Emergency Medicine Flashcards
POCUS finding on Tension PTX
no comet tails, no lung sliding
Big 5 causes of Chest Pain
MI, PE, TPX, Aortic dissection, esophageal rupture
CXR findings for aortic dissection
widened mediastinum, left pleural effusion, indistinct aortic knob, separation of >4mm of intminal calcification, depressed mainstem bronchi
Pathogenesis of Stable Angina
fixed stenosis of atheroma resulting in mismatch between oxygen supply and demand
Pathogenesis of ACS
plaque rupture
3 Characteristics of Typical Chest Pain
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
MGMT of Chronic Stable Angina
- General - lifestyle, RF reduction
- antiplatelet - ASA, clopidogrel if contraindicated
- beta-blocker (metoprolol, atenolol)
- Nitrates for symptoms
- Revascularization
What is Variant Angina/Prinzmetal angina
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
DDx for troponitis
MI, CHF, AFib, acute PE, myocarditis, chronic renal insufficiency, sepsis, hypovolemia
Acute MGMT of NSTEMI
- General - VOMIT, ASA, NG SL/IV, morphine IV
- Antiplatelet - ASA x2, ticagrelor/prasugel, +/- IV GP IIb/IIIa inhibitor (abciximab) if PCI
- Anticoagulation - UFH/bivalirudin if PCI, LMWH for thrombolysis or nothing
- beta blockers
- coronary angiography +/- reperfusion.
NO THROMBOLYSIS FOR UA/NSTEMI
Acute MGMT of STEMI
- General
- Antiplatelet - ASA
- Anticoagulation - GB IIb/IIIa inhibitor (abciximab); UFH post PCI, LMWH post thrombolysis
- PCI or thrombolysis
Absolute Contraindication to Thrombolysis in STEMI
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
Complications of MI
arrhythmia, myocardial rupture (LV wall, papillary muscle, ventricualr septum), CHF, post-infarct angina, recurrent MI, thromboembolism, percarditis, dressler’s syndrome
Classic Triad for Spinal Epidural Abscess (only seen in 13%)
fever, back pain, neurological deficits
post void residual cut offs for cauda equina
> 200 is positive test, < 100 cc less likely
Indications for plain film spinal/back Xray
> 70 yo, unexplained weight loss, pain worse with rest, prolonged steroid use, cancer, IV drug use, osteoporosis
Cauda Equina/SCC MGMT
IV opioids, IV dexamethasone, consult neurosurgery stat
Bones of the hand: “so long to pinky here comes the thumb”
Scaphoid lunate triquetrum pisiform hamate capitate trapezoid trapezium
Terry Thompson Sign (X Ray)
Scapholunate dissociation
What do you see on x ray of Lateral view of hand
RLC- Radius lunate capitate; best way to see triquetrum fracture
Perilunate dissociation
Lunate and capitate not aligned
Areas high risk of tissue necrosis with epi in lidocaine
Fingers toes penis nose
Lidocaine time of onset, duration
Instantaneously, 20-60 minutes
Dose of lidocaine without epi, with epi
5 mg without epi, 7 with epi (vasoconstriction)
Signs of lidocaine toxicity
Perineal numbness, dizziness, seizures, cardiovascular collapse, death
Ways to help with lidocaine irritation during administration
Small needle, bicarbonate, warming solution
Topical anaesthetics used
Lidocaine-epi-tetracaine (LET), eutectic mixture of local anaesthetics (EMLA)
Symptoms of hyperkalemia
Nausea, palpitations, muscle stiffness, muscle weakness, parenthesis, areflexia, ascending paralysis, hypoventilation
ECG changes from hyperkalemia
Peaked and narrow T-waves, decreased amplitude and eventual loss of p waves, prolonged PR interval, widening of the qrs, AV block, vfib, asystole
Hyperkalemia MGMT
“C BIG K Drop”: calcium gluconate, bicarbonate, Beta agonist, Insulin, glucose, k exylate, diuretics, dialysis
How to shift K
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
Difficult BVM ventilation
BOOTS - beard, obese, older, toothless, snores/stridor`
Difficult intubation
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.)
Temporizing measures for airway
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)
Indications for intubation (4Ps)
patency, protection, predicted deterioration, pulmonary toileting, positive pressure ventilation
Definition of Rapid Sequence intubation (RSI)
simultaneous adminstration of sedative (induction) and paralytic agent (maintenance) to decrease risk of aspiration
Steps for RSI
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)
Contraindication to RSI
anticipated difficult airway, particularly difficult BVM ventilation - awake intubation, inadequate familiarity and comfort with technique, unnecessary (patient is in cardiac arrest, near-arrest)
Tools to help with intubation
bimanual laryngoscopy, bougie, video laryngoscopy (glidescope)
Life-threatening causes of dyspnea
PE, pulmonary edema (CHF), acute exacerbation of COPD, acute severe asthma, TPTX,
Kussmaul’s breathing
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.
