Emergency Med

Question 1

treatment of unstable bradycardia, Mobitz II (2nd degree AV block type 2), 3rd degree AV block

Answer 1

Need to be paced. While preparing for transcutaneous pacing, give ATROPINE 0.5mg IV q3-5 x3. Can also give dopamine 2-10 micrograms/kg/min or epinephrine 2-10 micrograms/min, esp. if transcutaneous pacing ineffective. (ACLS)
***try to give midazolam for sedation & amnesia prior to pacing

Question 2

treatment of VF or pulseless V-tach

Answer 2

Attempt unsynchronized cardioversion. Next, give a vasopressor: EPINEPHRINE 1mg IV q3-5 min x3 or vasopressin 40units IV (replaces only 1st or 2nd dose of epi). Give another shock. Then, give antiarrhythmic agent: amiodarone 300mg IV (150mg for subsequent doses) q3-5 min or lidocaine 1-1.5 mg/kg IV (0.5-0.75 mg/kg for subsequent doses) q5-10 min. Give another shock. Return to vasopressor step.

• **Continue “vasopressor-shock-antiarrhythmic-shock” loop until pt regains a pulse or resuscitation efforts are stopped
• **Set defibrillator to 360J if monophasic or 250J if biphasic

Question 3

treatment of torsades de pointes

Answer 3

magnesium 1-2g IV

Question 4

treatment of asystole or PEA

Answer 4

NOT shockable rhythms. Give vasopressors. If bradycardia develops, give atropine 1mg IV q3-5 min x3

Question 5

potential underlying causes of PEA

Answer 5

5 Hs & 5 Ts:
hypovolemia
hypoxia
hydrogen (acidosis)
hyper-/hypokalemia
hypothermia
toxins/tablets (drug OD)
cardiac tamponade
tension pneumothorax
coronary thrombosis (ACS)
pulmonary thrombosis (PE)

Question 6

treatment of unstable tachycardia (e.g. CP, SOB, hypotension, ischemic ECG changes)

Answer 6

immediate synchronized cardioversion (at 100, 200, 300, and then 360J)

Question 7

treatment of stable narrow complex tachycardia that is regular

Answer 7

1st: vagal stimulation
2nd: adenosine 6mg IV followed by 12mg q2min x2
3rd: metoprolol 5mg IV q5min x3 or diltiazem 15-20mg IV over 2 min (if no CHF)

Question 8

treatment of stable, irregular narrow complex tachycardia

Answer 8

metoprolol 5mg IV q5min x3 or diltiazem 15-20mg IV over 2 min (if no CHF)

Question 9

treatment of stable, regular wide-complex tachycardia

Answer 9

amiodarone 150mg IV over 10 min or procainamide 17 mg/kg @ 50 mg/min (if no CHF).
If rhythm persists, synchronized cardioversion

Question 10

treatment of stable, irregular wide complex tachycardia

Answer 10

Torsades de pointes: mag 1-2g IV over 5-60min w/ overdrive pacing
WPW: amiodarone 150mg IV over 10 min or procainamide 17 mg/kg @ 50 mg/min (if no CHF).
If rhythm persists, synchronized cardioversion

Question 11

symptoms & causes of cholinergic toxidrome

Answer 11

si/sx: (DUMBBELS) Diarrhea, Urination, Miosis, Bradycardia, Bronchospasm, Emesis, Lacrimation, Salivation

causes: muscarine-containing mushrooms, organophosphates, pilocarpine, pyridostigmine

Question 12

symptoms & causes of anticholinergic toxidrome

Answer 12

si/sx: fever, skin flushing, dry mucous membranes, psychosis, mydriasis, tachycardia, urinary retention

causes: antihistamines, antipsychotics, atropine, Jimson weed, scopolamine, TCAs

Question 13

opioid toxidrome

Answer 13

coma, respiratory depression, miosis, bradycardia, hypothermia, diminished bowel sounds

Question 14

sedative-hypnotic toxidrome

Answer 14

CNS depression, resp. depression, & coma

Question 15

hallucinogenic toxidrome & causes

Answer 15

disorientation, panic, seizures, HTN, tachycardia, tachypnea, hyperactive bowel sounds, diaphoresis
**caused by amphetamines, PCP, cocaine

Question 16

extrapyramidal toxidrome & causes

Answer 16

Parkinsonian symptoms: tremor, torticollis, trismus (lockjaw), rigidity, oculogyric crisis, opisthotonos (rigid body position with arched back), dysphonia, dysphagia
**caused by haloperidol, metoclopramide, phenothiazines

