Emergency Med Flashcards

Question

Lower Gi Bleed

Answer 1

- LGI is diverticular disease, colitis, adenomatous poyps, and malignancies - Due to an UGI source 10-14% - Angiography should be considered for the evaulation and management of cases of severe lower gi bleed. - scintigraphy has been used to localize the site of bleeding in obscure hemorrhage.

Answer 2

-Dysphagia is defined as difficulty in swallowing. -Watch them take a sip of water. -Protecting the airway is vital. -Heartburn is GERD. -GERD can cause complications such as stricutres, inflammatory esophagitis, and barrets esophagus. -Favorable response to antacid treatment. -

Answer 3

-high mortality rate regardless of the underlying cause -iatrogenic injury is mc cause of esophageal perforation. -Acute, severe, unrelenting, diffuse and is reported in the chest, neck, and abdomen -radiate to the back and shoulders, back pain may be predominant symptom. -Swallowing exacervates pain. -tachycardia, tachypnea, abd rigidity, hotn, fever, mediastrinal emphysema may take time to develop. CXR, CT or endoscope can confirm. -Rapid managment is key to minimizing bad stuff. -Resuscitate shock- PIP TAZO, emergent surgical consult. All sohuld be admitted.

Answer 4

-Children 1.5-4y account for 80% of all cases. -Once it gets past the pylorus it ususally continues through the GI tract. -Plain fills can screen for radiopqaur objects. -coins in esophagus are AP, trachea are LAT CT for nonradioopaque. Proximal removal with indirect laryngoscopy or fiber optic scope. Button battery lodged in esophagus is true emergency -Urgeny endoscope for esophageal foreign bodies are sharp, mutliple,button batteries, perforation,coin at crico, airway compromise,

Answer 5

PUD is chronic illness manifested by recurrent ulcers in stomach. H Pylori or NSAID use. Hpylori is 95% of patients who develop duodenal ulcer and 70% who develop gastric ulcer. -Burning pain recurs at night. GOld standard for diagnosis is visualization. PPIs H2 blockers. CAP treatment -Peptic Ulcer Disease • Patient will be complaining of gnawing epigastric pain ◦ Duodenal ulcer - pain is alleviated by ingesting food (Mnemonic: DUDe give me food) ◦ Gastric ulcer - pain is exacerbated by ingesting food • Diagnosis is confirmed by endoscopy • Diagnosis of H. pylori infection is made by H. pylori fecal antigen or urea breath test • Most commonly caused by Helicobacter pylori infection or non-steroidal anti-inflammatory use • Comments: Most common cause of upper GI bleed • Increases risk of perforation

Answer 6

-Cholelithiases and etoh abuse account for 90% of acute pancreatitis in us. Biliary colic is obstruction pain from stones. -Unregulated intracellular activation of trypisn. -N/v epigastric pain. CUllen or turner signs are only present in severe cases. -Chole is RUQ N/V -Jaundice is not typical. -Murphy’s signs. Charcot triad- RUQ pain, fever, jaundice. -LIPASE 3X UPPER LMIIT OF NORMAL, and US or CT findings Most sensitive finding for acute cholecystitis is postive murphy’s sign. HIDA scan is adjunctive test when initial studies for gallbladder disease are indeterminate. ERCP is rarely used in ED. Ranson’s criteria Pancreatitis-pain and nausea control, hydrate, and bowel rest and regular assessments. IVF! Gallstone pancreatitis is urgent ERCP. -Dont use abx for pancreatitis unless specific source is suspected. -Biliary colic requires outpatient referral to gen surg. -Acute cholecystitis requires surg consult. (US is the test for biliary, wall thickening (3-5+mm) and pericholecystic fluid. ABx sohuld be given as soon as confirmed. Ceftriaxone1Gm**** with metro. or quinolone plus metro if pen allergic. Severe disease require pip tazo. -AScending cholangitits requires fluid resuscitation,broad spectrum abx, and emergent consult. -Choledocho or gallstone pancreatits require urgen ercp/

Answer 7

- yellow discoloration of the skin is symptoms of hyperbilirubinemia - Unconjugated is from too much out there, conjugated is can’t get it out. - Sudden onset with fever, malaise, and tender enlarged liver points to hepaitits - Spontaneous resolution fmhx points to gilbert’s syndrome. - PT is mose sensitive LAE. - 1/3 have hep a acquired immunity. - Rest, no hepatotoxins, fluids, hygiene. - etoh hepatitis should receive 100 mg PO of thiamine. - Fulminant hepatic failure should warrant lactulose (20gs po) for heaptaic encephalopathy.

Answer 8

-Appendicitis • Patient will be complaining of fever, pain that began periumbilical then moved to RLQ, nausea, and anorexia • PE will show Psoas sign (RLQ pain on extension of right hip), Obturator sign (RLQ pain on internal rotation of flexed right hip), Rovsing sign (right lower quadrant pain when the left lower quadrant is palpated) • Diagnosis is made by ultrasound, CT • Most commonly caused by fecalith • Treatment is surgery RLQ pain is 81% sensitive. Anorexia, n/v. Rebound tenderness is most reliable pe sign in kids. Fever is late finding. CT is 98 and 95% NPO, IVA, pain (fentanyl) and abx(zosyn and amp/sulbac) ******

Answer 9

- Small herniations through wall of colon. - High colonic pressures, resulting in erosion and microperforation. - Steady, deep discomfort in LLQ. - Tenesmus and changes in bowel habits. - Can irritation GU also. - low grade fever. - Fluids, electrolyte replacement, pain and nausea control. - completebowel rest. Morphine. Metro and cipro or IV levo (inpatient)

Answer 10

- SBO s more common than LBO - adhesions are mc cause of SBO with incarcerated inguinal hernias second. - LBO are most commonly due to neoplasm. - Sigmoid is more common in elderly. - Vomiting, abd distention, pain, past hx of abd surg or hernia. - Crampy and intermittent pain, ileus is constant. - dehydration. - Films help localize. - Contrast CT has been advocated. - cbc,bun,electrolytes, and ua.

Answer 11

- Abscesses origination from infected anal crypts and spread to perianal spaces. - Obstrucction of anal gland. Polymicrobial abscess. - Dull, aching, throbbing pain that increases prior to defecation is typical. - Pain with walking and sitting. - Fever, leukocytosis, painful tender mass on DRE. - Deep space abscesses can be difficult to detect on pe. - Endorectal us, ct,mri, or needle locations may be needed to diagnose deep space abscess. - Simple perianal abscess w/o ststemic illness is the only - Simple perianal abscess without systemic illness is the only abscess that shoudl be drained in the ED.

Answer 12

-Hemorrhoids are associated with constipation, straining at stool, frequent diarrhea, advanced age, and preggo. Above and below dentate line Internal hemorrhoids are usually visualed at 2-5-9 oclock positions. -Hot sitz bath, topical steroids, analgestics, bulk laxatives. Acute non-tolerable painful thrombosed external hemorrhoids can be managed by clot excision.

Answer 13

-Pre-renal ARF is most common community acquired cause, with most having volume depletion. -Intrinsic renal causes ATN- mc etiology for hospital acquired ARF- common in ICU and multi-organ failure patients. -Serumcreatinine changes from baseline are good for checking fast kidney function. -Excess nitrogen waste products in serum . Bun:creatine over 20 is prerenal 10:1 is rental GEt fluids going for prerenal. Flujids for renal Foley catheter shoudl be placed to relieve obstructoin. -If all else fails hemodialysis or peritoneal dilysis.

Answer 14

-Skeletal muscle necrosis -Measure CK- 5x upper limit of normal. -heme without rbc on ua. -IVF with crysalloids-several liters are normal. Treat phos when between 1-7 -hyperkalemia requires aggressive therapy. Monitor UO

Answer 15

-Cystitis • Patient will be complaining of low-grade fever, increased urinary frequency, dysuria, and suprapubic or abdominal pain. • Labs will show positive leukocyte esterase and nitrites • Definitive diagnosis is made by urine culture • Most commonly caused by Escherichia coli • Treatment is: ◦ Acute uncomplicated cystitis: TMP-SMX, nitrofurantoin, or fluoroquinolone for 3-5 days ◦ Acute uncomplicated cystitis with comorbid conditions: TMP-SMX, nitrofurantoin, or fluoroquinolone for 7 days • Pregnancy - asymptomatic bacteruria - treat ◦ Cephalosporins, nitrofurantoin (during first trimester - only when needed) • Complications: ↑ Risk of preterm birth, low birth weight, perinatal mortality Gold standard is UC. Complicated should be 10-14days.

Answer 16

-Blood in urine. Gross requires 1mL of blood per liter. -microscopic is greater than 5rbc. -MC cause is UTI, nephrolithiasis, neoplasms, BPH, glomerulonephritis. - COnsider strenuous activity, post strep infection. -All hematuria should be followed by PCM within 2wks, Treatment is directed at cause.

Answer 17

-Fluids should be corrected in the following order volume, ph, k, ca,mg, na, cl. NS can be used with blood Low Na-below 120. Check for renal, pulm, psych disorders. -Calculate anion gape ROME- respiratory opposite, Metabolic equal Comparing Ph and CO Treat the underlying condition If its anxiety related maybe give lorazepam.

Answer 18

-MC cuase is BPH. -more common in men. -Sympathetic innervation of bladder originates from t10-12 levels of the spinal cord. -Comprehensive neuro exam -US is good start. -Foley cath is both diagnostic and therapeutic. Low abd pain and sensation for needing to void.