Cheyne-Stokes Breathing
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]
syncope definition
sudden and transient loss of consciousness with loss of postural tone accompanied by rapid return to baseline
pathophysiology of syncope
dysfunction of both cerebral hemisphere or brainstem, usually from hypo-perfusion
DDx of syncope (cardiac)
cardiac vs. non-cardiac; cardiac: arrhythmias, pacemaker, structural (AS, HOCUM), MI, dissection, cardiomyopathy, PE
DDx of syncope non cardiac
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)
Hx and Physical for syncope
exertional, cardiac RF, comorbidities, medication/drug use, family hx, orthostatic symptoms, r/o seizure/stroke/head injury; cardiac exam, CNS exam
Investigations for syncope
CBC, glucose, lytes, extended lytes, BUN, Cr, CK, troponin, BHCG, ECG
ECG changes for syncope
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
MGMT of syncope
cardiogenic: cardiology consult, pacemaker; non-cardiogenic: d/c with follow-up, outpatient cardiac workup, use Canadian Syncope Risk Score for stratification
Migraine definition
POUND: pulsatile, onset 4 - 72 hours, unilateral, NV, disabling intensity, photophobia/phonophobia, chronic, recurrent, +/- aura
Cluster HA Definition
unilateral sudden sharp retro-orbital pain, < 3 hours, pseudo-Horner’s symptoms, precipiated by alcohol/smoking
Tension HA
tight band-like pain, tense neck/scalp muscles, precipitated by stress or lack of sleep
DDx of headaches
intracranial: bleed, infection, mass, cerebral venous sinus thrombosis; extra-cranial AACG, temporal arteritis, carotid artery dissection, CO poisoning
Red Flags for HA history
sudden onset, thunderclap, exertional onset, meningismus, fever, neurological deficits, AMS), increased ICP (persistent vomiting, HA worse lying down, and in the AM)
Investigations for HA
imaging to r/o deadly causes. refer to Ottawa SAH Rules for CT. LP if suspicion for SAH
MGMT for benign HA
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
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
age > 40, neck pain/stiffness, witnessed LOC, onset during exertion, thunderclap (peaking pain within 1 second), limited nec flexion on examination
CT Head window to r/o SAH
non-contrast CT head scan within 6 hours of HA; LP if continued suspiciou and CT head is normal, CTA if cerebral aneurysm
3 Is to rule out in bloody diarrhea
Ischemia, infection (bacteria), inflammation (colitis)
Red flags of diarrhea
Blood, pain, recent travel, recent antibiotic use, elderly with CV/AFib
DDX for SOB
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
PERC Criteria
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
DDx of deadly CP
PET MAC - PE, esophageal rupture, TPTx, MI, aortic dissection, cardiac tamponade
DDx of CP (non-deadly)
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
MGMT of ACS
ASA, nitro (avoid in RV infarct), ticagrelor/clopidogrel, LMWH, code STEMI
MGMT of PE
anticoagulation, thrombolysis if massive PE
MGMT of esophageal rupture
urgent thoracics consult, IV antibiotics, NPO
MGMT TPTX
needle decompression (2n ICS at MCL), chest tube (4-5th ICS)
MGMT tamponade
pericardiocentesis
MGMT Dissection
urgent vascular consult, reduce BP and HR with IV labetalol, surgery vs medical MGMT
HEART Score (Chest Pain Risk stratification)
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
DDx of RUQ Abdo pain
biliary disease, hepatitis, pancreatitis, PNA, pleural effusion, PE
DDx of Epigastric pain
gastritis, PUD, duodenitis, pancreatitis, ACS
DDx of LUQ
pancreatitis, gastritis, PNA, pleural effusion, PE
DDx of Right Flank
colitis, perforation, obstruction, renal colic, AAA, pyelonephritis
DDx of umbilicus
colitis, perforation, obstruction, aortic dissection, AAA
DDx of L flank pain
colitis, perforation, obstruction, renal colic, pyelonephritis, AAA
DDx of RLQ
appendicitis, ectopic pregnancy, ovarian torsion, testicular torsion, PID, TOA, epididymitis, orchitis, renal colic
DDx of hypogastric
UTI, renal colic, obstruction
DDx of LLQ
diverticulitis, ectopic, PID, TOA, testicular torsion, epididymitis, orchitis, ovarian torsion, renal colic
Ruptured Ectopic RF
Hx of STI/PID, recent IUD, previous ectopic, fallopian tube surgery, tubal ligation
Ruptured AAA RF
elderly, hx of HTN/DM, smoking, trauma Hx
Pancreatitis RF
alcohol, biliary pathology
Charcot’s Triad (cholangitis)
fever, jaundice, RUQ pain
Mesenteric Ischemia RF
elderly, CAD, CHF, dehydration, infection
Obstruction RF
previous surgery, malignancy, elderly
Perforated Viscus RF
diverticulitis, PUD, malignancy, instrumentation
Complicated diverticulitis RF
elderly, low-fibre diet, western population
Pelvic Pain GYNE DDx
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
Pelvic Pain non-GYNE DDx
urolithiasis, pyelonephritis, cystitis, testicular torsion, prostatitis, sexual abuse
Back Pain DDx (DEADLY)
cauda equina, spinal cord compression (mets, epidural abscess, hematoma, disc herniation, spinal fracture with subluxation), meningitis, vertebral OM, transverse myelitis
Back Pain DDx (vascular)
aortic dissection, ruptured AAA, PE, myocardial infarction
Red Flags of Back Pain
“BACK PAIN”: bowel/bladder dysfunction, anesthesia (saddle), constitutional symptoms, chronic disease, paresthesia, > 50 yo, IVDU/infection, neurological deficits
MGMT Epidural abscess or vertebral OM
MRI for definitive dx, bone scan (OM), broad spec antibiotics, orthopedics consult
Anaphylaxis definition
life-threatening immune hypersensitivity systemic reaction leading to histamine release, vascular permeability, vasodilation
DDx of Anaphylaxis
other causes of shock, angioedema, flush syndrome, asthma, red man syndrome
