EMED Phase 2 Flashcards
ACS includes ? three Dxs
What is the MC Sx for ACS
What are the atypical Sxs
N/STEMI, UA
Angina
Diaphoresis Dizzy Palpitations Nausea SOB Back/Ab pain
? type of MI doesn’t produce Q-waves and is Dx by ?
Repeat troponins in ? time frame if Dx is uncertain
What are the 3 characteristics of UA
Posterior- tall R-wave in V1-2
3hrs
Began <2mon,
Inc frequency, intensity, duration
Occurs at rest
Vessel involvement of MIs
Inferior- RCA > RCX Lateral- LCX Septal- LAD septal branch Anterior- LAD RV- RCA Posterior- LCX Atrial- RCA
What are the absolute c/i for fibrinolytic therapy when Tx STEMIs
Any prior intracranical hemorrhage Structural cerebral vascular lesion Intracranial neoplasm Ischemic stroke <3mon Actively bleeding Suspected dissection/pericarditis
Define Cardiogenic Shock
This is MCC by ?
What causes coronary artery hypoperfusion
NSTEMI reduction of output leading to dec perfusion despite normal volume available for circulation
AMI dec contractility= pump failure w/ dec CO and hypoperfusion
Dec DBP d/t lack of systemic resistance
Define Situational Syncope
Define Carotid Sinus Hypersensitivity
When does this DDx become a likely Dx
Autonomic reflex response from urination, defecation or coughing
Syncope w/ head turning/wearing tight neck clothes
Recurrent syncope w/ neg cardiac workup
What are S/Sxs of brain stem ischemia/vertebrobasilar insufficiency
What structure is occluded if syncope was induced by overhead physical activity
What is the MC Dx mistaken as syncope and what makes this more likely
Posterior circulation deficits-
Diplopia Vertigo Focal neuro deficit Nausea
Brachiocephalic, Subclavian artery
Seizures- Postictal state, Epileptic aura, Tongue bite, Incontinence
What are the 3 most important parts of a syncope work up
What PE results suggests Subclavian Steal Syndrome
Per San Francisco Syncope Rules, ? Pts are at increased risk for adverse events from their syncope
Hx, PE, EKG
> 20mmHg difference between extremities
Abnormal EKG, SOB, SBP <90, Hct <30%, Age >45, MedHx of ventricular dyshythmia/CHF
What are the MC precipitating factors to acute HF
What are the 6 classifications of HF
Afib, MI, D/c meds, Inc Na, Overexertion
HTN: SBP 140 w/ S/Sx of CHF, +CXR and Sxs <48hrs
Pulm edema
Cardiogenic shock: hypoperfusion and SBP <90
Acute on Chronic- SBP <140 but >90 w/ edema
High output: Tachy, Warm w/ pulmonary congestion
Right HF: low output w/ JVD, hepatomegaly, HOTN
What is the most useful part for Dx acute HF
What Sxs have the highest sensitivity for this Dx
What Sxs have the highest sensitivity for this Dx in order
Hx of acute HF
Dyspnea
Paroxysmal nocturnal dyspnea
Orthopnea
Edema
What are the most specific CXR findings for Dx of Acute HF
How can the Sxs of HF be reduced
? is the primary indication for cardiac transplant in the US
Venous congestion, Megaly, Interstitial edema
Dec after load w/ vasodilators
Idiopathic dilated cardiomyopathy
How are cardiomyopathies Dx
How are complex ventricular ectopy Tx in the setting of cardiomyopathy
What meds are used for the chronic therapy
Echo
Amiodarone
ACEI, BB (carvedilol)- improve survival
Diuretics Digoxin- improve Sxs
What are the MC Sxs of HOCM in order
What should be prescribed to Pts once Dx is made
What is an uncommon Sx of Restrictive Cardiomyopathy
Dyspnea > Angina, Palpitations Syncope
Atenolol
Chest pain
Define Kussmaul Sign and when is it seen
How are Pts w/ Restrictive Myopathy Tx
What is the MC Sx of pericarditis
