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Emerg Flashcards

1
Q

Criteria for consideration of termination of resuscitation

A

All of the following present:

1) Arrest not witnessed
2) No bystander CPR
3) No ROSC before transport
4) No shock delivered before transport

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2
Q

Epinephrine dose in asystole/PEA

A

1 mg IV/IO every 3-5 min

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3
Q

Epinephrine dose in anaphylaxis

A

1:1000 epinephrine
0.01 mg/kg, max 0.5mg
Every 5-15 min as needed

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4
Q

Autoinjector doses for various weights

A

<10kg –> 0.1 mg dose (Auvi-Q)
10-25 kg –> 0.15 EpiPen Jr
25+ –> 0.3 mg EpiPen

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5
Q

After 3 shocks for VF/pVT, consider what meds?

A

Amiodarone 300 mg IV/IO followed by 150 mg

Lidocaine 1-1.5 mg/kg IV/IO followed by 0.5-0.75

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6
Q

Ddx mnemonic for symptomatic/unstable bradycardia

A

Don’t led bradycardia patients DIE
Drugs
Ischemia
Electrolytes

(also many others)

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7
Q

Crystalloid fluid bolus quantity in critically ill patient (w/out fluid overload condition like CHF or advanced renal failure)

A

30 ml/kg (2-4 L in adults)

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8
Q

Initial management of patient with suspected sepsis (11)

A

2 large bore IVs
Lactic acid
Initial fluid bolus of 30 mL/kg over first 3 hours
CBC
CMP
2 sets blood cultures
CXR, EKG
Continuous sat monitoring/supplemental O2
Urinalysis w/ culture + pregnancy test in WOCBA
(LP if meningitis suspected)
Empiric ABs (ideally after blood cultures obtained)
(Pressors if continued high lactate or hypotension after fluid bolus)

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9
Q

Example of antibiotic approach to sepsis with source unclear?

A

Pip/tazo (broad spectrum GN, covers pseudomonas, tazo is B-lactamase inhib)
Vancomycin (GP/MRSA, quite narrow-spec)
Amikacin (aminoglycoside)

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10
Q

Diagnostic criteria for ARDS

A

1) Acute onset
2) Bilateral infiltrates on CXR consistent w/ pulmonary edema
3) Pulmonary artery wedge pressure <18 mmHg or clinical absence of left atrial hypertension - i.e. resp failure not accounted for by heart failure/fluid overload
4) Hypoxemia with PaO2/FiO2 <300 (ALI) or <200 (ARDS)

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11
Q

What test should be done post-cardiac arrest? If pt can’t follow commands what should be done?

A

EKG (cardiac ischemia may be cause of Vfib)

Comatose –> targeted temperature management (hypothermia 32-34C for 24-28hrs), EEG

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12
Q

Trauma resuscitation principle that reduces bleeding and improves outcomes (regarding vitals)

A

Permissive hypotension
SBP goal is 85-90 mmHg (preserves perfusion to brain + vital organs)
- note: permissive hypotension shouldn’t be applied to hypotensive trauma pts w/ mod-severe TBI bc low BP can increase secondary brain injury

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13
Q

Target MAP in septic shock management
Target urine output
Target CVP

A

MAP 65+
>0.5 mL/kg/hr
CVP 8-12 mmHg (normal range)

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14
Q

MAP formula

A

=2DBP + SBP / 3

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15
Q

If pt remains in shock after fluid resus, what pressors are given?

A

Norepinephrine (Levophed) drip
2nd line: vasopressin (improves cellular response to catecholamines)
If STILL doesn’t work –> corticosteroids

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16
Q

Initial issue that should be immediately managed in DKA?

A

Fluid deficits (can be up to 10L!)
2L saline bolus in adults
10-20 mL/kg saline in children

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17
Q

DKA: rehydration + insulin will lower serum glucose faster than clear ketones. Insulin infusion should be continued until when?

A

Until anion gap returned to normal

Add dextrose to IV infusion when glucose falls to ~15 to prevent hypoglycemia

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18
Q

What type of insulin do you give during DKA?

A

Short-acting (Regular)

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19
Q

___ replacement is often necessary before hypokalemia can be reversed

A

Mg (deficiency increases ROMK K+ secretion)

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20
Q

___, ____ ,and ____ confirm the diagnosis of DKA and are enough reason to start ____. Some providers prefer to wait for a ____ level before starting ____

A

Hyperglycemia, ketosis, and acidosis
Start fluids
Wait for K+ levels before starting insulin

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21
Q

DKA patients are almost always ___- and have significant ___ and ___ deficits regardless fo specific lab values

A

Dehydrated

Sodium/potassium

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22
Q

Antidote to beta-blocker overdose

A

Glucagon (increases HR/contractility bypassing beta-AR site)

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23
Q

True anaphylaxis is a ____ hypersensitivity reaction occurring after a previous sensitizing exposure

vs anaphylactoid?

A

Type 1
IgE-mediated activation of basophils/mast cells –> PG + leukotriene + histamine release
Anaphylactoid has release of these compounds through non-immune-mediated pathways so doesn’t require prior sensitization

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24
Q

Diagnosis of anaphylaxis

A

Any 1 of the following 3 criteria:

1) Acute onset w/ reaction of skin or mucosal tissue PLUS resp Sx or hypotension
2) Acute onset of 2+ of the following after exposure to a likely antigen (skin-mucosal tissue, resp, hypotension, GI)
3) Acute hypotension after exposure to known allergen (faintness, AMS)

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25
Q

No response to 3 epipens in anaphylaxis –>

A 
IV epinephrine (2-10 ug/min for adults)
*Can cause MI in pts w/ CAD
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26
Q

Give an example of a SAMA and a LAMA

A

SAMA: ipratropium bromide
LAMA: tiotropium bromide

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27
Q

Role of H1 and H2 antihistamines (and examples) in anaphylaxis

A

H1 antagonists such as cetirizine or diphenhydramine can be given for cutaneous symptoms (no affect on resp/CV/GI)
H2 (ranitidine) in combo with H1 for better cutaneous treatment
Diphenhydramine for vomiting

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28
Q

Big diff between first gen and 2nd gen H1 antihistamines?

A

First gen have central effect (sedating)

2nd gen used more as antiallergic

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29
Q

H2 antihistamines are indicated primarily for…

A

gastric reflux (block H2 receptors in parietal cells of gastric mucosa)

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30
Q

Cetirizine (Reactin), fexofenadine (Allegra) and loratadine (Claritin) are what type of antihistamine

A

2nd gen H1

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31
Q

Risk factors for severe anaphylaxis (4)

A

Hx of poorly-controlled asthma or COPD
Advanced age
Pregnancy
B-blocker or ACEi use

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32
Q

STEMI is a ___ infarct, NSTEMI/UA are ___ infarct/ischemia

A

Transmural

Subendocardial

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33
Q

STEMI is diagnosed when ST elevation is found in __ continuous ECG leads

A

2+

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34
Q

ACS management mnemonic

A 
MONA greet chest pain at the door (immediate)
Morphine
Oxygen 
Nitroglycerine
Aspirin 162 mg!!!
BASH later
Beta-blockers
ACEi/ARB
Statins
Heparin (e.g. enoxaparin = LMWH)
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35
Q

BOERHAAVE SYNDROME:

A

Barotrauma induced rupture of the esophagus, usually caused by vomiting.

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36
Q

Initial treatment of Boerhaave syndrome (if perforation is contained)

A 
NPO status
NGT placement w/ suction
Broad-spectrum IV antibiotics
Parenteral nutrition
Analgesics + antiemetics
urgent surgical consultation!
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37
Q

Treatment of uncomplicated pericarditis

A

Analgesics
NSAIDS
Colchicine

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38
Q

Define Mallory Weiss tear

Complications? (3)

A

Tear in mucosal layer @ esophageal-gastric junction

GI hemorrhage, intramural esophageal hematoma, perforation

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39
Q

1/3 of afibers are “lone Afibers” (no clear cause)

The most common causes are what?

A 
PIRATES
PE
Ischemia (MI)
Resp disease (e.g. COPD)
Atrial enlargement/myxoma (atrial tumor) 
hyperThyroid
Ethanol
Sepsis/Sleep apnea

Also, systemic idsease (obesity/metabolic syndrome, diabetes)
CV diseases: CAD, Htn, valvular diseases, cardiomyopathy

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40
Q

Tenets of treating afib (4)

A

1) Address overall clinical status/instability
2) Determine/treat cause
3) Control rate and/or rhythm
4) Prevent thromboembolism

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41
Q

In the ED, ___ is generally the first priority in treating AFib

A

Ventricular rate control

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42
Q

Afib patients with valvular Afib, risk factors for stroke, or duration > ___ get what anticoag?

A

Duration > 48hrs
Therapeutic OAC 3+ weeks before cardioversion OR TEE to exclude LA thrombus (+enoxaparin)
+ anticoagulation 4 weeks post-cardioversion (long-term based on CHADS-65)

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43
Q

2 best drugs for rate control of Afib in the ED? 2 other options and why they aren’t as ideal?

A

CCBs & BBs are best (if pt already on something start by trying that)
Digoxin (slow onset, work via vagal mech, not as effective if high SNS tone, won’t control rate during exercise etc; may be combined w/ CCB or BB)
Amiodarone or Dronedarone (antiarrhythmics w/ some BB activity, less effective but could be 2-in-1)

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44
Q

Which CCB/BB has the lowest risk of hypotension and why?

A

Diltiazem, least negative inotropic effect

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45
Q

Consideration in pt w/ WPW & Afib?

A

Pharmacological/electrical cardioversion

NOT AV-block agent because can increase accessory pathway conduction –> Vfib

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46
Q

Why is thromboembolism very common post-conversion of AFib?

A

“Atrial stunning” (delayed onset of atrial contractility after cardioversion, lasts several week)
Or dislodging of old clot

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47
Q

3 exceptions to the 48 hour rule in afib?

A

Past stroke, mitral valve disease, severe LV dysfunction

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48
Q

Name 2 common drugs used for rhythm control in Afib

A

Propafenone (Class Ic Na-channel blocker, contraindicated in CAD)
Amiodarone (Class 3 K-channel blocker, preferred if any structural heart disease)

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49
Q

In pts w/ Afib, anticoagulation therapy traditionally consists of ___ with an INR goal of ____. Now what is preferred?