Definition of Asthma
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
MGMT of anaphylaxis
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
Disposition of Anaphylaxis
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)
Asthma definition
chronic inflammatory airway disease with recurrent reversible episodes of bronchospasm and variable airflow obstruction
Common triggers in asthma
lack of medication, URTI, environmental allergens, smoking, exercise
Mild Asthma definition
SOBOE, chest tightness, >95% O2 Sat, expiratory wheezing, FEV1 > 60% predicted
Mod Asthma definition
SOB at rest, cough, congestion, nocturnal symptoms, >95% O2, expiratory wheezing, FEV1 40 - 60%
Severe Asthma definition
agitated, diaphoretic, laboured breathing, difficulty speaking, tachycardia, high BP, O2 90 - 95%, worsening resp distress, expiratory and inspiratory wheezing, FEV1 < 40% predicted
Respiratory Arrest
altered mental status, cyanotic, decreased respiratory effort, bradycardia, high RR, low O2 sat < 90% despite oxygen, silent chest (ready for intubation)
Asthma Hx
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
MGMT of acute asthma exacerbation
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
MGMT of severe asthma
MgSo4 2g IV over 30 mins, epinephrine 0.3 mg IM then 5 mcg/min IV infusion, ketamine 1 mg/kg with BiPAP
Triggers of COPD
viral URTI, PNA, environmental allergens, smoking, CHF, PE, MI
COPD Hx
sputum production/purulence, duration of symptoms, previous exacerbations, comorbidities, functional status, home O2, intubation
COPD Signs for Severity
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
MGMT of COPD
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
MI Definition
evidence of MI on ACS diagnosed by cardiac marker abnormalities and one of: ECG changes, HPI consistent with ACS
Stable Angina Definition
Transient episodic chest discomfort precipitated by exertion/emotion, lasts < 15 mins, relieved by rest or nitro
STEMI Definition
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
NSTEMI Definition
infarction without ST elevation
MGMT Of ACS
ASA 325 mg chewed, ticagrelor 180 mg (if PCI), UFH 4000 U if PCI then 12 U/kg/hr, LMWH if thrombolytics
CHF Etiology
CAD, HTN, valve abnormalities, cardiomyopathy, infarction, pericardial disease, myocarditis, cardiac tamponade, metabolic disorder, toxins, congenital
CHF triggers
ischemia, dysrhtyhmia, mechanical (papillary muscle rupture), medications (forgot, BB, NSAIDs, steroids), anemia, infection, pregnancy, hyperthyroidism, high salt, PE, HTN, renal failure
Sx of L-sided HF
SOB, orthopnea, PND, nocturia, fatigue, altered LOC, syncope, angina, pulmonary congestion
Sx of R-sided
fatigue, abdominal distension, swelling, weight gain; pitting edema, JVP elevation, hepatomegaly, ascites
MGMT of HF
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)
Causes of dysrhythmias
MI, drugs, toxins, lyte imbalances
Types of SVTs
regular: sinus tachy, atrial tachy, atrial flutter; AV node: SVT (AVNRT > AVRT), juctional tachycardia; a fib, multifocal atrial tachycardia, SVT with aberrancy
Types of Ventricular tachydysrhythmias
VTach, SVT with aberrancy, Vfib, polymorphic VT, AFib with WPW
Signs of “unstable patient” in dysarrhythmias
altered LOC, respiratory distress, hypotension, syncope, chest pain, signs of CHF, shock
ACLS for bradycardia
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
ACLS for tachycardia
synchronized cardioversion
VF or pVT MGMT as per ACS
shock-cpr-shock, epi 1 mg IV q3-5mins, consider amiodarone 300 mg IV with 2nd dose 150 mg IV bolus
Ruptured AAA RF
FHx, HTN, CAD/PVD, DM, connective tissue disease, smoking
Risk of rupture for < 5 cm, 5 - 7 cm, > 7 cm
< 5cm: 0.3% /yr; 5 - 7 cm: 10% risk/yr; >7 cm: 20% risk/yr
Classical Sx of ruptured AAA
acute onset back/abdo/flank pain, hypotension, pulsatile abdominal mass
Inv for AAA
POCUS to identify > 3 cm, ECG, CTA
MGMT of AAA ruptured
ABCs, VOMIT, STAT vascular consult, IV fluid, BP for 90 - 100 mg, massive transfusion protocol, open surgery vs. endovascular aneurysm repair
Post-Op Complications of AAA ruptured
infection, ischemia, aortoenteric fistula (GI bleeding), endo leak
Acute Arterial Occlusion definition
acute embolus or thrombosis; true emergency as irreversible damage can occur within 6 - 8 hours
RF for acute arterial occlusion
atherosclerosis, MI with LV thrombus, AFib, valve stenosis, stents/grafts
Hx in Acute arterial occlusion
6Ps: pain, paresthesia, pallor, polar, pulselessness, paralysis
Investigations for Acute Arterial Occlusion
doppler probe with proximal BP cuff (perfusion pressure < 50 mmHg, ABI < 0.5)
MGMT for acute arterial occlusion
heparain 5000 IU bolus, revascularization vs. CT angio
DVT and PE RF
venous stasis, vessel injury, hypercoagulability
MGMT DVT
LMWH, heparin infusion if renal impairment, DOAC
PE MGMT
LMWH, DOAC, heparin, warfarin transition
GI Bleeding RF
medications, excessive vomiting, bleeding disorders, malignancy, alcohol use, ulcer history, H.Pylori
DDx of Upper GIB
PUD (gastric > duodenal), gastritis/esophagitis, esophageal varices, MW tears, gastric CA
DDx of LGIB
colitis (inflammatory/infectious/ischemic), anorectal (hemorrhoids, fissures, proctitis), angiodysplasia, divertculosis, malignancy
Mimics of melena
pepto-bismol, iron ingestion, fruits (blueberries)
MGMT UGIB
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
MGMT LGIB
NPO, IV fluids, colonscopy
ACA stroke definition
leg > face/arm contralateral motor and sensory deficits, bowel and bladder incontinence, impaired judgement/insight
MCA Stroke definition