Inspiratory JVD w/ restrictive myopathy
ACEi w/ diuretics
CCS- Sarcoidosis
Chelation- Hemachromatosis
Sharp/stabbing chest pain worse w/ supine, relieved w/ sitting and leaning fwd
What c/c is unique and specific to pericarditis
What is the best location to hear the friction rub
What are the 4 stages of EKG findings
Pain radiating to left trap muscle ridge
LLSB, Apex
1: ST elevation w/ PR depression
2: ST normalizes, dec T-wave amplitude
3: T-wave inversions
4: resolution, returns to normal EKG
How is Pericarditis Dx when sequential EKGs are not available
When should pericarditis Pts be admitted
Early repolarization:
ST/T-wave amplitude ratio > 0.25 in leads 1, V5-6= pericarditis
Myocarditis Enlarged silhouette on CXR Effusion Uremic pericarditis Hemodynamic compromise
What is a classic but rare EKG finding of cardiac tamponades
How are these Dx
Gold standard for Dx myocarditis
Electrical alternans
Bedside US or Echo w/ RA/RV collapse
Biopsy
What are two rare but significant findings for DVT
What are the two MC Sxs of PEs
Phlegmasia Cerulea Dolens- swollen, cyanotic limb d/t obstruction and inc compartment pressure
Phlegmasia alba dolens- pale limb d/t arterial spasm
Dyspnea, Pleuritic chest pain
What cardiac d/os can present w/ Sxs similar to PE
What 3 PE findings also aid w/ a Dx of PE
Well’s Score for PE
CHF Angina MI Pericarditis Tachydysrhythmia
Clear lungs w/ hypoxemia/dyspnea and clear CXR
Suspected DVT/PE, Alternative Dx less likely- 3
HR >100, Prior VTE, Immobile <4wks- 1.5
Active malignancy, Hemoptysis- 1
>6: high 2-6: mod <2: low
What can cause an elevated D-dime w/out DVT presence
Age Pregnancy Malignancy Surgery Liver/Rheum dz Infection Trauma Sicle cell dz
Image of choice to Dx PE
Only medication approved for fibrinolysis Tx of PE
Indications for this type of Tx
Pulmonary angiography
Alteplase w/ UFH/LMWH started after
SBP <90 Dec in SBP >40mm Right heart strain on EKG Inc troponin/BNP Hypoxemia/Respiratory distress
Pts w/ PE are admitted to ? ward
Define HTN Emergency
What are examples of end organ damage
Telemetry monitoring
Organ dysfunction d/t persistent wall stress/endothelial injury leading to inc permeability and fibrinoid necrosis
Chest pain, SOB, Neuro Sxs, Peripheral edema
JNC-7 HTN Classifications
What are the secondary precipitants of acute HTN
Norm: <120 and <80
Pre: 120-30 or 80-90
1: 140-59 or 90-99
2: ≥160 or ≥100
Pregnancy Sympathomimetic toxicity Adverse drug reaction Drug interactions Withdrawal
What lab results suggest renal injury from HTN
How are Aortic Dissections Tx
What are the VS goals
Hema/Protein-uria and Red cell casts
Inc BUN, Cr, K
B-antagonists before vasodilators:
Esmolol/Labetalol or Diltiazem/Nicardipine
HR <60, SBP 100-140 w/ ideal target <120
S/e of using Enalaprilat for HTN Pulmonary Edema
How are HTN Emergencies in Peds Tx
Define P-HTN and how is this Dx
First dose HOTN, Pregnancy Cat-D
Lower MAP by 25% in 1st hr w/ Labetolol or Nicardipine
Pulm artery pressure >25mm at rest/>30 w/ exertion; Dx w/ Right heart cath
What adverse outcome can occur when intubating Pts w/ severe P-HTN
What two meds are used to augment RV function
How is coronary artery perfusion maintained during P-HTN
Cardiovascular collapse d/t inc throacic pressure
Dobutamine, Milrinone
NorEpi
How can RV after load be dec during P-HTN
Abdominal aorta is considered aneurysm at ? size and surgical repair is needed when?
Pts w/ aortic grafting after AAA repair are at increased risk for fistula development located ?
