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
X-ray results for coins in trachea vs esophagus
How are these removed from the trachea
How quickly can button batteries lead to perfs
Trach: narrow to anterior, Eso: enface w/ anterior
Foley balloon catheter
<6hrs
What time frame for ingested button battery removal vs allowing them to pass
How are sharp ingested objects managed
? procedure is c/i in drug mules
Foley balloon if ≤2hrs since ingestion,
Passed esophagus- repeat x-ray at 24 and 48hrs
Distal to duodenum: monitor passage
Consider removal on day 3 if not passed
Endoscopy
PUD ulcers affects ? part of the GI system
What two factors create these ulcers
? medical conditions contribute to their production
Stomach, Proximal duodenum
Acid, Pepsin, NSAIDs, H Pylori
Behcet’s Dz
Zollinger Ellison syndrome
Helicobacter heilmannii
CMV, Crohns Dz, Cirrohsis w/ P-HTN
? are the protective factors of the stomach against PUDz
? Tx method has shown to increase ulcer healing time and decrease relapse/re-bleeding
Lab result of H Pylori
Prostaglandins- enhance mucus, bicarb production and increase blood flow
H Pylori eradication
Gram-neg spiral flagellated bacteria that produces urea
How does H Pylori’s presence induce ulcer formation
? is an almost universal finding in Pts w/ H Pylori
H pylori has been found to be associated w/ the development of ? lymphoma
Urease, Cytotoxins, Proteases, Inc gastrin
Chronic active but ASx gastritis
Mucosa associated lymphoid tissue- Tx H Pylori can help induce remission
H Pylori places Pts at risk for developing ? Ca
H Pylori has shown to induce ? Heme issue w/ Tx helping ? other Heme Dx
Why do concurrent use of NSAIDs increase the risk for ulcer development
Gastric adenocarcinoma
Causes FeDAnemia, Improves ITP
Inhibit prostaglandin synthesis= dec mucus/Bicarb production and blood flow
What causes acute gastritis
? is the MC classic Sx of PUD
? may be the only positive PE finding of uncomplicated PUD
Severe illness- Shock Trauma Burn Organ failure
Toxic effects- NSAID Steroid Bile acids
Burning epigastric pain
Epigastric tenderness- neither sensitive or specific
? is the MC presentation of acute gastritis
Older Pts >65y/o are more likely to present w/ ? atypical Sxs of PUDz
What is the gold standard for Dx PUDz
GI bleeds, occult to massive
N/V, anorexia, weight loss, bleeds
Upper GI endoscopy
What are the “alarm features” that warrant endoscopy for suspected PUDz
IDAnemia/bleeds FamHx of upper GI malignancy >50y/o w/ new onset of Sxs Dys/Odyno-phagia Mass/adenopathy Vomiting Weight loss
How is a Urea Breath test of H Pylori conducted
What is this test better used for
What is also a useful test of cure
Urea w/ Carbon-13/14 (instead of 12) is ingested and will be reduced to Co2 and Ammonia by H Pylori
Presence of infection after therapy
Stool Ag testing ≥4wks after therapy completion
What medications need to be stopped prior to H Pylori testing
How is PUDz Tx
Pt education or taking Tx meds
D/c PPIs Bismuth ABX H2 antagonist 2-4wks prior to testing
PPI- first (-azole), heal ulcers faster
Irreversibly bind w/ proton pump in parietal cells blocking H+ secretions
Take 30-60min prior to food w/ s/e of HA, GI upset
What are the long term risks of taking PPI therapy for PUDz/H Pylori
What occurs when abrupt medication d/c occurs
Risk of using H2 antagonists (-tidine) for Tx
C Diff, Fxs, Pneumonia, CKDz, HypoMg
Rebound hyper-acid and dyspepsia Sxs
Renal dosing adjustments, especially Cimetidine d/t medication interactions
? medication is used PRN for pain from PUDz
What are the s/e of using this medication class
? medication can be used for Pts that must continue taking NSAIDs w/ ulcers
Antacids
Inc Aluminum- osteoporosis, encephalopathy
HyperMg
Misoprostol- prostaglandin analogue that inc bicarb and mucus (abortant- don’t use in possible pregnancy)
? is Triple Therapy for H Pylori eradication
? is the MCC of GI-related admissions
If endoscopy is ordered, ? two meds are given prior
PPR Clarithromycin and Amoxicillin or Metronidazole x 10-14days
Upper GI bleeds d/t PUDz
Bolus PPI and Erythromycin
PUDz lesions are described using ? classification to predict risk for re-bleeds
? are three groups of meds that can cause pancreatitis
? medication can cause potentially fatal pancreatitis
Forrest
Chemo: Dideoxyinosine
ImmSuppressant- Azathioprine
Antiretrovirals
Pancreatitis etiology may be d/t ?