Answer 19

-Acute phenomenon of renal stones migrating down the ureter is referred to as renal colinc. -URinary stones are more common in men. -75% under 5mm pass -40% over 7mm pass Noncontrast CT is good. US is okay. KUB can follow migration. -Pain meds, Nsaids Antiemetics, ABX should be used if UTI also. Alpha blockr

Answer 20

-Most SENSITIVE SIGN IS UNILATERAL ABSENCE OF THE CREMASTER REFLEX -Can attempt manual detorsion. Open the book. US US may be helpful PHren sign- doesn’t improve pain

Answer 21

-Gradual onset of pain. -Bacterial infx. -Swelling. Phren sign makes it feel better. Admission for IV abx. Treat them for G/C.

Answer 22

-Abd pain, vaginal bleeding, amenorrhea. -Sudden, lateralized, and extreme. -Urine HCG immediately -US to see if IUP is present DISCRIMINATORY ZONE OF 1500 above that and empty uterus suggests EP. -Check VS. IVF for rapid infucsion, CBC, blood typing, repeat hcg in 2 days if its under 1k.

Answer 23

-chromosome abnormalities account for more fetal wastage. Inevitable and inomplete are open. DDX includes ep and GTD. Manage hemodynamic instability. Septic abortion requires amp or clinda plus gent. -Incomplete aboriton requires or GTD require D+c.

Answer 24

-Abruptio placentae, placenta previa, and preterm labor are most common causes. -Manage stability, IV and/or prbc. -CBC and type and cross. DIC profile, electrolyte studies. Administer Rhogam 300mg to ALL RH NEG PATIENTS. -ABruption is premature separation of placenta from uterine wal. Previa-implantation of placenta over the cervical os. -PROM rupture of membranse prior to labor. Alkaline ph, ferning on smear. Preterm is prior to 37 wks. HTN, PRe-E, HELLP

Answer 25

-Hemorrhage and infection are the most common post partum complications presenting to the ED. Postpartum pre-e or e, amniotic fluid embolism, and postpartum cardiomyopathy are rare. Postpartum hemorrhage-ATONY, rupture, laceration, retained tissue, uterine inversion, and coag. -

Answer 26

- Precipitous delivery in an emergency is a relatively uncommon occurance. - Slow fetal hr is an indicator of fetal distress. (Under 100) - False laber is irregular brief contractiors in lower abd.

Answer 27

-MC gyn complaint presenting to the ED. -20% of untreated g/c progress to PID -ascending infx of lower genital tract -abd pain, vag bleeding, postcoital bleeding, irritative voiding symptoms, fever, n/v, malaise. CERVICAL MOTION TENDERNESS TVUS shows TOA. -RUQ especually with jaundice is fitz-hugh curtis syndrome. -Clinical diagnosis. Cephalosporins and doxy Pain and IVF

Answer 28

-Severe, toxin-mediated, life threatening syndrome used to be related to tampons for menstruating women -Most likely associated with colonization or infection with Staph Aureus. -Conditions can be met during menses with the introduction of tampons or intraveginal devices. -MArked Vasodilation. TSS is characterized by high fever, profound hotn, diffuse rash, mucous membrane hyperemia, diffuse myalgias, ha, sore throat, vomiting, diarrhea, and constitutional symptoms. TSS is a diffuse, blanch-able erythroderma, painless sunburn. Generalized desquamation with notable peeling over the palms. IVF, Initiate antistaph.

Answer 29

-SIRS- temp, tachycardia, RR, white count. HOTN DIC is common with septic shock. Septic shock should be suspected with tempr and hotn. Oxygenation, ventilate, and circulate ABX therapy and other drug therapy Control source of sepsis Keep O2 stats greater then 90% IVF If they are still hotn after 4L of fluid, dopamine or norepi can be stated. Get abx after cultures.

Answer 30

-HA of rapid onset, generally associated withfever, meningismus, and photophobia Prompt empitic abx therapy. Abx therapy should not be delayed for LP or imaging Mediam age of 39yo. Purpuric rash characteristic of meningococcemia. LP is mandatory GEt CT before LP Low glucose and high protein is bacterial Get ABX asap, you have 2 hours to get LP.

Answer 31

-Warm, red, tender. MAy be draining a purulent fluid. Clinda, bactrim, keflex is good for strep. Vancomycin if inpatient. GAS and stapoh are common Pain out of proportion, sense of heaviness int he affected part Edema, skin discolored, bullae, malodorous serosanguineous discharge, and crepitance. Low grade fever, tachycardia. Necrotizing soft tissue infecitons should be adequately resuscitated with IV fluids and packed RBC. IV Vanc, pip tazo. Tetanus prophylaxis.

Answer 32

-Mitral valve -natie valve endocarditis RF is leading risk factor. -IVDU is RF. FEVER, chills, weakness, dyspnea, -BC, echo. BC from 3 seperate sites, withn an hour between first and last. -PRosthetic valves should get anticoag. -abx for 4-6wks -prophylactic abx before procedures. IVDU- nafcillin, gentamicin, vanco Prosthetic-vanco,gent, rifampin

Answer 33

-Either primary or secondary causes.

Answer 34

``` -HA with gradual onset, lasts 4-72 hours. Typically unilateral pulsating, and worsened by physical activity. N/V, Photophobia, phonophobia. Visual auras, hemiparesthesias, POUND CRITERIA Pulsatile quality Duration 4-72hrs Unilateral location N/V Disabiling intensity LR is 24. ``` Toradol, dopamine antiemetics. Sumatriptans

Answer 35

``` -Most commonly presetns with HA. Often unilateral severe and throbbing. Associated syptoms may include jaw claudication, 50yo female Esr over 50 High dose steroids ```

Answer 36

-Ipsilateral ptosis, miosis, and anhydrosis is present. | CXR, CR scan of brain and neck, Specific treatment is determined by the cause.

Answer 37

-Bilateral edema of the head of the optic nerve to increased ICP. Blurred disc margin wiht a diminished or absent cup, with an elevated nerve head. When its unilateral, it is not from increased ICP and is referred to as optic nerve edema (noninflammatory) or papillitis (inflammatory) visioin is generally preserved.

Answer 38

-Increased ICP and pipilledema with normal mental status, CSF, and neuroimaging and occures in young women of childbearing years. HA, N/V, visual field deficits, blurred vision. CN 6 deficit, resultant horizontal diplopia on lateral gaze. CT of head shoudl be obtained to rule out intracranial pathology LPcan be performed to measure ICP Neurosurg constul should be obtained also.