A

Warfarin
INR 2-3
Now DOACs preferred

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50
Q

Most common precipitant of acute HF exacerbations

A

Ischemia/infarction or noncompliance with meds/dialysis/diet

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51
Q

Name 1 specific cause of acute left HF and 1 specific cause of acute right HF

A

Left: sympathetic crisis w/ hypertension (increased afterload)
Right: pulmonary embolism

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52
Q

Name 3 causes of high-output HF

A

Thyrotoxicosis, anemia, AV fistulas (decreased PVR)

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53
Q

Name 2 causes of peripheral edema other than CHF

A

DVT

Hypoproteinemia (liver failure, nephrotic syndrome, renal failure)

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54
Q

Things that may be seen on CXR in heart failure in order of increasing L atrial pressure

A

Upper zone vascular redistribution (“cephalization”)
Kerley B lines (near costophrenic angles; =interstitial edema)
Perihilar “batwing” appearance (alveolar pulmonary edema)

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55
Q

Patient with CHF presenting with hypotension and poor perfusion (i.e. ____) may require what 3 therapies?

A

Cardiogenic shock

1) Inotropes (dobutamine or milrinone to enhance myocardial contracility)
2) Vasopressors (NE for coronary diastolic perfusion by increasing DBP)
3) Small fluid bolus (increase preload)

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56
Q

Patient with CHF exacerbation involving resp distress and very high blood pressure likely has…

A

Cardiogenic pulmonary edema secondary to catecholamine surge (hypertensive emergency)

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57
Q

What is the goal & treatment for Cardiogenic pulmonary edema secondary to catecholamine surge (hypertensive emergency)

A

Redistribution of fluid from pulmonary circulation to rest of body

1) Oxygenation
2) Reduce preload & afterload
3) Diuresis (only after adequate afterload reduction if pt clinically volume overloaded)

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58
Q

2 ways to reduce preload/afterload in cardiogenic pulmonary edema?

A

BiPAP (preload/afterload)
Nitroglycerine (preload/afterload)
ACEi (afterload)

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59
Q

____ is no longer recommended as standard therapy for CHF

A

Morphine

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60
Q

Approach to hypertensive encephalopathy

A

1) NCHCT to rule out mass lesion/stroke
2) IV antihypertensives to lower MAP by 10-15% in first hour, no more than 20-25% by end of first day (not to normal range!) - e.g. nicardipine (DCCB) or labetalol

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61
Q

General approach to hypertensive urgency

A

Reduce BP over days to weeks

Discharge from ED, f/u outpatient in 24-48 hrs

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62
Q

Examples of evidence of acute end-organ damage in hypertensive emergency

A

REtinal hemorrhages
Cerebral infarction/hemorrhage, encephalopathy (altered AMS)
MI, aortic dissection, acute LV failure (chest pain, dyspnea)
Acute pulmonary edema (e.g. dyspnea)
Acute renal failure (e.g. anuria)
Microangiopathic hemolytic anemia
Preeclampsia/eclampsia

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63
Q

According to traditional teaching, what drug is contraindicated in cocaine/sympathomimetic intox?

A

Beta-blockers (unopposed alpha stimulation –>vasospasm)

**newer research indicates may not be true in humans

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64
Q

Gold standard imaging to diagnose/rule out aortic dissection?

A

CTA

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65
Q

What is Cerebral Perfusion Pressure? (CPP) Significance of this in management of hypertensive emergency in a chronically hypertensive patient?

A

Proxy for Cerebral Blood Flow used for monitoring (can’t measure CBF directly)
CPP = MAP-ICP

CBF is being maintained at a higher CPP, so if you reduce MAP too fast –> cerebral hypoperfusion

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66
Q

Preferred antihypertensive for preeclampsia/eclampsia

A

Hydralazine

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67
Q

Acute cerebral infarction in the context of hypertensive crisis - general approach to BP management?

A

Acutely elevated BP often necessary to perfuse watershed areas, so generally don’t lower acutely
(cautious lowering if >220/120 may be ok)
EXCEPTION is if candidate for thrombolysis, then lower below 180/105

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68
Q

In ACS should beta blockers be administered immediately?

A

Better to wait until hemodynamically stable bc can exacerbate LV failure

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69
Q

What is the only hypertensive emergency where rapid, aggressive BP reduction is indicated? Why? BP & HR target?

A

Aortic dissection - need to reduce shear forces of LV ejection (prevent extension of dissection)
SBP 100-110
HR <60

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70
Q

First line medication for aortic dissection hypertensive emergency? 2nd line if BBs contraindicated?

A

Beta-blockers (simultaneously lower HR & BP)

CCB is 2nd line if can’t use BB

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71
Q

Delayed phase of asthma is more ____ and can be targeted with ____

A

Inflammatory

Corticosteroids

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72
Q

5 main classes of agents for acute asthma

A

1) Oxygen
2) Adrenergic agents (preferable inhaled salbutamol; epi or terbutaline if can’t inhale)
3) Anticholinergic (ipratropium bromide = SAMA)
4) Corticosteroids
5) Magnesium sulfate

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73
Q

Induction agent of choice for IPPV (or sedation during PPV if can’t tolerate fully awake)

A

Ketamine (catecholamine release, bronchodilation)

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74
Q

An asthmatic patient who is intubated should be set to promote the goal of…

A

Pemrissive hypercapnia (high risk for hyperinflation/auto-PEEP, so use low RR/TV, limit plateau pressures)

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75
Q

Asthmatics who are discharged from the ED should receive…

A

Salbutamol
MDI spacer device
3-10 day course oral steroids (stop based on Sx resolution & self-monitored peak flow)

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76
Q

Best way to assess asthma severity in the ED is history + physical &…

A

Peak expiratory flow

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77
Q

What is the role of ECG/CXR/ABG in PE diagnosis

A

Mostly to rule out other etiologies of Sx!

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78
Q

Utility of V/Q scans in PE diagnosis

A

Many patients with PE have normal V/Q scan (need to factor in clinical suspicion/other tests)
Most beneficial in pts w/ renal failure who can’t have CT contrast (or contrast allergies)

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79
Q

General gold standard for diagnosing/confirming PE? Caveat?

A

Computed tomography pulmonary angiography (CTPA)

*can lead to false-positives

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80
Q

First line test for DVT?

A

Venous duplex ultrasonography (esp good for iliac, femoral, popliteal veins)

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81
Q

In what location should DVT be anticoagulated?

A

Definitely if popliteal or above

Isolated calf DVTs may be anticoagulated (recommended if Hx or RFs) or repeat U/S in 1 week

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82
Q

____ is the preferred anticoagulant for initial treatment of DVT

A

Enoxaparin (LMWH), self-administered subQ injection patients can do at home

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83
Q

PE has a notoriously vague/variable presentation. What is the most “classic” triad of Sx?

A

Dyspnea
Pleuritic chest pain
Tachycardia

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84
Q

What is a lung phenomenon that can occur 24-72 hrs after a PE?

A

Loss of surfactant –> atelectasis, focal infiltrate

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85
Q

The classic but uncommon EKG change in PE?

A

S1Q3T3
(deep S wave in lead I, Q wave in III, inverted T wave in III (20%). This “classic” finding is neither sensitive nor specific for PE)

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86
Q

What is the PERC criteria. Age component

A

Pulmonary Embolism Rule out Criteria
In pts w/ LOW risk of PE (Well’s score), if all 8 are absent, then no further workup needed :)
Age cutoff is 50! So anyone 50+ automatically loses on PERC

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87
Q

When is D-dimer useful? What predictive value is this?

A

NEGATIVE predicted value

i.e. if normal, excludes PE in patients w/ low pretest probability who don’t meet PERC criteria

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88
Q

Imaging for PE diagnosis in pts hemodynamically unstable (definitive imaging unsafe)

A

Bedside echo (look for signs of RH strain –> presumptive PE diagnosis so you can start treatment)

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89
Q

Can you prescribe BBs and CCBs at the same time?

A

NO! Both block AV node –> can lead to high degree blockade and significant BP drop

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90
Q

How might the elderly present with pneumonia?

A 
Minimal Sx; AMS, decline in baseline function
Often afebrile (may even by hypothermic), tachypnea may be most sensitive sign
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91
Q

Lobar consolidation is typical of what bacteria?

A

Streptococcus pneumoniae

Klebsiella

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92
Q

Most common causes of CAP

A

Streptococcus pneumoniae
Mycoplasma pneumonia
Chlamydia pneumoniae
Resp viruses

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93
Q

HAP and HCAP are most commonly caused by?

A

Gram-negative bacilli: Pseudomonas aeruginosa, E coli, Klebsiella pneumnoia, Acinetobacter

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94
Q

Healthy patients with presumed CAP and no AB use in the past 3 months should be treated with what AB?

A

A macrolide (azithromycin)

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95
Q

Antibiotic for patients w/ CAP and comorbid disease, AB use in past 3 months, or high risk of macrolide-resistant Streptococcus pneumoniae

A

Fluoroquinolone (levofloxacin)

or beta lactam (cefpodoxime = 3rd gen cephalosporin) + macrolide

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96
Q

Pts with concern for HAP/HCAP should receive what AB therapy and why?

A

Concern for multi-drug resistant pathogens. 3 drug combo therapy

1) Antipseudomonal cephalosporin (cefepime or ceftazidime), antipseudomonal carbapenem, or pip-tazo
2) Antipseudomonal fluoroquinolone (e.g. levofloxacin)
3) Anti-MRSA coverage (linezolid or vancomycin)

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97
Q

Good antibiotic for a presumed anaerobic infection (or multibacteria) in pt w/ pneumonia. What kind of patient would be likely to need a drug with a spectrum covering anaerobes?

A

Clindamycin

Aspiration pneumonia, e.g. alcoholic pt

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98
Q

Foregut, midgut, hindgut structures

A 
foregut = oropharynx - mid-duodenum + liver, biliary tract, pancreas, spleen
Midgut = distal duodenum to mid-transverse colon
Hindgut = distal-transverse colon to rectum
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99
Q

Where is pain perceived from the foregut, midgut, and hindgut?

