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STEP2 > Emergency Med > Flashcards

Emergency Med Flashcards

1
Q

What should the first step be in treating a patient with a very recent pill overdose of unknown type?

A

gastric lavage, which is most useful in the first hour but can be helpful up to two hours after ingestion

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2
Q

When is gastric lavage indicated and contraindicated?

A
  • indicated within the first two hours of a toxic ingestion

- contraindicated for those with altered mental status or a caustic ingestion

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3
Q

Describe the role of gastric emptying in the treatment of poisoning/overdose.

A
  • gastric lavage can be useful in the first two hours
  • whole bowel irrigation is only useful for massive iron ingestion, lithium overdose, and ingestion of drug-filled packets (e.g. smuggling)
  • ipecac, cathartics, and forced diuresis are never helpful
  • gastric emptying is always wrong with altered mental status, caustic ingestion, and acetaminophen overdose
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4
Q

What are the indications for whole bowel irrigation?

A

massive iron ingestion, lithium overdose, and ingestion of drug-filled packets (i.e. smuggling)

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5
Q

Gastric emptying should never be used in what circumstances?

A
  • patients with altered mental status
  • caustic ingestions
  • acetaminophen overdose
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6
Q

What are the two most common causes of death by overdose?

A

aspirin and acetaminophen

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7
Q

What is the best initial management of altered mental status of unclear etiology?

A

give naloxone and glucose; these work instantly, have no adverse effects, and treat very common etiologies

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8
Q

What roll does charcoal play in treating overdose?

A

it is benign and occasionally helpful so should be given to anyone with a pill overdose

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9
Q

What are two circumstances in which flumazenil should not be given?

A
  • anyone who chronically uses benzodiazepines as this may induce an acute, fatal withdrawal
  • anyone who also took TCAs as benzodiazepines may be preventing seizures in those with a TCA overdose
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10
Q

How should acetaminophen overdose be managed?

A
  • if a clearly toxic amount (more than 8-10 grams) was ingested within the last 24 hours, give n-acetylcysteine
  • if an unknown about was taken, get a drug level
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11
Q

When is n-acetylcysteine ineffective for the treatment of acetaminophen overdose?

A

when the ingestion was more than 24 hours ago

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12
Q

How does charcoal affect the effectiveness of N-acetylcysteine?

A

it doesn’t and the two can be given together

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13
Q

Describe the presentation, including ABG, and treatment of aspirin overdose.

A
  • presents with tinnitus, altered mental status, renal toxicity, hyperventilation, and an anion gap metabolic acidosis
  • hyperventilation produces a respiratory alkalosis and inhibition of oxidative phosphorylation produces a lactic acidosis
  • typical ABG has a nearly normal pH as these two negate one another
  • treat with alkalinization of the urine to increase excretion
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14
Q

Describe the presentation and management of TCA overdose.

A
  • presents with anticholinergic effects, seizures, and arrhythmias
  • management should start with an ECG and treatment with sodium bicarbonate to protect the heart against arrhythmia
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15
Q

How should caustic ingestion be managed?

A
  • do not attempt to reverse acids or bases

- flush out caustics with high volumes of water and perform an endoscopy to assess the injury

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16
Q

Describe the pathophysiology, presentation, ABG, diagnosis, and treatment of carbon monoxide poisoning.

A
  • CO binds oxygen and prevents the release of O2 into peripheral tissues, causing a functional anemia
  • presents with dyspnea, lightheadedness, confusion, seizures, and ultimately death from MI
  • ABG demonstrates a lactic acidosis predominating over a respiratory alkalosis
  • PaO2 and SaO2 will be normal, so diagnosis requires a carboxyhemoglobin level
  • treat with 100% in most cases; use hyperbaric oxygen for those with CNS symptoms, cardiac symptoms, or a metabolic acidosis
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17
Q

Describe the pathophysiology, etiology, presentation, diagnosis, and treatment of methemoglobinemia.

A
  • oxidation of hemoglobin produces ferric iron which cannot carry oxygen
  • this is most often secondary to benzocaine and other anesthetics, nitrites, nitroglycerin, or dapsone exposure
  • presents with dyspnea, cyanosis, headache, confusion, seizures, and metabolic acidosis
  • PaO2 is likely normal because this is a measure of unbound oxygen and SaO2 is ~85%, so diagnosis requires a methemoglobin level
  • the best initial therapy is 100% oxygen and the most effective is methylene blue
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18
Q

Cyanosis in the presence of a normal PaO2 is suggestive of what illness?

A

methemoglobinemia

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19
Q

What is the best initial step in treating organophosphate poisoning?

A

atropine

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20
Q

What is the best initial step in treating nerve gas exposure?

