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PGY1 > Emergency Medicine > Flashcards

Emergency Medicine Flashcards

1
Q

POCUS finding on Tension PTX

A

no comet tails, no lung sliding

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2
Q

Big 5 causes of Chest Pain

A

MI, PE, TPX, Aortic dissection, esophageal rupture

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3
Q

CXR findings for aortic dissection

A

widened mediastinum, left pleural effusion, indistinct aortic knob, separation of >4mm of intminal calcification, depressed mainstem bronchi

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4
Q

Pathogenesis of Stable Angina

A

fixed stenosis of atheroma resulting in mismatch between oxygen supply and demand

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5
Q

Pathogenesis of ACS

A

plaque rupture

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6
Q

3 Characteristics of Typical Chest Pain

A

retrosternal CP/tightness/discomfort radiating to shoulder/arm/neck/jaw, associated with diaphoresis, nausea, anxiety, precipitated by 3Es - exertion, emotion, eating, brief duration lasting < 15 mins, typically relieved by rest and nitreates

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7
Q

MGMT of Chronic Stable Angina

A
  1. General - lifestyle, RF reduction
  2. antiplatelet - ASA, clopidogrel if contraindicated
  3. beta-blocker (metoprolol, atenolol)
  4. Nitrates for symptoms
  5. Revascularization
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8
Q

What is Variant Angina/Prinzmetal angina

A

myocardial ischemia secondary to coronary artery vasospasm, can be associated with infarction or LV dysfunction. Sx occur between midnight and 8 AM, unrelated to exercise, relieved by nitrates; ECG shows ST elevations; MGMT: nitrates and CCBs

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9
Q

DDx for troponitis

A

MI, CHF, AFib, acute PE, myocarditis, chronic renal insufficiency, sepsis, hypovolemia

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10
Q

Acute MGMT of NSTEMI

A
  1. General - VOMIT, ASA, NG SL/IV, morphine IV
  2. Antiplatelet - ASA x2, ticagrelor/prasugel, +/- IV GP IIb/IIIa inhibitor (abciximab) if PCI
  3. Anticoagulation - UFH/bivalirudin if PCI, LMWH for thrombolysis or nothing
  4. beta blockers
  5. coronary angiography +/- reperfusion.
    NO THROMBOLYSIS FOR UA/NSTEMI
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11
Q

Acute MGMT of STEMI

A
  1. General
  2. Antiplatelet - ASA
  3. Anticoagulation - GB IIb/IIIa inhibitor (abciximab); UFH post PCI, LMWH post thrombolysis
  4. PCI or thrombolysis
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12
Q

Absolute Contraindication to Thrombolysis in STEMI

A

prior intracranial hemorrhage, known structural cerebral vascular lesion, known malignant intracranial neoplasm, significant closed-head or facial trauma < 3 months, ischemic stroke < 3 months, active bleeding, suspected aortic dissection

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13
Q

Complications of MI

A

arrhythmia, myocardial rupture (LV wall, papillary muscle, ventricualr septum), CHF, post-infarct angina, recurrent MI, thromboembolism, percarditis, dressler’s syndrome

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14
Q

Classic Triad for Spinal Epidural Abscess (only seen in 13%)

A

fever, back pain, neurological deficits

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15
Q

post void residual cut offs for cauda equina

A

> 200 is positive test, < 100 cc less likely

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16
Q

Indications for plain film spinal/back Xray

A

> 70 yo, unexplained weight loss, pain worse with rest, prolonged steroid use, cancer, IV drug use, osteoporosis

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17
Q

Cauda Equina/SCC MGMT

A

IV opioids, IV dexamethasone, consult neurosurgery stat

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18
Q

Bones of the hand: “so long to pinky here comes the thumb”

A

Scaphoid lunate triquetrum pisiform hamate capitate trapezoid trapezium

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19
Q

Terry Thompson Sign (X Ray)

A

Scapholunate dissociation

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20
Q

What do you see on x ray of Lateral view of hand

A

RLC- Radius lunate capitate; best way to see triquetrum fracture

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21
Q

Perilunate dissociation

A

Lunate and capitate not aligned

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22
Q

Areas high risk of tissue necrosis with epi in lidocaine

A

Fingers toes penis nose

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23
Q

Lidocaine time of onset, duration

A

Instantaneously, 20-60 minutes

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24
Q

Dose of lidocaine without epi, with epi

A

5 mg without epi, 7 with epi (vasoconstriction)

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25
Q

Signs of lidocaine toxicity

A

Perineal numbness, dizziness, seizures, cardiovascular collapse, death

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26
Q

Ways to help with lidocaine irritation during administration

A

Small needle, bicarbonate, warming solution

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27
Q

Topical anaesthetics used

A

Lidocaine-epi-tetracaine (LET), eutectic mixture of local anaesthetics (EMLA)

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28
Q

Symptoms of hyperkalemia

A

Nausea, palpitations, muscle stiffness, muscle weakness, parenthesis, areflexia, ascending paralysis, hypoventilation

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29
Q

ECG changes from hyperkalemia

A

Peaked and narrow T-waves, decreased amplitude and eventual loss of p waves, prolonged PR interval, widening of the qrs, AV block, vfib, asystole

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30
Q

Hyperkalemia MGMT

A

“C BIG K Drop”: calcium gluconate, bicarbonate, Beta agonist, Insulin, glucose, k exylate, diuretics, dialysis

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31
Q

How to shift K

A

Insulin 10-20U IV with 1-2 amps of D50W (give before insulin) q4-6 hrs; bicarbonate: 1-3 ampules (7.5% or 8.4%) if metabolic acidosis, nebulized ventolin (2 cc), furosemide 40 mg IV

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32
Q

Difficult BVM ventilation

A

BOOTS - beard, obese, older, toothless, snores/stridor`

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33
Q

Difficult intubation

A

MAP - mallampati score, measuremenets (3-3-2: 3 mouth opening, hyoid to chin, thyroid cartilage to notch hyoid bone), atlanto-occipital extension (35 degrees or more), pathological (tumour, hematoma, etc.)

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34
Q

Temporizing measures for airway

A

chin lift/jaw thrust, suctioning, nasal airway (for obtunded patients), oral airways (not for patients with intact gag reflex), BVM ventilation (use oral airway always in the EM), LMA (occludes hypopharynx)

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35
Q

Indications for intubation (4Ps)

A

patency, protection, predicted deterioration, pulmonary toileting, positive pressure ventilation

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36
Q

Definition of Rapid Sequence intubation (RSI)

A

simultaneous adminstration of sedative (induction) and paralytic agent (maintenance) to decrease risk of aspiration

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37
Q

Steps for RSI

A

6Ps - preparation, pre-oxygenation (100% O2 NP with high-flow oxygen), pre-treatment (succinylcholine, atropine, lidocaine, fetanyl, etc.), paralysis with induction (Sedative: ketamine, propofol, etomidate) (muscle relaxant: succinylcholine, rocuronium), place the tube with proof (ETCO2, CXR, auscultation), post-intubation MGMT (CXR, analgesia, sedation, resusciation)

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38
Q

Contraindication to RSI

A

anticipated difficult airway, particularly difficult BVM ventilation - awake intubation, inadequate familiarity and comfort with technique, unnecessary (patient is in cardiac arrest, near-arrest)

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39
Q

Tools to help with intubation

A

bimanual laryngoscopy, bougie, video laryngoscopy (glidescope)

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40
Q

Life-threatening causes of dyspnea

A

PE, pulmonary edema (CHF), acute exacerbation of COPD, acute severe asthma, TPTX,

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41
Q

Kussmaul’s breathing

A

deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure. It is a form of hyperventilation, which is any breathing pattern that reduces carbon dioxide in the blood due to increased rate or depth of respiration.

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42
Q

Cheyne-Stokes Breathing

A

Cheyne–Stokes respiration is an abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called an apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes.[1] It is an oscillation of ventilation between apnea and hyperpnea with a crescendo-diminuendo pattern, and is associated with changing serum partial pressures of oxygen and carbon dioxide.[2]

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43
Q

syncope definition

A

sudden and transient loss of consciousness with loss of postural tone accompanied by rapid return to baseline

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44
Q

pathophysiology of syncope

A

dysfunction of both cerebral hemisphere or brainstem, usually from hypo-perfusion

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45
Q

DDx of syncope (cardiac)

A

cardiac vs. non-cardiac; cardiac: arrhythmias, pacemaker, structural (AS, HOCUM), MI, dissection, cardiomyopathy, PE

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46
Q

DDx of syncope non cardiac

A

reflex (neurally mediated): vasovagal, situational, orthostatic, carotid sinus pressure (shaving), subclavian steal (arm exercises); medications (CCBs, BB, digoxin, insulin), CNS hypoperfusion (hypoxia, epilepsy, dysfunctional brainstem)

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47
Q

Hx and Physical for syncope

A

exertional, cardiac RF, comorbidities, medication/drug use, family hx, orthostatic symptoms, r/o seizure/stroke/head injury; cardiac exam, CNS exam