Answer 39

``` Polycystic kidneys are RF Rupture off berry aneurysm Worst ha of my life Xanthochromia. Avoid nitro ``` -Subarachnoid hemorrhage (SAH) accounts for approximately one-third of all hemorrhagic strokes. Atraumatic SAH is due to ruptured aneurysms. A history of polycystic kidney disease is a risk factor for the development of berry aneurysms which may spontaneously rupture and cause a subarachnoid hemorrhage. Other medical conditions associated with SAH include Marfan syndrome, coarctation of the aorta and fibromuscular dysplasia. Classic symptoms include an abrupt “thunderclap” headache that is maximal in severity at onset. Patients often have signs of meningeal irritation secondary to blood in the subarachnoid space. These include nuchal rigidity, painful extraocular movements, photophobia, and a positive Brudzinski or Kernig sign. Subarachnoid blood appears white on noncontrast head CT and most often appears in the cerebral cisterns within which lies the vessels that compose the circle of Willis. Management includes supportive care, including airway management as needed, nimodipine, and neurosurgical consultation. IV labetalol. Emergent neuro surgical consult.

Answer 40

-insidious onset ha. With neuro deficit following MAnage their symptoms, bed at 30 deg, if bp over 200 then consider reducing. Reverse any bleeding agents they have Send em to ICU And get a neurosurgeon

Answer 41

-Ischemic 90% of the time. -Sudden numbness or weakness of face, arm or leg. -Sudden confusion or aphasia -Sudden memory deficit -Dizziness, ataxia,severe ha, visual deficts, and diplopia. ANTERIOR CEREBRAL-contralateral leg weakness and sensory changes. MCA-Hemiparesis and sensory loss, aphasia if dominant hemisphere is affected. PCA-very subtly, unilateral ha, visual defects, dizzy, vertigog,diplopia, BASILAR ARTERY-locked in syndome Keep O2 sats above 94% Noncontrast head ct IF no tpa keep bp under 220 If TPa then keep it under 185 USe labetalol, nitro past,nicardipine. IV TPA within 3 hours of symptoms onset

Answer 42

Lasts 1-2 hrs. Transient Ischemic Attack • Transient episode of neurological dysfunction without acute infarction • 10% of TIA patients will have a stroke within 90 days • Aspirin + dipyridamole or clopidogrel monotherapy • ABCD2 score: predicts likelihood of subsequent stroke within 2 days -transient ischemic attack (TIA), commonly referred to as a “mini-stroke,” is characterized by the development of focal neurologic deficits that spontaneously fully resolve, typically within an hour of development. Symptoms depend on what area of the brain is involved in the ischemic event. Events involving the anterior circulation commonly present with hemispheric signs and symptoms such as hemiparesis, aphasia, hemisensory loss, and visual field defects. Events involving the posterior circulation can present with dizziness, vertigo, drop attacks, ataxia, or vomiting. The goal of treatment in these patients is to prevent stroke. Cerebrovascular accident (CVA), or stroke occur in up to 20% of patients within 90 days of a TIA. A diagnostic work-up should be initiated in these patients with a magnetic resonance angiography (MRA). Other studies include a cardiac work up to exclude dysrhythmias and studies to identify coagulopathies. Treatment may include prophylactic antiplatelet therapy or carotid endarterectomy if appropriate or indicated. ASA plue dipyridamile is recommonded.

Answer 43

- Cervical artery dissection causes 10-25% of strokes in young and middle aged patients. - Neck trauma, major or trivial (chiropractors), Unilateral head pain, neck pain, face pain.

Answer 44

-1/4 ED pts over 70 have AMS or delirium. Delirium is days, fluctuating, disordered attnention, hallucinations, delusions. Dementia is insidious, alert, normal attention, impaired cognition and orientation, hallucincations abset, 5mg haldol is frequent first choice. Does should be 1-2mg in elder,y Coma-state of reduced alertness and responsiveness from which patient cannot be aroused. Mannitol transiently reduces ICP. Hyperventilating can reduce ICP.

Answer 45

- Veritgo is mismatch of the perception of movement by visual, vestibular, and propioceptive symptoms - Sensation of movement when none exists. - peripheral vertigo- sudden and intsne onset. Horizontal, rotary nystagmus. - central vertigo-abrupt or gradual, ill-defined less severe symptoms. Constant. Vertical nystagmus - Find out if its really vertigo. - Dix hallpike if suspected BPPV First line therapy for peripheral vertigo is antihistamines- benadryl or meclizine and antiemetcs.

Answer 46

- Ataxia is failure to produce, smooth intentional movements. - Orthostatics point to systemic illness. - Ha, nausea, fever, deceased level of alertness. - Cerebellar lesions are sugested by undershooting or overshooting finger to nose. - Vibrattion and positioin sense in toses tests the posterior columns, - Senile gait (slow, broad based, shortened) may be seen with normal aging Give em Thiamine, Acute inability to walk or cannt be cared at home may require admissin for further eval.

Answer 47

-abrupt loss of consciousness without warning. -Rigid is tonic -Clonic is jerking. -After the arttack patient is flaccid and unconscious, -Generalized seizure lasts 60-90seconds followed by post ictal phase. -Absence are brief only lasting a few seconds. -Lorazepam 2-4mg IV is inital agent for seizures, diazepam is good Then if those don’t work IV phenytoin, Fosphenytoin

Answer 48

-Status epi is continuous seizure activity for mroe than 5 mins. -IV phenobarbital, Valproic acid Or propofol Oor ketamine.

Answer 49

-Occurs in freezing temperatures (-4) thawing of frozen tissue initiates an arachidonic acid cascade promoting vasoconstriction, pltl aggreatation, leukocyte sludging resulting in thrombosis and ischemia. First degree-frost nip, partial skin freezing, erythema, mild edema, lack of blisters, and occasional late skin desquamation. STINGING, BURNING, followed by throbbing. Second degree-full thickness skin freezing, substantial edema, CLEAR BLSITERS that form black eschars over several days. NUMBNESS, ACHING THROBBING 3rd dedgree- involves subdermal plexus-hemorrhagic blists, necrosis, BLUE GRAY discoloration. PArt feels like BLOCK OF WOOD, BURNING Throbbing, SHOOTING PAINS. 4th degree- involves everything- little edema, mottled skin, non-blanching cyanosis, formation of black mummified eschar. DEEP ACHING JOINT PAIN. Rapid rewarming with circulating water (104-107.6) for 20-30mins for extremities. Use compresses soaked in warm water for faces. Give em narcs, ibuprofen, tdap, pen G. Maybe bupivacaine.

Answer 50

- Pale, mottled, anesthetics, pulseless foot. Long term hyperhidrosis and cold insensitivity are commong. Anesthesia may be prolonged or permanent - Rewarming, drying elevation.

Answer 51

- painful inflamed skin lesions cuased by chronic, intermittent exposure to damp, nonfreezing ambient tempertures. - Rewarming, elevation, bandanging of affected tissues. NIFEDIPINE 20mg PO TID,

Answer 52

-Milkd hypothermia 89.6-95F results in an excitatory phase characterized by shivering and increases in heart rate and bp. Shivering ceases wwhen core temps drop below 86. Decreases HR, RR, and BP. Below 30C dysrhythmias begin to occur Mild use passive warming using insulated blankets. -Active rewarming exogenous heat to the body surface, through the use of heating blankets set at 104, radiant heat. Dont’ need to rapidly rewarm over 86degree.

Answer 53

``` -Heat Stroke • Loss of thermoregulatory mechanisms • Dry skin • AMS • Abnormal LFTs • Rapid cooling to 39º: evaporative or cold water immersion • Avoid antipyretics ```

Answer 54

-Wasps, bee,s ants are members of order hymenoptera. -Local reaction of pain, red, swelling, itching. -Toxic reactions response to multiple stings, greater frequency of GI disturbances. -The shorter the interval between sting and onset of symptoms, more severe the reaction. -Remove retained stingers and cleanse all wounds. For local reactoins- oral antihistamines. -treat severe reactions 1:1000 IM .3-.5mL H1 and H2 blockers and steroids should also be given. Bronchospams respons to courses of inhaled B-agonists. Brown recluse-cytotoxic. Wound care, tdap, pain meds. Black widow-erythematous skin lesions, swlling, diffuse muscle cramps, painful cramping of abd wall musculature. Neurotoxin. PAin meds and benzos.

Answer 55

-PIT VIPERS. 25% are DRY BITES Retractable fands, heat sensing pits.f Absence of findings after 8-12 hours rules out venom injection. Minimal envenomation is local swelling with no lab abnormalities. Severe causes hypotension, AMS, coag, Moder is hotn , tachy, nausea. -Tentanuss Rest limb below level of heart. ANY PT WITH progressive local swelling, systemic effectsm or coag should recieve antivenin therapy immediateiyl*********

Answer 56

- Coral snakes. - Potent neurotoxin capable of causing tremor, salivation, respiratory paaralysis, seizures, and bulbar palseis. - Must be admitted for 1-2days. Needs to get antivenom.

Answer 57

-Pasteurella, strep,staph, capno | Give em augmentin

Answer 58

-pasturella, bartonella | Give em augmentin or azithro

Answer 59

-rabies virus enters the CNS and causes a wide range of symptoms from headaches, anorexia, hallucinations, agitation to seizures, and hydrophobia. Bats are the most common animals to infect humans. Raccoons are the most common animal infected with rabies. The patient’s history and presentation suggest an infection with the rabies virus and post-exposure prophylaxis with the inactivated rabies vaccine and the human rabies immunoglobulin should be administered. The human rabies immunoglobulin is a one time dose where as the inactivated rabies vaccine is given 4 times over 14 days. In addition the bite wound should be examined and cleaned and antibiotics may be of benefit. -Fever,malaise, ha, anorexia, nausea, sore throat, cough, pain . -Confine animal and observed for 10 days. -HRIG once, half at exposure site, other half at im. Give vaccine 0,3,7,14.

Answer 60

-Prognosis after submersion injuries depends on the degree of pulm and CNS. Dry drowning-laryngospasm Wet drowning-aspiration of water into the lungs, surfactant gets washed out.

Answer 61

-Predominantly in T1DM, but may occur in T2DM. -Insulin d eficiency and regulatory hormone excess (epi) -Body has plenty of glucose, can’t use it bc no insulin, so body makes more sugar eith epi,gulcagon, cortriol, GF etc. -Dehydration, hotn, tachy, ketonemia. -Daignosed with glucose over 250, ph under 7.3. -Correct hypovolemia,ketonemia, acodid, and treat underlying cause. Get them fluids first. Check K. If high K then insulin!! If k is normal range then turn on insulin and give k. IF initial K is low, hold insulin drip for 30mins and initiate iv 60mEq at 250ml

Answer 62

-High anion gap metabolic acidosis that can occur after acute cessation of alcohol. -Heavy etoh intake and low food intake. -N/V/orthostasis, abd pain. Anion gap, metabolic acidosis. -Ketones are elevated. Treat IV infusin of D5NS. THiamine 100mg

Answer 63

-Poorly controlled T2DM. -HHS develops as result of insulin resistance,incrased hepatic gluconeogensis, osmotic diuresis and dehyrdation -As glucose goes up, fluid gets pulled into intravasucalr space. OVer 180glucose spills into urine. -Dehydration, orthostatics, dry skin, AMS -No ketosis. Glucose over 600. Ph over 7.3 -Start 1L NS per H initially. -Fliuods baby. -Insulin .1 u/kg/h IV -Keep potassium over or equal to 3.3. -If over 3.3 but under 5 give em k while your giving insulin.

Answer 64

- Common in diabetics treated with insulin or sulfonyureas. - Signs of epi (since epi and insulin work opposite each other) - Sweating, shaky, anxiety, nausea, dizziness, confusion, blurred vision, headache, and lethargy. - Diaphoresis, tachycardia, - Low glucose that gets better with treatment.

Answer 65

-Excess circulating thyroid hormone from any cause. -Suppressed TSH, T4/T3. -CNS disturbance (confusion, delirium, seizure, coma). Sinus tach, afib, pvc, CHF. Stimulated GI motility and diarrhea. PTU, Methimazole then propranolol, Prevent conversion of t4 to t3 with steroids.

Answer 66

-Demand for glucocorticoids and mineralcorticoids exceeds the supply from the adrenal cortex. -Pituitary secretes ACTH and MSH. -weakness,dehydration,hotn, anorexia, nausea, vomiting, weight loss, abd pain. -Adrenal suppression from prolonged steroid use with either abrupt steroid withdrawal or exposure to increased physiologgic stress such as injury illness or surgery. LOW NA, HIGH K, Low glucose, Anemia -IVF. Hydrocortisone is doc.