A

atropine because it inhibits the metabolism of acetylcholine and produces cholinergic poisoning

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21
Q

Organophosphates and nerve gas cause death due to what?

A

bronchospasm, bronchorrhea, and respiratory arrest

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22
Q

Describe the presentation, diagnosis, and treatment of digoxin toxicity.

A
  • most commonly presents in those with hypokalemia because potassium is a competitive inhibitor of digoxin
  • presents with GI upset, hyperkalemia, visual disturbance, confusion, and arrhythmia
  • the best initial test is a potassium level and an ECG, which will show downslopping of the ST segment
  • the most accurate test is a digoxin level
  • treat with potassium regulation and digoxin-specific antibodies
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23
Q

Describe the presentation, diagnosis, and treatment of lead poisoning.

A
  • presents with abdominal pain, acute tubular necrosis, sideroblastic anemia, peripheral neuropathies, and memory loss/confusion
  • the best initial test is a free erythrocyte protoporphyrin but the most accurate is a venous lead level
  • treat with succimer if level is > 45, dimercaprol and EDTA if greater than 70
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24
Q

Describe the presentation and treatment of mercury poisoning.

A
  • it presents with neurologic problems if orally ingested and interstitial fibrosis if vapors are inhaled
  • chelating agents like dimercaprol and succimer are effective at limiting neurologic toxicity and preventing progression of pulmonary disease, but the fibrosis is irreversible
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25
Q

How is osmolar gap calculated?

A

it is the difference between measured and calculated serum osmolality:
calculated = 2(Na) + BUN/2.8 + glucose/18

26
Q

Describe the etiology, presentation, and diagnosis of methanol poisoning.

A
  • methanol exposure is typically from wood alcohol, cleaning solutions, or paint thinner
  • toxicity results from the toxic metabolite formaldehyde
  • presents with intoxication, ocular toxicity, metabolic acidosis with an anion and osmolar gap
  • treat with fomepizole and dialysis
27
Q

Describe the etiology, presentation, and diagnosis of ethylene glycol poisoning.

A
  • exposure is typically from antifreeze and toxicity results from the toxic metabolite oxalate
  • presents with intoxication, renal toxicity, hypocalcemia, and a metabolic acidosis with anion and osmolar gap
  • treat with fomepizole and dialysis
28
Q

Why are methanol and ethylene glycol poisoning treated with fomepizole and dialysis?

A
  • fomepizole inhibits alcohol dehydrogenase to prevent the formation of toxic metabolites
  • dialysis is required to remove any remaining substance from the body
29
Q

What is the presentation and treatment for black widow spider bites?

A
  • present with abdominal pain, muscle pain, and hypocalcemia

- treat with calcium and antivenin

30
Q

What is the presentation and treatment for brown recluse spider bites?

A
  • present with local skin necrosis, bullae, and blebs

- treat with debridement, steroids, and dapsone

31
Q

Describe the general presentation and treatment of snake bites.

A
  • the most common injury is a local wound
  • some snakes produce a hemolytic toxin causing hemolysis and DIC while others produce a neurotoxin that cause respiratory paralysis
  • treat with pressure, immobilization, and antivenin
  • do not place tourniquets or ice and do not perform I&D
32
Q

Describe the etiology and treatment of dog, cat, and human bites.

A
  • human: Eikenella corrodens
  • dog/cat: Pasteurella multocida
  • treat all with amoxicillin and clavulanate
  • give a tetanus booster if more than 5 years since the last injection and a rabies vaccine if the animal had altered mental status or cannot be observed
33
Q

Under what circumstances is stress ulcer prophylaxis with PPI indicated?

A
  • head trauma
  • burns
  • ET intubation
  • coagulopathy with respiratory failure
34
Q

What is the best initial therapy for burn victims? Who should be intubated?

A
  • best initial therapy is 100% oxygen

- intubate for stridor, hoarseness, wheezing, or burns inside the nasopharynx or oropharynx

35
Q

Describe the fluid, volume, and rate for fluid replacement in burn victims.

A
  • replace with LR
  • total for 24 hours = 4 mL x kg x %BSA burned
  • give half in the first 8 hours and half over the next 16
36
Q

Describe the management of burn victims.

A
  1. best initial therapy is 100% oxygen
  2. intubate for stridor, hoarseness, wheezing, or burns inside the nasopharynx or oropharynx
  3. replace fluids with LR with total volume = 4 x kg x %BSA burned
  4. apply prophylactic topical antibiotics
37
Q

How can percent of body surface area burned be calculated?

A
  • rule of 9’s

- one patient hand equals 1% of total body area

38
Q

What is the best initial step when managing hypothermia?

A

get an ECG

39
Q

What is the characteristic ECG finding for those with hypothermia?

A

J waves are produced by a QRS that hits the ST segment and hypothermia results in marked elevation of the J point

40
Q

What is high altitude pulmonary edema, how does it present, and how is it treated?

