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Med > Emergency Medicine > Flashcards

Emergency Medicine Flashcards

1
Q

Rapid primary survey components

A 
Airway (C-spine)
Breathing and ventilation
Circulation (pulse, hemorrhage)
Disability (neurological status)
Exposure (complete) and Environment (temperature control)
  • continually reassess during secondary survey
  • if change in hemodynamic/neurological state, return to primary survey
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2
Q

If cardiac arrest, primary survey changes to

A

CABs

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3
Q

Airway in rapid primary survey

A

Immobilize with collar
Assess ability to breathe and speak
Reassess frequently
Assess facial fx/edema/burn

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4
Q

Basic airway management

A

Protect C-spine

If C-spine injury not suspected, head tilt
If C-spine injury suspected, jaw thrust

Sweep and suction

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5
Q

Temporizing measures

A

If gag reflex present (conscious): nasopharyngeal airway

If gag absent (unconscious): oropharyngeal airway

Rescue devices: laryngeal mask airway, Combitube

Last resort: transtracheal jet ventilation

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6
Q

Definitive airway Mx

A

ETT intubation + in-line stabilization of C-spine

  • Preferred: orotracheal +/- RSI
  • If conscious: nasotracheal better tolerated
  • no 100% protection agains aspiration
  • nasotracheal relatively contraindicated in basal skull fx

If unable to intubate: surgical airway
*cricothyroidotomy

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7
Q

Contraindications to intubation

A

Supraglottic/glottic pathology

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8
Q

Medications that can be delivered via ETT

A 
Naloxone
Atropine
Ventolin (salbutamol)
Epinephrine
Lidocaine
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9
Q

If trauma requiring intubation but no immediate need what’s the next step?

A

C-spine x-ray

If positive:
Fiberoptic ETT
Nasal ETT
RSI

If negative:
Oral ETT (+/- RSI)
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10
Q

Breathing in rapid primary survey

A

Look: mental status, color, chest movement

Listen: auscultate (signs of obstruction such as stridor), breath sounds, symmetry of air entry, air escaping

Feel: tracheal shift, chest wall crepitus, flail segment, sucking chest wound, emphysema

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11
Q

Objective measures for assessment of breathing

A

Rate, oximetry, ABG, A-a gradient

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12
Q

Mx of breathing

A 
In order of increasing FiO2:
Nasal prongs
Simple face mask
Nonrebreather mask
CPAP/BiPAP

If inadequate ventilation:
Bag-Valve mask
CPAP

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13
Q

Class I hemorrhagic shock

A 
<750 ml (<15% of blood volume)
PR <100
BP: Normal
RR: 20
Capillary refill: Normal
U/O: 30cc/h
Fluid replacement: Crystalloid
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14
Q

Class II hemorrhagic shock

A 
750-1500cc
15-30%
PR > 100
RR 30
BP Normal
Capillary refill decreased
U/O 20cc/h
Fluid replacement: crystalloid
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15
Q

Class III

A 
1500-2000
30-40% 
PR >120
BP decreased
RR 35
CR decreased
U/O 10 cc/h
Fluid: crystalloid+ blood
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16
Q

Class IV

A 
>2000
>40%
PR>140
BP decreased
RR > 45
CR decreased
U/O none
Fluid crystalloid + blood
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17
Q

Indications for intubation

A

Unable to protect airway (GCS <8, airway trauma)
Inadequate oxygenation with spontaneous respiration (O2 sat <90% with 100% O2, rising pCO2)
Impending airway obstruction: trauma, overdose, airway burns, CHF, asthma, COPD, anaphylaxis, angioedema, expanding hematoma
Anticipated transfer of critical patient

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18
Q

Mx of hemorrhagic shock

A

Clear airway/breathing

Direct pressure on external wounds

Start 2 large bore IVs (14-16)