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48
Q

Investigations for syncope

A

CBC, glucose, lytes, extended lytes, BUN, Cr, CK, troponin, BHCG, ECG

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49
Q

ECG changes for syncope

A

short PR: WPW; long PR: conduction block; deep QRS: HOCUM, wide QRS: BBB, Vtach, WPW, QT Interval (congenital QT syndrome), tachyarrhythmias (SVT, AFib, VTach, VFib), bradyarrhythmias, AV conduction blocks, sinus node dysfunction

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50
Q

MGMT of syncope

A

cardiogenic: cardiology consult, pacemaker; non-cardiogenic: d/c with follow-up, outpatient cardiac workup, use Canadian Syncope Risk Score for stratification

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51
Q

Migraine definition

A

POUND: pulsatile, onset 4 - 72 hours, unilateral, NV, disabling intensity, photophobia/phonophobia, chronic, recurrent, +/- aura

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52
Q

Cluster HA Definition

A

unilateral sudden sharp retro-orbital pain, < 3 hours, pseudo-Horner’s symptoms, precipiated by alcohol/smoking

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53
Q

Tension HA

A

tight band-like pain, tense neck/scalp muscles, precipitated by stress or lack of sleep

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54
Q

DDx of headaches

A

intracranial: bleed, infection, mass, cerebral venous sinus thrombosis; extra-cranial AACG, temporal arteritis, carotid artery dissection, CO poisoning

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55
Q

Red Flags for HA history

A

sudden onset, thunderclap, exertional onset, meningismus, fever, neurological deficits, AMS), increased ICP (persistent vomiting, HA worse lying down, and in the AM)

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56
Q

Investigations for HA

A

imaging to r/o deadly causes. refer to Ottawa SAH Rules for CT. LP if suspicion for SAH

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57
Q

MGMT for benign HA

A

fluids, antidopaminergic agent (metoclopramide 10 mg IV), analgesia: tylenol, NSAIDs: ketorolac 15-30 mg or ibuprofen 600 mg PO, steroids: dexamethasone 10 mg IV/PO; sumatriptan, verapamil for cluster headaches, magnesium lidocaine propofol ketamin for refractory HA

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58
Q

Ottawa SAH rules of headache (only for 15+yo, atraumatic HA, maximum intensity within 1 hour): any of the following are positive, SAH r/o

A

age > 40, neck pain/stiffness, witnessed LOC, onset during exertion, thunderclap (peaking pain within 1 second), limited nec flexion on examination

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59
Q

CT Head window to r/o SAH

A

non-contrast CT head scan within 6 hours of HA; LP if continued suspiciou and CT head is normal, CTA if cerebral aneurysm

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60
Q

3 Is to rule out in bloody diarrhea

A

Ischemia, infection (bacteria), inflammation (colitis)

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61
Q

Red flags of diarrhea

A

Blood, pain, recent travel, recent antibiotic use, elderly with CV/AFib

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62
Q

DDX for SOB

A

airway obstruction, respiratory failure, anaphylaxis, PE, TPTX, pulmonary edema, MI, cardiac tamponade, pericardial effusion, arrhythmias, toxin ingestin, sepsis, DKA, thyrotoxicosis, GBS, amyotrophic lateral sclerosis, MS

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63
Q

PERC Criteria

A

to r/o PE if none are present (pre-test must be < 15%): 50+, HR 100+, SaO2 < 95% on RA, unilateral leg swelling, hemoptysis, recent surgery or trauma, prior PE/DVT , hormone use

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64
Q

DDx of deadly CP

A

PET MAC - PE, esophageal rupture, TPTx, MI, aortic dissection, cardiac tamponade

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65
Q

DDx of CP (non-deadly)

A

pericardititis/myocarditis/endocarditis, PNA, pleural effusion, acute chest syndrome (SCD), lung/mediastinal mass, MW tear, esophageal spasm, GERD, dyspepsia/PUD, pancreatitis, biliary colic, cholecystitis, cholangitis, MSK, HSV

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66
Q

MGMT of ACS

A

ASA, nitro (avoid in RV infarct), ticagrelor/clopidogrel, LMWH, code STEMI

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67
Q

MGMT of PE

A

anticoagulation, thrombolysis if massive PE

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68
Q

MGMT of esophageal rupture

A

urgent thoracics consult, IV antibiotics, NPO

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69
Q

MGMT TPTX

A

needle decompression (2n ICS at MCL), chest tube (4-5th ICS)

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70
Q

MGMT tamponade

A

pericardiocentesis

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71
Q

MGMT Dissection

A

urgent vascular consult, reduce BP and HR with IV labetalol, surgery vs medical MGMT

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72
Q

HEART Score (Chest Pain Risk stratification)

A

Inclusion: 21+ yo with symptoms of ACS; Exclusion: new STEMI > 1 mm or other new ECG changes, hypotension, life expectancy < 1 yr, other illness/comorbidities

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73
Q

DDx of RUQ Abdo pain

A

biliary disease, hepatitis, pancreatitis, PNA, pleural effusion, PE

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74
Q

DDx of Epigastric pain

A

gastritis, PUD, duodenitis, pancreatitis, ACS

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75
Q

DDx of LUQ

A

pancreatitis, gastritis, PNA, pleural effusion, PE

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76
Q

DDx of Right Flank

A

colitis, perforation, obstruction, renal colic, AAA, pyelonephritis

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77
Q

DDx of umbilicus

A

colitis, perforation, obstruction, aortic dissection, AAA

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78
Q

DDx of L flank pain

A

colitis, perforation, obstruction, renal colic, pyelonephritis, AAA

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79
Q

DDx of RLQ

A

appendicitis, ectopic pregnancy, ovarian torsion, testicular torsion, PID, TOA, epididymitis, orchitis, renal colic

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80
Q

DDx of hypogastric

A

UTI, renal colic, obstruction

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81
Q

DDx of LLQ

A

diverticulitis, ectopic, PID, TOA, testicular torsion, epididymitis, orchitis, ovarian torsion, renal colic

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82
Q

Ruptured Ectopic RF

A

Hx of STI/PID, recent IUD, previous ectopic, fallopian tube surgery, tubal ligation

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83
Q

Ruptured AAA RF

A

elderly, hx of HTN/DM, smoking, trauma Hx

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84
Q

Pancreatitis RF

A

alcohol, biliary pathology

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85
Q

Charcot’s Triad (cholangitis)

A

fever, jaundice, RUQ pain

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86
Q

Mesenteric Ischemia RF

A

elderly, CAD, CHF, dehydration, infection

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87
Q

Obstruction RF

A

previous surgery, malignancy, elderly

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88
Q

Perforated Viscus RF

A

diverticulitis, PUD, malignancy, instrumentation

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89
Q

Complicated diverticulitis RF

A

elderly, low-fibre diet, western population

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90
Q

Pelvic Pain GYNE DDx

A

ovaries (ruptured cyst, abscess, torsion), fallopian tubes (salpingitis, tubal abscess, hydrosalpinx), uterus (PID, endometriosis, fibroids), pregnancy related (ectopic, pregnancy, threatened abortion, ovarian hyperstimulation), prengnacy related (late): placental abruption, round ligamaent pain, braxton-hicks contraction

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91
Q

Pelvic Pain non-GYNE DDx

A

urolithiasis, pyelonephritis, cystitis, testicular torsion, prostatitis, sexual abuse

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92
Q

Back Pain DDx (DEADLY)

A

cauda equina, spinal cord compression (mets, epidural abscess, hematoma, disc herniation, spinal fracture with subluxation), meningitis, vertebral OM, transverse myelitis

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93
Q

Back Pain DDx (vascular)

A

aortic dissection, ruptured AAA, PE, myocardial infarction

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94
Q

Red Flags of Back Pain

A

“BACK PAIN”: bowel/bladder dysfunction, anesthesia (saddle), constitutional symptoms, chronic disease, paresthesia, > 50 yo, IVDU/infection, neurological deficits

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95
Q

MGMT Epidural abscess or vertebral OM

A

MRI for definitive dx, bone scan (OM), broad spec antibiotics, orthopedics consult

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96
Q

Anaphylaxis definition

A

life-threatening immune hypersensitivity systemic reaction leading to histamine release, vascular permeability, vasodilation

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97
Q

DDx of Anaphylaxis

A

other causes of shock, angioedema, flush syndrome, asthma, red man syndrome

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98
Q

Definition of Asthma

A

acute onset (mins -hours) and any of the following (3): involvement of skin +/- mucosa with either respiratory difficulty or low BP, exposure to likely allergen with 2+ (skin-mucosa, respiratory difficulty, low BP, GI symptoms), low BP after exposure to known allergn

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99
Q

MGMT of anaphylaxis

A

protect airways (ketamine), epinephrine (0.5 mg IM to anteriolateral thigh q5-10 mins), anthistamines (benadryl 50 mg IV/PO, ranitidine 50 mg IV or 150 mg PO), methylprednisolone 125 mg IV, fluids 0.5 - 1 L NS bolus

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100
Q

Disposition of Anaphylaxis

A

can d/c early as 2 hours if stable, fu with GP in 24 0 48 hours to avoid biphasic reaction, education to avoid allergen, consider allergy testing, epipen prescription, meds at disc (benadryl, ranitidine, prednisone 50 x3 days)