face/arm > leg contralateral motor + sensory deficits; contralateral hemianopia, gaze preference towards lesion; aphasia (dominant) or neglect (non-dominant)
PICA stroke (Wallenberg syndrome)
pain/tempoerate loss on contralateral side + ipsilateral face, ipsilateral horner’s syndrome, 4Ds dysphagia, diplopia, dysarthria, dysphonia
Acute Stroke MGMT
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
DKA Definition
insulin deficiency + stressor –> counter-regulatory hormone excess –> lipolysis (ketoacidosis) and osmotic diuresis (Dehydration); serum glucose > 16 mmol/L, HCO3 < 15, pH 7.3
HHS Definition
relative insulin deficiency + stressor –> counter regulatory hromone excess –> osmotic diuresis; glucose > 30 mmol/L; severe dehydration, hyperosmolality
Triggers for DKA
7Is: infection, ischemia, iatrogenic, incision, intoxication, initial, insulin
Inv for DKA/HHS
lytes, glucose, urine and serum ketones, beta-hydroxybutryate, CBC, extended lytes, BUN, Cr, cardiac enzymes if symptoms
MGMT of DKA
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
SIRS definition
2+ of T<36 or >38, HR >90, RR > 20 or Co2 > 32, WBC < 4 or > 12
sepsis definition
life threatening organ dysfunction caused by dysregulated response to infection
Inv for sepsis
CBC, lytes, extended lytes, BUN/Cr, LFTs, VBG, lactate, INR/PTT, blood urine C+S, ECG, CXR
MGMT for sepsis
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
Causes of hyperkalemia
pseudohyperkalemia, chronic renal failure, acute acidosis, medications (ACEi, NSAIDs, diuretics, digoxin, septra), cell death (rhabdo, burn/crush injuries, hemolysis, TLS)
ECG changes with hyperkalemia
peaked T wave, PR prolongation, loss of P waves, widened QRS, sine wave
MGMT Of hyperkalemia
C Big K Drop: calcium gluconate 3 amps, bicarb, insulin 10U R 1-2 amps D50W, salbutamol, lasix, Kexylate, dialysis
Hypokalemia Causes
renal losses (diuretics), non-renal losses, metabolic alkalosis
ECG Changes in hypokalemia
loss of T waves –> U waves –> prolonged QT -> torsades, VTAch, VFib
MGMT of hypokaelmia
replace K+ (KCl 10 - 20 mmol/hr IV, MgSo4 500 mg/h IV to ensure K being driven into cells
Causes of hyponatremia
hypo-osmolar: hypervolemia (CHF, cirrhosis, nephrotic syndrome), euvolemia (SIADH), hypovolemic (adrenal insufficiency, vomiting, diuretics)
MGMT of hyponatremia
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)
Causes of hypercalcemia
malignancy (breast, kidney, lung), hyper PTH, granulomatous disease, medications (thiazides, lithium, estrogen, vitamin A/D toxicity)
ECG changes in hypercalcemia
short QT, ST elevation, bradyarrhythmias, AV block
MGMT of hypercalcemia
IVF bolus, then infusions, UOP of 2L/day target. lasix to promote diuresis, bisphosphonates, calcitonin
Causes of peripheral vertigo
BPPV, vestibular neuronitis, labyrinthitis, meniere’s disease
Causes of central vertigo
cerebellar hemorrhage, PICA stroke, head trauma, vertebrobasilar migraine, MS, TLE
BPPV definition
short lived positional, associated with NV, no auditory symptoms
Vestibular neruonitis definition
sudden and severe vertigo, increasing intensity over hours, symptoms subside over days to weeks, exposure to infections or toxins, no auditory symptoms
labryinthitis definition
positional, co-existing ENT infection, +/- febrile/toxic apperance, auditory symptoms of mild to severe hearing loss
menieres disease definition
recurrent episode of sudden severe rotational vertigo, NV, lasting hours, +hearing loss or tinnitius
Signs and Symptoms for peripheral vertigo
sudden severe onset, horiztonal/rotary nystagmus, auditory findings, no neurological findings
Signs and symptoms for central vertigo
gradual onset, weeks to months, vertical nystagmus, no auditory findings, may have neuro findings
physical exam for vertigo
gait/coordination, neuro exam, Dix-Hallpike, roll test, HINTS exam (if AVS)
HINTS Exam
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)
MGMT of peripheral vertigo
BPPV: Epley maneuver, betahistine/histamine for Meniere’s, antibiotics and steroids fore vstibular neuronitis or labryinthitis
Causes of Epistaxis
trauma, URI, allergies, low humidity, polyps, FB, idiopathic, systemic (antigoaculoation, pregnancy)
BW for epistaxis:
CBC, INR/PTT, +/- cross and type
MGMT of epistaxis
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
MGMT Of anterior epistaxis
anterior packing: nasal tampon, rhino rockets or vaseline gauze packs; apply anterior pack to active side first, if ineffective, pack both nares
MGMT of Posterior epistaxis
epistat or foley catheter, apply traction once inserted; keflex x 5 days or until pack removed to prevent toxic shock syndrome
Peritonsillar abscess signs
muffled voice, uvular deviation
retropharyngeal abscess signs
drooling, airway compromise
tracheitis signs
stridor, laboured breathing
epiglottitis signs
fever, stridor, rapidly progressive swelling
Centor Criteria
no cough, exudates, LN anterior cervical, temperature, or age: +1 if 3 - 14 yo; -1 if 44 yo
MGMT of pharyngitis
fluids, antipyretics, single dose dexamethasone, antibiotics can reduce symptoms by 16 hours but do not reduce complications
Renal Colic RF
lifestyle, hereditary (RTA, G6PD), medications (loop diuretics, acetazolamide, topiramate), medical conditions (UTI, IBD, gout, DM, hypercalcemia), obesity
Signs and Symptoms of Renal Colic
unilateral flank pain radiating to groin, writhing in pain, N/V, trigonal irritation (frequency, urgency); fever, CVA tenderness
Investigations for Renal Colic
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
MGMT of Renal Colic
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.