Prostanoids- Epoprostenol
PD-5 inhibitors- Sildenafil
≥3cm= aneurysm
Sxs/≥5 cm- repair
Duodenum
How do Pts present if this fistula develops
What outcome are these Pts at risk for
What is the MC incorrect Dx given to AAA
Hematemesis, Melena, Hematochezia
High output HF w/ dec flow distal to fistula
Renal colic
BP goal during fluid resuscitation
? is the MC peripheral aneurysm
Aortic dissections occur when blood separates ? layers
SBP >90
Popliteal
Intimal and Adentitia
How can the location of pain indicate the area of dissection
Most Pts w/ dissection have ? RFs
Stanford dissection classifications
Anterior- ascending
Abdominal/back- descending
Male, >50, HTN, Cocaine, Cardiac surgery
Ascending- A, Descending- B
DeBakey classifications
What are the MC CXR findings
What is the imaging modality of choice for aortic dissections
1: ascending and descending
2: ascending only
3: descending only
Abnormal aortic contour
Widened mediastinum
CT w/ contrast
What are the HR/BP goals during dissection Tx
Define Dyspnea
What can cause an artificially elevated pulse-ox reading
HR 60-70 bpm, SBP 100-120
Subjective feeling of difficult/uncomfortable breathing
Methemoglobinemia
What findings may suggest a cardiologic etiology to a Pts dyspnea complaint
What use do ABGs have during dyspnea
What test is used for reactive airway dzs
S3 Edema JVD Orthopnea Inc BNP/Troponin CXR w/ edema and megaly
Detects hypoxia and hypercarbia
IDs metabolic causes
Peak expiratory flow rate
What test suggests neurological cause of dyspnea
What are the goals of O2 therapy for Pts being Tx for dyspnea
When would these goal ranges be ignored
Negative inspiratory force
PaO2 >60 or O2 sat above 90%
COPD
Define Hypoxia and Hypoxemia
? PE finding is not a sensitive or specific indicator of hypoxemia
How are these conditions Dx
- xia: Insufficient O2 delivery to tissues
- mia: PaO2 <60mmHg
Cyanosis
ABG
What are the 5 mechanisms that cause hypoxemia
What physiological responses occur d/t this
Hypoventilation R-L shunt bypassing lungs Vent/Perfusion mismatch Impaired diffusion Low inspired O2 (altitude)
Pulm arterial constriction
Inc minute ventilation
Inc sympathetic tone- tachy/tachy
STEMI O2 goal
Acute HF O2 goal
P-HTN O2 goal
Dyspnea O2 goal
Asthma/COPD O2 goal
Sepsis O2 goal
Cyanide poisoning Tx
> 95%
> 95%
> 90%
> 90%
> 90%
> 90%
100%
Define Hypercapnia
What factors affect and can create this condition
Hypercapnia causes HA and confusion d/t ?
Alveolar hypoventilation w/ PaCO2 >45mmHg
RR, Tidal/Dead space volume
Inc ICP
What are the risks when hypercapnia rise above 80mmHG
Define Wheeze
This is usually present d/t ?
Coma Encephalopathy Seizure
Musical lung sounds through central airways during exhalation
Lower airway dz- asthma, COPD, Pulmonary edema, Foreign body, Bronchiolitis
MCC of coughs lasting >6wks
Cough d/t ACEI/ARB can take up to ? to develop and ? to stop after d/c meds
What two types of meds can be used to Tx cough Sxs
Smoking
12mon, 1-4wks
Antitussive- block cough reflex
Demulcents- soothe pharynx w/ mild cough suppression
How can intractable coughing paroxysms in the ED be Tx
? is the only drug FDA approved for Tx hiccups
Why does cyanosis develop
Nebulized lidocaine
Chlorpromazine
Deoxyhemoglobin (reduced Hb) >5mg/dL
Central cyanosis is most reliably visualized in ? locations
How is this Dx
Pleural effusions will create ? PE findings
Under tongue, Buccal mucosa
ABG w/ co-oximetry
Dullness w/ percussion, Dec breath sounds
How much fluid is removed during thoracentesis of pleural effusions
Why is removal stopped at this amount
? is the MC bacterial infection of the alveolar lung
1-1.5L
Re-expansion pulmonary edema
Pneumonia, MC d/t Strep pneumo
Pts w/ pneumonia typically present w/ ?
What will be seen on PE
HCAP is d/t ? and is applicable Dx to ? Pts
Productive cough, Fatigue, Fever, Dyspnea, Pleuritic pain
Tachy, Tachy, low pulse ox, Wheeze
MRSA, Pseudomonas; Admitted >48hrs in past 90days Residents of nursing facility Chemotherapy Home IV ABX Outpatient dialysis Wound care
Aspiration pneumonia is most likely to be found ?
Untreated/Incompletely Tx aspiration pneumonia can develop into ?
Uncomplicated pneumonia are usually Dx by ?