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101
Q

Asthma definition

A

chronic inflammatory airway disease with recurrent reversible episodes of bronchospasm and variable airflow obstruction

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102
Q

Common triggers in asthma

A

lack of medication, URTI, environmental allergens, smoking, exercise

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103
Q

Mild Asthma definition

A

SOBOE, chest tightness, >95% O2 Sat, expiratory wheezing, FEV1 > 60% predicted

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104
Q

Mod Asthma definition

A

SOB at rest, cough, congestion, nocturnal symptoms, >95% O2, expiratory wheezing, FEV1 40 - 60%

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105
Q

Severe Asthma definition

A

agitated, diaphoretic, laboured breathing, difficulty speaking, tachycardia, high BP, O2 90 - 95%, worsening resp distress, expiratory and inspiratory wheezing, FEV1 < 40% predicted

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106
Q

Respiratory Arrest

A

altered mental status, cyanotic, decreased respiratory effort, bradycardia, high RR, low O2 sat < 90% despite oxygen, silent chest (ready for intubation)

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107
Q

Asthma Hx

A

triggers, recent infections, prior exacerbations, hospitalizations, ICU stay, FHx, daytime symptoms < 2 weeks, no activity limitation, no nocturnal symptoms, rescue puffers < 2/weeks, normal PFT

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108
Q

MGMT of acute asthma exacerbation

A

atrovent 0.5 mg nebulized or 4 - 8 puffs via MDI + spacer q15 mins x 3; ventolin 5 mg nebulized or 4 - 8 puffs MDI + spacer q15 mins; prednisone 50 mg PO

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109
Q

MGMT of severe asthma

A

MgSo4 2g IV over 30 mins, epinephrine 0.3 mg IM then 5 mcg/min IV infusion, ketamine 1 mg/kg with BiPAP

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110
Q

Triggers of COPD

A

viral URTI, PNA, environmental allergens, smoking, CHF, PE, MI

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111
Q

COPD Hx

A

sputum production/purulence, duration of symptoms, previous exacerbations, comorbidities, functional status, home O2, intubation

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112
Q

COPD Signs for Severity

A

rapid shallow pursed-lip breathing, use of accessory muscles, paradoxical chest wall movement, worsening central cyanosis, peripheral edema, hemodynamically unstable, decreased LOC or confusion, decreased O2 sat

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113
Q

MGMT of COPD

A

venturi mask (hi-flow), target SaO2 > 88%; salbutamol 2.5 - 5 mg via nebulizer, atrovent 500 mcg via nebulizer, oral prednisone 50 mg, antibiotics (if 2+ of cough, sputum production, purulence), NIPPV

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114
Q

MI Definition

A

evidence of MI on ACS diagnosed by cardiac marker abnormalities and one of: ECG changes, HPI consistent with ACS

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115
Q

Stable Angina Definition

A

Transient episodic chest discomfort precipitated by exertion/emotion, lasts < 15 mins, relieved by rest or nitro

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116
Q

STEMI Definition

A

infarction with ST elevated: 1+ mm in 2 contiguous leads; V1 - 3: > 1.5 mm in females, > 2.5 mm for males under 40, > 2 mm for males over 40

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117
Q

NSTEMI Definition

A

infarction without ST elevation

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118
Q

MGMT Of ACS

A

ASA 325 mg chewed, ticagrelor 180 mg (if PCI), UFH 4000 U if PCI then 12 U/kg/hr, LMWH if thrombolytics

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119
Q

CHF Etiology

A

CAD, HTN, valve abnormalities, cardiomyopathy, infarction, pericardial disease, myocarditis, cardiac tamponade, metabolic disorder, toxins, congenital

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120
Q

CHF triggers

A

ischemia, dysrhtyhmia, mechanical (papillary muscle rupture), medications (forgot, BB, NSAIDs, steroids), anemia, infection, pregnancy, hyperthyroidism, high salt, PE, HTN, renal failure

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121
Q

Sx of L-sided HF

A

SOB, orthopnea, PND, nocturia, fatigue, altered LOC, syncope, angina, pulmonary congestion

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122
Q

Sx of R-sided

A

fatigue, abdominal distension, swelling, weight gain; pitting edema, JVP elevation, hepatomegaly, ascites

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123
Q

MGMT of HF

A

ABCs, monitor, 100O2 non-rebreather facemask, vitals, IV acess, upright positioning, foley catheter, morphine PRN; NG, furosemide (double home dose), NG; if hypotensive can consider vasopressor (norepi 2 - 12 mcg/min)

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124
Q

Causes of dysrhythmias

A

MI, drugs, toxins, lyte imbalances

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125
Q

Types of SVTs

A

regular: sinus tachy, atrial tachy, atrial flutter; AV node: SVT (AVNRT > AVRT), juctional tachycardia; a fib, multifocal atrial tachycardia, SVT with aberrancy

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126
Q

Types of Ventricular tachydysrhythmias

A

VTach, SVT with aberrancy, Vfib, polymorphic VT, AFib with WPW

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127
Q

Signs of “unstable patient” in dysarrhythmias

A

altered LOC, respiratory distress, hypotension, syncope, chest pain, signs of CHF, shock

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128
Q

ACLS for bradycardia

A

atropine 0.5 mg IV bolus q3-5mins x 6 (max 12 mg); dopamine (2-10 mcg/kg/min) or epi (2 - 10 mcg/min), transcutaneous pacing, IV pacing; for Type II and 3rd degree go to transcutaneous pacing

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129
Q

ACLS for tachycardia

A

synchronized cardioversion

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130
Q

VF or pVT MGMT as per ACS

A

shock-cpr-shock, epi 1 mg IV q3-5mins, consider amiodarone 300 mg IV with 2nd dose 150 mg IV bolus

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131
Q

Ruptured AAA RF

A

FHx, HTN, CAD/PVD, DM, connective tissue disease, smoking

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132
Q

Risk of rupture for < 5 cm, 5 - 7 cm, > 7 cm

A

< 5cm: 0.3% /yr; 5 - 7 cm: 10% risk/yr; >7 cm: 20% risk/yr

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133
Q

Classical Sx of ruptured AAA

A

acute onset back/abdo/flank pain, hypotension, pulsatile abdominal mass

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134
Q

Inv for AAA

A

POCUS to identify > 3 cm, ECG, CTA

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135
Q

MGMT of AAA ruptured

A

ABCs, VOMIT, STAT vascular consult, IV fluid, BP for 90 - 100 mg, massive transfusion protocol, open surgery vs. endovascular aneurysm repair

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136
Q

Post-Op Complications of AAA ruptured

A

infection, ischemia, aortoenteric fistula (GI bleeding), endo leak

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137
Q

Acute Arterial Occlusion definition

A

acute embolus or thrombosis; true emergency as irreversible damage can occur within 6 - 8 hours

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138
Q

RF for acute arterial occlusion

A

atherosclerosis, MI with LV thrombus, AFib, valve stenosis, stents/grafts

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139
Q

Hx in Acute arterial occlusion

A

6Ps: pain, paresthesia, pallor, polar, pulselessness, paralysis

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140
Q

Investigations for Acute Arterial Occlusion

A

doppler probe with proximal BP cuff (perfusion pressure < 50 mmHg, ABI < 0.5)

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141
Q

MGMT for acute arterial occlusion

A

heparain 5000 IU bolus, revascularization vs. CT angio

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142
Q

DVT and PE RF

A

venous stasis, vessel injury, hypercoagulability

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143
Q

MGMT DVT

A

LMWH, heparin infusion if renal impairment, DOAC

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144
Q

PE MGMT

A

LMWH, DOAC, heparin, warfarin transition

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145
Q

GI Bleeding RF

A

medications, excessive vomiting, bleeding disorders, malignancy, alcohol use, ulcer history, H.Pylori

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146
Q

DDx of Upper GIB

A

PUD (gastric > duodenal), gastritis/esophagitis, esophageal varices, MW tears, gastric CA

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147
Q

DDx of LGIB

A

colitis (inflammatory/infectious/ischemic), anorectal (hemorrhoids, fissures, proctitis), angiodysplasia, divertculosis, malignancy

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148
Q

Mimics of melena

A

pepto-bismol, iron ingestion, fruits (blueberries)

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149
Q

MGMT UGIB

A

pantoprazole 80 mg IV bolus then 8 mg/h infusion; octreotide 50 mcg IV bolus then 50 mcg/h infusion if variceal bleeding, ceftriaxone 2g IV if variceal bleeding to prevent sBP, tranexamic acid, balloon tamponade

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150
Q

MGMT LGIB

A

NPO, IV fluids, colonscopy

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151
Q

ACA stroke definition

A

leg > face/arm contralateral motor and sensory deficits, bowel and bladder incontinence, impaired judgement/insight

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152
Q

MCA Stroke definition

A

face/arm > leg contralateral motor + sensory deficits; contralateral hemianopia, gaze preference towards lesion; aphasia (dominant) or neglect (non-dominant)