A

Foregut: epigastrum
Midgut: periumbilical
Hindgut: hypogastrium

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100
Q

6 categories of surgical abdo pain

A

I O HIPI

1) Infectious
2) Obstructive
3) Hemorrhagic
4) Ischemic
5) Perforating (may overlap with hemorrhagic)
6) Inflammatory

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101
Q

Mnemonic for pertinent headache history questions

A 
SNOOP MEETS PREGNANCY
Systemic Sx
Neurological Sx (focal, AMS, seizures)
Old age
Onset (sudden)
Pattern changes
Mornings worse
Exertion/posture/sexual activity
Exposures (drugs/toxins)
Trauma
Secondary risk factors (HIV, cancer...)
Pregnancy
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102
Q

What is a population that has a very high rate of serious disease (but also high rate of misdiagnosis) when they present with abdo pain? Name 3 common diagnoses in this population

A 
Elderly folks (up to 1/3 may require surgery!)
Biliary tract disease, diverticular disease, bowel obstruction
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103
Q

Mortality of mild and severe acute pancreatitis

A

5% mild

25% severe

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104
Q

Focus in early management of severe acute pancreatitis?

A

Recognition & prevention of organ dysfunction (e.g. repleting intravascular volume to prevent renal dysfunction)
**AP causes severe inflammation, capillary leakage, 3rd space loss shock

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105
Q

Utility of CT abdo for acute pancreatitis. Safety consideration re contrast?

A

Not necessary, can be useful if diagnosis uncertain
Can show degree of necrosis/disease severity
**don’t use contrast until volume depletions corrected

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106
Q

Is upper or lower GI bleeding more likely to deteriorate into rapid/large volume hemorrhage? What is the implication of this for most important test in pt w/ GI bleed of unknown source?

A

Upper more likely to deteriorate –> upper endoscopy the most important test!

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107
Q

What is an important distinction to make rapidly in patients with upper GI bleeds? Why?

A

Variceal vs non-variceal

Bc if variceal want to give octreotide (somatostatin analogue, causes splanchnic vasoconstriction)

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108
Q

Name 5 differentials for upper GI bleeding

A 
Peptic ulcer disease
Varices (gastric/esophageal)
Mallory-Weiss tear
Esophagitis
Gastritis
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109
Q

Name 7 ddx for lower GI bleeding

A

1) Upper GI bleeding ;)
2) Hemorrhoids
3) Diverticulosis
4) Angiodysplasia
5) Malignancy
6) Inflammatory bowel disease
7) Infectious conditions

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110
Q

Name 4 common ddx for GI bleeding in children

A

1) Intussusception
2) Volvulus
3) Meckel diverticulum (congenital outpouching of ileum)
4) Polyps

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111
Q

Where is abdominal pain felt in most patients with GI bleeding?

A

Trick question! Most patients w/ GI bleeds don’t exhibit abdo pain (though important to do abdo exam for peritoneal signs)

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112
Q

As a general rule, a ____ should be given to patients w/ upper GI bleeds to decrease rebleeding rates

A

PPI

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113
Q

Transfusion of PRBCs should be considered in what patients w/ GI bleeding

A

1) Hemodynamically unstable after crystalloid infusion
2) Ongoing blood loss
3) Hb <70 (this restrictive transfusion threshold shown to be superior)

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114
Q

Why is vasopressin no longer favoured for treating variceal bleeding? What should be used instead?

A 
Vasopressin has side effects, end-organ ischemia
Somatostatin analogue (octreotide) preferred
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115
Q

Temporary control of massive variceal bleeding can be achieved using

A

Balloon tamponade

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116
Q

Risks of button battery ingestion? Management?

A

High risk for mucosal burns/esophageal perf if lodged in esophagus
Confirm location with x-ray; if past esophagus/asymptomatic –> expectant management
In esophagus or symptomatic –> surg
Repeat CXRs until cleared

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117
Q

After clearing an esophageal food impaction, what test should you do?

A

Barium swallow to confirm clearance and r/o esophageal pathology

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118
Q

Most common location of ingested FB in children?

In adults?

A 
Cricopharyngeal narrowing (upper esophageal sphincter, pharyngoesophageal segment) in children
In adults, usually lower esophageal sphincter
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119
Q

In patients with FB ingestion, fever, subcutaneous air, or peritoneal signs suggest…

A

Perforation –> immediate surg conseult!

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120
Q

In general, once an ingested foreign body passes the ____ , it will continue through GI tract and be expelled without incident

A

Pylorus

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121
Q

If plain films don’t reveal ingested FB, what are 3 other options?

A

Esophagogram (barium swallow, if perf not suspected), CT, endoscopy (latter can also remove it at the same time)

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122
Q

Treatment for injested sharp object

A

If in duodenum or proximal –> endoscopic removal (risk of intestinal perf)
If past duodenum, surgical consult and/or serial radiographs

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123
Q

Treatment for foreign body ingestion of “body packing” (illicit drugs)

A

Rupture may be fatal, do NOT to endoscopy bc may rupture packet
May use whole bowel irrigation w/ peg to hasten packets through GI tract, otherwise surgery to remove packets

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124
Q

Crampy abdo pain and high-pitched bowel sounds are features of what type of bowel obstruction?

A

Mechanical (not functional)

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125
Q

What type of bowel obstruction does NOT allow decompression? 2 examples? What type of intervention is usually required?

A

Closed-loop obstruction (blockage proximal & distal, e.g. volvulus, complete large bowel obstruction + competent ileocecal valve)
Usually require surgery

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126
Q

Small and large bowel obstructions: which is more likely to have distention? Which more likely to have vomiting>

A

Small bowel –> vomiting
Large bowel –> distention
(though both can have either; large less likely to have vomiting bc of ileocecal valve competence in closed-loop obstruction)

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127
Q

3 most common causes of small bowel obstruction?

A

Adhesions (70-75%)
Malignancy (8-10%)
Hernia (8-10%)

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128
Q

3 most common causes of large bowel obstruction?

A

Carcinoma (65%)

Volvulus (15%)

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129
Q

Why might a patient temporarily appear to improve clinically as a mechanical bowel obstruction progresses?

A

At first there is an increase in peristalsis, then activity diminishes –> dilated/atonic bowel proximal to obstruction (less cramps)
Blood flow also increases then decreases –> mucosal breakdown + ischemia

So baiscally spastic pain first, then ischemic/peritoneal pain

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130
Q

What is the significance of localized vs diffuse tenderness in bowel obstruction?

A

Diffuse due to distention of bowel wall, visceral pain can be resolved by NG decompression/emesis if open-loop
Localized is a BAD sign, usually means closed-loop, necrosis, perforation –> urgent CT

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131
Q

3 main management strategies for uncomplicated small or large bowel obstruction if identified early?

A

NPO
IV hydration
NG tube decompression

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132
Q

What defines an “uncomplicated” bowel obstruction. What imaging modality can differentiate?

A

No compromise to intestinal blood flow
May be partial or complete
CT scan

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133
Q

What imaging modality can differentiate mechanical vs functional large bowel obstructions in most patients?

A 
CT scan 
(if still unclear, can do contrast enema)
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134
Q

Common clinical sign of colonic perforation in LBO?

A

Severe volume contraction due to inflammation, failure to improve with aggressive fluid management
May or may not have frank peritonitis

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135
Q

Most likely cause of SBO in pt w/out previous abdominal operations?

A

Hernia

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136
Q

Most acute diarrhea is ___

A

Viral

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137
Q

Most common cause of traveller’s diarrhea

A

Enterotoxigenic E Coli

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138
Q

Which type of bacterial diarrhea should NOT be prescribed antibiotics and why?

A

Enterohemorrhagic E Coli (shiga toxin) –> hemylotic uremic syndrome

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139
Q

Class of drugs commonly used to treat infectous diarrhea?

A

Fluoroquinolones:

Ciprofloxacin, levofloxacin, norfloxacin

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140
Q

What is a pathogen that can cause watery profuse diarrhea within 4-12 hours of ingestion

A

S aureus

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141
Q

Name 5 pathogens that commonly cause noninflammatory diarrhea

A 
Enterotoxigenic E coli
Staph aureus
Rotavirus
Norovirus
Vibrio cholerae
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142
Q

Name 5 pathogens that commonly cause inflammatory diarrhea (fever, blood, tenesmus)

A 
Salmonella
Shigella
Campylobacter
Enterohemorrhagic E coli, Enteroinvasive E coli
C diff
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143
Q

Kidney stone are most common in which sex?

A

Men (M:W 3:1)

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144
Q

Positional differences bw patients w/ acute abdomen and nephrolithiasis (comfort)

A

Acute abdo –> supine, still, knees to chest

Nephrolithiasis –> move around, can’t get comfy

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145
Q

Is pain w/ nephrolithiasis constant or colicky?

A

Can be either

ureteric usually colicky (stretching ureter); renal pelvis/bladder usually asymptomatic but if pain usually constant

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146
Q

Are neophrolithiasis stones radioopaque?

A

Usually (90%), most stones are Ca-based

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147
Q

Triad of Sx that indicate a medical emergency in nephrolithiasis

A

Fever, pyuria, severe CVA angle tenderness

pyelonephritis caused by obstruction –> sepsis

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148
Q

2 best imaging modalities for renal colic (older and newer methods of choice_

A

Traditionally: IV pyelogram
Newer: Helical CT imaging w/out contrast (more sensitive/specific and assesses surrounding structures, although doesn’t show degree of compromised excretion in the kidney like IVP does)

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149
Q

3 main goals of working up nephrolithiasis

A

1) Pain control
2) Determine degree of obstruction
3) Detect infection

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150
Q

In nephrolithiasis, definitive therapy is determined how?

A

Based on the types of stones being formed (strain all urine to recover stones)

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151
Q

Indications for urgent urologic consultation in nephrolithiasis

A

1) Inadequate oral pain control
2) Persistent nausea & vomiting
3) Associated pyelonephritis
4) Large stone (>7mm)
5) Solitary kidney
6) Complete obstruction

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152
Q

Most small stones (<6mm nephrolithiasis) can be managed via…

A

Conservative management: analgesics, hydration, ABs if necessary
Most patients can go home w. instructions to increase fluid intake & strain urine

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153
Q

When is surgery indicated for nephrolithiasis?

