Emergency Med Rotation Flashcards
Morphine dosing for Peds
6 mo- 12 yo
0.1- 0.2 mg/kg/dose
every 2-4hr
Morphine dosing for Adults
SC/IM/IV
2-10 mg every 4 hours
Epi dosing for O-shit heart rhythms (MI)
Asystole
PEA
V-tachy
V-fib
1 mg IV/IO
q3-5 min
Epi dosing for Bradycardia
when Atropine doesn’t work
2-5 micrograms (mcg) / min
every minute
Epi strength for cardiac stuff
1: 10,000 solution
Epi strength for Anaphylaxis (allergic rxn) and Asthma exacerbation
1: 1000 solution
Epi dosing for Allergic rxn/ Anaphylaxis
- 15 mg every 5-15 min if you are <66 lbs
0. 30 mg every 5-15 min if you are >66 lbs
Epi dosing for Asthma exac
0.30- 0.50 mg every 20 min x 3 doses prn
Which dose is higher for Epinephrine, Asthma exac or Anaphylactic rxn?
Asthma exac
Asthma: 0.30- 0.50 mg
Anaphylactic: 0.15 or 0.30 depending how much you weigh
HOWEVER, dose more frequently (every 5 min) for anaphylaxis. Dosing for Asthma is q20 min
Peds Morphine dosing
0.1-0.2 mg/kg/dose
max 15 mg/dose
Bupivacaine max per DOSE
175 mg/dose
Lidocaine max per DOSE
300 mg/dose
Bupivacaine max mg/kg/dose
2 mg/kg/dose is MAX for Bupivacaine
ABCDD risk of Stroke after TIA
Age >60 yo
BP >140/90
Clinical sx (unilateral wkness: 2pts, facial asymm: 1 pt)
Duration sx (more than 1 hr: 2pts, between 10 min and 1 hr: 1 pt)
Diabetes hx
6-7 High risk: Consult neuro, consider MRI + Carotid US, probably admit pt
NIHSS
How bad was the stroke?
Perform after STAT Head CT b4 and after tPA if pt is getting tPA
LOC- casually assess, then Qs (month and age), commands
Best gaze- move 1 finger have pt follow
Visual field- cover one of pts eyes
Facial palsy- test CN 7, smile, eyes, puff cheeks
Arm motor- 10 seconds at 90 deg
Leg motor- 5 seconds at 30 deg
Ataxia- finger to nose, heel to shin
Sensory- pin prick face, trunk, arms, legs
Language- picture and words to read
Dysarthria- repeat words back to me
Exctinction/ Inattention- compare visual reception and sensory on bilateral sides
NEXUS spinal cord trauma (5 things)
if all 5 are negative, no need for Head CT
Midline spiny tenderness Focal neuro def AMS Intoxication Distracting injury
PERC r/o criteria
only use for Low risk pts
“AOU, HHH, PR”
Age >50 O2 sat <95% Unilat leg swelling Hemoptysis HR >100 bpm Hormone use Prior DVT/PE Recent trauma/injury within 1 mo
If pt is Low risk but doesn’t pass the PERC r/o criteria,
Order D-dimer
if negative, can prob go home
if positive, consider CT angio or V/Q
Revised Geneva Score for PE
5 pts: HR >95 bpm
4 pts: pain on palpation and unilat edema
3 pts: previous DVT/PE, unilat pain, HR >75
2 pts: Active CA, hemoptysis, surgery/fx in past mo
1 pt: age >65
Revised Geneva for PE
Score of 0-3: Low risk
<10% risk of PE
Revised Geneva for PE
Score of 4-10: Moderate risk
Depends on D-dimer
(-) D dimer, no further workup
(+) D dimer, consider CT and Ultrasound
Revised Geneva for PE
Score of 11+: High risk
CT and US automatically
if those don’t tell you anything, consider Angiography
Wells criteria for PE
3 pts: Clinical sx of DVT, Other dx is less likely
1.5 pts: previous DVT/PE, recent surgery or immobilization, HR >100 bpm
1 pt: CA, Hemoptysis
if >4, PE is likely and you should get a CTA
Wells Criteria for PE
if score is 0-4 “PE unlikely”
Get D-dimer
Wells Criteria for DVT
All pts are worth 1, besides the one that is -2
Active CA Bedridden >3d or surg past 12 wks Calf sw >3cm more than other Collateral superficial vein present Entire leg swollen Localized TTP along deep vein system Pitting edema on symptomatic leg Paralysis, Paresis, or recent cast Previous DVT
-2: other dx is as likely or more likely
Wells for DVT
score is 0-2
still get D dimer
Wells for DVT
score is >3
get US
skip the D-dimer step
HEART score
when does someone need to be admitted to hospital?
score of 4 or greater
HEART score
0-2 points for each category, max of 10 pts
History EKG Age Risk factors Trop (initial)
Risk factors for MI
HTN, HLP, DM Obesity, Smoking Family hx Atherosclerotic dz (previous MI, CABG, CVA, TIA) PAD
Based on HEART score, when can someone go home?