Answer 67

-MC in under 10yo. Staph -warm, indurated, erythematous eyelids, NO decreased acuity, painful eye movement, Can give Augmentin, war packs, close followup. -toxic appearing= admit and give ancef and vanco.

Answer 68

-Orbital cellulitis is an infection of the ocular muscles and periorbital fat, in contrast to preseptal cellulitis, which only involves the anterior soft tissue. Orbital cellulitis does not involve the globe. Orbital cellulitis is most frequently seen in young children and in older adults. The most common cause of orbital cellulitis is bacterial rhinosinusitis. Staphylococcus aureus is the most frequently identified pathogen in orbital cellulitis. Distinguishing orbital cellulitis from preseptal cellulitis is important because orbital cellulitis is potentially vision and life threatening. Orbital cellulitis and preseptal cellulitis both cause ocular pain and eyelid erythema and swelling however, only orbital cellulitis causes painful eye movements, proptosis, and ophthalmoplegia. Fever and chemosis can occur in severe preseptal cellulitis, but are more common in orbital cellulitis. Computed tomography is used to confirm clinically suspected orbital cellulitis. Blood cultures are recommended in all cases of orbital cellulitis prior to antibiotic initiation. An ophthalmology and otolaryngology consult should obtained for all patients. Patients with orbital cellulitis require empiric intravenous antibiotics aimed at S. aureus. Typical antibiotic regimens include vancomycin plus one of the following: ceftriaxone, cefotaxime, ampicillin-sulbactam, or piperacillin-tazobactam. CT WITHOUT

Answer 69

-hordeolum (B), or stye, is a more acutely presenting, painful eyelid lesion. It more commonly occurs on the lid margin, but can also occur on the internal surface. Internal surface eyelid lesions typically develop from plugging of a meibomian gland, while lid-margin or external surface eyelid lesions may represent infection of the more anteriorly located glands of Moll/Zeiss. Hordeola usually self-drain within one week of lid hygiene and antibiotic ointment treatment

Answer 70

-A chalazion is a lipogranuloma of either a meibomian gland or a Zeis gland. When the meibomian gland is involved, the lid nodule is characteristically hard and painless. If the Zeis gland is involved, it is marginal or superficial. Lipid breakdown products, possibly from bacterial enzymes or from retained sebaceous secretions, leak into the surrounding tissue and incite a granulomatous inflammatory response. The resulting mass of granulation tissue and chronic inflammation (with lymphocytes and lipid-laden macrophages) distinguishes a chalazion from an internal or external hordeolum (stye) which is primarily an acute pyogenic inflammation with polymorphonuclear leucocytes and necrosis with pustule formation. Upon examination, the single, nontender, firm nodule or, in rare cases, multiple nodules are located deep within the lid or the tarsal plate, whereas a hordeolum (stye) is more superficial and is typically centered on an eyelash. Eversion of the lid may reveal the dilated meibomian gland and chronic inspissation of adjoining glands. With judicious pressure on the lid, the thick secretions can be seen extruding like toothpaste, resulting in tear debris. Chalazia are more common on the upper lid than on the lower lid because of the increased number and length of meibomian glands present on the upper lid. Small, inconspicuous, asymptomatic chalazia may be ignored. Conservative treatment with lid massage, moist heat, and topical mild steroid drops usually suffices. Rarely one may administer oral tetracycline (eg, doxycycline 100 mg or minocycline 50 mg every day for 10 days) to minimize the infectious component and decrease the inflammation. Chronic therapy with low-dose tetracycline (eg, doxycycline 100 mg orally every week for 6 months) frequently prevents recurrence.

Answer 71

-Blepharitis • Patient will be complaining of eyelid changes and eyelash flaking • PE will show crusting, scaling, and red-rimming of the eyelid • Diagnosis is made by slit-lamp examination • Most commonly caused by dysfunctional meibomian gland • Treatment is warm compresses, irrigation, lid massage, and topical antibiotics for flare-ups • Comments: associated with seborrhea and rosacea Topical erythromycin ointment is an appropriate first-line treatment for an acute exacerbation of anterior blepharitis. Blepharitis is a common inflammatory condition of the eyes involving the lid margins. In anterior blepharitis, the eyelashes are typically involved and physical exam may demonstrate scaling or granulations at the lid margins. The eyes may also appear “red-rimmed”. Treatment involves lid hygiene, including washing the lids daily with a gentle shampoo (such as baby shampoo) that is not irritating to the eyes. Acute exacerbations and inflammation can be treated with either topical bacitracin or erythromycin ointment applied to the lid margins.

Answer 72

Bacterial Conjunctivitis • Patient will be complaining of red/pink eye with discharge usually worse in the morning • PE will show purulent (yellow) discharge and crusting • Most commonly caused by Staph aureus, Strep pneumoniae, H.Flu. ◦ Contact lens wearers: Pseudomonas aeruginosa • Treatment is topical antibiotic drops Viral conjunctivitis is the most common type of conjunctivitis in adults and is most often caused by adenovirus. Patients present with symptoms of redness, watery or mucoserous discharge, and irritation. It is typically bilateral (but may initially affect only one eye) and there is often a preceding or concomitant upper respiratory illness. Physical examination findings include preauricular lymphadenopathy, diffuse conjunctival injection, and enlarged follicles on the inferior palpebral conjunctiva. Visual acuity, examination of the cornea and anterior chamber, and intraocular pressures are normal. Treatment consists of supportive care with cool compresses. Some patients may get relief from an over-the-counter topical antihistamine or ocular decongestant but this treats only the symptoms and not the cause. Topical antibiotics are reserved for those patients in whom the etiology is unclear or if there is concern for a superimposed bacterial infection. Allergic Conjunctivitis • Patient will be complaining of bilateral red eyes, itching and tearing • PE will show cobblestone mucosa on the inner/upper eyelid • Treatment is topical antihistamine H1 blockers

Answer 73

-Corneal ulcer- pain, redness, photophobia Staining corneal defect with a surrounding white hazy infiltrate. Treat with hourly topical oflocacin or ciprofloxacin drops. -Dont’ patch

Answer 74

-dendrite**** Linear branchiong, epithelial defect with terminal bulbs that stain brightly with fluoroscein dye during slit lamp exam. Treat with topical antivirals (trifluridine*********)

Answer 75

- Shingles in a trigeminal distribution, ocular involvement, and ffrequently a concurrent iritis. - Shigles on the nose (hutchinson sign) - Oral acyclovir therapy (for lesions under 1wk) along with erythromycin ointment with cool compresses.

Answer 76

-Corneal Ulcer • Patient will have a history of trauma, incomplete closure, or extended contact lens use • PE will show oval ulcer with ragged edges, severe conjunctival inflammation • Most commonly caused by Staphylococcus, Pseudomonas(contact lens wearers), Streptococcus pneumoniae • Treatment is emergent ophthalmology consult Topical ciprofloxacin is first-line treatment for a corneal ulceration. This is because of the necessary coverage against Pseudomonas aeruginosa. A corneal ulcer is a bacterial infection that develops secondary to a break in the corneal epithelium. Risk factors for developing a corneal ulcer include incomplete lid closure (e.g. secondary to Bell’s palsy) and soft contact lenses use. Symptoms include redness, swelling of the lids, foreign body sensation, and photophobia. Physical exam may reveal a round or an irregular ulceration with a white or hazy base. A secondary iritis can develop and cause ciliary flush or a limbal injection. Treatment includes topical antibiotics and emergent ophthalmologic consultation. Cultures can be obtained of the ocular drainage to guide antibiotic therapy. Cycloplegic drops can be used to help with the pain from the secondary iritis. Complications include corneal scarring, corneal perforation, and secondary glaucoma.

Answer 77

-Trauma can cause hemorrhage into or behind the bitreous. | Sudden painless vision loss with black spots, cobwebs, hazy vision.

Answer 78

-subconjunctival hemorrhage. These hemorrhages occur when a blood vessel ruptures under the surface of the conjunctiva. On physical examination, the hemorrhage is flat and bright red and does not cross the limbus. These hemorrhages may occur spontaneously or as a result of Valsalva maneuvers or trauma. In this case, the patient reports multiple episodes of vomiting over the night preceding recognition of the hemorrhage. The hemorrhages do not cause any long-term sequelae and treatment is aimed at reassurance. A subconjunctival hemorrhage is typically painless without any associated visual impairment or photophobia. If these conditions are present, other diagnoses should be pursued Subconjunctival Hemorrhage • Patient will be complaining of blood in the eye • PE will show blood under conjunctiva and stops at limbus • Most commonly caused by coughing, sneezing, minor trauma • Treatment is reassurance

Answer 79

-Corneal abrasions occur when the corneal epithelium becomes disrupted. There are several causes, such as dry eyes, foreign bodies (fingernails, animal paws, chips of wood or metal and branches or leaves) and contact lens use. They usually heal on their own with no complications. The major symptoms are pain, foreign body sensation, photophobia, blurred vision, tearing, eyelid edema, conjunctival injection, difficulty opening the eye and multiple patient attempts of washing out the eye. If suspected, initial evaluation requires the use of fluorescein and a slit lamp. If ocular penetration or retained foreign body is suspected, then order an ocular CT or MRI, depending on the metal content of the object. Fluorescein sodium-impregnated filter paper is commonly used in staining the eye to identify defects in the cornea. “Fluorescein uptake” occurs in areas of defects. This is performed using a blue light that will show the fluorescein as yellow-green in the area of defect.