A

Stone >8mm
Persistent pain
Failure to pass despite conservative management

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154
Q

Name 2 meds that can help pass a stone

A

Alpha-blocker (Tamsulosin)

Corticosteroids (reduce edema)

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155
Q

Stones in the lower UT can be removed via ____, upper UT stones treated by _____

A

Ureteroscope

Extracorporeal Shock Wave Lithotropsy

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156
Q

Does degree of hematuria correspond to degree of obstruction (nephrolithiasis)

A

No! e.g. a complete obstruction could involve 0 hematuria

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157
Q

Testicular torsion can occur at any age but is most common at what ages?

A

<1yo

Puberty (hormones)

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158
Q

What is a congenital deformity that increases the probability of testicular torsion?

A

Bell Clapper Deformity
Horizontal lie of testis in scrotum, epididymis & testicle hang freely and can rotate in scrotum rather than being firmly attached

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159
Q

What are some characteristics of the presentations of epididymitis/orchitis that help differentiate them from testicular torsion?

A

Gradual onset of scrotal pain
Lower UTI Sx (including fever)
Normal anatomical position of testis (but swollen/tender), intact ipsilateral cremasteric reflex

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160
Q

What scrotal pathology involves INCREASED blood flow on color doppler?

A

Epididymitis

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161
Q

What reliefs pain in epididymitis

A

Elevating the testicle (Prehn sign)

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162
Q

Is pain on epididymitis or orchitis more sudden

A

Orchitis more sudden, epididymitis more gradual

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163
Q

Tender nodule/”blue dot sign” on scrotum are characteristic of

A

Appendageal torsion

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164
Q

Salvage time after onset of pain for testicular torsion

A

4-6 hours

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165
Q

“Classic” presentation of testicular torsion

A

Sudden onset severe pain in lower abdomen, inguinal area, or scrotum
Often preceded by physical activity/trauma (though can occur during sleep)
Nausea/vomiting
Horizontal lie of testicle and loss of cremasteric reflex

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166
Q

If uncertain whether there is testicular torsion, what study?

A

Ultrasound with color Doppler

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167
Q

Treatment for testicular torsion

A

1) Emergent manual detorsion (try medial to lateral “opening a book” first)
2) Surgical intervention - emergent if manual failed, elective if it worked temporarily

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168
Q

Does pyuria/bacteruria rule out other testicular pathologies?

A

No! e.g. 50% of patients w/ epididymitis have it, could also still be a torsion

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169
Q

Name 2 med classes that increases risk of hyperkalemia

A 
ACE inhibitor (potassium retention)
Potassium-sparing diuretics: aldosterone antagonists (e.g. spironolactones), ENaC blockers (e.g. amiloride)
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170
Q

Meds for hyperkalemia

A

a) Cardioprotection: Ca
b) Shift K+ into cells: insulin, beta-adrenergics, NaHCO3
c) Remove K+ from body: loop diuretics, sodium polystyrene sulfonate (SPSS)

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171
Q

Normal serum K+

A

3.5-5

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172
Q

What is a condition that predisposes someone to hyperkalemia?

A

CKD

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173
Q

Name 6 clinical features of hyperkalemia

A 
Fatigue
Weakness
Paresthesias
Paralysis
Palpitations
Anorexia/nausea/vomiting
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174
Q

Serum level for severe hyperkalemia –> requires immediate aggressive threatment

A

7.0+

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175
Q

What can happen if blood sample is hemolysed prior to K+ measurement?

A

Pseudohyperkalemia (false positive)

*most labs will report this when detected

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176
Q

EKG change in hyperkalemia

A 
"Peaked" T wave (too pointy to sit on!)
Wide QRS
Long PR/QT
ST changes (can mimic MI)
Wide/absent P waves
Blocks/arrhythmias
**HONESTLY ALMOST ANYTHING
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177
Q

What is the best test to guide initial hyperK treatment? Caveat?

A

EKG findings

BUT correlation b/w changes and severity is poor!! Can change suddenly

178
Q

All dialysis pts in cardiac arrest should receive…

A

Calcium (hyperK is commonly contributing)

179
Q

___toxicity can cause hyperkalemia

A

Digoxin (Na-K ATPase is a target)

180
Q

Type of Calcium and duration of action in hyperkalemia

A

Only lasts minutes, not long-term treatment
Ca Chloride for arrests
Ca gluconate in less-acute cases (less elemental Ca but safer)

181
Q

How is insulin administered for hyperkalemia

A

5-10 units of regular insulin IV (lower K by 0.5 for 1-2 hours)
give w/ 25-50g of D50 to avoid hypoglycemia

Note: some docs just give D50 and let pt’s own insulin do their thing but many pts have diabetes, and high osmolar load may transiently INCREASE K

182
Q

Diuresis after crystalloid repletion isn’t effective for hyperkalemia in what pts? Good in which patients?

A

End-stage kidney disease

good in dehydration, med effects, rhabomyolysis

183
Q

Ideal treatment for pts w/ hyperkalemia & renal failure

A

Dialysis

184
Q

Advantages of salbutamol for hyperK

Dose? Duration?

A

Aerosol 10-20mg, lowers K+ by 0.5 for 1-3 hours (add to insulin!)
Advantages: reduces hypoglycemia from insulin, no IV access required

Note: dose MUCH higher than for asthma (~2.5 mg)

185
Q

Sodium polystyrene sulfonate (SPSS, e.g. Kayexalate) is what? Administered how for hyperK?
In what context is this most effective?

A

Ion-exchange resin administered orally (enema less effective)
Best for maintenance therapy bc takes several hours to start working, can last days

186
Q

Mnemonic for blood transfusion reactions

A 
Fever HALO
Febrile nonhemolytic transfusion reaction
Hemolysis
Anaphylaxis
Lung (TRALI)
Overload (TACO)
187
Q

Urine dipsticks for UTI measure…

A

Leukocyte esterase

Nitrate

188
Q

What groups of patients require imaging for UTI-type complaints

A

Men or children <4 w/ first UTI
Suspected obstruction
Negative urinalysis
Complicated UTI

189
Q

Common AB regimes for lower uncomplicated UTI (4)

A 
TMP-SMX DS 1 tab bid for 3-5 days
Ciprofloxacin 250 mg bid for 3-5 days
Nitrofurantoin sustained-release 100mg bid for 3-5 days
Amox/clavulanate 875/125 for 3-5 days
(**amox can't be monotherapy for UTI!)
190
Q

Common AB regimes for upper uncomplicated or lower complicated UTI (3)

A

Ciprofloxacin 500mg bid for 7-14 days
Nitrofurantoin 100mg bid 7-14 days
Amox/clavulanate 875-125mg bid for 7-14 days

191
Q

Drug that can be used for UTI SYMPTOM relief

A

Phenazopyridine (Pyridium), up to 3 days

symptom-masking

192
Q

Admission criteria for pyelonephritis

A 
Sepsis/shock (ICU)
Can't tolerate oral AB
Obstruction of urogenital tract
Pregnant
Extremes of age
Failed outpatient management
Immunocompromised host
Inadequate follow up/poor social circumstances
193
Q

Antibiotics for UTIs during pregnancy

A

Keflex (Cephalexin)
Erythromycin
Amox-clavulanate
Nitrofurantoin (avoid during 1st TM if possible)

194
Q

5 critical diagnoses in patients with delirium

A 
Hypoxia/diffuse cerebral ischemia (resp failure, CHF, MI)
Hypoglycemia
CNS infection
Hypertensive encephalopathy
High ICP
195
Q

Symptomatic hyponatremia causing seizure should be treated with…

A

Hypertonic (3%) saline

196
Q

Initial treatment for hypo/hypercalcemia

A

Hypocalcemia –> Ca

Hypercalcemia –> IV fluids

197
Q

Pt w/ delirium who has asterixis/seizures likely has what? Treatment

A 
Uremic encephalopathy (from renal failure)
IV hydration, possible hemodialysis
198
Q

Empiric treatment for suspected meningitis

A

Vancomycin + ceftriaxone

steroids given before or with ABs

199
Q

3 differentials for endocrine causes of AMS

A

Pancreatic abnormalities –> hypoglycemia
Hypothyroid/hyperthyroid (thyrotoxicosis, thyroid storm)
Adrenal crisis

200
Q

Treatment of thyroid storm

A

1) Beta blocker to decrease sympathetic activity (e.g. propranolol)
2) Thioamide: Methimazole or Propylthiouracil (PTU) - block TPO, reducing TH synthesis
3) Give iodine (inhibit production/release of stored T4)
4) Steroids to treat underlying immune process if present (e.g. Grave’s)

201
Q

Treatment for adrenal crisis

A

Hydrocortisone (replacement)
IV fluids/vasopressors as needed for BP support
Correct underlying problem

202
Q

When do myoclonic jerks occur in syncope vs seizure? Eye deviation?

A

Seizure: BEFORE LOC, horizontal deviation
Syncope: AFTER LOC, vertical deviation

203
Q

What is something important to keep in mind when suspecting a pt has a psychiatric cause of syncope (due to a prev psych history)

A

Many neuroleptic agents cause QT prolongation which can beget dysrhythmia!

204
Q

Is vasovagal or situational syncope commonly diagnosed in elderly folks in the ED?

A

No, can’t safely rely on this diagnosis in most cases –> admit for monitoring (in young/healthy people more often can)

205
Q

high-yield labs in pts w/ syncope (if indicated by Hx/physical)

A

CBC (anemia)
BMP (electrolytes, glucose)
Urinalysis (hydration, ketones, glucose, infection)
Urine pregnancy test (ectopic pregnancy)

206
Q

After ensuring ABCs, what is the most important test for pt presenting w/ syncope?

A

EKG (abnormal usually –> admission!)

207
Q

9 red flags for suspected facial nerve palsy

A 
CN involvement other than 7
Weakness/numbness of arms or legs
Bilateral facial weakness
Headache, visual deficits, nausea/vomiting
Hx of time in woods/tick bite
Recurrent unilateral facial paralysis
Slow progression of Sx
Ulceration/blisters near ear (Ramsay Hunt syndrome = herpes zoster oticus, shingles affecting facial nerve)
208
Q

How does Bell’s palsy typically present?

A

Ipsilaterally facial palsy along cranial nerve 7
Can’t close eye fully (eye rolls up when you try = Bell phenomenon)
Droop of mouth (orbicularis oris)
Tearing of eye (paralysis of orbicularis oculi prevents closure and causes lacrimal duct to sag away from conjunctiva)
Can’t wrinkle forehead (frontalis)

209
Q

___ is the most common cause of facial paralysis but is a diagnosis of ____

A

Bell’s palsy

Diagnosis of EXCLUSION (don’t anchor!!)