Right lower lobe
Empyema- Tx w/ Piper/Tazo (add Vanc if MRSA suspected)
CXR
How is uncomplicated CAP Tx outpatient
How is this Tx outpatient in Pts w/ comorbidities
How is pneumonitis that progresses into pnemonia prior to or shortly after ER presentation Tx
Azithromycin, Doxy then Fluroquinolones for Tx failures
Levoflox or Augmentin w/ Azithromycin
Levofloxacin w/ Clindamycin
How are lung abscesses Tx
? is the MC RF for Spot Pneumos
What are the MC presenting Sxs
Clinda w/ Ceftriaxone
Smoking
Sudden, ipsilateral, pleuritic chest pain and dyspnea
What is the MC PE finding of Spot Pneumos
What will be found on PE
? is the primary image obtained for stable Pts
Sinus tachycardia
Dec sound/expansion w/ hyper resonance
Erect PA CXR
What CXR findings of a supine AP CXR suggest pneumothorax
Why are CT images needed prior to placing chest tubes for tension pneumos
What image can be used for young, healthy Pts w/out lung dz
Cardiophrenic recess hyperlucency,
Deep sulcus sign (angle enlargement)
R/o emphsematous bullae as etiology
Beside US- comet tails, ants on a log
How much air is give to Pts one tension pneumothorax is ID’d
When can Pts be d/c
? size needles are used for decompression
> 28% or 2-4L by cannula
Supplemental O2 x 4hrs, repeat CXR;
Improvement- d/c w/ 24hr f/u and weekly until resolution
Adult: 14g Peds: 18g at least 2”/5cm long;
Anterior to 2nd ICS at MCL
Lateral in 5th ICS at AAL
Chest tube procedure name
Preferred size and location
What are the four Tx complications that can occur
Thoracostamy
10-14F for non-trauma
14-22F for traumatic
Vessel hemorrhage Parenchymal injury Empyema Tube malfunction Re-expansion injury- collapse >72hrs
Half of iatrogenic pneumothoraxes are caused by ?
Define Massive Hemoptysis
? is an ominous sign in these Pts
Transthoracic needle procedures: biopsy, thorecentesis
100-1000ml/24hrs
HOTN
Pts w/ ongoing, massive hemoptysis may benefit/have Sx relief in ? position
Intubate these Pts w/ ? size tube
? is the MC chronic Dz of childhood
Decubitus w/ bleeding lung in dependent position
8mm- facilitates bronchoscopy
Asthma
? is the only major cause of death that is increasing in frequency
Asthma exacerbations are d/t ? while COPD exacerbations are d/t ?
How are severe asthmatic exacerbations categorized
COPD d/t tobacco abuse
A: expiratory flow limitations
C: ventilation-perfusion mismatch
FEV1 or PEFR <40%= severe
? is a severe and ominous lab finding during an asthmatic exacerbation
Asthma and COPD co-existance/mistakenly Dx more often in ? gender
How are these exacerbations Tx
Normal/Elevated PaCO2
Females
1st: Albuterol sulfate (SABA)
2nd: Terbutaline/Epi
3rd: Ipratropium added to SABA
4th: 40-60mg Pred or IV Methylpred
COPD exacerbations d/t bacterial infections are Tx w/ ?
? air adjunct is used during asthma/COPD exacerbations and lowers intubation rates
Refractory asthma may benefit from intubation w/ ? med
Azithromycin, Doxy, Amoxicillin/Augmentin
Non0invasive Partial Pressure Ventilation
Ketamine
What is the most important part of the PE for abdominal pain
? finding is the clinical criterion standard for peritonitis
What sign is a test that is reliable for Dx of abdominal wall pain
Palpation
Rebound tenderness (Pt wants to lie still)
Carnett Sign- sit up test w/ finger on tender area; same/increased pain= Pos for dx of abdominal wall syndrome
What are the 4 MCC of abdominal pain in Pts >50y/o
? type of pregnancy test do all post-puberty Pts need
? is the MC ordered lab test in Pts w/ abdominal pain
Biliary dz, Obstruction, Diverticulitis, Ca, Hernia
Qual
CBC
CT imaging is the preferred imaging modality for ? etiologies of abdominal pain
? is the MC resuscitation needed in Pts w/ abdominal pain
Only use NSAIDs/Ketrolac for ? conditions of pain
Urolithiasis Appendicitis Mesenteric ischemia Aortic aneurysm Pancreatitis
NS/LR
Renal colic
ED Pts w/ vomiting can have an outlet obstruction r/o be the presence of ?
Vomit induced HOTN is Tx w/ ?
Avoidance of ? products can aid in reducing vomiting episodes
Bile in emesis
NS 20mL/kg
Raw fruit, Caffeine, Lactose, Sorbitol
? anti-vomiting agents are used for persistent vomiting
Metoclopramide- catebory B
Ondansetron- category B
Promethazine
Prochlorperazine
Meclizine- vomiting d/t vertigo
Criteria for diarrhea
What are the 4 mechanisms behind it’s development
Most cases are d/t ? etiology
3 or more per day (chronic: >3wks, acute: <3wks)
Inc intestinal secretion (cholera) Dec absorption (toxin, inflammation, ischemia) Inc osmotic load (laxative, lactose intolerance) Abnormal motility (IBS)
Infectious
? diarrhea illnesses can cause neuro Sxs
What illness can cause paresthesia and reverse temp sensations
Diarrhea after eating ? products suggest ? microbe
Shigellosis, HypoNa
Ciguatoxin
Lake/stream water- Giardia Oyster- Vibrio Rice- Bacillus cereus Eggs: Salmonella Meats: Campylobacter, Staph, Yersinia, EColi, Clostridium
Most specific test for diarrheal illnesses is ?