Answer 80

-Corneal foreign bodies result from numerous mechanisms. -May present with associated iritis and presence of hyphema suggests the presence of globe perforation. Superficial corneal foreign bodies can be removed witha fine needle tip, after applying a topical anesthetic.

Answer 81

-corneal abrasion, or corneal epithelial defect, will appear as an area of increased uptake of fluorescein with a UV lamp examination. Topical anesthetics can be used for analgesia before fluorescein is applied and allows for an easier examination of the cornea. Typically, corneal abrasions are caused by eye trauma. Symptoms include pain, conjunctival injection, photophobia, and a foreign body sensation. If a penetrating injury is suspected, spiral CT may be indicated to detect a ruptured globe or a nonmetallic foreign body. Patients should be prescribed topical antibiotics and ophthalmic nonsteroidal anti-inflammatory drugs can be considered for pain. Prognosis is generally favorable with most corneal abrasions healing within two to three days after injury. If the pain, redness, or photophobia persists then the patient should be referred to ophthalmology. Patient should also be instructed to avoid wearing contact lenses until the abrasion is completely healed.

Answer 82

Globe must be immediately assessed as well as the visual acuity. Abnormal anterior anterior chamber depth, irregular pupil, blindness indicate a ruptured globe until proven otherwise. If any of these signs then eye shielded and emergent referral. -ethmoid bone fracture is a fracture of part of the medial wall of the orbit and can occur with blunt force trauma to the periorbital area. Patients will complain of swelling in the periorbital area and facial pain. They may have minimal bruising in the eyelids; however, they may complain of swelling that worsens when they blow the nose. This is due to the collection of subcutaneous emphysema from the communication between the ethmoid sinus and the orbit.

Answer 83

-Hyphema • Patient with a history of blunt or penetrating trauma • Complaining of blurry vision • PE will show unequal pupils, injected conjunctiva/sclera and blood in anterior chamber • Treatment is with eye protection, limitation of activity, and head elevation of 30–45 degrees

Answer 84

-Orbital Blowout Fracture • Patient with a history of direct trauma to the orbit • Complaining of limitation of upward gaze, infraorbital anesthesia • PE will show inferior rectus entrapment, enophthalmos • CT will show teardrop sign • Diagnosis is made by CT • Management includes ABX, decongestants

Answer 85

-Blunt and penetrating trauma. Any projectile injury ccan penetrate the eye and any puncture or laceration of the eyelid or perioribital area should raise suspicion of this injury. -Associated eye pain may range in severity. -Irregular pupil, APD, shallow or deep anterior chamber, hyphema, SEIDEL TEST IS PATHOGNOMONIC although it may be absent. Once GLOBE IS SUSPECTED! DONT DO ANY MORE PE!!!!!! NPO, protective metallic shield, iv abx, analgesia, sedation, antiemetic. Tetanus. Opthalmologist should be called immediately if a globe rupture.

Answer 86

-Blunt trauma can cause blood to collect in retrobulbar space, raising intraocular pressure, causing decreaseed blood flow. -pain, decreased vision, proptosis. -CT scan of orbits. Intraocular pressure over 40mm should get EMERGENT LATERAL CANTHOTOMY. Emergent opthalmology consultation should be obtained, but should not delay canthrotom.

Answer 87

-Damage to the eye and nasolacrimal system must be excluded in all eyelid and adnexal lacerations. Less than 1mm lid edge lacerations do not require repair. Visible orbital fat is a clue to a penetrated ocular septum.

Answer 88

-immediate irrigation with normal saline prior to the initiation of any other management. A rapid assessment of the pH of the conjunctiva with pH paper and application of a topical anesthetic may be rapidly performed prior to initiation of irrigation but no procedure or intervention should delay irrigation. Irrigation should continue for a minimum of 30 minutes followed by a check of the pH. Irrigation should be continued until the pH normalizes. Once the pH normalizes, application of a cycloplegic, topical antibiotics and a complete ocular assessment should be performed. After immediate management, focus should be placed on identifying the substance the patient was exposed to and ophthalmologic consultation for any significant injuries. Typically, alkaline substances with a pH less than 12 and acidic substances with a pH greater than 2 are not thought to cause significant injury. This may be altered if the duration of contact was prolonged. Long-term complications include perforation, scarring and neovascularization of the cornea. Glaucoma and cataracts can also occur.

Answer 89

-Acute angle closure glaucoma. OPtic neuritis CRAO

Answer 90

-HA, eye pain, cloudy vision, colored halos around lights, cloudy or steamy appearance of the cornea. N/V common. Common in walking into moving theatres Check Intraocular pressure. Normal is under 20, they will read 40-70mmHg If pressure greater than 50 then acetazolamide should be considered IV mannitol if its still not corrected. Timolol drops

Answer 91

Unilateral - -Optic neuritis, an inflammatory, demyelinating disease of the optic nerve, presents as an acute monocular loss of vision. It is more frequently seen in young women. Although often idiopathic, approximately 30% of patients will develop multiple sclerosis (MS) within five years. Vision loss, most commonly a loss of central vision, and loss of color perception, develop over a period of hours and peaks in about one week. Eye pain, typically worse with eye movements, occurs in about 90% of patients. On examination, an afferent pupillary defect is usually present as is a swollen disk. Diagnosis is made based on history and physical exam findings. Magnetic resonance imaging of the brain and orbits with gadolinium will confirm the diagnosis and is helpful in determining those patients at risk for developing multiple sclerosis. After peak vision loss at one to two weeks, symptoms will gradually improve. Intravenous corticosteroids have been shown to increase the rate of recovery, as well as delay the onset of multiple sclerosis, although long-term visual outcome and rate of developing MS at five years are not affected by this treatment.

Answer 92

-Central retinal artery occlusion (CRAO) causes painless vision loss. CRAO occurs when a clot obstructs the ophthalmic artery, the first intracranial branch of the internal carotid artery, causing an ischemic stroke of the retina. It is most common in patients between the 5th and 7th decades of life. Hypertension, diabetes, vasculitis, connective tissue disorders, sickle cell disease and cardiac disease are the most common risk factors. Patients present with a complaint of a sudden and severe vision loss developing over seconds. Physical examination reveals decreased visual acuity and an afferent pupillary defect. The retina appears edematous and pale with comparative prominence of the fovea (“cherry-red spot”) on fundoscopic examination. Treatment is directed at attempting to dislodge the embolus from the artery and restore blood flow. Digital global massage should immediately be started. Reducing intraocular pressure with timolol or acetazolamide may result in dislodgement of the clot by increasing the perfusion gradient. Emergent ophthalmologic consultation should also be obtained for surgical options.

Answer 93

- Central retinal vein occlusion occurs as a result of thrombus formation in the retinal vein. This can occur in the setting of multiple causes including mechanical compression, sluggish circulation, vasculitis, and hypercoagulability. As the central retinal vein is occluded, there is increased resistance to venous flow in the retinal venous system. The impaired bloodflow can increase pressure causing retinal hemorrhages and the classic “blood and thunder” appearance on funduscopic examination. In addition to these findings, the retinal veins may appear dilated and tortuous with macular and optic disc edema (unilateral). Ultimately the pressure increase leads to retinal ischemia and subsequent vision loss. The degree of vision loss depends on how much venous obstruction actually occurs.

Answer 94

-Vitreous separation causes flashes and floaters, dark curtain or veil in the field of vision, and diminished visual acuity. A dileted indirect retinal exam by an opthalmologist is mandatory within 24 hours.

Answer 95

-Can be trauma, infx, foreign body, cerumen impaction, choleseatoma, and neoplasm. May be referred otalgia with dental disease, oropharyngeal and retropharyngeal processes. Nasal cavity patholoy, and disorders of the throat and neck,

Answer 96

-Perception of sound without external stimuli. ASA, Nsaids aminoglycosides, loops, and chemotherapy can cause cause it.

Answer 97

- may be idiopathic (MC), infectious, vascular, metabolic, rheumatologic. - Severe hearing loss on presentation and presenve of vertigo is poor prognostic indicator

Answer 98

-Erythema, edema white exudate in the EAC. Mild can get acetic acid. Ciprodex. Pseudomonas aeruginosa. Acidifying agents, topical antimicrobials. Ciprodex, acetic acid/steroids, If severe swelling of external canal is present, a wick or gauze may be inserted into the canal

Answer 99

-Strep pneumo -abnormal function of eustachian tube appears to be the dominant dactor in the pathogenesis of middle ear disease. -peak age beteen 6-36mos. -Bulging pus behing TM, immobile tm, Amox 90 mg/day . POSTERIOR SUPERIOR IS MOST LIKELY TO HAVE PROBLEMS WITH BONES*****

Answer 100

-Infx spreads from middle ear to mastoid air cells. Otalgia, fever, postauricular erythema, swelling, and tenderness. Protusion of auricle. CT will delineate the extent of bony involvement. IV ABX ENT Surgical drain

Answer 101

-Most ear lacerations are the result of blunt head trauma. Thus, it is imperative to rule out traumatic brain injury before addressing the wound. The exam should include looking for signs of altered consciousness or mental status, abnormal breathing pattern, and signs of basilar skull fracture. The signs of basilar skull fracture include: clear discharge from the nose or ears, hemotympanum, periorbital ecchymosis (raccoon eyes), and retro-auricular bruising (Battle’s sign.) Impaired function of cranial nerves VI, VII, and VIII is also concerning for a basilar skull fracture, so in-depth assessment of extraocular movements, facial movement and symmetry, and hearing and balance should be performed. If the patient demonstrates any sign of brain injury or basilar skull fracture he or she must be referred urgently to an Emergency Department or surgeon for evaluation before addressing the wound.