0-3: can be d/c home
Score of 4-6 and 7-10 mean what for HEART score?
4-6: Admit
7-10: Admit and pt is Candidate for early invasive measures
TIMI heart score, when can someone be d/c?
NEVER really
This risk stratification only tells us how much at risk pt is, but cannot r/o enough to send someone home
Low risk 0-1
High risk >4 points: pt likely needs aggressive mgmt and early invasive measures
SIRS criteria
“T, HR, RR, W”
Temp
HR
RR
WBC
SIRS
Temp >100.4 or <96.8
HR >90 bpm
RR> 20 or CO2 >32 mmhg
WBC >12k or <4k
What should you do next if pt has 2 or more + elements of SIRS?
Obtain a Lactate level
If infection is found and 2 or more of SIRS, what is this now called?
SEPSIS
If infection is found, 2 or more, AND Lactate is 4 or greater mmol/L, what is this considered?
Severe Sepsis
Tx: Broad Spectrum Abx, IVF, Vasopressors
If infection is found, 2 or more, AND pt is Hemodynamically Unstable… what is this?
Septic Shock
PECARN for <2 YO
if all of these are present, don’t need to get head imaging
Normal mental status and behavior No head bruise (other than frontal) LOC <5 seconds Nonsevere mechanism No palpable skull fx
PECARN for >2 YO
If all of these are present, don’t need to get Head imaging
Normal mental status No LOC No Vomiting No Severe HA Nonsevere mechanism No signs of basilar fx
High risk features of Head Injury for >16 yo
if any Yes, get Head CT
Vomiting Severe HA Focal neuro def Signs Basilar fx On Blood thinner Inherited blood disorder or Liver dz Thrombocytopenia Dangerous MOI- ejected from car, fall>3 ft, or fall >5 stairs
If no High risk features in >16 YO head injury, what do you ask next?
Was there LOC or Post injury memory loss?
If Yes to LOC or post injury memory los….
Are any of these?
Pt >60 YO Intoxicated Short term mem loss Visible trauma above clavicles Post trauma seizure
If yes, get CT
GCS scale
4, 5, 6
Eyes
Talking
Motor
GCS for Eyes
4: spontaneous
3: open to verbal command
2: open to pain
1: nuttin
GCS for Speech
5: oriented
4: confused speech
3: not appropriate
2: slurred, cant understand
1: nuttin
GSC for Motor
6: obeys commands
5: localizes pain, moves it away
4: generalizes pain
3: flexes to pain
2: extensor rxn to pain
1: nuttin
CURB 65 for PNA
Confusion Urea >7 mmol/L RR >30 Blood pressure <90, <60 65 years or older
THRESHOLD score: 3 or greater, admit
CURB 65 score interpretation
1: outpatient
2: Short inpatient stay, then supervised outpatient
3 or greater: Admitted for a few, possibly ICU
HiNTs is used to differentiate b/w what two things?
Vestibular Neuritis (peripheral) or CVA stroke (central)
What is used to confirm the suspicion of BPPV?
Dix Hallpike Maneuver
pt will likely have vertical nystagmus with rotary component
4 Components of HiNTS+ exam
Nystagmus
Skew
Head impulse test
Hearing loss
Seconds of vertigo brought on by movement
BPPV
Tx of BPPV
Epley Maneuver
Many hours/days of continuous vertigo that is WORSENED by movement
Vestibular Neuritis vs Stroke
Perform HiNTS+ exam
Results that are CENTRAL for the HiNTS+ exam
Bidirectional nystagmus
Vertical skew (when one eye is covered)
Normal response to Head impulse
Hearing loss
Results that are PERIPHERAL for HiNTS+ exam
Note: all must be peripheral to overall have a Peripheral result and be able to d/c someone home with dx of “Vestibular Neuritis” without imaging for stroke
Unidirectional Nystagmus
No skew with eye covering
Abnormal head impulse test (eyes jump)
No new hearing loss
Max dosing of Lidocaine with Epi
1% Lidocaine
50 mL or 500 mg
Max dosing of Lidocaine only
30 mL or 300 mg
Max dosing of Bupivacaine with Epi
0.5% Bupivacaine
45 mL or 225 mg
Max dosing of Bupivacaine only
35 mL or 175 mg
Moral of story, if you use EPI,
you can use a larger amount of substance
Tylenol dosing, do not exceed
4g per day
4000 mg in one day
SA node intrinsic rate
60-100 bpm
our physiologic normal
AV node intrinsic rate
40-60 bpm
Purkinje fibers rate
20-40 bpm
Limb Leads
“Standard”
I, II, III
augmented leads
“a___”
avR
avL
avF
unipolar
Precordial aka Chest leads
V1-V6
also unipolar
Normal PRI