This pain is worse w/ ? and better w/ ?
What are 3 late but severe PE findings
Activation of trypsin in the pancreatic acinar cells
Worse laying supine, better sitting w/ knees flexed
Cullins, Grey-Turner, Erythematous skin nodules d/t fat necrosis
? lab results are used for Dx pancreatitis
? rapid test may be used but not used often
? lab result predicts a positive gallstone pancreatitis
Amylase 2x normal, Lipase 3x normal
Urine trypsinogen-2 dipstick test
Alanine Aminotransferase >150 w/in first 48hrs of Sxs
? image is used to evaluate for pancreatitis
? medication intervention lowers morbidity and mortality
When can Pts be d/c home
Abdominal CT w/ contrast, MRI if RF, pregnant or contrast allergy
Aggressive fluid therapy w/ crystalloids LR > NS
Non-biliary pancreatitis and able to tolerate PO feeding/pain control
When do Pts w/ pancreatitis need to be admitted
Define Cholecystitis
What are the RFs for this Dx
First time Dx, Biliary pancreatitis, IV meds/PO intolerant
Inflammation of gallstone d/t obstructing gallstone
Gender F>M, Bariatric surgery
? is the MC complication of gallstone dz
What can develop if cholecystitis is left untreated/persistently blocked
Define Choledocholithiasis
Biliary colic
Emphysematous cholecystitis- infected w/ gas producing organisms (Ecoli/Klebsiella)
Gallstones in common bile duct, more commonly secondary- form in gallbladder and migrate to duct
? condition can further complicate choledocholithiasis
? type of cholecystitis is more likely to result in complications
Normally, what causes the gallbladder to contract
Cholangitis- infected biliary tree
Acute acalculous cholecystitis
Cholecystokinin and Neural stimulation
What makes black gall stones
What makes brown gall stones
What stones are radiopaque vs lucent
Ca bilirubinate d/t liver dz/hemolysis
Bacterial/Helminthe infection d/t bile duct stasis/Asian
Cholesterol- lucent, Pigemented- paque
? microbes are more likely to infect gallstones
? PE test is used for cholecystitis evals
Define Mirizzi Syndrome
Gram-neg: EColi, Klebsiella
Murphy’s
Impacted cystic duct/stone w/ adjacent inflammation
? is the classic presentation of cholangitis
What makes this into a pentad
? is the most sensitive and specific marker for choledocholithiasis Dx
Charcot’s Triad: Fever RUQ pain, Jaundice
AMS w/ shock
Y-glutamyl transpeptidase
? is the imaging modality of choice for cholecystitis
Definitive evaluation of choledocholithiasis is done by ?
When are ellective cholecystectomys recommended
RUQ US
ERCP/MRCP, Endoscopic US
Sickle Cell, Pre-organ transplants, High risk for gallbladder cancer
How is biliary colic managed in the ED
What is the risk of using opiates
What ABX are used for Tx
NSAIDs- first line
Induce Sphincter of Odi spasms
2nd/3rd Gen cephalosporins or
Metronidazole and Fluroquinolones combo
? is the Tx of choice for cholangitis
What is done if this Tx of choice is not available
Emphysematous cholecystitis is more common in ? populations
ERCP w/ generous fluids and ABX
Percutaneous drainage/decompression
Diabetics, Elderly
? imaging modality may be used to better visualize Emphysematous cholecystitis
? causes gallstone ileus to form
How is this issue more reliable Dx
IV contrasted CT
Cholecystitis inflammation causing biliary-enteric fistulas
CT
? is the classic radiographic appearance of gallstone ileus’
In the early post-cholecystectomy period, ? is the primary concern
What is a common cause of post-ectomy pain
Rigler Triad: small bowel obstruction, pneumobilia, ectopic stone
Bile leak
Choledocholithiasis
How much of an elevated bili is needed for skin color changes to be seen
What causes increase in total and indirect bili
What causes increase in total and direct bili
> 2.5mg
Over production, Hepatocyte injury
Obstruction preventing conjugated excretion
? liver enzyme is elevated during biliary obstruction and cholestasis
Most reliable Sx of appendicitis is ?