Run 1-2 L bolus of IV normal saline/ Ringer’s lactate

If no response/ continued bleeding, pRBC (crossmatched or O- for women, O+ for men)

FFP, Plt, Tranexamic in eatly bleeding

Cosider common sites of internal bleeding (surgical intervention)

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19
Q

Disability in primary survey

A 
Assess LOC (GCS)
And 
Eyes:
Pupils (size, symmetry, reactivity to light)
Extraocular movements/nystagmus 
Fundoscopy (papilledema, hemorrhage)
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20
Q

Decreased LOC + reactive pupils

A

Metabolic cause
Or
Structural cause

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21
Q

Decreased LOC + non-reactive pupils

A

Structural cause

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22
Q

GCS use

A

For use in trauma pt (less meaningful for metabolic coma)
Indicator of ”severity” of injury and neurosurgical “prognosis”
Needs to be repeated (changes more relevant than absolute number)

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23
Q

GCS in intubated pt:

A

Reported out of 10 + T

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24
Q

The GCS used for prognosis determination

A

Best post-resuscitation GCS

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25
Q

Eye in GSC

A

Eyes open

4: spontaneously
3: to voice
2: to pain
1: none

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26
Q

Verbal response in GCS

A

5: Answers questions properly
4: Confused and disoriented
3: Inappropriate words
2: incomprehensible sounds
1: none

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27
Q

Motor response in GCS

A

6: Obeys commands
5: localizes to pain
4: Withdraws from pain
3: decorticate
2: decerebrate
1: none

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28
Q

Exposure/Environment in primary survey

A 
Assess entire body
Log roll
DRE
Keep pt warm (blanket, radiant heat) 
Warm IV fluids/blood
Keep provider safe
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29
Q

3:1 rule for saline crystaloids

A

30% remains in IV space, so give 3x estimated blood loss

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30
Q

Fluid resuscitation

A

Bolus: until HR decreases, U/O increases, pt stabilizes

Then
Maintenance: 4:2:1 rule
0-10 kg: 4 cc/kg/h
10-20 kg: 2 cc/kg/h
Remaining wt: 1 cc/kg/h

+ ongoing losses and deficits ( 10% of body wt)

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31
Q

If unilateral dilated, non-reactive pupil, DDx?

A

Focal mass
Epidural hematoma
Subdural hematoma

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32
Q

Resuscitation components

A

Done concurrently with primary survey
Attend to ABC
Manage life-threatening problems as they are identified
Vital signs q5 to 15 minutes
ECG, BP, O2 monitoring
Foley cath and NG if indicated
Tests: CBC, lytes, BUN, Cr, glucose, amylase, INR/PTT, B-hCG, toxicology screen, cross and type

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33
Q

Contraindications to foley insertion

A

Blood at urethra meatus
Scrotal hematoma
High-riding prostate on DRE

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34
Q

NG tube contraindications

A

Basal skull fracture

Significant mid-face trauma

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35
Q

Airway for CPR

A

Head tilt-chin lift
For all ages
(If C-spine stable)

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36
Q

Breaths for CPR

A

2 breaths at 1 s/breath

Stop once see chest rise

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37
Q

Foreign-body airway obstruction

A

> 8 y: abdominal thrust

<1 y: back slaps, chest thrusts

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38
Q

Compression landmarks in CPR

A

> 1 y: chest centre, between nipples

<1 y: just below nipple line

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39
Q

Compression method in CPR

A

> 8y: 2 hands, 2-2.4 inches
<8y: 1/3 to 1/2 the depth of the chest
1-8 y: 2 or 1 hand
<1 y: 2 fingers or thumbs

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40
Q

Compression rate in CPR

A

100-120/ min

Allow complete chest wall recoil

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41
Q

Compression to ventilation ratio

A

30 compression to 2 ventilations

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42
Q

Defibrillation

A

If sudden witnessed collapse: immediate AED

If unwitnessed arrest: compression (5 cycles/2 min), then AED

If children/infant: manual defibrillator preferred (but use adult dose if not available)

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43
Q

When is secondary survey done?