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153
Q

PICA stroke (Wallenberg syndrome)

A

pain/tempoerate loss on contralateral side + ipsilateral face, ipsilateral horner’s syndrome, 4Ds dysphagia, diplopia, dysarthria, dysphonia

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154
Q

Acute Stroke MGMT

A

ABCs, VOMIT, BP control if > 220/120; target BP 185/110 if giving tPA, consult neuro, admit to stroke unit, antiplatement (TIA - ASA; if acute stroke, hold ASA until d/c), tpa within 4.5 hours +/- intra-arterial thrombectomy by IR, CT angio of carotids +/- endarterectomy, CHADs score for anticoagulation

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155
Q

DKA Definition

A

insulin deficiency + stressor –> counter-regulatory hormone excess –> lipolysis (ketoacidosis) and osmotic diuresis (Dehydration); serum glucose > 16 mmol/L, HCO3 < 15, pH 7.3

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156
Q

HHS Definition

A

relative insulin deficiency + stressor –> counter regulatory hromone excess –> osmotic diuresis; glucose > 30 mmol/L; severe dehydration, hyperosmolality

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157
Q

Triggers for DKA

A

7Is: infection, ischemia, iatrogenic, incision, intoxication, initial, insulin

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158
Q

Inv for DKA/HHS

A

lytes, glucose, urine and serum ketones, beta-hydroxybutryate, CBC, extended lytes, BUN, Cr, cardiac enzymes if symptoms

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159
Q

MGMT of DKA

A

NS bolus, D51/2NS when BS < 16, insulin short acting regular 0.1U/kg/h (lower BG by 4 - 5), close the gap, overlap IV with SC insullin, give KCL if 5, hold insulin if < 3.3; replace phosphate

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160
Q

SIRS definition

A

2+ of T<36 or >38, HR >90, RR > 20 or Co2 > 32, WBC < 4 or > 12

161
Q

sepsis definition

A

life threatening organ dysfunction caused by dysregulated response to infection

162
Q

Inv for sepsis

A

CBC, lytes, extended lytes, BUN/Cr, LFTs, VBG, lactate, INR/PTT, blood urine C+S, ECG, CXR

163
Q

MGMT for sepsis

A

VOMIT, lactate, IVF, early antibiotics early, send fluid; repeat lactate, fluids and MAP > 65 after 6 hours; fluids bolus, vasopressors (norepi 2- 12 mcg/min), steroids if refractory (hydrocortisone 100 mg IV), antibiotics (piptazo 3.375 g IV + vanco 1g); aim to maintain MAP > 65 mmHg, UPO > 0.5 cc/kg/hr

164
Q

Causes of hyperkalemia

A

pseudohyperkalemia, chronic renal failure, acute acidosis, medications (ACEi, NSAIDs, diuretics, digoxin, septra), cell death (rhabdo, burn/crush injuries, hemolysis, TLS)

165
Q

ECG changes with hyperkalemia

A

peaked T wave, PR prolongation, loss of P waves, widened QRS, sine wave

166
Q

MGMT Of hyperkalemia

A

C Big K Drop: calcium gluconate 3 amps, bicarb, insulin 10U R 1-2 amps D50W, salbutamol, lasix, Kexylate, dialysis

167
Q

Hypokalemia Causes

A

renal losses (diuretics), non-renal losses, metabolic alkalosis

168
Q

ECG Changes in hypokalemia

A

loss of T waves –> U waves –> prolonged QT -> torsades, VTAch, VFib

169
Q

MGMT of hypokaelmia

A

replace K+ (KCl 10 - 20 mmol/hr IV, MgSo4 500 mg/h IV to ensure K being driven into cells

170
Q

Causes of hyponatremia

A

hypo-osmolar: hypervolemia (CHF, cirrhosis, nephrotic syndrome), euvolemia (SIADH), hypovolemic (adrenal insufficiency, vomiting, diuretics)

171
Q

MGMT of hyponatremia

A

if acute (< 48 hours) or symptomatic (decreased LOC, focal neuro): max Na 8 mmol/L in 24 hrs to prevent central pontine myelinoysis - Iv 3% saline 100 cc IV over 10 mins (if seizing)

172
Q

Causes of hypercalcemia

A

malignancy (breast, kidney, lung), hyper PTH, granulomatous disease, medications (thiazides, lithium, estrogen, vitamin A/D toxicity)

173
Q

ECG changes in hypercalcemia

A

short QT, ST elevation, bradyarrhythmias, AV block

174
Q

MGMT of hypercalcemia

A

IVF bolus, then infusions, UOP of 2L/day target. lasix to promote diuresis, bisphosphonates, calcitonin

175
Q

Causes of peripheral vertigo

A

BPPV, vestibular neuronitis, labyrinthitis, meniere’s disease

176
Q

Causes of central vertigo

A

cerebellar hemorrhage, PICA stroke, head trauma, vertebrobasilar migraine, MS, TLE

177
Q

BPPV definition

A

short lived positional, associated with NV, no auditory symptoms

178
Q

Vestibular neruonitis definition

A

sudden and severe vertigo, increasing intensity over hours, symptoms subside over days to weeks, exposure to infections or toxins, no auditory symptoms

179
Q

labryinthitis definition

A

positional, co-existing ENT infection, +/- febrile/toxic apperance, auditory symptoms of mild to severe hearing loss

180
Q

menieres disease definition

A

recurrent episode of sudden severe rotational vertigo, NV, lasting hours, +hearing loss or tinnitius

181
Q

Signs and Symptoms for peripheral vertigo

A

sudden severe onset, horiztonal/rotary nystagmus, auditory findings, no neurological findings

182
Q

Signs and symptoms for central vertigo

A

gradual onset, weeks to months, vertical nystagmus, no auditory findings, may have neuro findings

183
Q

physical exam for vertigo

A

gait/coordination, neuro exam, Dix-Hallpike, roll test, HINTS exam (if AVS)

184
Q

HINTS Exam

A

for active vertigo, observed nystagmus, normal neuro exam; Head Impulse: turn head quickly to midline for 30 degrees - if corrective saccade/nystagmus, it is likely peripheral cause. Nystagmus test: do not use finger, ask to look left and right, if fast beat is to one side only, it is peripheral. if nystagmus bidirectionally or vertical : central cause. Test of skew: any corrective eye re-alignment on cover-uncover is abnormal (i.e., r/o central cause)

185
Q

MGMT of peripheral vertigo

A

BPPV: Epley maneuver, betahistine/histamine for Meniere’s, antibiotics and steroids fore vstibular neuronitis or labryinthitis

186
Q

Causes of Epistaxis

A

trauma, URI, allergies, low humidity, polyps, FB, idiopathic, systemic (antigoaculoation, pregnancy)

187
Q

BW for epistaxis:

A

CBC, INR/PTT, +/- cross and type

188
Q

MGMT of epistaxis

A

compress cartilaginous party of nose for 20 mins. compress x 20 mins with lidocaine/epi soaked pledget +/- silver nitrate if able to identify site of bleeding +/- TXA intranasally or IV

189
Q

MGMT Of anterior epistaxis

A

anterior packing: nasal tampon, rhino rockets or vaseline gauze packs; apply anterior pack to active side first, if ineffective, pack both nares

190
Q

MGMT of Posterior epistaxis

A

epistat or foley catheter, apply traction once inserted; keflex x 5 days or until pack removed to prevent toxic shock syndrome

191
Q

Peritonsillar abscess signs

A

muffled voice, uvular deviation

192
Q

retropharyngeal abscess signs

A

drooling, airway compromise

193
Q

tracheitis signs

A

stridor, laboured breathing

194
Q

epiglottitis signs

A

fever, stridor, rapidly progressive swelling

195
Q

Centor Criteria

A

no cough, exudates, LN anterior cervical, temperature, or age: +1 if 3 - 14 yo; -1 if 44 yo

196
Q

MGMT of pharyngitis

A

fluids, antipyretics, single dose dexamethasone, antibiotics can reduce symptoms by 16 hours but do not reduce complications

197
Q

Renal Colic RF

A

lifestyle, hereditary (RTA, G6PD), medications (loop diuretics, acetazolamide, topiramate), medical conditions (UTI, IBD, gout, DM, hypercalcemia), obesity

198
Q

Signs and Symptoms of Renal Colic

A

unilateral flank pain radiating to groin, writhing in pain, N/V, trigonal irritation (frequency, urgency); fever, CVA tenderness

199
Q

Investigations for Renal Colic

A

do not require CT unless first presentation, elderly patient, suspicion of serious alternative diagnosis; US is good alternative. KUB may be used to assess stone progression

200
Q

MGMT of Renal Colic

A

IV NS if dehydrated, Zofran. Morphine or ketorolac 30 mg IV or naproxen 500 mg PO. Tamsulosin 0.4 mg daily x 3 weeks if large stone (> 4mm or distal); d/c with GP/urology follow-up.