Reasons to consult urology for renal colic
intractable pain, infected stone, compromised renal function (bilateral obstruction, single kidney, transplated kidney)
UTI and Pyelonephritis Etiology
“KEEPS” - klebsiella, ecoli, enterococci, proteus, saprophyticus
Signs and Sx of UTI/Pyelo
LUTS (frequency, urgency, dysuria, hematuria), pyelo (fever/chills, flank pain, NV), associated vaginal/cervicitis symptoms, sexual history
Investigations for UTI/pyelo
urine dip, R&M, C&S, CBC, BUN/Cr
MGMT of UTI
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
Hx and Phys of fractures
mechanism of injury, neuro symptoms, blood loss; active and passive ROM, NV status, assess bleeding/open fractures, compartment syndrome, joint above and below fracture
Colles Fracture definition
FOOSH, distal radius fracture with dorsal displacement; “dinner form deformity. MGMT: restore radial length, correct dorsal angulation
Scaphoid fracture definition
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
Boxer’s fracture
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
Jones Fracture
stress injury, midshaft 5th MT fracture, high incidence of non-union. non-WB BK cast x 6 weeks
Hip facture signs
shortened and externaly rotated leg, painful ROM
Definition of status epilepticus
continuous or intermittent seizure activity for greater than 5 mins without regaining consciousness
Sx and signs for seizures
preceding aura, rapid onset, loss of bladder/bowel control, tongue-biting (sides of tongue), injuries to head and spine, aspiration, urinary incontinence
Investigation for first time presentation of seizure
CBC, differential, electrolytes including extended lytes, head CT
pheyntoin adverse effects
dysrhythmias, hypotension - place on cardiac monitor
Causes of seizures
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
Hx for seizures
time of onset, PMH, ingestion of toxins/alcohol, fever, headache, infectious, pregnancy
tonic-clonic seizure presentation
foaming at mouth, abrupt onset, tongue biting, urine or fecal incontinence, post-ictal state lasting 20 - 30 mins
Physical for seizures
pupil reactivity skin, vital signs for toxidrome
investigations for Status epilepticus
bedside glucose, CBC, lytes, extended lytes, VBG, calcium, ETOH, serum salicylates, urine tox screen, ECG, LP CT head if necessary
MGMT of status epilepticus
ABCs, hypoglycemia - give 1 ampule IV d50, benzo, phenytoin, intubate if not already especailly before phenobarbitol
Dosing for status epilepticus (70 kg)
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
complications of SE
cardiovascular (MI, arrhythmias, cardiac arrest), hypotension, respiratory failure from drugs or seizures, rhabdomyolysis, non cardiogenic pulmonary edema
Definition of radiculopathy
Spinal nerve root compression
Definition of myelopathy
Compression of spinal cord
Features of MSK related neck pain
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
Features of cervical myelopathy or radiculopathy
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
Reflexes for spinal cord level
C5: biceps, C6: brachioradial, C7: triceps, L4: knee S1: Achilles
Etiology for positive SLR
Herniated disc
Hoffman Sign
Flexion of thumb and index finger when flicked middle finger - upper motor neuron sign
Indications for CSpine X-ray
Chronic persistent neck pain, trauma, malignancy, surgery, rheumatological disease
Spinal infection MGMT
Vancomycin + pip-taxi
Shock index definition
HR/sBP. If greater than 1, sign of poor pefusion/shock
Mortality rate of heart failure
50% in 5 years
Most common Precipitating Factors of Heart Failure
AFib, MI, medication changes, high Na diet, drugs, physical exertion
Clinical Features of HF
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)
DDX for HF
COPD, asthma, PNA, PTX, pleural effusion, PE< ACS
Diagnosis of HF
clinical! highest sensitivity is SOB on exertion, specificity is PND, orthopnea, edema
CXR for HF
up to 20% will have initially normal CXR; pulmonary venous congestion, cardiomegaly, interstitial edema
acute MGMT of HF
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),
Indications for ICU admission for HF
altered LOC, persistent hypoxia, hypotension, troponitis, ischemic ECG changes, BUN > 43, Cr > 2.75, tachypnea, decreased urine output
BUN Value
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
Value of BUN:Cr
kidney function
Definition of AKI
< 3 months ; CKD is > 3 months
Types of AKI
Pre-renal, renal, post-renal
Pre-renal AKI definition
decreased renal blood flow (most common cause); Etiology: decreased ECF volume (CHF, liver failure/cirrhosis, drugs (NSAIDS, RAAS blockers), hepato-renal syndrome
Lab findings for pre-renal AKI
