Emergency Medicine Flashcards
Define hypothermia?
- A reduction of core body temperature below 35°C (normal 37°C).
- Core temperature is measured with a rectal probe or through the esophagus
- Severe hypothermia is a core
temperature below 30°C.
Describe the clinical presentation for Hypothermia?
- Lethargy, confusion and weakness.
- Death usually occurs from arrhythmia because the cold alters cardiac conduction.
- Patients may have metabolic acidosis, respiratory acidosis, kidney injury and hyperkalemia.
How do you diagnose hypothermia?
- EKG shows an arrhythmia, either ventricular fibrillation or ventricular tachycardia.
- Elevation of the J point, known as Osborne waves.
- J wave elevation looks like ST-segment elevation
How do you treat hypothermia?
- Warm bed, bath or heated blankets.
- Warmed IV fluids or warmed humidified oxygen in severe cases.
- Caution because rapid heating may also cause arrhythmias.
- If arrhythmia presents, continue resuscitative measures until body temperature is >35°C (95 F)
Name three exertional heat disorders.
- Heat cramps
- Heat exhaustion
- Lethal heat stroke
Name two nonexertional heat disorders.
- Malignant hyperthermia
- Neuroleptic malignant syndrome
What are heat cramps and how are they treated?
- Occurs with fluid and electrolyte depletion
- Develop painful muscle contractions with muscle tenderness
- Patient is able to sweat normally with no neurological abnormalities.
- Treat with rest, oral rehydration and salt replacement.
What is heat exhaustion and how do you treat it?
- More severe exertional disorder .
- Patient is weaker, has systemic symptoms, body temperature is slightly elevated,.
- Neurologic symptoms include headache, nausea and anxiety.
- Death is unlikely but can progress to heat stroke if not treated.
- Patient can still sweat and remove heat from the body.
- Treatment is oral fluid rehydration and electrolyte replacement, may require IV.
What is a heat stroke and how do you treat it?
- Severe and potentially life threatening.
- Patients have lost ability to sweat and remove heat from the body.
- Body temperature may be elevated (>41°C or 105 F) resulting in confusion, disorientation, nausea, blurred vision and seizures.
- Labs may show hemoconcentration, rhabdomyolysis, elevated BUN, creatinine and white cell count.
- Anuria, DIC and lactic acidosis may develop.
- Treat with IV fluid replacement and rapid cooling off of the body such as placing in a cool environment and spraying with water and fanning to evaporate the fluid.
What is malignant hyperthermia?
Occurs as an idiotsyncratic reaction to the use of anesthetic agents such as halothane or succinylcholine (paralytic)
- May be caused by any anesthetic.
- Rhabdomyolysis may develop
How do you treat malignant hyperthermia?
Dantrolene
- Depresses excitation-contraction coupling in skeletal muscle by binding to the ryanodine receptor 1 and decreases intracellular calcium concentration.
What is neuroleptic malignant syndrome?
- Idiosyncratic reaction to a wide variety of phenothiazines or butyrophenones such as haloperidol.
- Muscular rigidity and rhabdomyolysis may occur.
- Treat with bromocriptine, stimulates dopamine receptors, specifically in the nigrostriatal pathway.
What is asystole?
- Complete absence of electrical activity in the heart
- Does not necessarily mean a flat line
- Usually due to ischemia
- Presents as unresponsive person with no pulse
- Treatment
1. CPR, obtain IV access and prepare for intubation
2. 1 mg epinephrine via IV push every 3-5 minutes
3 Reevaluate for atypical clinical features
Most common causes of asystole and other arrhythmias
Hypoxia Hypo/Hyperkalemia Hypothermia Hypoglycemia Hypovolemia Trauma Toxins (Includes overdose) Tamponade Tension Pneumothorax Thrombosis (coronary and pulmonary)
When is bicarbonate helpful in asystole?
When due to: Pre-existing acidosis: Tricyclic antidepressant (amitriptyline) Aspirin Hyperkalemia Diabetic Ketoacidosis
What is the recommended treatment for a patient that presents to the ED within 12 hours of an MI?
- Percutaneous coronary intervention (PCI)
- Preferred choice
- Lower rates of intracerebral hemorrhage and recurrent MI - Fibrinolysis
- Only if PCI not available
- Use tenecteplase or alteplase
- Contraindicated if GI bleeding or recent surgery
- It binds fibrin in the thrombus and converts entrapped plasminogen to plasmin
- Plasmin causes clot lysis and restores coronary flow
- Hemorrhage is most adverse therapy
Clinical signs that a patient has an intracranial hemorrhage?
- Decreased level of consciousness
- Asymmetric pupils
- Irregular breathing
Clinical signs of intraventricular septum perforation
- Presents with chest pain, dyspnea, cardiogenic shock and a harsh holosystolic murmur on the left sternal border
- Results in a left to right shunt and symptoms of acute heart failure
Clinical presentation of pulmonary embolism?
