Emergency Med Flashcards
Acute Chest pain
Typical ischemic CP is felt as tightness,squeezing, crushing, or pressure in the retrosternal/epigastric area. Radiating to jaw or arm is associated with a higher risk of ischemia.
Less than 2 min and over 24hrs are less likelyt to be ischemic.
Pleuritic and positional are less likey.
PE-sharp pleuritic chest pain, tachy, WELLS, PERC, D dimer is good in low risk, CT is TOC
Aortic dissection-ripping or tearing pain radiating to back, unilateral pulse deficit. D-dimer and CXR can lower odds, but if suspected get a CT Aortogram or TEE.
PNA-focal, pleuritic, fever, hypoxia
Esophageal rupture-substernal after vomiting, ill appearing, crepitus in neck/chest. CT with water soluble contrast
Spontaneous pneumo-CXR,
Pericarditis-Substernal, sharp, constant, pleuritic, back, neck, shoulder, pain, fever, pericardial friction rub, ST elevations and PR depression
Chest wall-chostochondritis, reproductible by palpation,
GO-PUD, post prandial.b
CXR is go to imaging, CT might be helpful, get EKG, troponins, ck-mb and myoglobin, BNP, TIMI Score,
Acute coronary syndrome
-Unstable angina, nstemi, stemi. Troponin, CK-B, Myoglobin are good. Get the EKG. Give O2 Nitro-IV, avoid in R ventricular infarct, watch for viagra Morphine only for severe pain BB- acute MI STatin- all pts get it ASA unless absolute contraindicaitons Anticoag-LMW heparin
More than 1mm ST elevation in 2 or more contiguous leads.
Nstemi is no st elevations but elevated biomarkers.
Early reperfusion is achieved by preferreed modality, PCI, or fibro.
PCI within 90mins of ED arrival or fibrinolysis within 30mins of ED arrival(6-12hrs from symptom onset).
Immediately get IV access, O2, cardiaca monitoring, and obtaining ECG.
STEMI should receive- asa, clopidogrel, nitro, oral bb, antithrombin, and pci or fibrino. Gg2b/3a can be delayed until arrival in the catheterization laboratory.
Cardiogenic shock
- MC cause of inhospital mortality from acute MI.
- Insufficient pumping ability of the heart to support the metabolic needs of the tissue.
- Secondary to extensive MI.
- Chest pain or angina equivalent.
- Hypotension, cool, clammy, mottled skin.
- LV failure causes tachypnea, rales, and frothy sputum.
- ECG, CXR, cardiac biomarkers, BNP, TTE.
- PCI, ET if necessary, IV access, high flow o2, place patient on monitor, obtain ecg.
- DO NOT GIVE BB, can use NTG or morphin. If Right sided, robust fluid resuscitation is warranted. Norepi can be given for severe hotn, for hotn w/o hypovolemia give dobutamine.
Acute CHF/pulm edema
-Preload, afterload, and contractility determine stroke volume. Couple with heart rate, stroke volume determines cardiac output. MC cuase of right sided failure is left sided failure.
Failure activates RAAS and other systems which leads to fluid overload and clinical manifestations of CHF.
Pulm edema, severe respiratory distress, frothy sputum, moist pulm rales.
BNP is important.
Give 100% O2 and get o2 sat to 95%.
If in respiratory distress, consider CPAP.
ADMINISTER NITROglycerin if hypertensive**
Furosemide 40-80mg IV
If presistent HTN then nitroprusside.
If HOTN begin dopamine
Assess ecg
Consider thrombolytics,
Morphine can be given
Pulmonary Edema
- Only 50% of patients will survive 1 yr after the development of pulmonary edema.
- Respiratory disress, reduced O2 saturation from baseline
Read
Syncope
-Idiopathic in 40% of patients.
-Lack of blood flow or vital nutrient delivvery to the brain stem.