What microbes are tested for
Diarrhea >7d need to be tested for ?
Stool study in lab
Salmonella/Shigella
Campylobacter
Shiga toxin from EColi
Amoebic infections
Giardia, Crypto
How does HUS present
Diarrhea induced HOTN is best Tx w/ ? fluid
? is the MC/majority etiology of infectious diarrhea in the US
Hemolytic anemia
Acute renal failure
Thrombocytopenia
NS
Norovirus
Most infectious diarrhea are Tx w/ ?
C Diff Tx
Cyclospora diarrhea Tx
Cipro
Metronidazole preferred
TMP-SMX
Giardia diarrhea Tx
Vibrio cholerae diarrhea Tx
Entabmoeba histolytics diarrhea Tx
Tinidazole
Doxy or Azith
Metronidazole and Paromomycin
? meds are used to reduce/slow diarrhea
? ABX can cause C Diff infections
? MC stat does this own
Loperamide
Bismuth subsalicylate
Diphenoxylate and Atropine
Clinda, Cephalosporins Am/Amox-icillin, Fluroquinolones w/ onset 7-10 days after start
MCC of infectious diarrhea in admitted Pts
? type of hand hygiene is needed for C Diff Pts
How is C Diff Tx if outpatient w/ Metronidazole is not an option
Pseudomembranous colitis d/t toxic megacolon are Tx w/ ?
Soap and water w/ contact isolation- alcohol bases are ineffective
Vanc
Metronidazole and Vanc
Nearly 1/3 of C Diff Pts will relapse and have recurrent episodes which are Tx w/ ?
Most useful Dx test for Crohns Dx
What meds are used for Tx
1st: Metronidazole
2nd: Vanc w/ 4wk taper
Abdominal CT
Sulfasalazine/Mesalamine
Hydrocortisone/Pred
6-Mercaptopurine/Azaioprine- steroid sparing and surgical c/is
Cipro, Metronidazole and Rifaximin
Crohns Dz w/ fulminant colitis is Tx w/ ?
How are medically resistant cases Tx
How can diarrhea d/t the Dz be Tx
Piper-Tazo
Infliximab, Adalimumab
Loperamide, Diphenolxylate, Cholestryamine
? is the MC digestive complaint in the USA
What differs functional from organic causes
Constipation
Functional:
Medication/diet, Dec fluid/fiber, Change in activity
Organic:
Acute onset, Weight loss, Bleeding, N/V/F, Change in caliber
? is the most important Rx for functional constipation
? fiber can be used to improve Sxs
? defines an Upper GI bleed
Diet, Fluids, Exercise
Bran, Psyllium, Docusate sodium
Source above Ligament of Trietz
MCC of upper and lower GI bleeds
Melena suggests a bleeding source located ?
All Pts w/ significant GI bleeds need ? lab order
Upper: PUDz, Lower: diverticular dz
Proximal to right colon
Type and Cross
PUD induced bleeding can be Tx w/ ?
? other med can be used for upper GI bleeds
? balloon can be used as a tamponade
Pantoprazole- PPI
Octreotide
Sengstaken Blakemore
What are the two types of dysphagia
MC type of structural dysphagia
MC type of motor lesion leading to dysphagia is from ?
Transfer: oropharyngeal
Transport: esophageal
SCC
CVA
? is the classic Sx of GERD
How are mild Dzs Tx
? are the prokinetics used for Tx
Heart burn
Ranitidine, Omeprazole
Metoclopramide
MCC of infectious esophagitis in ImmSupp Pts
MCC of perforations
? syndrome can lead to esophageal perfs
Candidiasis
Iatrogenic
Boerhaave- inc intraesophageal pressure
? PE findings can help aid Dx of esophageal rupture from dissection
? are these Dx
? ABX are used to cover Pts w/ esophageal perfs
Pain w/ swallowing, Hammon crunch
CXR then esophagram/endoscopy
Piper-Tazo, Cefotaxime/Ceftriax w/ Clinda or Metronidazole
MC location for swallowed foreign bodies to become lodged
Once the object passes ? landmark, it’s considered to be passing
What images are used for identifying objects
Peds: Prox esophagus, Adult: distal
Transverses the pylorus
X-ray and CT scans
MCC of food impactions
? med is c/i in Tx
What can be attempted but w/ poor results
Meat
Proteolytic enzymes containing papain
Glucagon