210
Q

What does it mean if a patient has drooping of mouth but can wrinkle forehead normally

A

Probably an INTRACRANIAL process (supranuclear rather than peripheral)

  • innervation of upper facial muscles is bilateral, lower is contralateral
  • LMN lesion like Bell’s Palsy impacts the full half of the face
211
Q

Describe the onset of Bell’s palsy?

A

Fairly abrupt, can progress from weakness –> paralysis over 1 week
>50% of pts recall a preceding viral prodrome
May have ipsilateral loss of taste, tearing changes, hyperacusis (all impacted by facial nerve)
May say face feels numb but no actual sensory loss

212
Q

80% of Bell’s palsy patients recover within…

A

Weeks to a few months

213
Q

Treatment for Bell’s palsy

A

Medical (ASAP!): prednisone 1mg/kg/day for 7-10 days (reduce facial nerve edema)
Antiviral use controversial
Surgical decompression of facial nerve may be useful if steroids don’t help

Supportive: eye patch at night, eye drops hourly during day

214
Q

80% of strokes are ___ and occur in people of what age?

What type more common in younger patients?

A

80% ischemic, usually >50yo

Hemorrhagic typically seen in younger pts

215
Q

Is hypertension cause or effect in intracranial bleed?

A

Both! Re effect, it’s partly bc of overcoming increased ICP (?protective but also harmful)

216
Q

Thrombolytics (alteplase) can only be given within how long of Sx onset in an ischemic stroke? Within how long from arrival at hospital is the stroke algorithm?

A

4.5 hours!
rtPA within 60 minutes of ED arrival (eval within 10 min, neuro notification within 15, CT within 25 min, read within 45)
“Golden hour” of stroke care

217
Q

TIA symptoms typically resolve within…

A

24 hrs

218
Q

Is the NIH Stroke Scale used to diagnose stroke?

A

No! But should do it to assess severity and track changes

219
Q

In a suspected stroke pt, what are some important diagnostic tests to RULE OUT other differentials?

A

O2 satus
EKG
Capillary blood glucose
CBC (platelets >100 to administer thrombolytics), coagulation studies (intracranial bleed risks w/ tPA), cardiac markers

220
Q

Usual diagnostic imaging for stroke pt

A

Non-contrast head CT (vital to rule out intracerebral bleed!)
Early finding in ischemic stroke = loss of gray-white differentiation (increased water in ischemic tissues)

221
Q

Best imaging modality for subacute/chronic intracranial hemorrhage

A

MRI

222
Q

BP control in ischemic stroke

A

Permissive hypertension to maintain cerebral perfusion pressure
But treat SBP >220 or DBP >120 w/ IV labetalol or nitrates (titratable)
Do not lower by more than 25% of map
BP should be <185/110 for rtPA admin

223
Q

Fundamentals of treating hemorrhagic stroke

A

BP control (nimodipine = CCB that prevents vasospasm in SAH)
Possible reversal of anticoag (cryoprecip or platelets)
Neurovascular imaging
Surg/heme consults

224
Q

What is the interesting paradox with non-contrast CT imaging in stroke

A

Takes 6 hours after stroke onset for it to be visible on non-contrast CT (longer that the tPA window!)
You do it to RULE OUT bleeding, masses, etc. Not to diagnose but to ensure no contraindications to empiric tPA treatment!

225
Q

What is bright on T2 MRI?

A

WWII: Water white on T2!

Grey matter is hyperintense compared to white on T2

226
Q

Stroke with visual symptoms = ___artery
Numbness & weakness more of contr. arm/face>leg =
Weakness of contr. leg>arm w/ mild sensory deficits=

A

Posterior cerebral artery
Middle cerebral artery
Anterior cerebral artery

227
Q

Recurrent “thunderclap” headaches could be…

A

Reversible cerebral vasoconstriction syndrome

228
Q

Does a normal CT rule out SAH?

A

No, but it’s important to do to rule out intracranial mass before performing LP

229
Q

Gold standard diagnostic for SAH?

A

LP revealing xanthochromic CSF (may take up to 12 hrs to develop so bloody CSF also concerning)

230
Q

Temporal arteritis almost always occurs in patients of what age range?

A

> 50yo

231
Q

Temporal arteritis diagnostic criteria= 3 of the following 5 characteristics:

A 
>50yo
New-onset localized headache
Decreased pulse or tenderness over temporal artery
ESR >50
Abnormal TA biopsy
232
Q

2 abortive treatments for cluster headaches

A

High-flow O2

Sumatriptan

233
Q

Metoclopromide (e.g. for acute migraine treatment in ED) can cause what side effect? What can be done to mitigate this?

A

Akathisia (restlessness, distress, non-purposful limb movement)
Diphenhydramine co-administration (only if 20mg IV metoclopromide given, not required for 10 mg)

234
Q

Labs to order in first-time seizure

A

Glucose, lytes, renal function tests, drug/tox screen

Pregnancy test

235
Q

Head CT should be performed in first-time seizure patients that meet what criterisa?

A 
Recent head trauma
Persistent AMS/headache
Fever
Malignancy
Immunocompromised
Anticoagulation
New focal deficits
Partial-onset seizure
>40yo

(overall: if no clear etiology identified or acute intracranial process suspected)

236
Q

___ is one of the most frequent causes of drug-induced seizures

A

Cocaine

237
Q

Pts w/ TCA overdose who are seizing should be treated w/ standard seizure therapy + what?

A

Sodium bicarb to alkalize pH –> 7.5 (decreases drug’s free form and activity)

238
Q

Isoniazid-induced seizures should be treated with what?

A

IV pyridoxine (vitamin B6) bc INH binds/depletes it and it’s necessary for GABA function

239
Q

Is CT head useful in alcohol-related seizures? What else should be done?

A

Yes! High diagnostic yield due to high incidence of intracranial lesions (subdural hematomas/hemorrhages)
Test electrolytes, IV fluid hydration w/ glucose + thiamine + Mg + K + multivitamins

240
Q

“Red flags” for low back pain

A 
TUNA FISH
Trauma
Unexplained weight loss
Neurological deficits 
Age <18 or >50, Anticoagulants/coagulopathy, Abnormal vital signs
Fever/systemic Sx
IV drug use/Immunocompromise/recent Infection
Steroid use/osteoporosis
History of cancer
241
Q

Name the landmarks of the back

A

Bony prominence at base of neck = C7
Spine of scapula = T3
Angle of scapula = T7
Iliac crests = L3/L4

242
Q

Conus medullaris and cauda equina are at what spinal levels?

A 
CM = T12-L2
CE = L3-S5
243
Q

Most patients w/ acute low back pain have resolution within…

A

4-6 weeks

244
Q

Most common location of herniated disk of lumbar spine? Presentation?

A

L4-L5 insterspace

–> low back pain radiated down posterior aspect of leg (if weakness or bowel/bladder symptoms –> emergency!)

245
Q

Out of conus medullaris and cauda equina syndromes, match to unilateral/bilateral and sudden/gradual onset

A

CM = sudden, bilateral
CE = gradual, unilateral
(usually)

246
Q

Rule to treat hypoglycemia (e.g. in seizures)

A

“Rule of 50”
Neonate (up to 6 mo): D10 x 5 ml/kg
Infant - preschool: D25 x 2 ml/kg
Child-adult: D50 x 1 mg/kg (or 1 “amp” = 25g glucose in 50 mL syringe, 50%)

247
Q

Benzos doses for seizure in adults

A

10 mg IV/IM midazolam
4 mg IV/PR lorazepam
(Can repeat lorazepam x1)

248
Q

Name 4 drugs that can be used for status epilepticus refractor to benzos

A

IV: fosphenytoin, valproic acid, levetiracetam, phenobarbital

249
Q

Name 3 drugs for status epilepticus refractory to benzos AND anticonvulsants

A

Thiopental (barbiturate)
Propofol
Phenobarbital (barbiturate)

250
Q

Concern with using succinylcholine in patient who has been seizing for a long time?

A

Hyperkalemia

251
Q

Temp in infants must be measured how?

A

Rectal thermometer (>38 = fever)

252
Q

The Rochester, Boston, and Philadephlia criteria are CDRs used for what? What do they agree on?

A

Identification of febrile infants low-risk for SBI

All support use of CBC, blood cultures, urinalysis/urine cultures

253
Q

Do all febrile infants need CXR and/or stool sample?

A

No, only if resp Sx or GI Sx respectively

254
Q

All ill-appearing infants <3 mo should be treated how?

A

Empiric ABs (ceftriaxone!) prior to lab results + admit to hospitals (45% will have SBI)

255
Q

If LP is NOT performed on febrile infant, should you give empiric ABs?

A

No! could mask Sx of bacterial meningitis on f/u

256
Q

What is a discharge condition of low-risk well-appearing infant with FWS?

A

Follow-up within 24 hours (adequate social situation)

257
Q

Most common cause of SBI in infants w/ FWS!

A

UTI

258
Q

does negative urine dipstick/urinalysis exclude UTI in infants?

A

No, pyuria absent on initial urinalysis in 20% of infants w/ pyelo! Need a culture

259
Q

Demographics most commonly presenting with septic arthritis, and most common joint?

A

Hip joint
Children <3 years old
Males > females (2:1)

260
Q

3% of children who present to the ED for ___ have septic arthritis

A

Limp

261
Q

Most common 3 organisms in septic arthritis? Another in neonates/sexually active adolescents?

A

Most common = Staphylococcus aureus, then Group A Strep (S. pyrogenes) and Strep pneumoniae
Neisseria gonorrhea in neonates/teens

262
Q

Appropriates tests in child presenting w/ limp w/ no preceding trauma

A

CBC, ESR/CRP, blood cultures
Plain radiographs (r/o ddx)
Bedside U/S (check for effusion)

263
Q

Good physical exam test to see if limping child’s pathology is localized tothe hip

A

Log roll test (straight leg, rotate foot in/out to rotate hip joint)

264
Q

Ideal imaging test for osteomyelitis?

A

MRI (plain films may not show changes until 10-20 days after Sx onset)

265
Q

Most common cause of acute hip pain in children 3-10yo? What commonly precedes it? What test may be required to differentiate from septic arthritis?

A

Transient synovitis, commonly after URTI

Synovial fluid analysis

266
Q

What is Legg-Calve-Perthes disease? Demographic?