hemo-concentration (elevated Hgb, albumin), low urinary flow (elevated serum urea:Cr ratio), bland urine, low urinary Na excretion
Common causes of pseudohyponatremia
increased large molecular particles (i.e., hypertriglyceridemia or hyperproteinuria), inaccurate blood draw (near 5% dextrose infusion site), hyperglycemia
DDx of d-dimer
Artero-thromboembolism, Stroke, MI, A Fib, DVT, PE, DIC, preeclampsia, sepsis, autoinflammatory disease, surgery, liver disease, malignancy, renal disease, AKI,CKD, pregnancy
Causes of A.Fib
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
Definition of massive hemoptysis
200 - 600 cc/24 hours
Warfarin reversal
Octoplex, vitamin K
Dabigatran
Idareyousisimab, PCC
Lemierre disease definition
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,
Definition of ARDS
Bilateral patchy infiltrated consistent with pulmonary edema, paO2/FiO2 less than or equal to 300, no clinical evidence of left atrial hypertrophic
Medications given via ETT
“Navel”- naloxone, atropine, ventolin, epinephrine, lidocaine
DDx for hemoptysis
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
Source of hemoptysis
massive: bronchial/pulmonary arteries, minor: tracheobronchial capillaries
Bronchiectasis definition
chronic necrotizing infection resulting in bronchial wall inflammation and dilation resultingin tissue destruction and remodeling
Inv for hemoptysis
CBC+Diff, G&S, renal, CXR, CT Chest (can have normal CXR), eventual bronchoscopy
Hemoptysis + tracheostomy
rule out tracheo-innominate artery fistula (TIF)
Key Deadly DDx for hemoptysis
PE, DIC, tracheo-innominate artery fistula, aortobronchial fistula, post-op; trauma, bronchiectasis, PNA, abscess/fungal, endocarditis
Crystal meth rx management for hallucinations
Low dose olanzapine
Snakebites in Ontario
Necrotizing toxin- do not do anything! Call poison control, give antidote
ARDS MGMT (ventilator)
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
Ventilation settings: AC, SIMV, PSV
A/C: assisted control
SIMV: synchronized intermittent mechanical ventilation
Volume vs. pressure-targeted; pressure supported ventilation (PSV)
Tidal volume approach for ventilation patients
8 ml/kg of IBW, lower if status asthmaticus or ARDS/ALI; in pressure-targeted modes, start pressure at 20 cmH2O
RR approach for ventilation patients
2/3 of pre-intubation rate; higher if sepsis, ARDS, metabolic acidosis; exception is status asthmaticus
minute ventilation approach for ventilation patients
MV: RR x TV; thus if you decrease one or both, it will decrease minute ventilation
PEEP setting in ventilation
5 for almost all adults, can adjust by increments of 2 for marked hypoxia
FiO2 setting ventilation
100%
Flow Rate setting ventilation
60L/min
Sx and signs of hypoglycemia
altered/depressed LOC, seizures, neuro deficits
Sx and signs of myxedema coma (hypothyroidism)
hypothermia, altered LOC, hyponatremia, high pCO2, high CK, high catecholamines, low cardiac voltage, +/- pericardial effusion
physical exam findings on myxedema/hypothyroidism
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
precipitating factors for myxedema coma
hypothermia, infection, CVA, CHF, GI bleeding, trauma, medications - discontinuation of meds, anaesthestic or sedatives, narcoties, amiodarone, lithium, raw bok choy
MGMT of myxedema coma
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)
definition of adrenal crisis
life-threatening emergency due to acute deficiency of adrenocortical hormones (cortisol and aldosterone)
classic findings in adrenal crisis
severe hypotnesion refractory to IV fluids and vasopressors
function of adrenal glands
produces mineralcorticoids (aldosterone) and glucocorticoids (cortisol) and androgens in outer cortex; catecholamines produced in inner medullary zones are
HPA Axis for corticosteroids
hypothalamus –> CRH to anterior pituitary –> ACTH to adrenal cortex – >cortisol; stress activates at all levels of HPA axis
Sx and Signs of adrenal crisis
non-specific: weakness, confusion, fever, N/V, abdominal pain; shock and fever
Common triggers for adrenal crisis
infection, surgery, burns, sepsis, trauma, metabolic, cardiovascular events
effect of glucagon
promotes gluconeogenesis and glycogenolysis, as well as lipolysis (fat into fatty acid)
Definition of DKA
pH < 7.3, bicarb < 15, anion gap > 12, positive serum ketones (beta hydroxybutyrate), hyperglycemia, type 1 DM
Signs in DKA
Kussmaul respirations, tachycardia, fruity breath, abdo pain, vomiting, polyuria, AMS
Triggers for DKA
3 Is - infection, infarction, indiscretion (med noncompliance, medications, substance abuse, pancreatitis, pregnancy, trauma, MI)
medications associated with DKA
steroids, atypical antipsychotics, sympathomimetics, SGLT2 inhibitors, HIV meds, anti calcineurin immunosuppressives.
