EMED Block 4 Flashcards
1
Q
What type of underlying issues cause visceral pain?
What do PTs present complaining of?
Where will they locate their pain to?
A
Obstruction Ischemia Inflammation
Stretched unmyelinated fibers innervating organs
Cramp Dull Ache
Steady/Colicky
Localized to spinal cord level
2
Q
What types of underlying issues cause parietal pain?
PTs will localize pain to?
What happens as this pain develops?
A
Irritated myelinated fibers innervating peritoneum (anterior wall)
Dermatome above origin
Rigidity/rebound tenderness, still PT
3
Q
Define Referred Pain
What is an example and why does this happen?
A
Pain felt distant from origin but on same side
Ureter obstruction w/ ipsilateral testicle pain d/t shared innervation
4
Q
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?
A
PT acuity, RFs
Emergency release blood
5
Q
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
A
30-40%
Tachy
Peds- compensated shock
6
Q
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
A
Orthostatic VS
Cardiopulmonary
Axiety
Metabolic acidosis
Panic
7
Q
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
A
Chem panel- E+ BUN/Cr
CBC w/ platelet
PT/PTT/INR
Type, Ag Screen
Cross-matched
8
Q
What are the high risk groups of PTs to present w/ abdominal pain?
A
Cognitive impairment
Lack of communication
Asplenic
Minimal/obscured lab results
Transplant/ImmSupp/Mod
Impaired immune system
Neutropenic
9
Q
Mild-Mod immune dysfunctions have ? presentations of common dzs
Severe immune dysfunction PTs are more likely to present w/ ?
A
Delayed/atypical
Opportunistic infections
10
Q
? is the most important measure of immune competency in AIDS PTs
What level in these PTs are less likely to present w/ opportunistic infections
A
CD4
> 200
11
Q
When PTs present w/ acute abdominal pain, what is the abdomen inspected for?
A
Distension Obvious masses Ecchymoses Scars Stigmata of liver dz
12
Q
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?
A
Dec: Narcotic Infarction Peritonitis Ileus
Inc: Small bowel obstruction
Bowel distension
Dilated loops of bowel
13
Q
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?
A
Necessary rebound tenderness for Dx of peritonitis
Pelvic infection
Ectopic pregnancy
Hernia
Testicular
Prostate
14
Q
What abdominal issues present w/ pain, vomiting and/or rigidity
What abdominal issues present w/ pain, vomiting and distension?
A
Diabetic gastric paresis
Incarcerated hernia
DKA
Acute pancreatitis
Bowel obstruction
Cecal volvulus
15
Q
What abdominal issues present w/ pain and/or vomiting?
What abdominal conditions present w/ pain, shock and rigidity
A
MI Acute diverticulitis Mesenteric ischemia Adnexal torsion Testicular torsion
Perforated appendix, diverticula, ulcer
Ruptured esophagus, spleen
16
Q
What abdominal issues present w/ distension and/or pain?
When giving opioids for pain to these PTs what is coupled with it?
A
Bowel obstruction/volvulus
Anti-emetics
17
Q
What lab result is used to Dx pancreatitis if lipase is unavailable?
What are lactate results used for identifying?
A
Amylase
Mesenteric ischemia
18
Q
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
A
Female Elderly Diabetic
6-12hrs
19
Q
Plain films have limited benefit for abdominal pain PTs when screening for ?
? is the preferred imaging modality for biliary tracts?
A
Constipation
Obstructions
Perforation
Sigmoid volvulus
US
20
Q
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?
A
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
21
Q
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?
A
Ureteral calculi
Retroperitoneal hematoma
Non-contrast CT
22
Q
When is PO contrast CT the preferred imaging modality?
When is IV contrast CT procedures preferred?
A
Perforation
Fistula
GI abscess
Bowel mucosa
Visceral organs
Vascular structures
Sm/Lg bowel obstruction and transition points
23
Q
? is the initial ToC for suspected AAA rupture or mesenteric ischemia
How are suspected abdominal sepsis and peritonitis Tx
A
IV contrast CT
Zosyns
24
Q
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?
A
Ceftriaxone Metronidazole Doxy
Non-communicative
ImmComp
Cognitively impaired
Elderly
Non compliant (d/c, f/u)
Ill-appearing
Lack of social support
Intractable pain/vomit
25
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
26
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
27
? 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
28
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
29
MC cause of mechanical SBO?
What PT populations are more likely to present w/ appendicitis?
Adhesion from prior surgery
F>M 10-19y/o
30
? is the MC cause of atraumatic abdominal pain in Peds >1y/o
? is the MC non-OB surgical emergency in pregnant PTs
Appendicitis
Appendicitis
31
Why does appendicitis pain start w/ umbilical pain?
What is the classic location?
Visceral innervation
McBurneys- 1/3 distance between ASIC-umbilicus
32
What are the causes for atypical appendicitis presentations?
Retrocecal- R flank/pelvic pain
Colo malrotation- LUQ pain
RUQ pain- pregnant, but RLQ still MC
33
? is a common early sign of appendicitis
What is the next Sx to present after non-specific Sxs
Anorexia
Periumbilical pain (pain then nausea)
34
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
35
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
36
# 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
37
? 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
38
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
39
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
40
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
41
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
42
# Define Cullen's Sign
Define Grey-Turner Sign
Blue discolor around umbilicus, indicates hemoperitoneum
Red-brown discolor along flanks, indicates retroperitoneal blood/extravasation
43
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
44
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
45
? 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
46
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
47
What defines mod-sev pancreatitis?