- Acute onset of dyspnea, pleuritic chest pain and possible hemoptysis
- Tachycardia, hypotension, cyanosis and loss of consciousness can occur if severe.
What is the mechanism of action of etoposide and podophyllin?
- Inhibit Topoisomerase II’s ability to seal the strand breaks it induces, cause chromosomal breaks to accumulate and eventual cell death.
- Used for testicular cancer and small cell lung cancer.
- Podophyllin is used for genital warts
ER migraine cockdtail?
Phenergan 50 mg Benadryl 50 mg Ativan 2 mg Caffeine 200 mg Normal Saline .9% 1000 ml
Scorpion Sting treatment and labs
Lipase UA without micro CMP CBC Give: - Normal Saline - Zofran 4-8 mg IVP - Ativan 1-2 mg IVP - Dilauted 1-2 mg Check for tongue fasciculations
Patient comes in with chest pain/tightness and SOB, what do you do?
- Prescribe 325 mg of aspirin
- EKG and Continous Cardiac Monitoring
- Labs
- EKG
- CBC
- CMP
- D-Dimer
- Troponin
- Creatine Kinase
What is ventricular fibrillation?
What are the causes?
How does it present?
How do you treat?
- Significant electrical activity with no signs of an organized pattern
- Due to ischemia, myocadial infarction, cardiomyopathy and severe underlying cardiac disease
- Dead person with ventricular fibrillation on EKG
- Treat with defibrillation, a single unsynchronized shock
What is ventricular tachycardia?
What is the cause?
How does it present?
- A wide complex tachycardia with an organized, uniform pattern on EKG
- No visible p waves
- Due to ischemia, MI and anotomic cardiac disease
- It originates from ectopic focus in the myocardium or from AV node due to reentry
- The slowness of the conduction produces slower and wider complexes
- Short bursts < 30 seconds may produce no symptoms.
- > 30 seconds is referred to as sustained tachycardia and may produce lightheadedness, hypotension, CHF, syncope and death
- Treat with amiodarone or lidocaine and cardioversion
What is torsade de pointes?
A form of VT where the morphology varies with an undulating amplitude , making it seem as it twists around a point
- May be associated with hypomagnesemia and preceded by long QT interval
What medications can prolong QT interval? What other causes?
TCAs Antipsychotics Erythromycin Methadone Fluoroquinolones Amiodarone Quinidine Sotolol Flecainide Procainamide Mg K Ca
What do leads I and aVL look at?
The left lateral ventrical
What do leads II, III and aVF look at?
The inferior wall of the heart
What does leads aVR look at?
- It is unipolar, determines if the electrical activity is traveling in the correct direction
- The wave should be inverted
What do leads V1 and V2 look at?
The interventricular septum
What do leads V3 and V4 look at?
The anterior left ventrical
What do leads V5 and V6 look at?
The left lateral ventricle along with leads I and aVL
What are the 6 steps when examining an EKG?
- General impression
- Calibration
- Rhythm Determination
- QRS Assesment
- Hypertrophy
- Ischemic Infarction
What is step 1 when examining an EKG?
- The general impression
- Does anything stick out?
1. Are there fast rhythms?
2. Are there slow rhythms?
3. Is anything ugly?
Jot down what you see quickly?
What is step 2 when examining an EKG?
Check if its standard, 2x or 1/2 amplitude?
- Standard calibration
- 1mV standard is 10 mm tall and .2mm wide (5mm) - 2X amplitude is 20 mm tall .2mm wide (5mm)
- 1/2 amplitude is 5mm tall and .2 mm wide
What is step 3 when examining an EKG?
Rhythm interpretation
- Rate
- Regularity
- P-wave
- PR-interval
- QRS-complex
- Interpretation
What is step 4 when examining an EKG?
QRS assesment
- R wave progression (RWP)
- Is it good RWP or poor RWP - QRS axis
- Is the axis normal, right, left or indeterminant? - Bundle branch block and fascicular block
- Is it RBBB or LBBB?
- Is it LAFB or LPFB?
What is step 5 when examining an EKG?
Is there hypertrophy?
- Atrial enlargement
- Look at the P waves - Ventricular rhypertrophy
- Look at the QRS complex
What is step 6 when examining an EKG?
Is there ischemia or infarction?
Is there ST segment elevation?
Is there ST segment depression?
Are there pathological q waves?
What is the treatment of choice when a patient ingests rodenticide that contains brodifacoum (long acting 4- hydroxycoumarin derivative) that cause coagulopathy and abnormal bleeding?
- Requires immediate treatment with fresh frozen plasma in addition to vitamin K
- Similar to warfarin toxicity
When conducting an emergency Cricothyrotomy, what structures do you have to cut through?
- The skin
- Superficial cervical fascia (including subcutaneous fat and platysma)
- Investing and pretracheal layers of the deep cervical fascia
- Cricothyroid membrane