killers in DKA
hypokalemia, hypoglycemia, alkalosis, CHF, cerebral edema
MGMT for DKA
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
HHS diagnostic criteria
glucose > 33.3; plasma osmolarity > 320 mmol/kg
MGMT of HHS
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
Sx of hypoglycemia
sweating, tremor, tachycardia, hunger, neuro smptoms, cofusion, seizures, coma
MGMT of hypoglycemia
PO intake, if altered 1 amp D50W (up to 3), if no IV access, glucagon 2 mg IM (will not work in alcoholics)
Somogyi phenomenon
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
role of cortisol
catabolic hormone creating fuel in times of stress (creates): stimulates gluconeogenesis in the liver, production of FFAs, release of AA
RFs for adrenal crsis
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
Signs and Sx of Adrenal Crisis
hypotension, vasodilatory shock (refractory to fluid and vasopressors), N/V, abdo pain/tenderness, fever, delirium cutaneous hyperpigmentation or vitiligo
Lab findings in adrenal crisis
electrolyte abnormalities due to minerallocorticoid deficiency; high K+, low Na, low bicarb, high Cr, low glucose, hypercalcemia, eosinophilia
Testing for suspected adrenal insufficiency
random cortisol level (if > 20, r/o adrenal insufficiency), ACTH stimulation test
definition of adrenal crisis (Rushworth 2019)
acute deterioration with absolute hypotension sBP M 100 or relative hypotension change in 20 sBP; resolution within 1-2 hours of IV steroid administration
MGMT of adrenal crisis
- 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
prevention of adrenal insufficiency
50 mg IV hydrocortisone q6hrs for patients experiencing severe stress
Signs of intracerebral hemorrhage
altered LOC, neck stiffness, seizures, DBP > 110, bilateral neurological findings, vomiting, HA
POCUS findings for ICH
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
initial MGMT of suspected ICH
- airway for risk of aspiration (nausea, vomiting, low GCS, apneic, herniating) 2. sBP < 180 before CT head if possible
DDx of ICH
HTN, amyloid angiopathy (large lobar bleeds), coagulopathy associated ICH and cerebral venous thrombosis
MGMT of ICH within the golden hour - 6 big considerations
BP, coagulopathy - reverse blood thinners + plt transfusion, glucose, temperature, seizure activity, ICP
target BP for ICH
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
target antihypertensive agents
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
indication for plt transfusion in ICH
plts < 50 000 absolute; < 100 000 relative at most sites
reversing warfarin MGMT for ICH
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
reversing LBWH and UFH in ICH
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
reversal for dabigatran in ICH
idarucizumab 5 g over 15-20 mins; if not available, factor 8 inhibiting bypass activity FEIBA or 4 factor PCC
reversal of Xa inhibitors (apix or rivarox)
4 factor PCC at dose of 50 IU/kg up to 3000 U
other MGMT for high ICP
- 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
intubation for ICH patients - neuroprotective
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,
hypertonic therapy for ICH
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)
ICH hematoma volume equation
ABC/2 formula: A - length x b - width x c - slice width (# of slices present with hemorrhage)
2 most important predictors of early deterioration in ICH based on imaging
hematoma volume and intraventricular hemorrhage
definition of spot sign on contrast CT
represents contrast extravasation and is independent predictor of hematoma expansion, functional outcome and mortality
indication for surgery in ICH
all posterior fossa bleeds unless GCS 14+ and small hematomas; for supratentorial bleeds, consult neruosx
SUMMARY OF MGMT OF ICH
- 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
Dx of SBP
paracentesis revealing > 1000 WBCs or > 250 PMNs
Abx for MRSA
vancomycin (IV), TMP-SMX, rifampin, clindamycin, tetracycline, linezolid
Abx for pseudomonas
pip-tazo, cefepime, FQ (cipro and levo), carbapenem (except ertapenem), ceftazidime, AG
Hepatic Encephalopathy Dx
dx of eclusio
what is the clinical endpoint of atropine administration with organophosphate poisoning?
bronchial secretion
Signs of cholinergic crisis
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)
MoA of organophosphates
inhibits cholinesterase breakdown of acetylcholine at NM junction –> excess acetylcholine at nicotinic and muscarinic receptors
antidotes for cholinergic toxicity
atropine, 2-PAM (pralidoxime)
Muscarinic signs of cholinergic toxicity: “SLUDGE DUMBBELLS”
Salivation, lacrimatio, urination, diarrhea, GI cramps, emesis, diarrhea, urination miosis, bradycardia, bronchospasm, emesis, lacrimation, lethargy, salivation, seizures
Nicotinic effects of cholinergic toxicity
fasciculations, muscle weakness, paralysis
the Killer Bs for cholinergic toxicity
Bradycardia, bronchorrhea, bronchospasm
Types of cholinergic toxins
organophosphates: parathion, fenthion, malathion, diazninon; carbamates: methomyl, aldicarb; nerve agents: sarin, tabun, soman
Pathogens in Epiglottitis
HFlu, Strep, Staph, moraxella catarrhalis
Clinical Sx of Epiglottitis
fever, sore, throat, drooling, muffled voice, anxios, ill-appearing
Physical Exam signs for epiglottitis
patient is leaning forward, drooling, inspiratory stridor
Imaging finding associated with epiglottitis
thumbprint sign
MGMT of epiglottitis
prepare for intubation with pediatric ENT ASAP, IV antibiotics
5 Causes of stridor in > 6month old
croup, epiglottitis, bacterial tracheitis, retropharyngeal abscess, airway foreign body
DDx of thunderclap HA
hemorrhage (intracranial), vascular (cerebral dissection), reversible cerebral vasoconstriction syndrome (RCVS), cerebral venous thrombosis (CVT), posterior reversible encephalopathy syndrome (PRES)
Red Flag of HA
sudden onset, trauma, exertional, vision changes, altered LOC, seizures, neurological symptoms, immunosuppression, anticoagulation, sLE, pregnancy, vasculitis, cancer
RF for idiopathic intracranial HTN
obese, women ages 20 - 44
Symptoms in idiopathic intracranial hypertension
HA, transient vision disturbances, back pain, pulsatile tinnitus
Phys in HA