Answer 102

-Mayh cause cauliflower ear. | Immediate I&D with compressive dressing.

Answer 103

-Ear foreign body • Removal via curette, forceps, or irrigation • Removal requires a cooperative or restrained patient • Irrigation is contraindicated if tympanic membrane may be violated • Irrigation is contraindicated if the material is organic and can swell • Any live insects should be killed prior to removal with alcohol or mineral oil • Otitis externa prophylaxis with ototopical antibiotics is indicated if the EAC or TM has been excoriated during the FB removal

Answer 104

-Use hydrogen perozide to loosen things up, mineral oil, debrox.

Answer 105

-TM perforation can results from lots. Most heal spontaneously, abx are not necessary unless there is persistent foreign material in the canal. Posteriorsuperior quadrant has the most likely to do well.

Answer 106

Soft tissue infection that involves the skin and subQ tissues. Erythema, edema, pain, warmth, loss of function. -ORal therapy- clinda keflex suspected mrsa is bactrim, clinda, doxy

Answer 107

``` Superficial form of cellulitis involving the epidermis, upper lever of dermis, and lymphatic system. Mostly strep. PAinful, red, raised, puffy. SHARPLY DEFINED, PALPABLE BORDER. Diagnosis is clinical. ``` -Oral therapy penicillin MSSA gets augmentin Bullous is bactrim, clinda, doxy.

Answer 108

Serious bacterial infection that occurs in patients with diminished salivary flow. Staph A Rapid onset, fever, trismus, erythema, pain over the parotid gland. Pus can be expressed from the stensens duct Hydration, local massage, heat, lemon drops (sialogogues) -nafcillin, or amp if pen allergy then clinda or keflex/metro

Answer 109

-a paramyxovirus is MC cause of viral parotitis in children under 15yo. Incubation period of 2-3wks consisting of fever, malaise, HA, myalgias, arthralgias, and anorexia. No pus from stensens duct. Analgesics and antipyretics. Contagious 9 days after parotid gland swelling. Bilateral enlargement.

Answer 110

-stones in a stagnany salivary duct -0% of salivary calculi occue in the sub mandibular duct and most of the remainder in the parotid duct. Unilateral pain, swelling, and tenderness of the involved gland that is EXACERBATED BY MEALS Ct only if abscess is in the differential diagnosis. Analgesics, massage, sialogogues. Palpable stones can be milked from the duct.

Answer 111

-4 contiguous potential spaces bounded by muscles of mastication. Typically polymicrobial. -Swelling, fever, pain, erythema, trismus. -CT can tell if its abscess. Stabilize, get ABX, ENT and hospitalizations.

Answer 112

-Tic doulourex presents as an intermittent seconds long, electric shock unilateral nerve distribution. Carbamazepine (100mg PO Twice daily)

Answer 113

Posterior Anterior Epistaxis • Most common source: ◦ Anterior bleeds: Kiesselbach’s plexus ◦ Posterior bleeds: Sphenopalatine artery • Treatment is: ◦ Anterior bleeding: direct pressure, chemical cautery (if vessel visualized), packing, • Posterior bleeding: packing (foley, gauze pack, intranasal balloon device) - afrin soaked gauze, Augmention for prophylaxis against TSS. ◦ Admit patients with posterior packing to a monitored bed

Answer 114

-MC facial fracture. -radiographic diagnosis is not necessary. ICe, pain relief, decongestants. Don’t blow their nose. Examined for septal hematoma (may lead to necrosis of nasal septum***)

Answer 115

-septal hematoma is considered an emergency. The problem is that the perichondrium, which supplies nutrition to the septum, is no longer in contact with the septum because of the intervening hematoma. Thus, the septal cartilage can necrose leading to a perforated septum. Septal hematomas should be drained acutely and the nose packed to keep the perichondrium in contact with the septal cartilage.

Answer 116

-unilateral nasal obstruction, foul rhinorrhea. PErsistent unilateral epistaxis. Topical vasoconstriciton with afrin, and possibly local anesthesia. REmove under direct visualization.

Answer 117

-24-48hrs of a tooth extraction; it responds well to analgesics. Postoperative edema can be managed with ice packs, elevations, nsaids, oral narcs. Trismus may show an infection developing.

Answer 118

-POst extration alveolar osteitis occurs when the clot from the socket is displaced, typically on postop day 2-3. Presents with severe pain ith foul oder and taste. Dental finls should be taken to rule out retained root tip or foreign body. Treatmen is saline irrigation, packing of the socket with eugenol-impregnated gauze. Dont smoke. Abx therapy is indicated in most cases with 24 dental followup

Answer 119

-Most cases can be stopped with direct pressure with folded gauze for 20mins, application of absorbable gelatin sponge, gentle suturing, injecting with lidocaine w/ epi.

Answer 120

-Trench mouth is the only periodontal disease in which bacteria invade non-necrotic tissue. Pain, ulcerated and punched out interdental papillae, gingival bleeding, fever, malaise, and fetid breath. Oral metro and chlorhexidine mouth rinses.

Answer 121

-common pattern of mucosal ulceration triggered by cell mediated immunity. Painful lesions typically resolve in 48hrs when treated with topical steroids

Answer 122

-Removable white, curd like plaques on an erythematous mucosal base. Clotrimazole troches or nystatin oral suspension or fluconazole.

Answer 123

-Coxsackie virus Begins as macules which progress to vesicles of the palate, buccal mucosa, gingiva, and tongue. Palms of hands, soles of feet, buttocks,

Answer 124

Class 1 is enamel of tooth. Class2 involves creamy yellow dentin underneath the white enamel. Class 3- involves the pulp. Tooth may be covered temporarily in zinc oxide/eugenol paste until the pt is seen within 24hrs. Oral analgesics may be needed. -a mandibular fracture. The mandible is the second most commonly fractured facial bone behind the nasal bone. The most likely fracture location is the body of the mandible, which is more likely to show signs of obvious tooth misalignment on exam. The mandibular condyle and the angle of the mandible are the other two common locations of mandibular fractures. Other signs and symptoms of a mandibular fracture include trismus, malocclusion of the bite, intraoral lacerations, and missing teeth. The tongue blade test is a way of detecting even subtle mandibular fractures. The patient bites the blade while the examiner attempts to break it. Inability to stabilize the blade is an indication that the patient may have a mandibular fracture and should undergo imaging. Plain mandibular X-rays and panoramic radiographs are screening tests for mandibular fractures; however, CT of the facial bones is the gold diagnostic standard. Management is variable depending upon location and whether the fracture is open or closed. Open fractures require IV antibiotics, such as penicillin or clindamycin, and hospital admission. Closed fractures may be discharged with dental follow-up. The patient should be given adequate oral analgesics and instructed to observe a soft diet and chew on the non-fractured side. Many fractures will require open reduction and internal fixation, but do not require admission initially if not open fractures.

Answer 125

-its so vascular you on’t need to jump on fixing it. | If its not into stensons/whartons duct then your okay.

Answer 126

-simple lacerations under 1cm on central of dorsal aspect of tongue don’t need repair. IF you have to repair use 4-0 absorbable sutures. Tie with at least 4 square knots

Answer 127

- Should get prophylactic abx. | - remove sutures in 5 days.

Answer 128

-unless unusually large doesn’t need to be repaired.

Answer 129

Viral- EBV- fever, sore throat, and malase. Cervical adenopathy and hsm may be present. Monospor is often negative in first week of illness. Decardon 10mg may be prescribed for severe disease. Bacterial-GABHS and neisseria gonorrhea. GABHS sore throat, fever, ha, abd pain, enlarged nodes, palatal petechiae, and hypertrophy of the tonsils. Absence of cough, 2 or more of centor should get rapid strep. Treaet with pen v, biccilin, erythro

Answer 130

-fever, sore throat, dysphagia, neck pain Trismus. Uvula displaced away from affected side CCT or US of neck may be helpful Needle drainage in ED with outpatient abx. Clinda, amp, augmentine

Answer 131

``` -High fever,sore throat, and drooling. APpear toxic, tripod, sniffing. Lateral neck veiw. Intubate, IV abx. Streoirds. All get hospitalized. ```

Answer 132

-2nd most common deep neck infections -Fever, sore throat, neck pain, drooling, dysphagia/odynophagia. -Appear toxic, neck swelling, torticollis. Rapid fatal airway obstruction from sudden rupture of thet abscess pocket can occur. Nuchal regidity. CT NECK IV CONTRAST Plain radiographs show widened retropharyngeal space. Immediate airway stabilise. Empirical abx. Steroids- ENT for operative i and d.

Answer 133

-Hemorrhage is a result of sloughing of fibrinous debris from the tonsillar bed and typicall occurse in post op days 5-10. Active bleeding needs ENT consult. BCB, coag studeis, and type and cross. Epi and lidocaine applied with direct pressure to the bleeding area.

Answer 134

-Non-pruritic, non pitting swelling of the subcutaneous and deep dermal layers of the skin. Angioedema sohuld get .3mg of epi IM in thigh. Benadryl,and steroids.

Answer 135

-Decreased MCV- chronic Fe deficiency, ACD Increased MCV B12 or folate, etoh abuse. Not sure how this would be an EMED question

Answer 136

-Decreased pltl production, increased pltl destruction, increased pltl loss, and splenic sequestration. -Bleeding is petechiae and mucosal bleeding. ITP, TTP, DIC. HELLP. Consider pltl transfusion when pltlt under 10k Pts with ITP get prednisone.