-Vasovagal reflex, cardiac related, and orthostatic hotn.
-Vasovagal- slow progressive prodrome of dizziness, nausea, diminished vision, pallor, diaphoresis.
Carotid sinus hypersensitivity-bradycardia, asystole, or hotn. Considered in older pts with recurrent syncope and negative cardiac evaluations.
Cardiomyopathy
-big heart. Depressed systolic funcion and pump failure with low cardiac output.
-Most are idiopathic.n
CHF symptoms, doe, orthopnea, paroxsymal nocturnal dyspnea.
-CXR, ECG, afib is common.echo confirms.
New diagnosed DCM will need to be monitored.
IV diurteics (lasix 40mg) and digoxin .5mg IV) can be given. And BB (carvedilol 3.125mg po).
Amiodarone can be given.
Anticoag shnould be considered.
Myocardititis
-Inflammation of heart muscle from systemic disorder or an infectious agent.
-coaxsackie B, echovirus, influenza.
-Corynebacterium.
-Pericarditis frequently accompanies myocarditis.
-Young, RECENT abrupt onset of symptoms during or immediately after a systemic or viral illness.
-myalgias, HA, rigors, feevr, and TACHYCARDIA OUT OF PROPORTION TO THE FEVER.
-Treat supportive for vrial or idiopathic myocardtitis.
ABX are needed for myocarditis complicating RF, etc.
Immunosuppressive therapy may be good, but unsure.
Admission is usually needed if they have CHF.
Acute Pericarditis
-Sudden or gradual onset of sharp or stabbing chest pain that radiates to the back, neck, left shoulder, or arm.
-Viral infx.
-Pain is relieved when sitting up and leaning forward.
-Transient intermittent friction rub heard best at LLSB.
-Echo is best diagnostic test.
-Motrin 400-600mg QID for 1-3wks
-
Thromboembolism
-DVT and PE.
-Stasis, hypercoag, and trauma.
-old people.
-DVT forms at venous cusps of deep veings. Occur in lower extremities,
-PE-venous clot breaks off, traverses the right ventricle, and lodges in a pulm artery. PE may cause tachy, right heart failure, or complete collapse of cardio.
DVT-calf or leg pain, redness, swelling, tenderness, and warmth.
PE- dyspnea (MC), and chest pain, may be pleuritic. 30% of DVT have subclinical PE. Tachypnea, tachycardia, hypoxemia.
WELLS score can predict for DVT.
PERC for PE probability.
DVT-
For low probability DVT- get D-Dimer.
For high DVT get US. If neg then D-Dimer again ->rule out or repeat US in 1wk.
PE-Classic is S1,Q3,T3. IF bad kidneys give em v/q or give em CTPA.
CAtheter-based pulm angiography is traditional gold standard but no one does it.
Give IVF to correct hotn, administer O2 to correct hypoxia.
Anticoag of heparin/xa for 3-6mos.
Use thrombolytic therapy for PE patients with unstable.
IVC may prevent PE when anticoag is contraindicated.
Outpt for dvt is favored over inpatient.
Hypertensice Emergencies
-Elevated BP associated with target organ dysfunciton such as aortic dissection, pulm edema, and other. 180/120. HAve end organ damage.
-Check eyes, heaert, and AMS.
-Look for hyperreflexia and peripheral edema in preggos, suggesting pre-e.
-UA is most cost effective test.
-EKG, CXR, CT of head with neuro compromise.
Aoritc dissection-First BB to 120 with HR of 60.
Acute htn pulm edema- reduce bp by no more 20%
Labetalol-200-400mg repeated 2-3hrs.
Pulmonary Htn
-Dyspnea, chest pain, syncope, fatigue.
-PHTN is pathologic from elevation of the pulm vascular pressure.
-
Aortic Dissection
- Young and old. Major RF is chronic htn.
- Intima is violated. False lumen.
- Stanford A and B.