Question 17

initial treatment of patients p/w AMS of unknown etiology

Answer 17

ThONG: thiamine, oxygen, naloxone, glucose

Question 18

treatment options for rabies exposure

Answer 18

active immunization w/ human diploid cell vaccine (HDCV), passive immunization w/ human rabies immune globulin

Question 19

dog bite–likely organism(s) & treatment

Answer 19

alpha-hemolytic streptococci, S. aureus, Pasteurella multocida, & anaerobes; treat w/ amoxicillin/clavulanate or 1st gen cephalosporin +/- rabies & tetanus PPX

Question 20

cat bite–likely organism(s) & treatment

Answer 20

Pasteurella multocida, anaerobes; treat w/ amox/clavulanate +/- tetanus PPX

Question 21

human bite–likely organism(s) & treatment

Answer 21

polymicrobial–Viridans streptococci most frequently, Eikenella corrodens
**Treat with amox/clav or clarithromycin, 2nd/3rd gen cephalosporin, dicloxacillin + PCN +/- tetanus PPX, HBV vaccine, HBIG, & HIV PEP

Question 22

Treatment of tetanus

Answer 22

BDZs to control muscle spasms, neuromuscular blockade if needed to control airway, metronidazole is antibiotic of choice, tetanus immune globulin &/or adsorbed tetanus & diphtheria toxoid vaccine as indicated

Question 23

types of frostbite

Answer 23

superficial: injury to cutaneous & subQ tissue; skin soft under frozen surface; large, clear, fluid-filled vesicles develop w/in 2 days (good prognosis); sloughing leaves new skin that’s pink & hypersensitive
deep: injury to above tissues plus deep structures (muscle, bone); skin is hard under a frozen surface

Question 24

treatment of frostbite

Answer 24

rewarm once refreezing can be prevented; circulating water at 40 C (104 F), wound care, tetanus PPX

Question 25

signs/symptoms/test findings of hypothermia

Answer 25

core body temp <95 F), arrhythmias &/or Osborn/J waves on ECG

Question 26

causes of hypothermia

Answer 26

environmental exposure, alcohol ingestion, drugs (barbs, BDZs, narcs), hypoglycemia, CNS or hypothalamic dysfnxn

Question 27

treatment of hypothermia

Answer 27

ABCs, CPR, & stabilization; rewarming; do NOT pronounce pts until they have been rewarmed to 35 C–full recovery is not uncommon; bretylium drug of choice for dysrhythmias

Question 28

si/sx of heat exhaustion + treatment

Answer 28

extreme fatigue w/ profuse sweating, N/V, dull HA, nl. or slightly elev. body temp, tachypnea, tachycardia, hypotension
*treat with IV NS & cool environment

Question 29

si/sx of heat stroke

Answer 29

AMS, elev body temp (>40 C), often no sweating, hot, dry skin, possible ataxia; labs may reveal hypovolemic hyponatremia, hypoglycemia, leukocytosis, & elev LFTs

Question 30

treatment of heat stroke

Answer 30

true emergency***monitor for convulsions & CV collapse; treat w/ aggressive cooling; treat NMS & drug fever w/ dantrolene; treat seizures w/ diazepam

Question 31

fluid resuscitation for burn pts

Answer 31

appropriate for pts w/ >20% BSA 2nd-degree burns

• Give 4 cc/kg per % total BSA (Parkland formula) over 24 hrs–the 1st half over the 1st 8 hrs & the 2nd half over the next 16 hrs
• Maintain a UOP of 1 cc/kg/hr
• Tetanus PPX & pain control

Question 32

timeline of neonatal conjunctivitis

Answer 32

within 24 hrs=chemical
2-5 days=gonorrheal
5-14 days=chlamydial

Question 33

retinal detachment–presentation & tx plan

Answer 33

painless, unilateral “veil” or floaters; requires emergent ophthalmologic eval/referral

Question 34

Hypothermia and biochemical abnormalities

Answer 34

Can cause metabolic acidosis, respiratory acidosis, azotemia, hyperK, hyperglycemia, elev lipase, elev hct, coagulopathy, leukopenia, thrombocytopenia; most of which should normalize with improved tissue perfusion and active external/internal warming; support bp, warm iv fluids, warm blankets and heating pads