Answer 137

-Activation of both coagulation and fibrinolytic systems. -Bleeding and thrombosis at the same time. PT is prolonged -Focus on underlying illness and hemodynamic suport Administer cryo Transfuse pltls Transfuse ffp With active bleeding- administer vitamin K and folate

Answer 138

``` -Pain weakness infectious complaints Infection Infarction Ischemia Admit pain ```

Answer 139

-ABCDE including. Complete set of vital signs, is characterized by the orderly idenification and immediate treatment of life threatening conditions. ``` Airway Breathing Circulation Disability (GCS, pupils, deficits) Exposure ```

Answer 140

-Rapid but thorough head to toe exam aimed toward the identificaiton of all injuries and thereby set priorities for care.

Answer 141

-keep em cool

Answer 142

Sub-xyphoid of pericardial fluid, morisons pouch (liver), splenorelan, and pouch of douglas and rectovesicular space -Ultrasound: Focused Assessment with Sonography for Trauma (FAST) • Views: hepatorenal, splenorenal, pelvis, pericardium • Stable patient + negative FAST --> observation • Stable patient + positive FAST --> CT • Unstable patient + negative fast --> repeat FAST or DPL • Unstable patient + positive FAST --> laparotomy

Answer 143

-TBI is mild, moderate, or serve. -MILD=Pts may be asymptomatic with only a hx of head trauma or may be confused and amnestic of the event. Maybe a brief LOC and complain of a diffuse ha, n/v. GCS of 14+ Moderate= GCS 9-13. Severe is under 9 and getting itubate. TREATMENT-O2 100%, cardiac monitoring and 2 IV lines. Cerival spine immobilizations. Keep MAP above 80. Head of bed elevated to 30 degrees. Consider mannitol. Impending brain hernitaiotn may need emergency decompression by trephination (burr holes) when all other methods to control ICP have failed. Treat seizures with benzos. Basilar skull fx or penetrating trauma gets ancef 1g q12h.

Answer 144

-Basilar skull fx-hemtympanum, CSF otorrhea, or rhinorrhea, periorbital ecchymosis, and retroauricular ecchymosis.

Answer 145

-Diffusely or focally increased ICP can result in herniateion of the brain. Uncal is is paralysis of the ipsilateral pupil, causing it to become FIXED AND DILATED. Central trantenrotial herniation offucse in midline lesions in front or occipital lobes or in vertex. Bilateral pinpoint pupils.

Answer 146

- Common locations for contrusions are the frontal poles, subfrontal coretx, and temporal lobes. - Contusions may occur directly under the site of impact or on the contralateral side. Focal deficts and neuro dysfunction may be profound and profounds.

Answer 147

-Disruption of subarachnoid vessels and presetns with blood in the CSF. Pt may complain of diffuse ha, nausea, and photophobia.

Answer 148

- Acute collection of blood between the inner table of the skuull and the dura mater. Typically associated with a skull fx that lacerates a MENINGEAL ARTETY, most commonly the middle meningeal artery. - EXPERIENCES LOC AFTER INJURY, PRESENTS WITH LUCI INTERVAL AND THEN HAS MENTAL DETERIORATION IN THE ED. FIXED AND DILATED PUPIL ONT HE SIDE OF THE LESION WITH CONTRALATERAL HEMIPARESIS IS A CLASSIC LATE FINDING. LENS ON CT SCAN

Answer 149

-Collection of venous blood between dura mater and arachnoid space. TREAT OF BRIDGING VEINS that extended from subarachnoid to dural venous sinuses. SUDDEN ACCELERATION DECELERATION. ELDERLY MORE SUSCEPTIBLE. CRESCENT SHAPED LESION.

Answer 150

-Nexus critera- absence of midline tenderness, normal level of alertness, no evidence of intoxicated, absence of focal neuro deficits, absence of painful distracting injury. CT is best fore cervical spine. For plain films use lateral, odontoid, and anteroposterior.

Answer 151

Anterior Cord Syndrome • PE will show loss of motor, pain, and temperature below injury • Most commonly caused by flexion injury • Comments: proprioception and vibration intact -Injury to the anterior two-thirds of the spinal column results in anterior cord syndrome which is characterized by bilateral loss of motor function and pain and temperature sensation below the level of injury. The dorsal column is usually spared so vibration sense and proprioception are preserved. Anterior cord syndrome occurs in cases of disruption or injury to the anterior spinal artery which can result from the protrusion of bone fragments from a traumatic injury to the vertebrae, disc herniation, or following aortic surgery. It can also result from a flexion/compression injury to the cord. Most improvement in function occurs in the first 24 hours. Anterior cord syndrome carries the worst prognosis of all the incomplete spinal cord syndromes, with less than 20% regaining any degree of muscle function.

Answer 152

-Hyperextension injuries. Disruption of blood flow to the spinal cord, CErvical spinal stenosis. Quadriparesis-greater in upper extremities than the lower extremities. Some loss of pain and temperature sensations, also greater in the upper extremities.

Answer 153

-Brown-Séquard syndrome is a hemisection of the spinal cord most commonly occurring after a penetrating injury. In this syndrome, patients have proprioception and vibratory sensory loss on the ipsilateral side of the injury as well as loss of motor function on the same side. The contralateral side loses pain and temperature sensation since these fibers cross the spinal cord at the level of their nerve roots. Brown-Séquard Syndrome • Patient with a history of penetrating trauma • PE will show ipsilateral loss of motor, position and vibration and contralateral loss of pain and temperature • Most commonly caused by spinal cord hemisection

Answer 154

-Peripheral nerve injury Variable motor and sensory loss in the lower extremities, sciatica, bowel/bladder dysfunction and SADDLE ANESTHESIA..

Answer 155

-O2, IVF, and pos inotropic pressors.

Answer 156

-If blood at meatus, don’t try a cathetter. Perform a Rectal access sphincter tone, blood, determining position of prostate. IV contrast CT is gold standard for stable patient. 1 shot intraoperative IV urogram is recommended by some for the unstable patient, although this i scontroversial. Retreograde urthrogram is good choice.

Answer 157

-FTT -CHanging story, or different than given by child. -Multyiple areas, of bruises etc. Munchausen by proxy. -Skeletal survery of long bones, cbc, anticoag labs. G/C of throat, vagina, rectum. -FTT should be admitted. Rapid antigen assays are NOT Considered reliabel forensci evidence in kids.

Answer 158

-needle d. 14g 2nd icl on mcl. Small pneumo may be treated with observation without a chest tube. 24French tube should be inserted. IF blood is there then do a 32 French

Answer 159

-Between left subclavian artery and ligamentum arteriosum. -Check bp’s, bruits, murmurs. -penetrating or rapid deceleration injury. CT angiogram with IV contrast. Echo is good at bedside. If lose VS prior to arrival then consider ED thoracotomy. On descending,

Answer 160

-CArdiac box, Hotn, distended neck veins, and muffled heart tones. Pericardiocentesis prior to definitve operative management.

Answer 161

-Become pulsless in ED are candidtates to be ED thor Abd tenderness or distention on palpation, coupled with hotn, indicates the emergent need for exploratory laparotomy in a pt who has sustained a penetrating abd injury. Place tubes as long as you don’t delay surg.

Answer 162

-MVC -Compression or crushing mechanism by direct energy transmission. -Falls from height hurt hollow visceral injuries more commonly. -Spleen is MC- kehr’s sign. -Serial exams -Hollow injuries=peritonitis may take time to develop Retroperitoneal=duodenal inuries are most often associateed with high speed vertical or horizontal decelerating trauma. Diaphragmatic injure-bowel sounds in thorax Plain films and FAST-easy, safe, improve resource you. Can’t tell where the bleeding or injury is. Administer 100%O2, cardiac monitoring, 2 large bore IV lines. Hotn? Give em fluid or maybe blood. If evisceratied- moist sterile dressing prior to surg STABLE AND POS FAST->CT UNSTABLE AND POS FAST->SURG

Answer 163

-Objects deeply impaled in the chest and abd sohuld be left in place and transport pt to surgery.

Answer 164

``` -high morbidity and mortality. MVC or fall from hieght -Avoid excessive movement. -PE is sensitive for pelvic fx -Unstable?-pelvic radiograph can identify the fx. -CT for stable -FAST for unstable. Angiograph, embolization and external fixation. Probably getting rotho consult ```

Answer 165

-classically shortened and externally rotated. -Plain films are good. -Significant pain with weightbearing should raise suspicion MRI is very sensitive at occult fxs Hip dislocations- most are posterior -Reduce hip within 6hrs to decrease incidence of avascular necrosis. A

Answer 166

-Elevated pressure in foot. LEg are forearm are most common compartment syndrome -30-50mmhg are detrimental to nerve and muscle. -diastolic minus intracompartmental pressure is delta. -PAIN OUT OF PROPORTION TO EXAM and pain with passive stretch are hallmarks of the syndrome. -Swollen, firm, tender compartment. DELTA PRESSURE 30 or less is compartment ment. Normal pressure should be like 10 or under in the compartment. IF your within 30 of diastolic then the compartment pressure is very high. - Surgical fasciotomy - O2, elevate limb to level of the heart.

Answer 167

-Humerus fx- axillary and radial nerve are most common injured nerves in proximal humerus and humeral shaft fxs. Proximal is axillary***** Shaft is radial

Answer 168

-take off clothes and wast the patient.