A

Once patient is hemodynamically and neurologically stabilized

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44
Q

Secondary survey components

A

Hx
Full physical exam
X-rays (C-spine,chest, pelvis),
Consider T-spine and L-spine if indicated

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45
Q

History taking during secondary survey

A 
SAMPLE
S: signs and symptoms
A: allergies
M: medications
P: past medical history
L: last meal
E: events related to injury
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46
Q

Physical exam during secondary survey

A

Head and neck: palpation of facial bones, scalp

Chest:
Inspect for: 1 midline trachea 2. Flail segment And associated hemothorax, pneumothorax and contusions
Auscultate lung fields
Palpate: Subcutaneous emphysema

Abdomen:
Assess for: peritonitis, distention, evidence of intra-abdominal bleeding
DRE for: GIB, high riding prostate, anal tone

MSK:
Extremities: swelling, contusion, deformity, tenderness, ROM
pulses (Doppler probe), sensation in injured limbs
Log roll and palpate thoracic and lumbar spines
Palpate iliac crest, pubic symphysis, assess pelvic stability (lateral, AP, vertical)

Neuro:
*GCS
*Full cranial nerve exam
*Alterations of rate and rhythm of breathing
*Spinal cord integrity
If conscious: distal sensation and motor function
If unconscious: response to painful or noxious stimulus applied to extremities

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47
Q

Initial imaging during secondary survey

A

Non-contrast CT head/face/C-spine
CXR
FAST or CT abd/pel (if stable)
Pelvis x-ray

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48
Q

Signs of increasing ICP in trauma patient

A 
Deteriorating LOC
Deteriorating respiratory pattern
Cushing reflex
Lateralizing CNS signs
Seizures
Papilledema (late)
N/V and headache
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49
Q

Golden hour in trauma

A

4-6 h

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50
Q

Height of fall considered high risk injury

A

> 12 ft (3.6 m)

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51
Q

Typical vault skull fx

A

Linear: temporal bone, middle meningeal artery area

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52
Q

The most common cause of epidural hematoma

A

Linear skull vault fx in middle meningeal artery area

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53
Q

Typical basal skull fx

A

Floor of anterior cranial fossa

Longitudinal

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54
Q

Best method if diagnosing basal skull fx

A

Clinical Dx superior to CT

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55
Q

High risk injuries in MVC

A

Ejection from vehicle
Motorcycle collisions
Vehicle versus pedestrian crashes
Fall from height Ford and 12 feet

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56
Q

Concussion

A

Mild traumatic brain injury (diffuse)
Alteration in mental status (must be < 30min)
Initial GCS (must be 13-15)
Post-traumatic amnesia (must be less than 24 h)

Hallmarks: confusion, amnesia immediately after trauma or minutes later

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57
Q

Diffuse axonal injury

A

Mild: coma 6-24 h, possibly lasting deficit

Moderate: coma >24h, little/no signs of brainstem dysfunction

Severe: coma > 24 h, frequent signs of brainstem dysfunction

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58
Q

Focal brain injuries

A

Contusion

Intracranial hemorrhage

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59
Q

Cushing response to increased ICP

A

Bradycardia
HTN
irregular respirations

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60
Q

Traumatic brain injury severity

A

Mild: GCS:13-15
Mod: 9-12
Severe: 3-8

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61
Q

Significant anisocoria in trauma

A

> 1mm in pt with altered LOC

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62
Q

Hx in assessment of brain injury in trauma pt

A

Pre-hospital status

Mechanism of injury

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63
Q

PEx in assessment of brain injury in trauma pt

A 
C-spine: assume injured
V/S: shock (infants), Cushing response
LOC
Pupils: size, anisocoria, response to light
Lateralizing signs (motor/sensory)
Reassess frequently
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64
Q