- 85% have abrupt, severe or worst pain ever. Sharp. Chest pain. Syncope occurs in 10% of patients. HTN and tachy are common, HOTN may also be present.
- Widened mediastinum. Abnormal aortic countor, pleural effusion, apical capping, and depression of the left main stem bronchus.
- Most have abrnomal CXR.
- CT scanning w or w/o is imaging of choice.
- TEE may be sensitive or specific.
- Decrease the shear force on the intimal flap. BB first line, nitro added if bp remains elevated.
- Dissection of ascending aorta requires prompt surgical repaire.
Aortic Aneurysm
AAA-increases with age, older than 60, males, 18% have fmhx, connective tissue disease, Marfans, atherosclerotic RF. LAPLACE LAW dictates that as the aorta dilates, the force on the wall increases, LARGER THAN 5CM RISK OF RUPTURE.
Tearing or RIPPING. Unilateral flank or groin pain. Bedside US is 90+% sensitive FOR UNSTABLE PT.
CT IS DONE IN STABLE PATIENTS*****
Stabilize with volume.
Acute Respiratory Distress/Failure Hemoptysis
-Hemoptysis-TB, neoplasm, cv disease, pe,pna.
-Pulm and bronchial artieries.
-Acute fever, cough, bloody sputum is pneumonia or bronchitis.
-Pulse ox and CXR, H/H, type and cross.
-Treat the ABCs, large bore IV,
Cough suppressants, o2, ivf, ffp,prbc, Intubation as needed
PNA pneumonia
- CAP, bacteria most common.
- Alveoli gets filled with organisms, exudate, or wbc.
- Strep pneumo is most common.
- Tachycardia and tachypnea.
- Abrupt fever, rigor, rusty brown sputum is pneumococcal.
- H Flu has no signs of consolidation
- Empyemas are common with staph a, klebsiella, and anaerobic.
- Legionella is patchy
- State with azithro or doxy
- resp fluoro if failed.
- 3rd gen ceph, augmentin
- Aspiration-levaquin and clinda. Use suction inititally.
Pneumothorax spontaneous Iatrogenic
-Smoking, chronic lung disease, infections.
-Maybe ng tube, ppv,
-Rupture of sub pleural bulla allowing air to enter space between parietal and viscreal pleura.
-Tension pneumo causes decreased venous return, hotn, and hypoxia.
-Tracheal deviation, hyperresonance, hotn.
-ST changes may be seen.
CXR is 83% sensitive.
US is near 100% sensitive.
-O2 nasal canula.
-Small with no known lung disease can observe for 6hrs and outpatient surgical f/u in 24 hours. 14g needle, or chest tube 10-14F and admission.
Acute asthma exacerbations348
-Asthma is common. REduction in airway diameter caused by smooth muscle contration, vascular congestion, bronchial wall edema, and thick secretions.
Dyspnea, chest tightness, wheezing,and cough.
-tripod position grasping for air, wheezing, diaphoresis, accessory muscle use.
Pulse ox
CXR
Duoneb, decardon, mag, cpap, bipap.
Chronic obstructive pulmonary disease
-Airflow obstrucitons, airway secretions, mucosal edema, bronchospasm.
-Dyspnea, chest tightness, wheezing,and cough.
-Emphysema and bronchitis. Pink puffers vs blue boaters.
Pulse ox is good.
Duoneb, decardon, mag, cpap, bipap.
Acute abdominal pain
Visceral abd pain is caused by stretching of fibers innervating the walls.
Can point to parietal pain.
-Rebound tenderness is peritonitis (cough pain)
-Carnett sign- sit up test, showing abd wall synodrome.
-Huge ddx
-hcg,pt,ptt,ecg,cmp,h/h,lactate (mesenteric ischemia), lipase, LFTs, pltls, UA.
Elderly-sigmoid volvulus, diverticulitis, acute mesenteric ischemia, and aaa.