Answer 169

-may require tetracainse instillation and lid retractors to facilitate copious irrigation with crystalloid solution, Get ph to 7.4 and then check again.

Answer 170

-can do orogastric lavage if within first hour of ingestion of life threatening amounnt of poison. Single dose activated charcoal-absorbs everything. Doesn’t work against metals, corrosives, etohs. Use against anticholingerivs or salicylates. Whole bowel irrigation- kinda stupid

Answer 171

-salisylate toxicity not meeting criteria for hemodialysis

Answer 172

Cholinergic Toxicity • Insecticides, drugs, sarin • SLUDGE: Salivation/Sweating, Lacrimation, Urination, Defecation, Gastrointestinal distress, Emesis • Killer B's: Bradycardia, Bronchorrhea, Bronchospasm • Rx: atropine • Organophosphate rx: pralidoxime -cholinergic toxicity secondary to organophosphate poisoning. Management of organophosphate poisoning should begin with decontamination. Anyone coming into contact with the patient should wear a gown and gloves to prevent transmission of the toxin. Clothing should be removed and discarded in a well-ventilated area and the patient should be thoroughly washed including ocular irrigation. The patient should then be resuscitated in a similar manner to any other ED patient. These patients often require early intubation and aggressive IV fluid resuscitation. There are two keys to definitive treatment in patients with organophosphate poisoning. The first is to temporize the life-threatening signs and symptoms of cholinergic toxicity. Atropine is a competitive inhibitor of acetylcholine at muscarinic receptors. The goal of treatment with atropine is to titrate to the drying of bronchial secretions. Pralidoxime (2-PAM) is the definitive antidote to organophosphate poisoning. 2-PAM forms a complex with the bound acetylcholinesterase enzyme to cause the release of the organophosphate from the enzyme. This results in regeneration of its ability to metabolize acetylcholine. Organophosphates bind tightly to acetylcholinesterase preventing the breakdown of acetylcholine. Signs and symptoms of organophosphate poisoning relate to excess acetylcholine at the nicotinic and muscarinic receptors. This produces the cholinergic toxidrome due to high postsynaptic parasympathetic activity, resulting in the classic SLUDGE mnemonic: Salivation, Lacrimation, Urination, Diarrhea, GI cramps and Emesis. Patients will also demonstrate diaphoresis, pupillary miosis, bradycardia, muscular fasciculations, paralysis, agitation, seizures, or even coma.

Answer 173

-anticholinergic toxidrome such as delirium, mydriasis, dry mucous membranes, tachycardia, hyperthermia, mild hypertension, urinary retention, and slow GI motility.

Answer 174

-Cocaine and meth Psychomotor agitation, MYDRIASIS (Dilated), diaphoresis, tachycardia, htn, hyperthermia. Seizures, rhabdomylosis, MI, death may result from seizures, cardiac arrest, hyperthermia. Cooling, sedation with benzo, hydration.

Answer 175

-SSRIs, meperidine, AMS, increased muscular tone, hyperreflexia, hyperthermia. Intermittent whole body tremor, death may result from hyperthermia. Cooling, sedation with benzos, supportive management, therorectical benefit of cyproheptadine.

Answer 176

APAP-Acetaminophen Toxicity • Patient will be complaining of abdominal pain, nausea, vomiting, and diaphoresis • PE will show RUQ tenderness • Labs will show elevated AST and ALT • Treatment is N-acetylcysteine (restores glutathione) • Comments: Rumack-Matthew nomogram - stratifies the risk of liver failure ◦ Above Rumack-Matthew nomogram line: treat ◦ Below Rumack-Matthew nomogram line: no treatment necessary ASA SALICYLATES-Salicylate Toxicity • Aspirin, wintergreen, Pepto-Bismol • Respiratory alkalosis + anion gap metabolic acidosis • Hypoglycemia • Tinnitus • Rx: activated charcoal (if < 1 hour from ingestion), urine alkalinization, K+ • Hemodialysis indications: ◦ Level > 100 mg/dL ◦ Coma ◦ Rising levels despite alkalinization ◦ Renal failure ◦ Pulmonary edema ◦ Altered mental status ◦ Clinical deterioration NSAIDS- GI bleeding and renal insufficiency. Activated charcoal for GI decontamination. OPIOIDS- Depression, miosis, respiratory depression, hypothermia, bradycardia, ventilation or nalaxone.

Answer 177

- Periodic breathing is normal in neonates. - Apnea is the cessation of respiration for 20 seconds. Apnea significes critical illness or injury. Apnea may be the first sign of bronchiolitis with RSV in neonates.

Answer 178

``` -LRTI RSV is MC. -PEak -dyspnea, coryza, cough, wheezing, hypoxema, accessory muscles, nasal flaring. 7-14 duration of illness. Clinical diagnosis. Suction of nasal passages O2 sats maintained above 92%. Nebulized hot salts may decrease mucus production. Epi may beokay. Cpap or bipap may improve. Severity increases over first 3-5days of illness. ```

Answer 179

``` -Croup Parainfluenza rsv, Clinical diagnosis. Steeple sign Decadron Nebulized racemic epi for respiratory distress. ```

Answer 180

- Influenza A and B are mc causes of pneumonia. - After aspiration of infectious viruses or bacterira. - Fever, cough, pleuritic chest pain, tachypnea, abnormal lung exam. Supplemental O2 Consider ppV for severe respiratory distress and ET for respiratory failure. Treat bronchospasms with B-agonists Treat bacterial pneumonia with empiric abx- azithro and maybe ceftriaxone or doxy

Answer 181

-sudden onset of respiratory distress in an unobserved setting is suggestive of a foreign body aspiration. The child’s inspiratory stridor is indicative of an upper airway obstruction, and he most likely has a laryngotracheal foreign body aspiration. Aspiration into the bronchi, and especially the right mainstem bronchus, is significantly more common than laryngotracheal aspiration. However, objects with sharp or irregular edges are more likely to become lodged in the upper airway. Children with laryngotracheal foreign body aspiration require immediate medical attention for airway stabilization and removal of the foreign body. Notably, if a child is able to cough, the airway obstruction is partial. A blind finger sweep of the mouth is not recommended, as this may lead to dislodgment of the foreign body and subsequent complete airway obstruction. Radiographic evaluation of the neck is recommended, but only approximately ten percent of foreign bodies are radio-opaque. Instead the radiograph may show subglottic swelling. However, radiographs are insufficient to rule out a foreign body. If the diagnosis is suspected, it should be further evaluated by bronchoscopy.

Answer 182

-projectile non-bilious vomiting that occurs after feeds, and may present anytime from 2-12wks of life. Palpation of an olive in the left upper abdomen, confirmed by US. Lab eval shows a hypokalemic, hypochloremic metabolic alkalosis

Answer 183

-Can occur at any age, vast majority of patients present in first year of life. Volvulus occurs when a malroatated gut twists, compromising perfusion and leading to bowel ischemia and necrosis. Key features may include sudden abd pain and distention, bilious emesis, irritability, and eventually peritonitits and shock. If the diagnosis is in question and the patient is stable, plain films and upper GI serires may aid in diagnosis but surgical consul should never be delayed

Answer 184

-Bilious vomiting int he first year of life should always be considered a symptom of obstruction and a true surgical emergency

Answer 185

- MC cause of blood in stool in infants under 6mos is cows milk intolerance and anal fissures. - Oral rehydrfation sohuld be attempted if patient is less than 5% dehydrated. Necrotizing entercolitis may present with bloody diarrhea.

Answer 186

-Constipation-Failure to poop in first 2 days is bad. Jaundice-First day is pathologic. 2-3 day of life is usually physiologic. After 3rd day is usually pathologic.

Answer 187

- Most common serious bacterial infection in children following the introduction of successful - neonates may just be irritable. - Pyruia alone does not confirm a UTI. - Neonates get hospitalized. - GIve kids cephalosporin

Answer 188

-MC bacteremia andmeningitis are e colie, GBS, listeria in under 3mo. Over 3mo is strep pneumo. -Under 3mos of age threshold is 100.4, is over 3mos its 102.2 Under 1mo gets FULL SEPSIS WORKUP, admission and empiric abx treatment. 1-3mos should be considered for discharge if workup is negative. 3mo-36mos UA, cxr may be only two tsts required for workup- should receive full spetic workup who appear ill.

Answer 189

-vague, lethargy, poor feeding, vomiting, irritability, or hypotonia. Fever is common, but they can be hypothermic. Tachycardia and tachypnea. -Sepsis can rapidly progress to shock. -Diagnosis based on clinical findings and positive bc. -all infants appearing toxic are septic. -serum glucose should be performed on any criticall ill child with ams. -O2, cardiac monitoring, secure IV or IO access. ETtube. Treat shock with 20ml/kg bolus of NS. Initiate Abx as soon as IV access. Give dopamin or norepi for volume refractory shock.

Answer 190

- Complication of primary bacteremia. GBS for neonates. - Irritable, hypotonia, lethargy. HA, photophobia, n/v, neck pain, stiffness. - LP and analysis of CSF. - CT should be performed BEFORE LP in thepresence of focal neuro signs or increased ICP. - ABCs, restoration of oxygenation and perfusion.

Answer 191

-Unexpected death of infant under 1yr of age. | REsuscitate per PALS guidelines.

Answer 192

-An episode that is frightening to the observer and involves any combo of apnea, color change, muscle tone change, chocking, or gagging. ALTE is a symptom for which the empa must look for an underlying diagnosis. Many represent normal or expected infant phenomonema. Careful hx and PE. Admit if under 2mos