A

Avascular necrosis of the femoral head, commonly found in boys 4-10yo

267
Q

What is Slipped Capital Femoral Epiphysis?

A

Posterior displacement of capital femoral epiphysis from the femoral neck through the growth plate, most common in obese or rapidly-growing boys 11-15 yo. 30-60% eventually bilaterally

Salter Harris Type 1
actually a misnomer, the epiphysis stays in the acetabulum, the diaphysis/metaphysis move forward

268
Q

What does SCFE look like on CXR?

A

Ice cream fallen off cone

269
Q

Toddler who presents with unwillingness to weight bear but no known trauma likely has…

A

Toddler’s fracture (nondisplaced hairline spiral fracture of tibia) - immobilize w/ boot

270
Q

Always do what tests on a child w/ fever who refuses to move a joint

A

Ultrasound

Arthrocentesis

271
Q

Criteria for a SIMPLE febrile seizure

A

6mo-5yo
Fever 38C+
Generalized tonic-clonic convulsions
Spontaneous cessation of convulsions within 15 min
No recurrence within 24 hours
Return to alert mental status after convulsions
No neuro abnormalities on exam

272
Q

What children w/ simple febrile seizure should get an LP?

A

Current AB use (can mask meningitis sx)

Unimmunized children 6-12mo

273
Q

When should AOM be treated w/ ABs? AB of choice?

A

If child <2yo
For >2yo, can give prescrip but say only fill if no improvement after a few days (“watchful waiting”)
Amoxicillin = drug of choice

274
Q

How do you prevent a simple febrile seizure?

A

You can’t prevent it with antipyretics or antiepileptics!

275
Q

Define PID

A

Pelvic Inflammatory Disease

Ascending infection from vagina or cervix –> upper genital tract (endometrium, fallopian tubes, ovaries)

276
Q

Diagnostic workup of suspected PID

A

Transvaginal U/S (r/o tubo-ovarian abscess)
Chlamydia/Gonorrhea assays, STI screen, HIV test
CBC
If uncertain diagnosis, laparoscopy = gold standard

277
Q

What is “chandelier sign”?

A

Cervical motion tenderness (bimanual exam)

Pt “hits the chandelier” they jump off bed so high out of pain

278
Q

PID may also be termed

A

Salpingitis

some sources say synonymous, others say salpingitis is a subset of PID

279
Q

Tubo-ovarian abscess is an important complication of…

Disposition? AB consideration?

A

PID
Requires inpatient therapy (note: can rupture –> hypotension/shock = surgical emergency)
Note, need to use ABs that are effective against anaerobes (clindamycin, metronidazole)
Most resolve w/ ABs, ~1/3 need surgery

280
Q

Is PID only caused by STIs?

A

No! Only ~50% of cases caused by gonorrhea/chlamydia, many causes from endogenous vaginal bacteria!
Usually polymicrobial

281
Q

Treatment of PID

A

Broad-spectrum ABs (usually parenteral), initiated as soon as presumptive diagnosis (prevent long-term sequelae: infertility, chronic pain)

282
Q

Disposition of pt w/ PID and an IUD

A

Hospitalization

283
Q

3 Known complications of PID

A

Infertility
Adhesions –> chronic pelvic pain
Chronic PID

284
Q

Classic triad of Sx in PID

A

Lower abdo tenderness
Adnexal tenderness
Cervical motion tenderness
(only 1 + clinical suspicion required)

285
Q

In someone presenting w/ asymmetric polyarthritis, tenosynovitis, & pustular skin lesions, ___ should be considered in the ddx

A

Disseminated gonococcal infection

286
Q

Quantitative hCG threshold where if you don’t see an IUP it’s probably an ectopic pregnancy

A

1500 IU/L

287
Q

97% of ectopic pregnancies occur where?

A

Fallopian tube (ampullary region, the long middle party)

288
Q

In a reliable & asymptomatic patient whose hCG <1500 (query ectopic pregnancy), what can you test?

A

Repeat hCG in 48 hours - should increase by 66%+ if a normal pregnancy
Lack of normal rise indicates probably ectopic OR miscarriage

289
Q

Does an IUP visualized on ultrasound r/o ectopoic?

A

Not in IVF pregnancies! (can have “heterotopic” pregnancies, where one is intrauterine and other is ectopic)

290
Q

Pharmacological treatment for ectopic pregnancy = ?

Requirements?

A 
Methotrexate
hCG <5000
No fetal cardiac activity
No clinical contraindications
Reliable pt follow-up (and patient preference for medical management)
291
Q

STI prophylaxis after sexual assault

A

Ceftriaxone (gonorrhea) + azithromycin or doxycycline (chlamydia)
Metronidazole (Trichomoniasis)
HBIG + vaccine (if non-immune to Heb B)
Consider HIV PEP

292
Q

Meds used for N&V in pregnancy

A

In order of severity:
Pyridoxine (vitamin B6) + doxylamine (antihistamine)
Diphenhydramine
Prochlorperazine or metocloparmide
Ondansetron (Zofran) IV or PO (for hyperemesis)

293
Q

Measure for asthma severity used in place of FEV1 (since FEV1 requires spirometry)

A

Peak Expiratory Flow Rate (PEFR)

294
Q

Treatment of asthmatics during pregnancy

A

Same thing, i.e. SABAs during attacks, ICS

295
Q

How do ABG findings shift during pregnancy (qualitatively)

Implication?

A 
Resp alkalosis (increased minute ventilation) w/ partial metabolic compensation
i.e. high pH, high PO2, low PCO2, low HCO3

So respiratory acidosis and high PCO2 means IMPENDING RESP FAILURE

296
Q

With hyperemesis gravidarum, the presence of what in urine is associated w/ significant volume depletion?

A

Ketones

297
Q

99-100% of patients w/ bacterial meningitis have what symptom(s)

A

Headache + 1 of the classic triad: fever, nuchal rigidity, AMS (only 50% of pts have the full triad)

298
Q

Meningitis caused by Neisseria meningitidis may case what 2 extra-CNS manifestations?

A

Palpable purpura

Septic arthritis

299
Q

Indications for head CT prior to LP

A

Altered LOC/AMS
Focal neuro deficit
Immunocompromised
Hx of CNS disease (lesions, strokes, infection, surg)
New-onset seizure (<1 week before presentation)
Papilledema
Head trauma

300
Q

WBCs and proteins and glucose in meningitis. Also which WBCs are dominant. Compare viral/bacterial for all of above

A 
WBCs increased (more in bacterial; bacterial has PMN dominance, viral has lymphocyte dominance)
Proteins increased (more in bacterial)
Glucose decreased (more in bacterial)
301
Q

2 most common bacteria that cause bacterial meningitis in adults

A

N. meningitidis

S. pneumonia

302
Q

Antibiotics for meningitis in adults

A

Ceftriaxone or cefotaxime (3rd gen cephalo)
Vancomycin
If >50, immunocompromised or alcoholic –> add ampicillin

303
Q

What should be co-administered with or before antibiotics in meningitis?

A

Dexamethasone

attenuate inflamm response to antibiotics

304
Q

Prophylaxis for household/daycare of people with meningitis caused by what organism? What AB?

A

N meningiditis

Rifampin or fluoroquinolones (ciprofloxacin) or ceftriaxone

305
Q

Clinical evaluation of SSTIs always begins with what?

A

Search for a pus pocket! Presence of pus/abscess vastly changes management. May need to use U/S

306
Q

What are furuncles? What is usually the causative pathogen? What might patients call these?

A

Spontaneous superficial skin abscesses
Usually caused by Staph aureus, >50% MRSA
“Spider bite”

307
Q

In SSTI eval, once abscess is r/o, what is the main diagnostic question?

A

NSTI (necrotizing soft tissue infection) vs cellulitis

308
Q

Nonpurulent cellulitis is typically caused by what pathogen?

A

Group A beta-hemolytic streptococci (Strep pyogenes)

309
Q

What is a superficial, sharply demarcated nonpurulent cellulitis that often occurs on face/lower extremities and causes fever & leukocytosis? Most common causative pathogen?

A

Erysipelas (usually caused by S pyogenes)

310
Q

RFs for necrotizing fasciitis

A

Injection drug use
Neglected diabetic foot ulcer
Infection of scrotum/perineum

311
Q

Combo of findings on bloodwork that suggests NSTI

A

Extreme leukocytosis

Hyponatremia

312
Q

When NSTI is suspected what is the best diagnostic approach?

A

Prompt SURGICAL exploration!!

313
Q

Antibiotics for NSTI

A

Clindamycin (anaerobes, staph, strep)
Vancomycin (MRSA)
Pip-Tazo (anaerobes, Strep)

314
Q

NSTI infections are usually polymicrobial and often involve what species?

A

Clostridium perfringens

315
Q

Nonpurulent cellulitis typically treated w/

A

Cephalexin (Keflex) or cefazolin (ancef, IV) = 1st gen cephalosporins

(Good for SSTIs, preventing surgical site infections esp Staph & Strep)

316
Q

Do all drained abscesses need AB treatment?

A

No, 5cm or less with minimal to mod cellulitis usually doesn’t need AB, just draining and loop drainage or packing (pt can remove packing themself)

317
Q

Define exanthem

A

widespread rash that is usually accompanied by systemic symptoms such as fever, malaise and headache. It is usually caused by an infectious condition such as a virus, and represents either a reaction to a toxin produced by the organism, damage to the skin by the organism, or an immune response

318
Q

Red flags for serious rash

A 
Immunocompromise
Fever
Toxic appearance
Hypotension
Petechiae/purpura (non-blanching!)
Diffuse erythema
Severe or localized pain
Mucosal lesions
319
Q

How long do sutures stay in?

A

Face: 5 days
Body: 7-10d

320
Q

What can be added to local anesthetics to increase their duration of action? What else does it do?

A

Epinephrine (local vasoconstriction decreases systemic absorption)
Also augments hemostasis

321
Q

In wound care does irrigation come before or after anethesia?