0.12-0.20 seconds
Normal QRS duration
0.06-0.12 seconds
60-120 ms
Normals in milliseconds (ms)
PRI: 120-200
QRS: 60-120
Anterior leads
V1-V4
Left Anterior Descending, LAD artery
Lateral leads
I, avL, V5-6
Inferior leads
II, III, avF
Right Coronary Artery
Large Box Estimate of HR
300, 150, 100, 75, 60, 50
Tall p wave
> 2.5 mm
RAE- Right Atrial Enlargement
“P pulmonale”
Wide p wave
> 100 ms
LAE
“P mitrale”
Where else can pacemaker signals come from? (normal: SA node)
Atria AV jx Bundle branches Purkinje fibers Ventricular myocardium
1 small square =
0.04 seconds
40 milliseconds
1 large box=
0.20 seconds
200 milliseconds
Atrial tachycardia
150-250 bpm
Atrial flutter
“Saw tooth P waves”
often well tolerated
enlarged atrial tissue, elevated atrial pressures
i.e. post cardiac surgery, valve dz, pericarditis, CHF, acute infarction, COPD, etc
A-Fib
irregularly irregular
Atrial rate is >350 bpm
Ventricular rate may be slow, normal, or fast
Risk of A-fib
Atria are not contracting properly so they may develop clot as blood is stagnant in the atria
pre-D to stroke
Junctional rhythms
P-wave usually INVERTED
QRS is normal
Junctional Escape Rhythm
40-60 bpm
Accelerated Junctional Rhythm
60-100 bpm
Junctional Tachycardia
100-180 bpm
Ventricular rhyrhms
P waves ABSENT
QRS are Wide and Bizarre
Idioventricular rhythm
20-40 bpm
Accelerated Idioventricular rhythm
40-100 bpm
Ventricular tachy
100-250 bpm
Torsades de Pointes is a unique subcategory of
Polymorphic V-tachy
Tx of Torsades
Magnesium Sulfate
2nd Degree
Mobitz type 1 AV block
“Wenckebach”
PRI progressively increase until a QRS is dropped
2nd deg type II
PRI is prolonged and constant
3rd deg AV block
P waves “march right through” QRS
No association b/w the P waves and QRS complexes
rhythms are regular but not at all related to each other
Where to look to find “Mean Axis”
Lead I and AVF
Normal Axis
Mean QRS deflection is positive in both Leads: I and avF
RAD
Mean QRS is negative in Lead I, positive in avF
LAD
Mean QRS is positive in Lead I, negative in avF
What does LAD mean?
LVH- Left ventricular hypertrophy* (most common)
Chronic CAD
Diffuse myocardial dz- cardiomyophaty, myocarditis
What does RAD mean?
Can be NORMAL in children and tall, thin adults
What lead do we look at for p waves?
Lead II and V1
RAE: taller than 2.5 mm
LAE: wider than 0.10 (2.5 blocks)
RAE criteria
P wave >2.5 mm tall
OR
Initial component (first part of wave) is larger in V1
RAE is present in
Pulmonic stenosis
Tricuspid stenosis and regurgitation
LAE
look at Lead II and V1
P wave >0.10 s
Terminal (last portion) of wave in V1 is bigger, going to be the part that DIPS DOWN
LAE present in
MITRAL
stenosis and regurg
LVH is present in
HTN
Valve heart dz
LVH criteria
Deep in V1-2
TALL TALL in V5-6
R in avL is very deep, >11 mm
HTN
Valvular heart dz
LVH- Left ventricular hypertrophy
RVH often coencides with
RAD
RBBB seen with
CAD and PE
Coronary artery dz and Pulmonary embolism
What leads do I look at to assess for BBB?
Lead V1
Lead I and V6
RBBB
M shaped in V1
Wide S wave (down part) in Lead I and V6
LBBB
wide R wave (up part) in Lead I and V6
Where to look for BBB
Lead I and V6
wide up part (LBBB)
wide down part (RBBB)
Wellens Syndrome
EKG changes
Deeply inverted or biphasic T waves in V2-V3
Highly specific for: Stenosis of LAD artery
Wellens syndrome
(LAD coronary artery) can leadd to
Anterior or Antero-lateral MI
Wolf Parkinson White syndrome
An extra electrical pathway in the heart causes a rapid heartbeat
Sx of Wolf Parkinson White
congenital (present at birth) but sx often develop later in life, age 11-50
Lightheaded, Dizzy
Tx of WPW
Meds
Ablation
Rarely: shock
Characteristic of Wolf Parkinson White
“Delta wave”
the upsloping before the QRS
What is setting off the electrical impulse with Wolf Parkinson White?
The Bundle of Kent is overriding the AV node
Be thinking about this is a Diabetic comes in with abnormal EKG
Hyperkalemia and Acid-base disturbance
Mean axis
Lead I and avF
Inverted T waves in V2-V3
Wellens syndrome
critical lesion in LAD (coronary artery)