Unstable get resuscitated immediattely
-antiemetics, morphine, abx should be used.
Nausea and vomiting
-Hotn, tachy, lethargy, suggest significant dehydration.
-Vomiting with blood represents gastritis, pud, or carcinoma.
-can mean lots of things.
-Resuscitate normal saline 20ml/kg.
-Zofran 4-8mg IV or ODt
-Promethazine 25mg IM or PR
Prochlorperazine10mg IM
Metoclopramide 10mg
Meclizine 25mg
Acute and chronic constipation
- Less than 3bm a wk.
- Check new meds, diet, decrease in fluid, change in activity level.
- Acute onset implies obstruction until proven otherwise.
- Cold intolerance (hypothyroid)
- nephrolithiasis-hyperparathyroid
- PE should focus on detection of hernia and masses.
- CBC, thyroid, CMP. Xray maybe. CT of abd and pelvis may be necessary.
- Chronic constipation is usually a functional disorder that can be worked up on an outpatient basis.
- Fluids, fiber, excercise.
- Magnesium lactulose or sorbitol, mineral oil is good in kids.
Acute diarrhea
-3+ watery stools per day.
-Increased secretion, decreased absorption, increased osmotic load, abnormal intestinal motility. 85% are infectious in nature.
Acute is under 3wks. Chronic is 3+wks.
Lakes=giardia
Oysters=vibrio
Rice=bacillus cereus
Eggs=salmonella
Meat=campy,staph,yersinia, ecoli
Radiographs are only used for intestinal obstruction
CT or angio may be indicated to diagnose acute mesenteric ischemia.
Correct fluid and electrolyte.
BRAT DIAET
Abx only in severe or prolonged diarrhea.
NOrovirs is 50-80%
Abd pain, fever, bloody stool should undergo stool studies.
Exposure of a traveler to untreated water for more than 7days should get protozoal pathogen.
Cipro, bactrim, metro, loperamide,
Upper Gi bleed
-UGI proximal to the ligament of treitz.
-PUD is common cause of UGI
-Predisposing factors for ugi include ETOH, salicylates, NSAIDS
-Hematemesis
-Hotn and tachy suggest severe bleeding
-Careful ENT examination.
-Rectal examination is mandatory.
-NG tube placement may diagnostic and therapeutic.
-Guaiac testing of NG
ENDOSCOPE IS TOC FOR UGI.
Significant bleeding needs type and cross.
Stabilize the pt, O2 large bore IV, monitors (use blood if no improvement after 2L of crystalloids).
NG tube for significant bleeding. Endoscope.
PPI sohuld be considered for treatment of bleeding peptic ulcers.
H2 bockers are good.
Lower Gi Bleed
- 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.
Esophageal emergencies
-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.
-
Esophageal perforation
-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.
Swallowed foregin bodies
-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,
Peptic Ulcer Disease
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
• Patientwill be complaining of gnawingepigastricpain
◦ Duodenal ulcer - pain isalleviatedby ingesting food (Mnemonic:DUDegive me food)
◦ Gastric ulcer - pain isexacerbatedby ingesting food
• Diagnosis is confirmed by endoscopy
• Diagnosis ofH. pyloriinfection is made byH. pylorifecal antigen or urea breath test
• Most commonly caused byHelicobacterpyloriinfection or non-steroidal anti-inflammatory use
• Comments:Mostcommon cause of upper GI bleed
• Increases risk of perforation
Acute Pancreatitis/acute cholecystis**
-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/
Jaundice
- 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.
Acute appendicitis
-Appendicitis
• Patient will be complaining of fever, pain that began periumbilical then moved to RLQ,nausea, and anorexia
• PE will showPsoas 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 byfecalith
• 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) ****
Diverticulitis
- 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)
Bowel Obstruction
- 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.
PEri-rectal abscess
- 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.
Hemorhhoids
Non-thrombosed vs thrombosed
-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.