A
  • it is pulmonary edema in the setting of a normal ejection fraction which occurs at elevations above 2500 meters
  • presents with two symptoms (dyspnea, cough, weakness, and chest tightness) and two signs (crackles, wheezing, cyanosis, tachypnea, tachycardia)
  • treat with oxygen, rapid descent, and either steroids, nifedipine, or sildenafil
41
Q

How should jelly fish stings be treated?

A
  • wash the wound with seawater
  • scrape off the stingers
  • inactivated the toxin with hot water
  • apply topical steroids and antihistamines for symptoms
42
Q

When should a “precordial thump” be given?

A

for cardiac arrest with onset in the last ten minutes with no defibrillator avilable

43
Q

What are the four major causes of sudden loss of pulse?

A
  • asystole
  • ventricular fibrillation
  • ventricular tachycardia
  • pulseless electrical activity
44
Q

What is the best initial management for pulselessness?

A

CPR

45
Q

What is the proper treatment for asystole?

A

CPR and epinephrine, which shunts blood to critical organs

46
Q

Unsynchronized cardioversion is only indicated for what two arrhythmias?

A

ventricular tachycardia and ventricular fibrillation

47
Q

How should ventricular fibrillation be managed?

A
  1. begin CPR
  2. unsynchronized cardioversion
  3. epinephrine
  4. unsynchronized cardioversion
  5. amiodarone or lidocaine
  6. unsynchronized cardioversion
  7. repeat drug then cardioversion cycle
48
Q

How should ventricular tachycardia be managed?

A
  • if hemodynamically stable: start with amiodarone, then lidocaine, then procainamide; if unsuccessful, cardiovert
  • if hemodynamically unstable: cardiovert several times and then try amiodarone, lidocaine, and procainamide
  • if pulseless: manage like VFib, alternating unsynchronized cardioversion with epinephrine, amiodarone, and lidocaine
49
Q

How is hemodynamic instability defined in those with rhythm disturbances?

A
  • hypotension
  • confusion
  • dyspnea
  • chest pain
50
Q

How should afib be treated in the post-CABG patient?

A
  • in this case it is a common and usually self-limited
  • rate control with beta-blockers or amiodarone is best in these cases lasting less than 24 hours
  • antigoculation and/or cardioversion should only be used for cases that persist for longer than 24 hours
51
Q

What is the difference between atrial flutter and atrial fibrillation?

A

fluter is a regular rhythm that tends to return to sinus or deteriorate into fibrillation which is an irregularly irregular rhythm

52
Q

Describe the management of atrial fibrillation.

A
  • for hemodynamically unstable patients, the first step is synchronized electroconversion
  • for acute but stable patients with an exogenous cause (post-CABG, cocaine, alcohol, etc.), rate control is all that is necessary; most cases with spontaneously revert
  • chronic cases (lasting >48 hours) should be managed with rate control first (beta-blockers, CCBs, or digoxin) and then started on anticoagulation (NOACs preferred in most cases, warfarin for mitral stenosis or metal valves, aspirin for CHADS-VASC less than 2)
53
Q

How should SVT be managed?

A
  • begin with vagal maneuvers
  • give adenosine if these don’t work
  • beta-blockers, CCBs, and digoxin are a last resort
54
Q

What are signs of Wolff-Parkinson-White syndrome?

A
  • SVT alternating with ventricular tachycardia
  • SVT that gets worse with diltiazem or digoxini
  • delta waves present on EKG
55
Q

How is Wolff-Parkinson-White syndrome treated?

A
  • for acute therapy, use procainamide or amiodarone for both atrial and ventricular arrhythmias if WPW is present
  • for chronic therapy, use an EP to identify the anatomic defect then perform radio frequency catheter ablation
56
Q

What is the best first step for a patient with asymptomatic bradycardia?

A

get an ECG to distinguish sinus brady from other causes

57
Q

What is the treatment for sinus bradycardia?

A
  • nothing if asymptomatic

- for symptoms, atropine is the best initial therapy followed by pacemaker as the most effective for chronic treatment

58
Q

What is the treatment for 1st degree AV block?

A

the same as sinus bradycardia: if symptomatic, atropine followed by pacemaker for long-term control

59
Q

What is the treatment for second-degree AV block?

A
  • for Mobitz I, treat like sinus bradycardia: nothing if asymptomatic but atropine and pacemaker if symptoms arise
  • for Mobitz II, treat like 3rd degree: pacemaker regardless of symptoms
60
Q

If a patient is post-MI and develops ventricular tachycardia, what is the best management?

A

arrhythmias from ischemia should be corrected by correcting the underlying ischemia so perform angiography or bypass

STEP2 (27 decks)

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