What is the classic point of max tenderness
ALP
Abdominal pain beginning per-umbilical/epigastric
RQL below middle line connecting umbilicus and ASIS- AKA McBurney’s point
Define Rovsing’s Sign
Retrocecal appendix may have ? pain
What is a late finding during appendicitis
Referred pain to right side w/ palpation of LLQ during appendicitis
Flank pain > abdominal pain
Fever
? scoring system is used for appendicitis
? is the imaging modality of choice for dx
How is this modality changes for Peds/Pregnancy
Alvarado’s
Non-contrast CT
Compression US
? is the MC surgical emergency in pregnancy
? ABX are used to decrease post-op infections
? is the MC Sx of diverticulitis
Appendicitis
Piper-Tazo or Amp-Sulbactam
Steady, deep LLQ pain
What Pt population may present w/ atypical presentations of diverticulitis
What atypical presentation can they have
? imaging modality is used for Dx
Redundant sigmoid, Asian, R-sided dz
R-side pain, Suprapubic pain
CT w/ IV and PO contrast
Pts w/ diverticulitis need to f/u w/ GI in ? long
What is the first line ABX regiment
What is the alternative ABX regiment
6wks
Metronidazole + Cipro or Levo or TMP
Augmentin, Moxifloxacin
Sigmoid volvulus is more common in ?
Cecal volvulus is more common in ?
Define Ogilvie Syndrome
Elderly taking anticholinergics
Gravid Pts
Intestinal pseudo-obstruction- elderly/bedridden taking anticholinergice or TCAs
? is the imaging modality of choice for bowel obstructions/volvulus
What lab results suggest gangrene, abscess or peritonitis
? is Dx and therapeutic for pseudo-obstructions
CT w/ IV and PO contrast
Leukocytosis >20K or L-shift noted
Colonoscopy
Where are internal hemorrhoids most likely to be found
What two DDx need to be considered in Pts >40y/o
? is the MC type of anorectal abscess
2, 5, 9 o’clock w/ Pt prone
Rectal, Sigmoid colon tumors
Perianal at anal verge
Acute/recently thrombosed hemorrhoids w/ pain can be Tx w/ ?
AKIs in kids are MCC by ?
What are the stigmatas of renal failure
<48hrs= clot excision
Hypoxic injury, Nephrotoxins
Nausea, Anorexia, HA, Edema, Dec UOP
How are AKIs Dx
How are pre/post-renal etiologies differed
What types of results may be seen w/ pre-renal AKIs
UOP w/ Cr
UA w/ microscopy
Normal UA w/ high SpecGrav
What types of results may be seen w/ interstitial AKI/tubular necrosis
How are Pre-Renal AKIs Tx
How are Intrinsic AKIs Tx
How are post-renal AKIs Tx
Hyaline casts
NS crystalloid at 10-20ml/kg w/out K+ added
Fluid restrictions despite Dec UOP
Foley catheter to remove obstruction
What are the 4 hallmarks of nephrotic syndrome
What life threatening event can develop d/t this condition
How are nephrotic syndromes Tx
Proteinuria Hypoalbumin Hyperlipid Edema
Thromboembolic events, Infections
NS at 20ml/kg
Furosemide for fluid overload
PO CCS
MCC of Rhabdo in adults
? is the most sensitive indicator of muscle damage
? E+ d/o may be seen early on in Rhabdo
Drug/Alcohol abuse
Inc serum creatine kinase 5x above normal
HypoCa
What needs to be avoided during the Tx of Rhabdo
? are the MC bacterial infections Tx in outpatient setting
What are the two types of lower UTIs
NSAIDs
UTIs
Urethritis d/t STDs, differentiated by + discharge
Cystitis- infected bladder
Define Uncomplicated UTI
When is it recommended to screen for ASx Bacteriuria
MC microbe of UTIs
Young, healthy, nonpregnant woman w/ normal urinary tracts