Acute Renal Failure
-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.
Rhabdomyolysis
-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
Acute UTI
-Cystitis
• Patient will be complaining of low-grade fever, increased urinary frequency, dysuria, andsuprapubicor abdominal pain.
• Labs will show positive leukocyte esterase and nitrites
• Definitive diagnosis is made by urine culture
• Most commonly caused byEscherichia coli
• Treatmentis:
◦ 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 - onlywhen needed)
• Complications: ↑ Risk of pretermbirth, low birth weight,perinatal mortality
Gold standard is UC.
Complicated should be 10-14days.
Hematuria
-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.
Acid-Base Disorder
-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.
Acute Urinary Retentio
-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.
Urologic Stone disease
-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
Testicular Torsion
-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
Acute Epididymitis
-Gradual onset of pain.
-Bacterial infx.
-Swelling.
Phren sign makes it feel better.
Admission for IV abx.
Treat them for G/C.
Ectopic Pregnancy
-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.
Emergencies in pregnancy
First 20 wks
-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.
Emergencies in pregnancy after 20 wks
-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
Postpartum period
-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.
-
Emergency delivery
- 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.
Pevlic Inflammatory Disease
-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
Toxic Shock syndrome
-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.
Septic Shock
-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.
Meningitis
-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.
Soft tissue infections
-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.
Inefective endocarditis
-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
HA and facial pain
-Either primary or secondary causes.
Acute Migraine
-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
Giant Cell Arteritis***
-Most commonly presetns with HA. Often unilateral severe and throbbing. Associated syptoms may include jaw claudication, 50yo female Esr over 50 High dose steroids
Horner Syndrome
-Ipsilateral ptosis, miosis, and anhydrosis is present.
CXR, CR scan of brain and neck, Specific treatment is determined by the cause.
Papilledema
-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.
Idiopathic Intracranial HTN
-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.
SPontaneous subarachnoid hemorrhage
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.
Intracerebral hemorrhage
-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
Stroke
-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
TIA
Lasts 1-2 hrs.
Transient Ischemic Attack
• Transient episode of neurological dysfunction without acute infarction
• 10% of TIA patients will have a strokewithin 90 days
• Aspirin +dipyridamoleorclopidogrelmonotherapy
• ABCD2score: predicts likelihood of subsequent strokewithin 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.
Cervical Artery Dissection
- 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.
Altered Mental Status/ Coma pg 1189
-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.
Vertigo and dizziness
- 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.
Ataxia and Gait disturbances
- 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.
Seizures pg 1210
-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
Status Epilecticus
-Status epi is continuous seizure activity for mroe than 5 mins.
-IV phenobarbital, Valproic acid
Or propofol
Oor ketamine.
Frostbite
-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.
Trenchfoot****
- Pale, mottled, anesthetics, pulseless foot. Long term hyperhidrosis and cold insensitivity are commong. Anesthesia may be prolonged or permanent
- Rewarming, drying elevation.
Chillblains
- painful inflamed skin lesions cuased by chronic, intermittent exposure to damp, nonfreezing ambient tempertures.
- Rewarming, elevation, bandanging of affected tissues. NIFEDIPINE 20mg PO TID,
Hypothermia
-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.
Heat emergencies
-CRamps, exhaustion, stroke
-Heat Stroke • Loss of thermoregulatory mechanisms • Dry skin • AMS • Abnormal LFTs • Rapid cooling to 39º: evaporative or cold water immersion • Avoid antipyretics
Arthropod Bites and stings
-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.
Crotalid*****
-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*******
Elapidae
- 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.
Dog Bites
-Pasteurella, strep,staph, capno
Give em augmentin
Cat Bites
-pasturella, bartonella
Give em augmentin or azithro
Rabies
-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 animalinfected 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.
Drowning
-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.
DKA
-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
Alcohol Ketoacidosis
-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
HHS
-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.