201
Q

Reasons to consult urology for renal colic

A

intractable pain, infected stone, compromised renal function (bilateral obstruction, single kidney, transplated kidney)

202
Q

UTI and Pyelonephritis Etiology

A

“KEEPS” - klebsiella, ecoli, enterococci, proteus, saprophyticus

203
Q

Signs and Sx of UTI/Pyelo

A

LUTS (frequency, urgency, dysuria, hematuria), pyelo (fever/chills, flank pain, NV), associated vaginal/cervicitis symptoms, sexual history

204
Q

Investigations for UTI/pyelo

A

urine dip, R&M, C&S, CBC, BUN/Cr

205
Q

MGMT of UTI

A

uncomplicated: macrobid 100 mg BID x 5 days; septra DS po BID x 3 days, STI suspected: levofloxacin 500 mg daily x 1 week, CTX 250 mg IM x1; complicated UTI: ciprofloxacin 500 mg PO BID or septra DS po BID x 10 - 14 days; consider US or CT if compliated UTI; complicated pyelo: ceftriaxone 1 g IV q24hrs

206
Q

Hx and Phys of fractures

A

mechanism of injury, neuro symptoms, blood loss; active and passive ROM, NV status, assess bleeding/open fractures, compartment syndrome, joint above and below fracture

207
Q

Colles Fracture definition

A

FOOSH, distal radius fracture with dorsal displacement; “dinner form deformity. MGMT: restore radial length, correct dorsal angulation

208
Q

Scaphoid fracture definition

A

15-40 yo with FOOSH; high risk of AVN/non-union. Phys: limited wrist/thumb ROM snuff box tenderness, axial loading of 1st MC pain to scaphoid tubercle volarity. MGMT: thumb spica splint for suspected fracture (even if Xray is negative x 6 - 12 weeks. repeat imaging in 10 days

209
Q

Boxer’s fracture

A

blow on distal/dorsal aspect of closed fist; angulation of nect of 5th MCP; closed reduction if angulation > 40 degrees; if stable, ulnar gutter splint

210
Q

Jones Fracture

A

stress injury, midshaft 5th MT fracture, high incidence of non-union. non-WB BK cast x 6 weeks

211
Q

Hip facture signs

A

shortened and externaly rotated leg, painful ROM

212
Q

Definition of status epilepticus

A

continuous or intermittent seizure activity for greater than 5 mins without regaining consciousness

213
Q

Sx and signs for seizures

A

preceding aura, rapid onset, loss of bladder/bowel control, tongue-biting (sides of tongue), injuries to head and spine, aspiration, urinary incontinence

214
Q

Investigation for first time presentation of seizure

A

CBC, differential, electrolytes including extended lytes, head CT

215
Q

pheyntoin adverse effects

A

dysrhythmias, hypotension - place on cardiac monitor

216
Q

Causes of seizures

A

epilepsy, withdrawal (anticonvulsant failure, alcohol, benzo failure, barbituates), toxins (lower the seizure threshold: anticholinergics, sympathomimetics, ASA/salicylates, lithium, lidocaine/bupivicaine, isoniazid), acute structural injury (brain mets/brain mass, ICH, stroke, cerebral infection), chronic structural injury (prior TBI, prior neurosx, cerebral palsy, AVM), metabolic abnormalities (hypoglycemia, hyponatremia, hypocalcemia, hypomagnesemia, lactic acidosis, uremia, hepatic encephalopathy), pregnancy

217
Q

Hx for seizures

A

time of onset, PMH, ingestion of toxins/alcohol, fever, headache, infectious, pregnancy

218
Q

tonic-clonic seizure presentation

A

foaming at mouth, abrupt onset, tongue biting, urine or fecal incontinence, post-ictal state lasting 20 - 30 mins

219
Q

Physical for seizures

A

pupil reactivity skin, vital signs for toxidrome

220
Q

investigations for Status epilepticus

A

bedside glucose, CBC, lytes, extended lytes, VBG, calcium, ETOH, serum salicylates, urine tox screen, ECG, LP CT head if necessary

221
Q

MGMT of status epilepticus

A

ABCs, hypoglycemia - give 1 ampule IV d50, benzo, phenytoin, intubate if not already especailly before phenobarbitol

222
Q

Dosing for status epilepticus (70 kg)

A

lorazepam: 2 - 4 mg IV q2 mins up to 0.1 mg/kg IV maximum of 10 mg; diazepam 5 - 10 mg IV up to 0.15 mg/kg IV, max of 30 mg; midazolam 10 mg IM/intranasal if > 40 kg; 5 mg if < 40 kg; phenytoin 20 mg/kg IV rate of 25 - 50 mg/min may repeat 10 mg/kg dose once to a total dose of 20 mg/kg; phenobarbital 20 mg/kg IV at 50 mg/min

223
Q

complications of SE

A

cardiovascular (MI, arrhythmias, cardiac arrest), hypotension, respiratory failure from drugs or seizures, rhabdomyolysis, non cardiogenic pulmonary edema

224
Q

Definition of radiculopathy

A

Spinal nerve root compression

225
Q

Definition of myelopathy

A

Compression of spinal cord

226
Q

Features of MSK related neck pain

A

Focal point of tenderness of muscle, atrophy of shoulder muscle on affected side (rotator cuff injury), pain with shoulder abduction of affected side (rotator cuff), repetitive movement of arm or shoulder, pain accompanied by stiffness of muscles around it

227
Q

Features of cervical myelopathy or radiculopathy

A

Pain radiating from neck down to arm in dermatome pattern, sensory changes along dermatone, spurling sign, pain worsen with valsalva, neck flexion resulting in shooting sensation down neck/spine (Lhermette sign), decreased or increased reflexes

228
Q

Reflexes for spinal cord level

A

C5: biceps, C6: brachioradial, C7: triceps, L4: knee S1: Achilles

229
Q

Etiology for positive SLR

A

Herniated disc

230
Q

Hoffman Sign

A

Flexion of thumb and index finger when flicked middle finger - upper motor neuron sign

231
Q

Indications for CSpine X-ray

A

Chronic persistent neck pain, trauma, malignancy, surgery, rheumatological disease

232
Q

Spinal infection MGMT

A

Vancomycin + pip-taxi

233
Q

Shock index definition

A

HR/sBP. If greater than 1, sign of poor pefusion/shock

234
Q

Mortality rate of heart failure

A

50% in 5 years

235
Q

Most common Precipitating Factors of Heart Failure

A

AFib, MI, medication changes, high Na diet, drugs, physical exertion

236
Q

Clinical Features of HF

A

hypertensive acute HF (preserved LVF, sbp> 140 mmHG, pulmonary edema, symptoms < 48 hours), pulmonary edema (respiratory distress, rales on chest auscultation, reduced oxygen saturation, CXR findings), cardiogenic shock (sbp < 90, tissue hypoperfusion signs), acute-on-chronic HF (mild-moderate symptoms not meeting hypertensive heart failure ; sBP< 140 and > 90, associated with increased peripheral edema, symptom over several days), high-output failure (high cardiac output, tachycardia, warm extremities, pulmonary congestion), R HF (low-output syndrome with JVP elevation, hepatomegaly, variable hypotension)

237
Q

DDX for HF

A

COPD, asthma, PNA, PTX, pleural effusion, PE< ACS

238
Q

Diagnosis of HF

A

clinical! highest sensitivity is SOB on exertion, specificity is PND, orthopnea, edema

239
Q

CXR for HF

A

up to 20% will have initially normal CXR; pulmonary venous congestion, cardiomegaly, interstitial edema

240
Q

acute MGMT of HF

A

95%+ O2, CPAP/BiPAP early, vasodilators if pulmonary edema to reduce afterload, NG 0.4 mg SL or NG 0.5 mcg/kg/min IV titrate (reduce afterload), loop diuretics (furosemide 40 mg IV),

241
Q

Indications for ICU admission for HF

A

altered LOC, persistent hypoxia, hypotension, troponitis, ischemic ECG changes, BUN > 43, Cr > 2.75, tachypnea, decreased urine output

242
Q

BUN Value

A

blood urea nitrogen: nitrogen in your blood coming from the waste product urea; urea is made when protein is broken down in the body in the liver and passed out into the urine; BUN used to see kidney function (i.e., able to remove urea); elevated in HF, dehydration); low BUN seen in liver dysfunction

243
Q

Value of BUN:Cr

A

kidney function

244
Q

Definition of AKI

A

< 3 months ; CKD is > 3 months

245
Q

Types of AKI

A

Pre-renal, renal, post-renal

246
Q

Pre-renal AKI definition

A

decreased renal blood flow (most common cause); Etiology: decreased ECF volume (CHF, liver failure/cirrhosis, drugs (NSAIDS, RAAS blockers), hepato-renal syndrome

247
Q

Lab findings for pre-renal AKI

A

hemo-concentration (elevated Hgb, albumin), low urinary flow (elevated serum urea:Cr ratio), bland urine, low urinary Na excretion

248
Q

Common causes of pseudohyponatremia

A

increased large molecular particles (i.e., hypertriglyceridemia or hyperproteinuria), inaccurate blood draw (near 5% dextrose infusion site), hyperglycemia