Pregnancy, Men prior to transurethral prostate resection
EColi
What are the two relevant dipstick results for UTIs
What 3 microbes are not detected w/ this test
What could cause one of the results to be falsely pos/neg
Nitrate- measurement for bacteriuria
Leukocyte esterase- measure of pyuria
Enterococcus Pseudomonas Acinetobacter
+: Vaginitis/Cervicitis/fecal contamination
-: Chlamydia
Work ups for UTIs should only have urine cultures ordered on ? Pts
First line Tx for uncomplicated UTIs
How are Complicated UTIs or Pyelo Tx
Complicated UTIs
Relapse/re-infected
Peds
Septic
Nitro > TMP-SMX or Fosfomycin
1st- Cipro, then Levo, Cefpodoxime, TMP, Augmentin
How is ASx Bacteriumureia and UTIs during pregnancy Tx
What med is used for bladder analgesic
? is the MCC of urinary retention
ASx: Nitro x 3d, Preg: Nitrox 7d
Phenazopyridine
Outlet obstruction 2/2 BPH
? much post-residual volume on US is Dx
How are these Pts Tx
How are Pts w/ urinary retention from hematuria Tx
50-150cc
Cath w/ 2% lidocaine
16F Coudea cath if straight cath fails
3 port foley w/ irrigation until blood fades away
? med can be used to control bladder spasms from urinary retention
Testicular torsion results from abnormal fixation within ? structure
? testicular issue occurs more often than torsions
Oxybutynin
Tunica vaginalis
Appendage torsion
Testicular torsion surgery is best done ? in time frame
Torsions typically occur in ? direction so manual manipulation efforts are done in ? direction
Where are the majority of kidney stones Dx
<6hrs
Lateral to medial= attempt in medial to lateral manner
Distal ureter
? is the best imaging for Dx kidney stone
US can be used for stones smaller than ?
How are Pts managed in the ED w/ this condition
Non-contrast helical CT
<5mm
Ketorolac- prostaglandin inc ureter dilation
Crystalloids, Metoclopramide, Tamsulosin/-zosin
? ABX are used for kidney stones if infection is also present
Criteria for Pts to be d/c from ED
Consult urology for stones bigger than ?
Cipro, Levo, Cefpodoxime
Stone <5mm, no infection, pain controlled PO w/ f/u in 7days
> 5mm
? is the leading cause of maternal death during the first trimester
? is the MC location for this leading cause to occur
What is the classic triad of presentation
Ectopic pregnancy
Fallopian tube ampulla
Abdominal pain, Vaginal bleeding, Amenorrhea
How much Rhogam do Pts w/ ectopic pregnancy receive
Threatened abortion
Inevitable abortion
50ug
Bleeding <20wks EGA, Closed os, No tissue passage
Dilated cervix
Incomplete abortion
Complete abortion
Missed abortion
Partial passage of tissue between 6-14wks
Complete passage of all tissue <20wks
Fetal death <20wks w/out passage of any tissue x 4wks after death
? medication can be used for ectopic/miscarriages
What ABX are used for septic abortions
What meds are used for vomiting d/t pregnancy
Misoprostol
Amp-Sulbactam or Clinda+Genta
Metoclopramide, Promethazine, Ondansetron, Doxylamine+Pyridoxine
Criteria for Pre-E
? is a clinical variant of Pre-E
When is this DDx a consideration
> 140/90 twice, 4hrs apart w/ proteinuria >300mg in 24hrs in a Pts 20wks EGA through 6wks post-delivery
HELLP Syndrome- hemolysis, elevated liver enzymes, low platelets
Pregnancy >20wks w/ abdominal pain
? steroid is used for pre-term labor <34wks
Shoulder dystocia steps
Pts w/ PID that are d/c from ED need to f/u in ?