A

Before! So that if there’s a foreign body etc the pt can feel it

322
Q

In patients with trauma to the ear region you should always examine for signs of…

A

Basilar skull fracture

Tympanic membrane rupture

323
Q

3 signs of basilar skull fracture

A

1) Periorbital ecchymosis (raccoon eyes)
2) Mastoid ecchymosis (Battle’s sign)
3) Hemotympanum

324
Q

Consequence of unaddressed auricular hematoma

A

Abnormal cartilage production –> “Cauliflower ear”

325
Q

Treatment of buccal (intraoral) wounds

A 
No sutures if <2cm (if >2cm prone to food getting stuck)
Prophylactic ABs (penicillin, amoxicillin, cephalexin, or clindamycin)
326
Q

Flagyl = what antibiotic? Used for what?

A

Metronidazole, for anaerobes & protozoa

327
Q

Dose of adacel

A

0.5 mL

328
Q

When should TDaP be administered

A

Clean, minor wound: unknown, <3, or 3+ but >10 years since last vax
Other wounds: unknown, <3, or 3+ but >5 years since last vax

329
Q

When should TIG be administered for wounds:

A

Clean, minor wound: never

Other wounds: if unknown of <3 vax history

330
Q

If someone can scrunch their eyes against resistance but has ptosis what is the likely nerve/muscle injury and what ISN’T

A

Likely injury to levator palpebrae superioris or CNIII (occulomotor nerve) which innervates it
Unlikely to be the facial nerve CN VII which innervates the orbicularis oculi for scrunching eyes against resistance

331
Q

What is chromic gut?

A

Absorbable suture

332
Q

Vicryl is a ____ sutuer

A

Absorbable

333
Q

What area of the body needs to be PRECISELY approximated for cosmesis if lacerated?

A

Vermillion border

334
Q

PEP for rabies? When is it indicated?

A

Rabies Ig (passive) + human diploid cell vaccine (HDCV, active)
After bites from uncaught wild animals and animals the start behaving abnormally
(esp bats!!)

335
Q

Wound irrigation should be performed with…

A

Saline

336
Q

Test to be performed after animal bite

A

Radiograph (look for foreign bodies/teeth, fractures)

337
Q

What type of bite injury to hand may require admission for IV Abx/Sx?

A

“Fight bite” (clenched-fist injury) because commonly bacteria embedded in joint spaces/tendon sheaths of hand

338
Q

Bites >12 hrs old should generally…

What other types of wounds also?

A

Be left open due to infection risk

Also puncture wounds, bites of hands/feet, infections

339
Q

Mainstay of treatment for cocaine intoxication

A

Supportive care

Benzos (lorazepam/diazepam) - don’t use haloperidol bc can lower seizure threhold and worsen hyperthermia/arrhythmia

340
Q

Physiologic impacts of cocaine

A

Release of NE, E, serotonin, dopamine –> sympathomimetic

Na channel blockade –> anesthesia, arrhythmias

341
Q

Tests in cocaine intox with

1) Hyperthermia or agitation
2) AMS/Seizures

A

1) BMP & CK (assess for renal failure, metabolic acidosis, rhabdomyolysis)
2) Head CT to assess for intracerebral hemorrhage

342
Q

Meds for arrhythmia in cocaine intox

A

Benzos
CCBs
NaHCO3 for wide complex tachy, or lidocaine if refractory

343
Q

Severe hypertension in cocaine intox should be treated with…

A

Phentolamine (alpha-antagonist)
Not BBs (controversial)
IV nitroglycerine or nitroprusside may also be used

344
Q

Seizures in cocaine intox treated w…

A

Benzos!

345
Q

“Antidote” used to decrease absorption of a toxin within 1-2 hrs after ingestion

A

Activated charcoal (very high surface area, adsorbs)

346
Q

What is the Rumack Matthew Nomogram?

A

Chart showing serum acetaminophen concentration vs time since injection, showing when hepatic toxicity is likely vs unlikely
Starts 4 hrs post-ingestion

347
Q

Antidote for acetaminophen overdose

A

N-acetylcysteine (NAC)

348
Q

What is the most common vessel infarcted in stroke? Presentation?

A

Middle cerebral artery
Contralateral hemiparesis & hemisensory loss
Contralateral central facial nerve palsy (can move eyebrows)
If dominant hemisphere (usually L) affected —> Broca or Wernicke aphasia
If nondominant hemisphere (usually R hemisphere) affected –> hemineglect

349
Q 
Toxidrome for antimuscarinics
Vitals:
Pupils: 
Skin: 
Bowels:
Antidote:
A 
Vitals: increased
Pupils: dilated
Skin: dry
Bowels: reduced
Antidote: physostigmine (acetylcholinesterase inhibitor; not for cyclic antidepressants); also benzos
350
Q 
Toxidrome for cholinergics
Vitals:
Pupils: 
Skin: 
Bowels:
Antidote:
A 
Vitals: decreased
Pupils: small
Skin: diaphoretic
Bowels: increased
Antidote: atropine, pralidozime (2-PAM) for organophosphates
351
Q 
Toxidrome for opioids
Vitals:
Pupils: 
Skin: 
Bowels:
Antidote:
A 
Vitals: decreased (esp resp)
Pupils: constricted
Skin: dry
Bowels: reduced
Antidote: naloxone
352
Q 
Toxidrome for sedatives/hypnotics
Vitals:
Pupils: 
Skin: 
Bowels:
Antidote:
A

Vitals: decreased
Pupils: unchanged (difference from opioids!)
Skin: dry
Bowels: decreased
Antidote: supportive care; flumazenil (rarely, can cause seizures in chronic benzo users)

353
Q 
Toxidrome for sympathomimetics
Vitals:
Pupils: 
Skin: 
Bowels:
Antidote:
A 
Vitals: increased
Pupils: dilated
Skin: diaphoretic
Bowels: increased
Antidote: benzos
354
Q

Antimuscarinic toxidrome mnemonic

A

Red as a beet (vasodilation/skin flushing)
Blind as a bat (myadrisis)
Hot as a hare
Mad as a hatter (hallucinations, incomprehensible)
Dry as a bone
Full as a flask (urinary retention, can cause agitation)
Stuffed as a pepper (constipation)

355
Q

What’s the difference between the agitation on sympathomimetics and the “mad as a hatter” in an anticholinergic overdose?

A

On sympathomimetics usually you can understand what they’re saying, they can be cursing at you etc
Anticholinergic often incomprehensible gibberish

356
Q

Although clinical evidence of hepatotoxicity may be delayed for _____, with maximum liver injury after _____, NAC most effective if started within ____ hours of ingestion

A

24-72, maximum 72-96

8 hours of ingestion

357
Q

What happens in the liver in acetaminophen overdose?

A

Glutathione depleted (usually combined w/ NAPQI, a toxic intermediate) –> NAPQI accumulation

358
Q

Glucagon can be used as antidote for..

A

CCB

BB

359
Q

Antidote to warfarin

A

Vitamin K1 (phytonadione)

360
Q

Antidote to UFH

A

protamine sulfate

361
Q

Antidote for hypermagnesia

A

Calcium gluconate

362
Q

In general, ____ and ____should be tested on any patient w/ overdose history even when denied

A

Acetaminophen & salicylate levels

363
Q

Malnourish patients with alcohol abuse should receive what supplements?

A

Thiamine and folate

364
Q

2 concerns w/ activated charcoal

A 
Charcoal pneumonitis (if aspirated)
Can make subsequent endoscopy challenging
365
Q

What compounds aren’t adsorbed well by activated charcoal? (4 categories)

A

Alcohols: ethanol, methanol, isopropyl alcohol, ethylene glycol
Hydrocarbons
Caustics (acids & bases)
Lithium & other salts

366
Q

The first dose of activated charcoal may be given with..

A

Sorbital

367
Q

3 substances that can be dialyzed in case of overdose. Common property?

A

Lithium
Methanol
Aspirin (also tylenol but usually just use NAC)
*key is they need a low volume of distribution, i.e. water soluble, stays in serum, less distributed into tissues

368
Q

What is an elimination method for aspirin & phenobarbital toxicities?

A

Urinary alkalization: give NaHCO3 –> urine with pH > 7.5, alkaline urine traps ions

369
Q

What might you see in overdose with TCAs, diphenhydramine, and other various antidepressants/antipsychotics? Treatment and precaution?

A

Prolonged QRS due to Na blockade
Treat w/ NaHCO3
**note can worsen long QT by pushing K into cells so check that QT is ok first

370
Q

How does the anti-muscarinic toxidrome differ from symopathomimetic?

A

Antimuscarinic had dry skin

Sypathomimetic has diaphoresis

371
Q

What can cause cholinergic toxidrome?

A

Insecticides (e.g. organophosphates)

ACh inhibitors e.g. physostigmine

372
Q

Mnemonic for cholinergic toxidrome

A 
DUMBBELLS
Defecation
Urination
Miosis
Bradycardia
Bronchorrhea/Bronchospasm
Emesis
Lacrimation
Lethargy
Salivation
373
Q

Poor prognostic indicator in overdose

A

Fever

374
Q

If you have a seizing patient who isn’t responding to benzos, consider ___ as the cause

A

Hyponatremia

375
Q

Treatment for acute hyponatremia of not seizing/altered/obtunded (usually just generally “weak”)

A

DO NOTHING
Just water restrict, do NOT hydrate even with normal saline bc correcting too rapidly can lead to central pontine myelinolysis –> neuronal damage/death

376
Q

If pt w/ hyponatremia is seizing/altered/obtunded what is the treatment? How much do you raise Na by?

A 
Hypertonic saline (3%):  3ml/kg x 3% saline pushed over 9 minutes (rule of 3s)
Increase by 6 points for severe symptoms (or until Sx cease) no more than this in 24 hrs
377
Q

Pnemonic for hyperkalemia treatment

A 
C BIG K DIE
Calcium
Beta agonists/Bicarb
Insulin 
Glucose
Kayexylate (polystyrene sulfonate)
Die -diuretics (Lasix), dialysis
378
Q

What are papilla?

A

Polygonal/cobblestone shapes on tarsal plate (eyelids)

Represent an acute innate inflamm process (bilateral often allergies, unilateral often bacteria)

379
Q

Bacterial conjunctivitis: what organism is bad in both neonates and adults, can puncture cornea, and is severely purulent

A

Gonococci (Neisseria gonorrhea)

*pseudomonas can also puncture cornea

380
Q

Treatment of bacterial conjunctivitis

A

Broad spectrum antibiotics
No steroids
EMERGENCY if not improved in 2 days

381
Q

What do you see on exam in bacterial conjunctivitis?