249
Q

DDx of d-dimer

A

Artero-thromboembolism, Stroke, MI, A Fib, DVT, PE, DIC, preeclampsia, sepsis, autoinflammatory disease, surgery, liver disease, malignancy, renal disease, AKI,CKD, pregnancy

250
Q

Causes of A.Fib

A

ischaemic heart disease, HTN, valvular heart disease, infection, lyte abnormalities (K+, Mg), thyrotoxicosis, drugs, PE, pericardial disease, acid-base disturbances, pre-excitation syndromes, cardiomyopathies, pheochromoytoma

251
Q

Definition of massive hemoptysis

A

200 - 600 cc/24 hours

252
Q

Warfarin reversal

A

Octoplex, vitamin K

253
Q

Dabigatran

A

Idareyousisimab, PCC

254
Q

Lemierre disease definition

A

Fusobacterium thrombophlebitis of internal jugular vein. Think about in patients with fever and pharyngitis, toxic appearing with pharyngitis, additional infectious sources (endocarditis, pneumonia). Inv: Ct neck soft tissue, Treatment: pip-tazo,

255
Q

Definition of ARDS

A

Bilateral patchy infiltrated consistent with pulmonary edema, paO2/FiO2 less than or equal to 300, no clinical evidence of left atrial hypertrophic

256
Q

Medications given via ETT

A

“Navel”- naloxone, atropine, ventolin, epinephrine, lidocaine

257
Q

DDx for hemoptysis

A

AIRWAY: bronchitis, bronchiectasis, neoplasm, trauma, FB; PARENCHYMA: TB, PNA, lung abscess, fungal, neoplasm; VASCULAR: AV malformation, PE, AA, Pulm HTN, vasculitis (Wegener’s, SLE, goodpasture’s), HEME: coagulopathy, DIC, thrombocytopenia; CARDIAC: Congenital, valvular, endocarditis; MISC: cocaine, post-op, tracheal-arterial fistula, SLE

258
Q

Source of hemoptysis

A

massive: bronchial/pulmonary arteries, minor: tracheobronchial capillaries

259
Q

Bronchiectasis definition

A

chronic necrotizing infection resulting in bronchial wall inflammation and dilation resultingin tissue destruction and remodeling

260
Q

Inv for hemoptysis

A

CBC+Diff, G&S, renal, CXR, CT Chest (can have normal CXR), eventual bronchoscopy

261
Q

Hemoptysis + tracheostomy

A

rule out tracheo-innominate artery fistula (TIF)

262
Q

Key Deadly DDx for hemoptysis

A

PE, DIC, tracheo-innominate artery fistula, aortobronchial fistula, post-op; trauma, bronchiectasis, PNA, abscess/fungal, endocarditis

263
Q

Crystal meth rx management for hallucinations

A

Low dose olanzapine

264
Q

Snakebites in Ontario

A

Necrotizing toxin- do not do anything! Call poison control, give antidote

265
Q

ARDS MGMT (ventilator)

A

estimate body weight, ventilation mode selection (VC or PC), start with Vtidal of 8 ml/kg, reduce by 1 ml/kg q30-60 mins to 6 mk/kg, adjust Vtidal and RR to achieve pH and Plateau pressures based on ARDSnet tables; if higher FIO2 required, consider more PEEP. ECMO may be helpful

266
Q

Ventilation settings: AC, SIMV, PSV

A

A/C: assisted control
SIMV: synchronized intermittent mechanical ventilation
Volume vs. pressure-targeted; pressure supported ventilation (PSV)

267
Q

Tidal volume approach for ventilation patients

A

8 ml/kg of IBW, lower if status asthmaticus or ARDS/ALI; in pressure-targeted modes, start pressure at 20 cmH2O

268
Q

RR approach for ventilation patients

A

2/3 of pre-intubation rate; higher if sepsis, ARDS, metabolic acidosis; exception is status asthmaticus

269
Q

minute ventilation approach for ventilation patients

A

MV: RR x TV; thus if you decrease one or both, it will decrease minute ventilation

270
Q

PEEP setting in ventilation

A

5 for almost all adults, can adjust by increments of 2 for marked hypoxia

271
Q

FiO2 setting ventilation

A

100%

272
Q

Flow Rate setting ventilation

A

60L/min

273
Q

Sx and signs of hypoglycemia

A

altered/depressed LOC, seizures, neuro deficits

274
Q

Sx and signs of myxedema coma (hypothyroidism)

A

hypothermia, altered LOC, hyponatremia, high pCO2, high CK, high catecholamines, low cardiac voltage, +/- pericardial effusion

275
Q

physical exam findings on myxedema/hypothyroidism

A

bradycardia, coarse hair, delayed relexation of deep tendon reflexes, dry/cool/pale skin, goiter, hoarseness, nonpitting edema, puffy eyes and face )orbitopathy), slow movement and speech, thinning lateral third of eyebrows

276
Q

precipitating factors for myxedema coma

A

hypothermia, infection, CVA, CHF, GI bleeding, trauma, medications - discontinuation of meds, anaesthestic or sedatives, narcoties, amiodarone, lithium, raw bok choy

277
Q

MGMT of myxedema coma

A

ABCs, intubation if necessary, IV volume repletion, correct for hyponatremia or hypoglycemia, passive warming, :-thyroixine IV (loading dose is usually 50% of oral dose), steroids IV (hydrocortisone 100 mg)

278
Q

definition of adrenal crisis

A

life-threatening emergency due to acute deficiency of adrenocortical hormones (cortisol and aldosterone)

279
Q

classic findings in adrenal crisis

A

severe hypotnesion refractory to IV fluids and vasopressors

280
Q

function of adrenal glands

A

produces mineralcorticoids (aldosterone) and glucocorticoids (cortisol) and androgens in outer cortex; catecholamines produced in inner medullary zones are

281
Q

HPA Axis for corticosteroids

A

hypothalamus –> CRH to anterior pituitary –> ACTH to adrenal cortex – >cortisol; stress activates at all levels of HPA axis

282
Q

Sx and Signs of adrenal crisis

A

non-specific: weakness, confusion, fever, N/V, abdominal pain; shock and fever

283
Q

Common triggers for adrenal crisis

A

infection, surgery, burns, sepsis, trauma, metabolic, cardiovascular events

284
Q

effect of glucagon

A

promotes gluconeogenesis and glycogenolysis, as well as lipolysis (fat into fatty acid)

285
Q

Definition of DKA

A

pH < 7.3, bicarb < 15, anion gap > 12, positive serum ketones (beta hydroxybutyrate), hyperglycemia, type 1 DM

286
Q

Signs in DKA

A

Kussmaul respirations, tachycardia, fruity breath, abdo pain, vomiting, polyuria, AMS

287
Q

Triggers for DKA

A

3 Is - infection, infarction, indiscretion (med noncompliance, medications, substance abuse, pancreatitis, pregnancy, trauma, MI)

288
Q

medications associated with DKA

A

steroids, atypical antipsychotics, sympathomimetics, SGLT2 inhibitors, HIV meds, anti calcineurin immunosuppressives.

289
Q

killers in DKA

A

hypokalemia, hypoglycemia, alkalosis, CHF, cerebral edema

290
Q

MGMT for DKA

A

fluids (2L), VBG, wait for K+ and replete if below 5.5 (40 KCL with NS/RL), insulin infusion at 0.1 U/kg/hr once K+ is 3.5, get accuchecks hourly, BMP q2hrs; if glucose is < 14, add D10W/D5W into 0.4 NS; goal is to close anion gap

291
Q

HHS diagnostic criteria

A

glucose > 33.3; plasma osmolarity > 320 mmol/kg

292
Q

MGMT of HHS

A

fluids carefully, replete K+, start insulin 0.1U/kg/hr; check glucose q1hr, BMP q2hrs; add glucose when < 14; use mental status to guide resolution

293
Q

Sx of hypoglycemia

A

sweating, tremor, tachycardia, hunger, neuro smptoms, cofusion, seizures, coma

294
Q

MGMT of hypoglycemia

A

PO intake, if altered 1 amp D50W (up to 3), if no IV access, glucagon 2 mg IM (will not work in alcoholics)

295
Q

Somogyi phenomenon

A

excessive insulin in T1DM causes un recognized hypoglycemic episode while asleep resulting in rebound hyperglycemia in the AM and insulin doses are raised instead of being lowered

296
Q

role of cortisol

A

catabolic hormone creating fuel in times of stress (creates): stimulates gluconeogenesis in the liver, production of FFAs, release of AA

297
Q

RFs for adrenal crsis

A

addison’s disease (primary adrenal insufficiency), chronic steroid therapy + stressors (infectious, trauma/surgery, volume status, pregnancy, psychological stress/exercise, reduced steroid dose, initiation of drugs (carbamazepine, etomidate, ketoconazole, fluconazole, etc.), rare: waterhouse-friedrichson syndrome (adrenal infarction due to DIC), pituitary apoplexy (infarction often postpartum or DIC), cancer patients on immunotherapy

298
Q

Signs and Sx of Adrenal Crisis

A

hypotension, vasodilatory shock (refractory to fluid and vasopressors), N/V, abdo pain/tenderness, fever, delirium cutaneous hyperpigmentation or vitiligo