Dexamethasone
XXXX
72hrs w/ OB/GYN
How are PID Pts Tx w/ IV meds
How is this Tx outpatient
? is the rash from TSS described
Genta and Cefotetan/Cefoxiten w/ Doxy or Clinda
Ceftriax or Cefoxitin and Probenecid
3rd Gen cephalosporin w/ doxy and/or metro
Painless sunburn d/t Staph A exotoxin
How is TSS Tx
What is the next step if no improvement is seen in 6hrs of starting ABX
How is STSS Tx
MRSA: Vanc or Linezolid and Clinda
MSSA: Naf/Oxa-cillin w/ Clinda
IVIG w/ IDz consult
Piper-Tazo or Meropenem w/ Clinda
Add Vanc if MRSA suspected
Define Thunderclap HA
What are the two DDxs if this occurs during exertion
HA w/ seizure, AMS, visual disturbance or focal neuro deficit may be d/t ? syndrome
HA pain reaching 7-10/10 in <1min
Subarachnoid hemorrhage, Carotid arterial dissection
Posterior Reversible Encephalopathy Syndrome
Pts w/ CD4 count less than ? are at increased risk for intracranial pathology
Medication use of ? places Pts at increased risk for meningococcal infections
Pts w/ ? dz are more likely to have aneurysm ruptures at younger ages
<200
Eculizumab
Autosomal dominant PCKDz
What is the classic pentad of meningitis
If papilledema is seen on PE, ? are the next steps
? PE finding suggests a posterior communicating artery aneurysm
Fever AMS Rigidity + HA
CT then LP
Asymmetrical/Ptosis pupil- CN3 compression
? is the fastest and most appropriate image for HA assessments
? imaging is used if suspected arterial pathology is causing Pts Sxs
What is the best position for LPs
CT w/out contrast
MRI angiography
Lateral decubitus- allows for measuring opening pressure
MC etiology of meningitis
Negative head CT but strong suspicion for subarrachnoid hemorrhage has ? next step
This next step is also done if Pt presents more than ?hrs after Sxs onset
Viral
LP
> 6hrs
? antiplatelet med increases risk for acute intracranial bleeds after trauma
Pts presenting w/ ? Sxs are considered cerebellar hemorrhage until disproven
Image of choice for suspected brain tumors
Clopidogrel
Vertigo, Ataxia
MRI w/ and w/out contrast
Define Temporal Arteritis
MC non-life threatening HA in ED is ?
How does this MC present
Inflammatory condition of small/med vessels
Migraine
Unilateral, pulsating HA w/ photo/phono-phobia and worse w/ exertion
What mnemonic is used for Dx migraines
Criteria for chronic migraine
What are 3 absolute c/i to migraine Tx in pregnancy
POUND
≥5 HA days/mon x 3mon
Isometheptene Caffeine Ergotamine
Define Horner’s Syndrome
Where will the lesion be located to cause this syndrome
Presence of ? PE finding mandates CT imaging before LPs
Ipsilateral ptosis, miosis, anhidrosis d/t interrupted sympathetic impulses controlling tarsal muscle (upper lid)
and iris dilators
Brain stem to plexus near carotid artery
Papilledema- edema of optic nerve head d/t ICP
What are 4 causes of Papilledema
Pentad of Pseudotumor Cerebri
What type of vision dysfunction can this cause
Malignant HTN
Pseudomotor cerebri
Intracranial tumors
Hydrocephalus
Inc ICP, Papilledema, Normal CSF/Images
CN6 paresis= horizontal diplopia (double vision w/ horizontal gaze)
Majority of atraumatic subarachnoid hemorrhages are caused by ?
Where are these etiologies usually found
These bleeds can be r/o w/ 100% certainty using ? rule
Ruptured aneurysm (5-10mm)
Bifurcation of Circle of willis
Ottawa Subarachnoid Hemorrhage rules: ANT LED
Age >40, Neck pain/stiff Thunderclap LoC Extertion Dec flexion
? is the initial image ordered for suspected subarrachnoid hemorrhages
What is the next step if this initial image is negative
Reassess these Pts for ? finding
Non-contrast CT
LP w/ RBC count of the 3/4th tube
Dec in GCS by 1pt= onset of complications
What is the greatest risk after a subarrachnoid hemorrhage
How is this risk dec
What needs to be avoided in these Pts
Rebleed in first 2-12hrs
BP control 120-60 w/ Labetalol/Nicardipine
Nitroprusside/Nitro
What is a common event to occur 2-21days after subarrachnoid hemorrhage
How is this event reduced
What post-d/c consideration is given to all Pts
Vasospasms
Nimodipine started w/in 96hrs of Sx onset
Seizure prophylaxis
Define TIA
This condition is considered analogous w/ ? other Dx
What two imaging orders do Pts need
Transient neuro dysfunction d/ ischemia w/out infarct
Unstable angina
EKG for Afib, Non-contrast CT
Any positive US test on TIA Pts is f/u w/ ? next step
How are TIAs Tx
Peripheral Vertigo involves ? structures while Central involves ?