papilledema + normal neurological exam; LP showing elevated pressure
Cluster HA Sx
uncommon unilateral retro-orbital/supraorbital/temporal pain, associated with lacrimation, nasal congestion, rhinorrhea, conjunctival injection ongoing for days to weeks
MGMT for cluster HA
12L/min O2, sumitriptan 6 mg SC
10 DDx for life threatening HA in the ED to know
SAH, subdural/epidural, stroke, meningitis, encephalitis, tumour, cervical artery dissection, hypertensive encelopathy, pre-eclampsia, cerebral venous thrombosis, idiopathic intracranial hypertension, AACG, TA, CO poisoning
Sx of cervical artery dissection
spontaneous or trauma; thunderclap HA or subacute HA with neck pain, partial Horner’s syndrome, +/- retinal or cerebral TIA within 1 week
Inv for cervical artery dissection
CTA
MGMT of cervical artery dissection
antiplatelet, anticoag with consultant advice
vertebral artery dissection sx
neck or occiput pain, posterior circulation symptoms
posterior circulation symptoms
ataxia, vertigo, dysarthria, diplopia, dysphagia
cerebral venous thrombosis sx
thundercalp or subacute, stroke like symptoms, seizures, vision changes (blurr, visual field defects)
RF for CVT
thromboembolism, papilledema, younger patients (<40), orbital chemosis and proptosis, dilated scalp veins, scalp edema, ENT infections
Inv for CVT
CT-V +/- LP
most common SAH aneurym
berry/saccular aneursym rupture; second is perimesencephalic, third is AVM
Sx for SAH
thundercalp HA, peaking within minutes, lasting longer than 1 hour, N/V, seizure, neck pain and stiffness, confusion, neurological deficits, elevated BP
Signs for SAH
stroke-like symptoms, seizures, CN III palsy (mass effect), CN VI palsy with diplopia, subhyloid hemorrhage, meningismus
RF for SAH
cerebral aneursym, FHx of SAH or polycystic kidney disease, CTD, HTN, binge drinking, cocaine, exertional syncope
ECG changes in SAH
neurogenic myocardial stunning ans coronary vasospasm resulting in deep wide precordial T wave inversions, bradycardia, prolonged QT
MGMT of SAH
treat BP if MAP is > 100 for few hours using labetalol or nicardipine, prevent seizures
Posterior Reversible Encephalopathy Syndrome (PRES) definition
neurologic syndrome defined by both radiologic and clinical features: HA, confusion, visual changes, seizures, MRI showing vasogenic edema predominatntly in posterior cerebral hemispheres
RF associated with PRES
pregnancy, hypertensive crisis, immunosuppresive cytotoxic therapy, hypomagnesemia, post-transplant
MGMT of PRES
hypertension MGMT with cuatious BP lowering to 120-140 systolic or 10-25% reduction (nicardipine, labetalol), antiseizure medications
Sx of PRES “CCCV”
cephalagia, convulsion, confusion, vision loss in the context of severe hypertension
“DRESS” Syndrome definition
drug reaction with eosinophilia and systemic symptoms; severe drug reaction with 10% mortlaity rate
Rx associated with DRESS
anticonvulsants, antibiotics, antivirals, antidepressants, antihypertensives, biologics, NSAIDs, allopurinol
Clinical period before DRESS occuring
2-6 weeks after first exposure
Sx of DRESS
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
Dx of DRESS
difficult - clinical, can use criteria like Bocquet et al: rash + 1 systemic and 1 hematologic symptom
ED MGMT of DRESS
steroids, stop offending agent, consult EM
definition of bleeding trach patient
minimal amount bleeding, usually 10 cc or more
DDx of bleeding trach patient
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
innominate artery in tracheo-innomiante fistula
brachiocephalic artery
ED MGMT for bleeding trach patient
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
DDx for intubated patient deterioration
“DOPES: - displacment of tube, obstruction, PTX, equipment problems, stacked breathing
approach to respiratory distress in trach patient
- 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)
Immediate assessment of breathing in resp distress
“MASH” - movement of chest during ventilation, arterial saturation (ABG), skin colour, hemodynamic instability
AHA definition of massive PE
acute PE sustained with hypotension (sBP < 90) for at least 15 mins or requiring inotropic support, pulselessness or persistent profound bradycardia (< 40 )
submassive PE definition from AHA guidelines
acute PE without systemic hypotension but with either RV dysfunction or myocardial necrosis
signs of RV dysfunction
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
digoxin toxicity acute vs. chronic
acute: younger patients, hyperK, atrial > ventral tachycardia; chronic: elderly patients, slightly elevated hyperK, ventral>atrial tachycardia
digoxin toxicity and hyperkalemia thing to remember!!
stone heart if you give calcium!! do not give, just treat with insulin and salbutamol
digifab requirements
K+ > 5.0, hemodynamic instability/vitals, digoxin > 5 - 7, other AV nodal blockers
ECG findings in digoxin toxicity
salvadore dali sign, normal, any dysrhythmias except rapid afib (slow AFib, junctional, tachycardia, biventricular tachycardia)
clinical sx of CCB vs. BB overdose
hyperglcyemia
MGMT of CCB and BB OD
bicarb for widening QRS, Na blockade, glucagon
dialysis for BB or CCB OD
“SANTA” - sotalol, acetalol, timolol, atenolol, nadolol
(3) zones of burns
concentric zones: irreversible coagulation and necrosis, ischemia with impaired microcirculation(risk of necrosis), transient hyperemia
6 indications to intubate burn patients
upper airway obstruction, unable to handle secretions, hypoxemia, obtunded, muscle fatigue suggested by RR, hypoventilation
Parkland formula for burns
4cc/kg/%BSA - first half in 8 hours, then second half over 16 hours
pediatric burn fluid resuscitation formula
lund-browder estimation
burn classification
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)
signs of upper airway burns
soot around nose/mouth, charring, mucosal inflammation, edema, carbonaceous sputum
true diagnosis of upper airway burn
direct visualization with fibroscopy before and after intubation showing soot, charring, mucosal inflammation, edema, necrosis
signs of lower airway burns
wheezing, crepitation, hypoxemia, abnormalities on chest Xray, V/q mismatch, ARDS
MGMT of aortic dissection
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)