299
Q

Lab findings in adrenal crisis

A

electrolyte abnormalities due to minerallocorticoid deficiency; high K+, low Na, low bicarb, high Cr, low glucose, hypercalcemia, eosinophilia

300
Q

Testing for suspected adrenal insufficiency

A

random cortisol level (if > 20, r/o adrenal insufficiency), ACTH stimulation test

301
Q

definition of adrenal crisis (Rushworth 2019)

A

acute deterioration with absolute hypotension sBP M 100 or relative hypotension change in 20 sBP; resolution within 1-2 hours of IV steroid administration

302
Q

MGMT of adrenal crisis

A
  1. identify trigger of crisis. 2. if known adrenal insufficiency, 100 mg Hydrocortisone IV STAT as loading dose + 50 mg IV hydrocortisone IV q6hrs as maintenance dose (alternative: methyl pred 40 mg IV)2. if suspected adrenal insufficiencym give dexamethasone 4 - 6 mg IV once 3. Resuscitation: use vasopressors as needed, treat hypoglycemia; 4. re-evaluate
303
Q

prevention of adrenal insufficiency

A

50 mg IV hydrocortisone q6hrs for patients experiencing severe stress

304
Q

Signs of intracerebral hemorrhage

A

altered LOC, neck stiffness, seizures, DBP > 110, bilateral neurological findings, vomiting, HA

305
Q

POCUS findings for ICH

A

optic nerve sheath diameter of > 6mm is highly specific for raised ICP (< 5 is sensitive for ruling out raised ICP); transcranial doppler to detect both emboli and stenosis of MCA to rule in ischemic stroke

306
Q

initial MGMT of suspected ICH

A
  1. airway for risk of aspiration (nausea, vomiting, low GCS, apneic, herniating) 2. sBP < 180 before CT head if possible
307
Q

DDx of ICH

A

HTN, amyloid angiopathy (large lobar bleeds), coagulopathy associated ICH and cerebral venous thrombosis

308
Q

MGMT of ICH within the golden hour - 6 big considerations

A

BP, coagulopathy - reverse blood thinners + plt transfusion, glucose, temperature, seizure activity, ICP

309
Q

target BP for ICH

A

based on INTERACT 2 and ATTACH 2 trials: +ICH with GCS > 7: lowering BP to 140/80 is not harmful and may be minimally beneficial; AVOID HYPOTENSION AT ALL COSTS - TARGET MAP OF 75- 80

310
Q

target antihypertensive agents

A

nicardipine (1st choice): does not affect inotropy of heart being pure arterial vasodilator - 5 mg/hr and increase q5mins by 2.5 mg until target BP achieved then immediately titrate down to maintenance infusion of 3 mg/hr; 2nd choice: labetolol 20 mg over 1 - 2 mins then 20 mg q3-5mins until target blood pressure achieved - then infusion of 1 - 8 mg/min

311
Q

indication for plt transfusion in ICH

A

plts < 50 000 absolute; < 100 000 relative at most sites

312
Q

reversing warfarin MGMT for ICH

A

IV 4 factor PCC 1500 U AND Vitamin K in 50mL of NS over 10 mins before INR comes back as hematoma expansion occurs within 1st hour ; repeat INR q15mins and 5-6 hours after PCCs for target of 1.5 ; additional PCC depending on INR

313
Q

reversing LBWH and UFH in ICH

A

IV protamine sulfate 1mg for every 100 U dalteparin to max of 50 mg over 15 mins;; 1mg of protamine supfate for every 1 mg enoxaparin to maximum dose of 50 mg over 15 mins; if > 8 hrs ago, give 0.5 mg per 1 mg of enoxaparin; 1 mg for every 100U of UFH given in previous 2-3 hours

314
Q

reversal for dabigatran in ICH

A

idarucizumab 5 g over 15-20 mins; if not available, factor 8 inhibiting bypass activity FEIBA or 4 factor PCC

315
Q

reversal of Xa inhibitors (apix or rivarox)

A

4 factor PCC at dose of 50 IU/kg up to 3000 U

316
Q

other MGMT for high ICP

A
  1. avoid hyper or hypoglycemia; avoid fever (core temp: < 37.5); elevate bed to 3- 45 degrees head at midline, appropriate analgesia and sedation, normocapneic ventilation or hyperventilation if herniating, hypertonic solutions
317
Q

intubation for ICH patients - neuroprotective

A

bed elevated to 20 degrees to prevent spike in ICP, have nicardipine or labetolol ready, titrate sBP to 140 - 160 with art line in place, consider fentanyl 3 - 5 mcg/kg pretreatment 3 mins before intubation, ketofol for induction,

318
Q

hypertonic therapy for ICH

A

hypertonic saline 3% 250 mL over 10 mins; use bladder catheter to match urinary losses; can also mannitol 500 mL containing 100 g (20% solution)

319
Q

ICH hematoma volume equation

A

ABC/2 formula: A - length x b - width x c - slice width (# of slices present with hemorrhage)

320
Q

2 most important predictors of early deterioration in ICH based on imaging

A

hematoma volume and intraventricular hemorrhage

321
Q

definition of spot sign on contrast CT

A

represents contrast extravasation and is independent predictor of hematoma expansion, functional outcome and mortality

322
Q

indication for surgery in ICH

A

all posterior fossa bleeds unless GCS 14+ and small hematomas; for supratentorial bleeds, consult neruosx

323
Q

SUMMARY OF MGMT OF ICH

A
  1. resuscitation with NS (not RL), low threshold to intubate (most patients deteriorate in first 12 hours) 2. avoid hypoxemia 3. bP 140/80 approximately 4. core temp of < 37.5 5. glucose of 4 - 10 mmol/L 6. analgesia - fentanyl and sedation (propofol), seizure prophylaxis (lorazepam/phenytoin), hyperteonic saline or mannitol
324
Q

Dx of SBP

A

paracentesis revealing > 1000 WBCs or > 250 PMNs

325
Q

Abx for MRSA

A

vancomycin (IV), TMP-SMX, rifampin, clindamycin, tetracycline, linezolid

326
Q

Abx for pseudomonas

A

pip-tazo, cefepime, FQ (cipro and levo), carbapenem (except ertapenem), ceftazidime, AG

327
Q

Hepatic Encephalopathy Dx

A

dx of eclusio

328
Q

what is the clinical endpoint of atropine administration with organophosphate poisoning?

A

bronchial secretion

329
Q

Signs of cholinergic crisis

A

salivation, lacrimation, emesis, diarrhea, bronchorrhea, urinary incontinence, diaphoresis, miosis, hypotension, bradycardia, CNS (anxiety, tremor, coma, HA, restlessness, emotional lability, dizziness, confusion, delirium, hallucination, lethargy, coma, seizures)

330
Q

MoA of organophosphates

A

inhibits cholinesterase breakdown of acetylcholine at NM junction –> excess acetylcholine at nicotinic and muscarinic receptors

331
Q

antidotes for cholinergic toxicity

A

atropine, 2-PAM (pralidoxime)

332
Q

Muscarinic signs of cholinergic toxicity: “SLUDGE DUMBBELLS”

A

Salivation, lacrimatio, urination, diarrhea, GI cramps, emesis, diarrhea, urination miosis, bradycardia, bronchospasm, emesis, lacrimation, lethargy, salivation, seizures

333
Q

Nicotinic effects of cholinergic toxicity

A

fasciculations, muscle weakness, paralysis

334
Q

the Killer Bs for cholinergic toxicity

A

Bradycardia, bronchorrhea, bronchospasm

335
Q

Types of cholinergic toxins

A

organophosphates: parathion, fenthion, malathion, diazninon; carbamates: methomyl, aldicarb; nerve agents: sarin, tabun, soman

336
Q

Pathogens in Epiglottitis

A

HFlu, Strep, Staph, moraxella catarrhalis

337
Q

Clinical Sx of Epiglottitis

A

fever, sore, throat, drooling, muffled voice, anxios, ill-appearing

338
Q

Physical Exam signs for epiglottitis

A

patient is leaning forward, drooling, inspiratory stridor

339
Q

Imaging finding associated with epiglottitis

A

thumbprint sign

340
Q

MGMT of epiglottitis

A

prepare for intubation with pediatric ENT ASAP, IV antibiotics

341
Q

5 Causes of stridor in > 6month old

A

croup, epiglottitis, bacterial tracheitis, retropharyngeal abscess, airway foreign body

342
Q

DDx of thunderclap HA

A

hemorrhage (intracranial), vascular (cerebral dissection), reversible cerebral vasoconstriction syndrome (RCVS), cerebral venous thrombosis (CVT), posterior reversible encephalopathy syndrome (PRES)

343
Q

Red Flag of HA

A

sudden onset, trauma, exertional, vision changes, altered LOC, seizures, neurological symptoms, immunosuppression, anticoagulation, sLE, pregnancy, vasculitis, cancer