CT/MR angiography
Antiplatelets- ASA+Dipyridamole*, Clopidogrel
Anticoagulation- Warfarin (r/o Afib first)
Endarterectomy
P: vestibular apparatus w/ CN*
C: brainstem/cerebellum w/out focal deficits
? mnemonic of tests are used to test for Central Vertigo
? is the MCC of Vertigo
? is the 2nd MCC of vertigo
HINTS: Head Impulse, Nystagmus, Test of Skew
BPPV- otoconia displaced in semicircular canals causing vertigo <2min
Vestibular Neuritis- post-viral infection causing vertigo x days w/out HL/tinnitus or pain
Labyrinthitis is a complication from ? but will have ? to separate it from other etiologies
? is the most feared cause of vertigo
? reflex prevent blurred vision during head movement
Otitis media; pain, HL and tinnitus
Cerebellar stroke
Vestibulo-ocular reflex
How is BPPV Tx
How is Vestibular Neuritis Tx
What daily med can be used for Tx
Epley maneuver
Anti-cholinergic- Scopalamine
H1 antihistamines- Diphenhydramine, Meclizine
Ondansetron- 5-HT antagonist
Promethazine, Metoclopramide- N/V
Betahistine- inc cochlear blood flow to dec peripheral vestibular input
How is vertigo during MS Tx
Define Status Epilepticus
Define Refractory Status Epilepticus
Gabapentin
Seizure ≥5min or ≥2 seizures in a row w/out returning to baseline
Persistent seizures despite two IV antiepileptics
Define Generalized Seizure
Define Todd’s Paralysis
? type of seizure allows Pts to recall events of attack
Simultaneous activation of cerebral cortex starting w/ abrupt LoC
Transient, unilateral deficit after a focal seizure that resolves <48hrs
Simple partial seizure
? labs are needed for Pts w/ documented seizure d/o and have single, unprovoked seizure
What type of acid-base disturbance can be seen after a first seizure
What two lab results will be temporarily elevated and help r/o malingering/pseudoseizure
Glucose, Medication level
Wide anion gap metabolic acidosis
Lactate, prolactin
? image is ordered for first time seizures
What meds are used after first time seizures
How are HIV Pts w/ seizures worked up
Non-contrast CT
Valproate Oxcarbazepine Lamotrigine Levetiracetam Topiramate
Non-contrast CT, LP then contrast CT/MRI
? is the MCC of secondary seizures
How are pregnant Pts w/ seizures Tx
What happens to the BBB during Status Epilepticus
Neurocysticercosis d/t T solium larva
+HTN after 20wks= eclampsia; Tx: Mg sulfate
Compromise allowing K/Albumin entrance (both hyperexcitatory)
Drug of choice for Tx Status Epilepticus
Define Trench Foot
What are the degrees of severity for frostbite
IV Lorazepam
Soft tissue injury d/t prolonged non-freezing temp/moisture exposure
1st: partial thickness skin freezing w/out blisters
2nd: full thickness freezing w/ clear bullae
3rd: deep; sking and subdermal plexus freeze w/ hemorrhagic bullae and necrosis
4th: muscle/tendon/bone involvement and black mummified eschar
How is frostbite Tx
How is Trenchfoot Tx
What meds are added to chilblain Tx
Warm water rewarming at 37-39* x 30min until pliable
Aloe verz q6hrs
Tetanus prophylaxis
Dry, elevate, rewarm and bandage
Nifedipine, Pentoxifyline LImaprost Fluocinolone cream
Criteria for Hypothermia
How do Pts die of this
What EKG finding can be seen in these PTs
<95*F- tachy, tachy, HTN
Afib to Vfib to Asystole
Osborn J wave- slow positive deflection at end of QRS
Cardinal features of Heat Stroke
? parts of the body are most susceptible to injury
Evaporation is the principle mechanism for heat loss but is rednered ineffective when ?
Hyperthermia >104 and end organ injury
Nerve, Liver, Kidney, Vessel tissues
Humidity >75%
Define Heat Syncope
Who does this occur to most often
Where are muscle cramps more likely to occur
Dec volume w/ peripheral dilation and dec tone
Elderly, Poorly acclimatized
Calf, Thigh, Shoulder after water replacement w/out Na
Hyperthermic Pts are cooled until ? w/ ? method being most effective
How are seizures and excessive shivering managed
How are anaphylactic reactions to Hymenaoptera Tx
Core temp 100.4 w/ external cooling
Lorazepam/Diazepam
Epi, Methyl/Pred, Albuterol
H1- diphenydramine
H2- famotidine
Crotaline snakes
Elapidae snakes
How are these bites managed
Pit vipers: Rattler, Copper, Moccasin, Massasauga
Coral snake- neurotoxin venom
Measure area circumference q60min
Polyvalent Crotalidae immune Fab
Pts that develop Serum Sickness post snake bite Tx are Tx w/ ?
