/over dose?
Un: laparotomy
Stable: laparoscopy
Ingestion
What does the AEIOU TIPS for poisonings stand for
A: alcohol acid/alkalosis E: endocrine E+ encephalopathy I: insulin O: opiates U: uremia T: trauma I: ICP infection P: poison psych S: seizure syncope
Define Toxicologist Handshake
What drugs are not detected by toxicology screens?
No axillary sweat- anti-cholinergic
Presence- sympathomimetic, cholinergic
Rohypnol
Methadone/Meperidine
MDMA
How do anti-cholinergic ODs present
How are cholinergic ODs going to present
Mad as a hatter-
Atropine Anti-histamine/psychotics
Rhabdo AMS Dry/Hot
Oganophosphate/Carbamate insecticides:
SLUDGE
How are hypoglycemic ODs going to present
How are opioid ODs going to present
Suflonylureas, Insulin:
AMS Diphoretic Tachy HTN
Codeine Morphine Heroine-
Hypothermia Brady Miosis
What is the goal pH range when utilizing urine alkalinization
What must be monitored for in these PTs
pH 7.5-8.5 but not w/out raising serum pH >7.55
HypoK
Volume overload
When is hemoperfusion an effective Tx?
How long are poisoning PTs monitored for after Tx
Large molecular weight toxin
Protein binding
6hrs
What fluid is used for HOTN during poisoning/ODs
How is hypoglycemia Tx
What med is given for Na channel blocker toxicity w/ CV complications (wide QRS, tachy)
IV crystalloids
IV Dextrose
Na Bicarb
How are drug induced seizures Tx
What drug is not sued
Benzos
Phenytoin
How are agitated poisoning PTs Tx
How are opioid induced hypoventilation Tx
How is cardiac arrest from Bupivacaine toxicity Tx
Titrated Benzo
Naloxone
IV Lipid emulsion
Antidote for CCBs
Antidote for HyperMg/CCBs
Ca chloride 10%
Ca gluconate 10%
Antidote for Cyanide/Hydrogen sulfide
Antidote for Digoxin or cardioactive steroid
Sodium nitrate
Digoxin fab
Antidote for Benzos
Antidote for CCB/BBs
Flumazenil
Glucagon
Antidote for Cyanide/Nitroprusside
Antidote for lipophilic cardiotoxins
Hydroxycobalamin
IV Lipid emulsion 20%
? US findings indicate ectopic pregnancy is highly likely
How are these cases Tx
Pelvic mass/free fluid
Empty uterus
Unruptured: laparoscopic salpingostomy
Methotrexate medical Tx
How are sedative/hypnotic ODs going to present
What is the first priority for any PT presenting w/ poisoning/OD
Benzo/Barbituate-
Brady, depression, ataxis
ABCs
What is the only poisoning case where antidotes take precedence over primary survey?
How is this exception Tx
Cyanide
O2
Amyl nitrate
IV sodium nitrate
IV sodiu thiosulfate
Antidote for oxidating toxins like nitrites, benzocaine or sulfonamide
Antidote for Chlonidine
Methylene blue
Naloxone
Antidote for Na channel blockers or urinary alkalinization
Antidote for Wernickes syndrome or Wet BeriBeri
Na Bicarb
Thiamine
What drug is used for local anesthetic during eye decontamination
How long is irrigation initiated
All alkali injuries get ?
0.5% tetracaine
pH 7.2-7.4
Ophthalmologic consult
Decontamination of ? is rarely done during poisoning management
Do not give PTs ?
GI
Ipecac syrup
What are the benefits of giving activated charcoal to poisoning PTs?
What toxins are not affected?
Less toxin for uptake
Enhanced elimination
Fe Hydrocarbon Lithium Lead Toxic alcohols
When would multi-dose activated charcoal Tx regimes be used?
What is given for whole bowel irrigation
When would this Tx be needed
Theophylline Carbamazepine Phenobarbital Quinine Dapsone
Polyethylene glycol
Sustained/delay release pills
Fe Lithium Lead
Stuffer/packers
When is whole bowel irrigation c/i
How is urine alkalization accomplished
When is this Tx commonly considered
Diarrhea substance
Bowel obstruction
Sodium Bicarb
Salicylate poisoning
What happens to abdominal pain due to peritoneal origins during palpation?
If need to know if PT is pregnant and what image to do, ? test is ordered
Pain in pelvic area, what test is ordered?
Refers from adjacent quadrant being palpated to point of max tenderness
Qualitative
Quant for US
How are PTs w/ obstructions managed
How is post-op urinary retention Dx and Tx
No complications- floor admit
High grade obstruction/peritonitis- Surgery
US, drainage
What are the less common causes of appendicitis obstructions
Fecalith* Lymph tissue Gallstone Tumor Parasite
Ranson Criteria
At admission: Glucose >10mmol Age >55y/o LDH >350 AST >250 WBC >16K
At 48Hrs: Ca 10% Hct O2 BUN Base deficit Sequestration of fluid >6L
What 3 groups of medication classes can cause acute pancreatitis?
? chest Dzs can present as RUQ pain mimicking cholecystitis
Antiretrovirals
Chemo
ImmSuppressants
Pneumonia
Pleurisy
PE
? US technique has a higher NPV for cholecystitis Dx
Normal CBD diameter is ? but can be enlarged in ? PTs
No Gallstone, + sonographic Murphys sign= 95%
<5mm
Prior cholecystectomy
Elderly
What ABX may be added on to PTs for cholecystitis prior to admission for surgery
What is the disposition for PTs w/ acute cholecystitis or cholangitis
2nd 3rd Gen Cephalosporin
B-lactams
Metronidazole/FQN
Carbapenems
Admit
Severe- admit to ICU
If needed, what is the more reliable method for imaging emphysematous cholecystitis
Define Gallstone Ileus
CT w/ contrast
Mechanical SBO from ectopic gallstone in small intestine via biliary enteric fistula
Dx w/ CT
Tx w/ surgery
PE finding seen in Boerhaave’s Syndrome
Cirrhosis + UGIB need ? ABX
Hamman sign- crunching during chest auscultation
Cipro
When are PPIs used for GI bleeds?
What diverticulosis PTs have inc M/M?
Non-variceal from PUD
NSAIDs
Anticoag use
Transfusion needs
Elderly w/ medical illness
Define Vascular Ectasia
How is ischemic colitis Dx
Arteriovenous malformations and angiodysplasia of colon
Endoscopy