What defines a severe dz?
Transient organ failure <48hrs
Local/systemic complications
One or more complications
Organ failure >48hrs
48
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
49
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
```
50
? is MC cause of progression from acute to chronic pancreatitis
How are these PTs care for upon presentation
Alcohol
Hydrate
Pain/nausea control
51
? 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
52
# 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
53
# Define Cholangitis
This complication can further complicate ? issues
Infection of biliary tree
Choledocholithiasis
Stricture/tumor obstruction
54
? 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
55
# Define Acute Acalculous cholecystitis
What are RFs
No gallstones, from Sepsis Burns Trauma Surgery
DM ImmSupp Age
56
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
57
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
58
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
59
# Define Charcot's Triad
What S/Sxs are added for it to become Reynolds Pentad
Cholangitis presentation:
Jaundice RUQ pain Fever
AMS Shock
60
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
61
? is imaging modality of choice for acute cholecystitis
W/ this image, ? Dx test can be done
Abdominal/RUQ US
Sonographic Murphys
62
? 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
63
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
64
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
65
? is a common cause of post-cholecystectomy pain
? is the landmark separating upper from lower GI bleeds
Choledocholithiasis
Ligament of Treitz
66
MC cause of UGI bleeds
What are common predisposing factors?
Peptic ulcer dz, H Pylori
Alcohol Salicylates Anticoags NSAIDs Glucocorticoids
67
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
68
# 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
69
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
70
? 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
71
What effect does UGIB have on BUN levels?
? lab result is a sentinel sign of severe illness?
Increases
Elevated lactate
72
? 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
73
? 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
74
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
75
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
76
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
77
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
78
? 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
79
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
80
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
81
What drugs are used for endoscopy prep?
What drugs are used if PT is unstable?
Fentanyl
Versed/Propofol
Ketamine Etomidate
82
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
83
? 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
84
? 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
85
? causes messenteric ischemia
What is a presenting clue of this condition?
Clot in SMA
Pain OOP on exam
86
? is the Dx study of choice for ischemic and mesenteric ischemia
Why is this Dx dangerous
Angiography
50% survival if Dx <24hrs
87
Where are Meckels MC found
More than half will contain ?
Terminal ileum
Ectopic gastric tissue
88
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
89
# 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
90
What microbes can cause diverticulitis
```
Fusobacterium
Gram neg rods- E coli
Bacteroides
Clostridium
Peptostreptococcus
```
91
What are two major RFs for diverticuli
What is a protective fact
Smoking
Obesity
Active life style
92
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
93
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
94
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
95
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
96
How is uncomplicated diverticulitis Tx
? are the MC complications from this dz process
Bowel rest, liquid diet
PO ABX
Abscess
Phlegmon
97
Diverticulitis PTs w/ abscess that measure ? size and ? are admitted
How are these PTs Tx
<4cm and phlegmon
IV ABX, no percutaneous drainage
98
? 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
99
# 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
100
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
101
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
102
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
103
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
104
? 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
105
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
106
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
107
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
108
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
109
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
```
110
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
111
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
112
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
113
? 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
114
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
115
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
116
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
117
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
118
How is GI decontamination accomplished
How is blood/tissue decon accomplished
NG lavage w/ charcoal and Cathartic
Urine alkalinization
Hemodialysis
119
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
120
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
```
121
# Define Toxicologist Handshake
What drugs are not detected by toxicology screens?
No axillary sweat- anti-cholinergic
Presence- sympathomimetic, cholinergic
Rohypnol
Methadone/Meperidine
MDMA
122
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
123
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
124
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
125
When is hemoperfusion an effective Tx?
How long are poisoning PTs monitored for after Tx
Large molecular weight toxin
Protein binding
6hrs
126
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
127
How are drug induced seizures Tx
What drug is not sued
Benzos
Phenytoin
128
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
129
Antidote for CCBs
Antidote for HyperMg/CCBs
Ca chloride 10%
Ca gluconate 10%
130
Antidote for Cyanide/Hydrogen sulfide
Antidote for Digoxin or cardioactive steroid
Sodium nitrate
Digoxin fab
131
Antidote for Benzos
Antidote for CCB/BBs
Flumazenil
Glucagon
132
Antidote for Cyanide/Nitroprusside
Antidote for lipophilic cardiotoxins
Hydroxycobalamin
IV Lipid emulsion 20%
133
? 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
134
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
135
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
136
Antidote for oxidating toxins like nitrites, benzocaine or sulfonamide
Antidote for Chlonidine
Methylene blue
Naloxone
137
Antidote for Na channel blockers or urinary alkalinization
Antidote for Wernickes syndrome or Wet BeriBeri
Na Bicarb
Thiamine
138
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
139
Decontamination of ? is rarely done during poisoning management
Do not give PTs ?
GI
Ipecac syrup
140
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
141
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
142
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
143
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
144
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
145
What are the less common causes of appendicitis obstructions
```
Fecalith*
Lymph tissue
Gallstone
Tumor
Parasite
```
146
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
```
147
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
148
? 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
149
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
150
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
151
PE finding seen in Boerhaave's Syndrome
Cirrhosis + UGIB need ? ABX
Hamman sign- crunching during chest auscultation
Cipro
152
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
153
# Define Vascular Ectasia
How is ischemic colitis Dx
Arteriovenous malformations and angiodysplasia of colon
Endoscopy