Mammal bites located ? are candidates for primary closure
Primary closure is avoided in ? populations
Pred
Face/scalp w/out devitalized tissue/underlying Fxs
ImmDefficient
Microbe from cat bites
Animal bite prophylactic ABX choice
? dog bite microbe can cause serious systemic infections in ? populations
Pasteurella multocida
Augmentin
Capnocytophaga carnimorsus- asplenic, alcoholics, ImmSupp
Microbe causing Cat Scratch Fever
What ABX is used for normal populations
What is used in ImmSupp populations
Bartonell henselae
Azithromycin
TMP-SMX, Cipro, Rifampin
Human bite microbe
How are these Tx
Post-exposure prophylaxis regiment for rabies
Eikenella corrodens
Augmentin w/out suture closure unless on face
Human Rabies Immunoglobulin x 1
Rabies vaccine x 4 on days 0, 3, 7, 14
ImmSupp- 5th vaccine on day 28
Most important means to reduce morbidity and mortality from near/drowning
What causes the fruity breath observed during DKA
BiCarb is given during Tx if pH is below ?
Prevention
Acetone d/t oxidation of ketone bodies
≤6.9
What causes Alcoholic Ketoacidosis
How is this Tx
Diabetics taking ? meds can have hypoglycemia
Dec glycogen stores, Inc lipolysis
D5Ns until rehydrated then, D5 .45NS w/out insulin
Thiamine before glucose administration- prevents Wernickes
Na BiCarb if pH remains <7.0
Insulin, Sufonylureas: Chlorpropramide Glyburide
How are Pts w/ Hypoglycemia Tx
Thyrotoxicosis is MC in ? Pts
What are the cardinal features of a thyroid storm
PO Glucagon
IV D50 then D10
Refractory 2/2 sufonylureas- Octreotide
Repeat blood glucose levels q30min
Antecedent Graves Dz
Fever, Tachycardia
How is Thyroid Storms Tx
All Pts w/ adrenal insufficiency have low levels of ?
Acetaminophen PTU > Methimazole to block peripheral T4 to 3 conversion Lugol solution or K iodide or Iopanoic Propranolol or Esmolol Hydrocortisone of Dexamethasone
Cortisol
Consider Dx of Adrenal Crisis in any Pt presenting w/ ?
How are Adrenal Crisis’ Tx
How does preseptal cellulitis differ it from orbital cellulitis
Unexplained HOTN refractory to pressors
5% dextrose in NS,
Hydrocortisone > Dexamethasone
No eye involvement= acuity, pupil response, appearance are normal w/out pain during movement
Preferred imaging for suspected preseptal cellulits
Once Dx, how are Pts w/ preseptal cellulitis Tx
How are postseptal cellulitis Pts Tx
CT w/out contrast of orbit
Augmentin
Cefuroxime or Ceftriax or Augmentin w/ Vanc for MRSA
PCN Allergy- =floxacin w/ metro or Clinda
Define Stye
Define Hordeolum
How are these Tx
Infected oil gland along lid margin
Inflammation d/t meibomian gland blockage
Warm compress w/ Erythromycin oinment
? ABX are used for Peds w/ bacterial conjunctivitis
What med is avoided during treatment
? is used for Herpes Simplex Keratitis Tx and ? is avoided
Cipro/O-cloxacin
Gentamicin
Trifluridine, Topical steroids
? two meds can be used for conjunctivitis in Pts wearing contact lenses
How is viral conjunctivitis Tx
Orbital blowout Fxs involve ? sides of the orbit
Cipro, Tobramycin
Naphazoline/Pheniramine w/ tears
Inferior and Medial wall entrapping inferior rectus muscle (diplopia w/ upward gaze)
? image is used for blowout Fxs
What ABX are used
? test is used for suspected high velocity penetrating trauma
CT w/ 1.5mm cuts
Cephalexin
Seidel test- bright green stream w/ fluorescein
Once a globe injury is suspected, ? is the next step
What types of eyelid lacerations need to be closed by Eye/Plastics
Lacerations less than ? size are able to self resolce
Stop all exam/manipulation and shield eye