344
Q

RF for idiopathic intracranial HTN

A

obese, women ages 20 - 44

345
Q

Symptoms in idiopathic intracranial hypertension

A

HA, transient vision disturbances, back pain, pulsatile tinnitus

346
Q

Phys in HA

A

papilledema + normal neurological exam; LP showing elevated pressure

347
Q

Cluster HA Sx

A

uncommon unilateral retro-orbital/supraorbital/temporal pain, associated with lacrimation, nasal congestion, rhinorrhea, conjunctival injection ongoing for days to weeks

348
Q

MGMT for cluster HA

A

12L/min O2, sumitriptan 6 mg SC

349
Q

10 DDx for life threatening HA in the ED to know

A

SAH, subdural/epidural, stroke, meningitis, encephalitis, tumour, cervical artery dissection, hypertensive encelopathy, pre-eclampsia, cerebral venous thrombosis, idiopathic intracranial hypertension, AACG, TA, CO poisoning

350
Q

Sx of cervical artery dissection

A

spontaneous or trauma; thunderclap HA or subacute HA with neck pain, partial Horner’s syndrome, +/- retinal or cerebral TIA within 1 week

351
Q

Inv for cervical artery dissection

A

CTA

352
Q

MGMT of cervical artery dissection

A

antiplatelet, anticoag with consultant advice

353
Q

vertebral artery dissection sx

A

neck or occiput pain, posterior circulation symptoms

354
Q

posterior circulation symptoms

A

ataxia, vertigo, dysarthria, diplopia, dysphagia

355
Q

cerebral venous thrombosis sx

A

thundercalp or subacute, stroke like symptoms, seizures, vision changes (blurr, visual field defects)

356
Q

RF for CVT

A

thromboembolism, papilledema, younger patients (<40), orbital chemosis and proptosis, dilated scalp veins, scalp edema, ENT infections

357
Q

Inv for CVT

A

CT-V +/- LP

358
Q

most common SAH aneurym

A

berry/saccular aneursym rupture; second is perimesencephalic, third is AVM

359
Q

Sx for SAH

A

thundercalp HA, peaking within minutes, lasting longer than 1 hour, N/V, seizure, neck pain and stiffness, confusion, neurological deficits, elevated BP

360
Q

Signs for SAH

A

stroke-like symptoms, seizures, CN III palsy (mass effect), CN VI palsy with diplopia, subhyloid hemorrhage, meningismus

361
Q

RF for SAH

A

cerebral aneursym, FHx of SAH or polycystic kidney disease, CTD, HTN, binge drinking, cocaine, exertional syncope

362
Q

ECG changes in SAH

A

neurogenic myocardial stunning ans coronary vasospasm resulting in deep wide precordial T wave inversions, bradycardia, prolonged QT

363
Q

MGMT of SAH

A

treat BP if MAP is > 100 for few hours using labetalol or nicardipine, prevent seizures

364
Q

Posterior Reversible Encephalopathy Syndrome (PRES) definition

A

neurologic syndrome defined by both radiologic and clinical features: HA, confusion, visual changes, seizures, MRI showing vasogenic edema predominatntly in posterior cerebral hemispheres

365
Q

RF associated with PRES

A

pregnancy, hypertensive crisis, immunosuppresive cytotoxic therapy, hypomagnesemia, post-transplant

366
Q

MGMT of PRES

A

hypertension MGMT with cuatious BP lowering to 120-140 systolic or 10-25% reduction (nicardipine, labetalol), antiseizure medications

367
Q

Sx of PRES “CCCV”

A

cephalagia, convulsion, confusion, vision loss in the context of severe hypertension

368
Q

“DRESS” Syndrome definition

A

drug reaction with eosinophilia and systemic symptoms; severe drug reaction with 10% mortlaity rate

369
Q

Rx associated with DRESS

A

anticonvulsants, antibiotics, antivirals, antidepressants, antihypertensives, biologics, NSAIDs, allopurinol

370
Q

Clinical period before DRESS occuring

A

2-6 weeks after first exposure

371
Q

Sx of DRESS

A

fever first, then rash (erythematous morbiliform rash from top of body moving down), lymphadenopathy, rash progresses to infiltrative, edematous and indurated, +/- bullae, vesicles, targetoid plaques, purpura, multiorgan system failure

372
Q

Dx of DRESS

A

difficult - clinical, can use criteria like Bocquet et al: rash + 1 systemic and 1 hematologic symptom

373
Q

ED MGMT of DRESS

A

steroids, stop offending agent, consult EM

374
Q

definition of bleeding trach patient

A

minimal amount bleeding, usually 10 cc or more

375
Q

DDx of bleeding trach patient

A

early bleeding DDx: irritation from suctioning, surgical site bleed, tracheitis; late bleeding ddx: granulation, infection from stoma site, tracheitis, tracheo-innominate fistula, blood from lungs, bleeding diathesis

376
Q

innominate artery in tracheo-innomiante fistula

A

brachiocephalic artery

377
Q

ED MGMT for bleeding trach patient

A

call for help, PPE, assess for obstruction, if bleeding at stoma apply pressure, if bleeding deep to stoma, apply pressure at base of the neck (sternal notch) to extrinsicially compress innominate artery, if patient has cuffed tube hyperinflate tube, if it is uncuffed, replace it with cuffed tube and hyperinflate, if continuing to bleeding it is likely bleeding distal to tube, thus insert small cuffed ETT into stoma and apply pressure to innomiante artery then insert 1 finger into stoma and apply pressure to innominate artery with thumb in the sternal notch as external pressure

378
Q

DDx for intubated patient deterioration

A

“DOPES: - displacment of tube, obstruction, PTX, equipment problems, stacked breathing

379
Q

approach to respiratory distress in trach patient

A
  1. remove inner cannula, attempt to pass suction. if it does not pass, assume displacement or obstruction; deflate cuff, immediately remove tube, intubate upper airway/mouth, ventilate stoma with ped facemask or size 2 LMA, intubate stoma with bougie, feel for holdup and advance small ETT (6.0)
380
Q

Immediate assessment of breathing in resp distress

A

“MASH” - movement of chest during ventilation, arterial saturation (ABG), skin colour, hemodynamic instability

381
Q

AHA definition of massive PE

A

acute PE sustained with hypotension (sBP < 90) for at least 15 mins or requiring inotropic support, pulselessness or persistent profound bradycardia (< 40 )

382
Q

submassive PE definition from AHA guidelines

A

acute PE without systemic hypotension but with either RV dysfunction or myocardial necrosis

383
Q

signs of RV dysfunction

A

RV dilation or RV systolic dysfunction on ECHO, RV dilation on CT, elevated BNP, ECG changes (new or incomplete RBBB, anteroseptal ST elevation/depression, anteroseptal T-wave inversions, elevated troponin

384
Q

digoxin toxicity acute vs. chronic

A

acute: younger patients, hyperK, atrial > ventral tachycardia; chronic: elderly patients, slightly elevated hyperK, ventral>atrial tachycardia

385
Q

digoxin toxicity and hyperkalemia thing to remember!!

A

stone heart if you give calcium!! do not give, just treat with insulin and salbutamol

386
Q

digifab requirements

A

K+ > 5.0, hemodynamic instability/vitals, digoxin > 5 - 7, other AV nodal blockers

387
Q

ECG findings in digoxin toxicity

A

salvadore dali sign, normal, any dysrhythmias except rapid afib (slow AFib, junctional, tachycardia, biventricular tachycardia)

388
Q

clinical sx of CCB vs. BB overdose

A

hyperglcyemia

389
Q

MGMT of CCB and BB OD

A

bicarb for widening QRS, Na blockade, glucagon

390
Q

dialysis for BB or CCB OD

A

“SANTA” - sotalol, acetalol, timolol, atenolol, nadolol

391
Q

(3) zones of burns

A

concentric zones: irreversible coagulation and necrosis, ischemia with impaired microcirculation(risk of necrosis), transient hyperemia

392
Q

6 indications to intubate burn patients

A

upper airway obstruction, unable to handle secretions, hypoxemia, obtunded, muscle fatigue suggested by RR, hypoventilation

393
Q

Parkland formula for burns

A

4cc/kg/%BSA - first half in 8 hours, then second half over 16 hours

394
Q

pediatric burn fluid resuscitation formula

A

lund-browder estimation

395
Q

burn classification

A

first degree (red, painful, dry), second degree superficial (pink, blister, moist, painful), sceond degree deep (pink, hemorrhagic blister, red, moist, painful), third degree (white/brown, dry, leathery, no sensation), fourth degree (brown, charred, dry, no sensation)

396
Q

signs of upper airway burns

A

soot around nose/mouth, charring, mucosal inflammation, edema, carbonaceous sputum

397
Q

true diagnosis of upper airway burn

A

direct visualization with fibroscopy before and after intubation showing soot, charring, mucosal inflammation, edema, necrosis

398
Q

signs of lower airway burns

A

wheezing, crepitation, hypoxemia, abnormalities on chest Xray, V/q mismatch, ARDS

399
Q

MGMT of aortic dissection

A

pain - fentanyl 25-50 mcg bolus, HR control of 60: labetolol (10-20 mg bolus), vasodilator for BP 110 (0.25-0.5 mcg/kg/min)

PGY1 (12 decks)

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