A

Normal visual acuity
Papilla
No corneal abrasion w/ fluorescein staining

382
Q 
Blepharitis: 
definition
Sx
O/E
Rx
A

Inflammation of sebaceous glands
Sx: gritty, tearing, crusting
O/E: red eyelin margins, debris in lashes, conjunctival hyperemia
Rx: warm washcloth

383
Q

clinical entity characterized by coarse, raised intraepithelial lesions surrounded by focal inflammatory cells, with punctate staining as well as areas of negative staining on fluorescein.

A

Punctate epithelial keratitis

can be seen with various corneal pathogens, sometimes dry eye

384
Q

What are follicles (eye)

A

Round nodules on tarsal plate, upper & lower fornix

Lymphocytic (adaptive) immune response

385
Q

DDx of follicular conjunctivitis that is acute, <30d, pre-auricular lymph notes

A

Viral

Chlamydia

386
Q

DDx of Chronic (>30d) follicular conjunctivitis

A

Molluscum contagiosum

Chronic eye drop usage

387
Q

What is the most common cause of red eye

A

Viral conjunctivitis (adenovirus)

388
Q

Prognosis of viral conjunctivitis

A 
Spontaneous resolution in 1-2 weeks, contagious for that time
Symptomatic relief (no steroids!)
389
Q

What eye issue commonly present w/ swollen lids, clear discharge, crusting, blurry vision, proceeding URTI, photophobia
preauricular nodes, follicles

A

Viral conjunctivitis

390
Q

Define keratitis

A

Inflammation of cornea

391
Q

What eye infection is characterized by keratitis, stromal edema, keratic precipitates, dendritic ulcers, and decreased corneal sensation over ulcer?

A

Herpes conjunctivitis (usually self-limited to 14d)

392
Q

What is stromal edema

A

Fluid in stroma of the cornea

393
Q

What eye injection presents with conjunctival hyperemia, follicles, mucoid discharge, enlarged lymph nodes, STI sx

A

Chlamydia conjunctivitis

394
Q

Treatment for chlamydia conjunctivitis

A

Peds: EMERGENCY referral!!
Adults: azithromycin, doxycycline/erythromycin
Prophylaxis for parents/partners
Refer adults within 72 hrs if no improvement (culture)

395
Q

What is the area direclty around the iris called? What is it termed when it’s red?

A 
Limbus
Ciliary flush (dilated blood vessels)
396
Q

What are anterior chamber cells and how are they diagnosed?

A

Inflammation in anterior segment of eye –> breakdown of blood-aqueous barrier –> more cells/protein in aqueous humor
Requires slit-lamp exam

397
Q

DDx of ciliary flush

A

Anterior uveitis/iritis

Acute angle closure, glaucoma

398
Q

DDx of anterior chamber cells

A 
Anterior uveitis/iritis
Acute angle closure, glaucoma
Endophthalmitis
Corneal Ulcer
Trauma
399
Q

What is hypopyon

A

WBCs in anter`ior chamber of eye

400
Q

Internal eye infection usually seen post-surgery (cataracts) that is characterized by pain, decreased VA, conjunctival edema, anterior chamber cells, hypopyon

A

Endophthalmitis

EMERGENCY referral required!

401
Q

Iritis is caused by what?

A

90% idiopathic, may be assoc w/ collagen vascular diseases

402
Q

What is episcleritis? How do you differentiate it from scleritis? Rx?

A

Dilation of radial vessels of episclera
Attempt to move vessels (freeze conjunctiva), if they move –> episcleritis; they don’t move –> scleritis (patterns indistinguishable looking at them)
If redness improves with phenyl it’s episcleritis and vice versa
Rx: Ibuprofin

403
Q

inflammation of ___ requires testing for an underlying disorder. Treatment?

A

Sclera (scleritis)

Ibuprofen , may require steroids

404
Q

Intraocular pressure (normal)

A

10-21 mmHg

405
Q

DDx of raised IOP

A 
Angle closure glaucoma
Open angle glaucoma
Trauma
Anterior uveitis
Hemorrhage-hyphema
Chemical burns
406
Q

What is hyphema?

A

Blood in front of eye between cornea and iris

407
Q

What eye problem present w/ pain, halos, blurred vision, headache, malaise, nausea/vomiting/epigastric pain, unreactive mid-dilated pupil, etc.

A

Acute angle closure glaucoma

408
Q

Rx for acute angle closure glaucoma

A

EMERGENT REFERRAL
Stabilize IOP ASAP
Start Diamox (acetazolamide)
Laser iridotomy

409
Q

What is going on in acute angle closure glaucoma?

A

Iris blocks trabecular meshwork –> Aqueous humor builds up –> vascular compromise, ischemia

410
Q

Using fluorescein dye and blue light on ophthalmoscope, what do the following findings indicate:

1) Multiple pinpoint uptakes
2) Single larger stained area
3) Dendriform staining

A

1) Punctate epithelial erosions, suggesting dry eye or exposure
2) Corneal abrasion or ulcer (ulcers white vs abrasions green??; abrasions have well-defined borders when stained)
3) Herpetic disease

411
Q

What is the diagnosis where pt present with glaucoma Sx but normal IOP?

A

???

412
Q

Sx of glaucoma (open angle)

A

Usually asymptomatic. Later in disease, get visual field deficits from nasal –> central (e.g. arcuate scotoma)

413
Q

Finding on exam of optic disc in glaucoma; cutoff value?

A

Increased “cup to disc” radio due to neuron damage (>0.5= suspicious for glaucoma)

414
Q

Treatment of corneal abrasion

A

Abx, eye patch

NO steroids

415
Q

Treatment of corneal ulcer

A

EMERGENCY referral + Abx

416
Q

____ needs to be performed before fluorescein staining and slit lamp exam

A

Visual acuity

417
Q

Dilated pupil exam should not be performed until ____ is ruled out

A

Globe injury

418
Q

Test performed to determine if someone has chlamydia causing eye infection

A

Corneal scrapings –> culture

take scraping before starting empiric ABs

419
Q

ADE of topical steroids for eye

A

Increased IOP (can lead to acute angle closure glaucoma)

420
Q

Purpose of fluorescein staining?

A

Visualize abnormalities of cornea

421
Q

Keratic precipitates are common with ___ infections

A

Herpes virus infections (less so with Chlamydia, Adenovirus)

422
Q

Way to tell follicles vs papilla

A 
Papilla = red (vascular)
Follicles = white (inflamm cells)
423
Q

Diagnosis of mesenteric ischemia

A

Noncontrast CT abdo

oral contrast can obscure mesenteric vessels & bowel wall enhancement

424
Q

Resus mnemonic

A 
MOVIE
M= Monitors:
3 lead cardiac monitors
Pulse oximetry
Blood pressure cuff

O=Oxygen
Nasal prongs 02 at 15L
Titrate to Spo2 > 95%

V= Vitals:
Repeat VITALS Always. They came in normotensive and may now be hypotensive and tachycardic

IV= IVs and bloodwork
2 large bore IVs.
IF CANT get IV access with two experienced operators, establish an IO.

E= Everything else

425
Q

2 general categories of PEA

A

Narrow complex –> usually mechanical (tamponade, tension pneumo, PE, hyperinflation)
Wide complex –> usually metabolic, toxicologic, or MI (or obstructive w/ abberancy) - hyperK, Na channel blockers, MI

426
Q

Empiric treatment of wide complex PEA (other than CPR)

A

Calcium chloride and sodium bicarbonate

427
Q

Noncontrast CT is sensitive for SAH within __ hrs of Sx onset, after that if it’s negative you need ____

A

6 hrs

LP for xanthochromia

428
Q

At what class of hemorrhagic shock (and what volume of blood loss) do you get tachy? Hypotension?

A 
Tachy = class II = 750-1500 mL lost
Hypotension = class III = 1500-2000 mL lost
429
Q

Triad of death

A

Coagulopathy, acidosis, hypothermia

430
Q

What do the FAST and eFAST exams look at?

A

FAST: Pericardial, perihepatic (RUQ), perisplenic (LUQ), pelvis
e-FAST adds pleural spaces

431
Q

Doses for Propofol, ketamine, etomidate, succinylcholine, and rocuronium (all mg/kg IV)

A 
Propofol = 1
Ketamine = 1.5
Etomidate = 0.3
Succs = 1.5
Roc = 1
(variable depending on source)
432
Q

Kawasaki disease: definition + diagnostic criteria

A

Self-limiting medium vessel vasculitis predominantly affecting Asian male children 1-5 yo

"WARM CREAM" 
Warm = 5 days of fever or more
Plus 4 of the following 5:
- Conjuncitivitis
- Rash (nonvesicular, generalized)
- Extremity changes - erythema/edema of hands and feet followed by desquamation
Adenopathy (cervical)
Mucous membrane changes (cracked red lips, "strawberry" tongue)
433
Q

Treatment for Kawasaki disease

A

IVIG + ASA to prevent cardiovascular complications

434
Q

BREATHE mnemonic for urgent differential of SOB?

A 
Bacteria (pneumonia, endocarditis)
Reactive airway disease (asthma, COPD, anaphylaxis)
Embolism (PE)
ACS
Tension pneumo, Tamponade
Heart failure
Electrical excitation (arrhythmia)
435
Q

Score for diagnostic probability of Strep throat?

A 
M-CENTOR
M - Must be older than 3 years
C - Cough absent (+1)
E - exudate or swelling of tonsils (+1)
N - cervical lymph Nodes (+1)
T - Temp >38C (+1)
O - Often Young <15yo (+1)
R - Rarely Old >45yo (-1)

2-3 rapid, ABs based on culture if rapid negative
4+ –> high likelihood, consider empiric therapy

436
Q

Bacterium that causes strep throat

A

Group A beta-hemolytic strep

= Streptococcus pyogenes

437
Q

Best Abx for strep throat?

A

Penicillin

438
Q

J wave AKA ___ is a finding in what clinical condition?

A

Osborn wave

Hypothermia

439
Q

4 stages of hypothermia: temps & treatments

A

1 (32-35C, shivering) - passive rewarming
2 (28-32C, not shivering) - active external, make sure any fluids given are warm
3 (24-28, unconscious) - active internal (+external)
4 (<24, VSA) - above + CPR, ECMO

440
Q

Common active external rewarming device used in hospital

A

Bear hugger (forced air)

Clerkship (6 decks)

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