<8mm medial canthus Duct/sac Inferior lid surface Margin Ptosis Levator palpebrae muscle Tarsal plate
<1mm
Eyelid lacerations that are not immediately evaluated by Ophtho are managed how
How are chemical injuries to the eye managed
? meds are used during Acute angle closure glaucoma
Cephalexin and Erythromycin w/ cool compresses and f/u <24hrs
Irrigate w/ 2L NS/LR, check pH (goal 7.4)
Cyclopentolate- plegic to aleviate spasms
Erythromycin
Opioids
Timolol Apraclonidine Acetazolamide Pilocarpine
What two PE findings may be seen w/ central retinal artery occlusions
What three things may be attempted until Ophtho consult arrives
What will be seen on PE during central vein occlusion
Cherry red spot, Boxcarring
Massage Acetazolamide Timolol
Blood and thunder fundus
MCC of Facial Cellulitis and Erysipelas
What ABX are used for Tx
Mumps is MCC by ? virus
Strep pyogenes > Staph A
Clinda Diclox Cephalosporin
Paramyxo
How long are Mumps Pts contagious
What PE finding can help distinguish mumps from suppurative parotitis
How are Masticator Space Abscesses Dx
9d after onset of swelling
Pus expressed from Supp-P
CT w/ contrast
Why do masticator space abscesses need prompt Tx
What is used for Tx of Trigeminal Neuralgia
? is the MC direction of mandibular dislocations
Communicate w/ mediastinum
Carbamazepine
Anterior d/t extreme mouth opening; Tx w/ down and back pressure w/ padded thumbs
How are superficial face lacerations Tx
All Pts w/ epistaxis Tx by packing need ? ABX
Nasal Fx involving ? structure can lead to CSF rhinorrhea
6-0 nonabsorbent monofilament w/ simple interrupted sutures, remove on day 5-7
Augmentin
Cribiform plate
How are Malignant Otitis Externa Tx after CT imaging
What are the possible complications that can arise from Otitis Media
Tobramycin and Piperacillin or Ceftriax/Cipro
Perf CHL Serous labyrinthitis CN7 paralysis Mastoiditis Sinus thrombosis Cholesteatoma Intracranial complications
What ABX are used to Tx Mastoiditis
What are 3 RFs for develops Post-Extraction Alveolar Osteitis
How are these Pts managed
Vanc or Ceftriax
Carbonated beverage, Smoking, Straws
Saline/Chlorhexidine irrigation
Eugenol impregnated gause pack
PCN VK or Clinda
F/u <24hrs
How are Periodontal Abscesses Tx
How does ANUG present
How are these Pts Tx
PCN Vk or Clinda
Chlorhexidine mouth wash
I&D if large
Refer all Pts
Punched out papillae w/ bleeding, foul taste, adenopathy and fever
Metronidazole and Chlorhexidine mouth wash
How are Aphthous Ulcers Tx
How are Dental Fxs classified
How are these Fxs managed
0.1% traimcinolone acetonide past or Chlorhexidine mouth wash
Ellis Classes:
1- enamel only
2- dentin
3- pulp
Ca hydroxide over exposed pulp and refer <24hrs
How are dental avulsions Tx
How are these transported if needed
What ABX are used after Tx
Rinse <10sec w/ water
Replant immediately if <3hrs
Hank’s salt solution, Milk, Saliva, Sterile saline
Adults: Doxy
Kids <12: PCN VK
? oral frenulum does and does not need repair
? type of image is used for PTAs
? structure is avoided during aspiration and ? ABX are used after
Maxillary= none, Lingual- 4-0 absorbable
CT w/ contrast
Internal carotid; PCN+metronidazole
Toxic= Piper-Tazo
How are adults w/ epiglotitis Tx
? are retropharyngeal abscesses Dx
How are these Tx
Cefotax+Vanc and Methylpred
CT w/ contrast
Clinda or Cefoxitin
Glasgow Coma Scale
Eye: Spont Speech Pain None
Verbal: A&O Disoriented conversation Speakin, nonsensical Moan/Uninteligible None
Motor:
Follows Locals Move/Withdraw Decor flex Decere extend None
? is the leading cause of death in hospitals of Pts w/ AMI
STEMIs