Investigations in assessment of brain injury in trauma pt

A

CBC, lytes, toxicology screen, PTT/INR, glucose
CT of head and neck
C-spine imaging

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65
Q

Goal of Mx of brain injury in ED

A

Reducing secondary injury by:

Avoiding hypoxia, ischemia, decreased cerebral perfusion pressure, seizure

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66
Q

Head injury Mx in ED

A 
General:
ABC
Intubate, prevent hypercarbia
sBP > 90
Treat other injuries
Neurosurgical consultation
Seizure Tx/Prophylaxis: BDZ, Phenytoin, phenobarbital

Treat suspected raised ICP

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67
Q

Treatment of raised ICP

A

Intubate
Calm(sedate)
Paralyze (if agitated)
Hyperventilate ( 100% O2, to pCO2 of 30-35)
Elevated bed head (20 degrees)
Adequate BP
Diuresis with mannitol 1g/kg, infused rapidly

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68
Q

Contraindications to manittol

A

Shock

RF

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69
Q

Mx of minor head injuries not requiring admission

A

24 h head injury protocol to competent caregiver

F/U with neurology

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70
Q

Indications of CT had in minor head injury

A 
GCS < 15 at 2 h after injury
Suspected depressed/open skull fx
Any sign of basal skull fx
Vomiting > 1 episode 
Age 65 or higher
Amnesia before impact > 30 min
Dangerous mechanism (fall > 3 foot, ejected occupant, pedestrian struck)
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71
Q

Definition of minor head injury

A

Witnessed loss of consciousness, definite amnesia, or witnessed disorientation in a patient with a GCS score of 13-15

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72
Q

Warning signs of severe head injury

A

GCS<8
Deteriorating GCS
Unequal pupils
Lateralizimg signs

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73
Q

Signs of mild traumatic brain injury

A

Somatic:
Headache, sleep disturbance, N/V, blurred vision

Cognitive dysfunction:
Attentional impairment, reduced processing speed, drowsiness, amnesia

Emotion and behavior:
Impulsivity, irritability, depression

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74
Q

Signs of severe concussion

A

Seizure, bradycardia, hypotension, sluggish pupils

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75
Q

Tx of mild traumatic brain injury

A

Close observation and F/U
Hospitalize if:
*abnormal CT
*normal CT with GCS<15, bleeding diathesis, seizure
Early rehab
Pharmacological Mx of pain, depression, headache
Return to play guidline

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76
Q

C-spine collar indications

A 
Midline tenderness
Neurological symptoms or signs
Significant distracting injuries
Head injury
Intoxication
Dangerous mechanism
Hx of altered LOC
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77
Q

When to assume cord injury?

A

Fall > 12 ft
Deceleration injury
Blunt trauma to head, beck or back

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78
Q

The most important film of cervical spine

A

Lateral cervical x-ray

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79
Q

Indication of MRI in traumatic brain injury

A

If worsening symptoms despite normal CT

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80
Q

Spinal cord injury Hx

A 
Mechanism
Previous deficits
SAMPLE
neck pain
Paralysis/weakness
Paresthesia
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81
Q

Spinal cord injury PEx

A

ABC

Abdomen:
Ecchymosis, tenderness

Neurological

Spine:
Palpate C-spine, log roll and palpate T-spineand L-spine, assess rectal tone

Extremities:
Capillary refill, if calcaneal fx, suspect thoracolumbar imjury

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82
Q

Investigations for spine injury

A

CBC, lytes, Cr, glucose, INR/PTT, cross/type, toxicology screen

Imaging:
C-spine x-ray series (AP, lateral, odontoid view)
Thoracolumbar x-rays (AP, lateral)

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83
Q

Level of injury for cauda equina syndrome

A

Below T10

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84
Q

Cauda equina symptoms

A 
Incontinence
Anterior thigh pain
Quadriceps weakness
Abnormal sacral sensation
Decreased rectal tone
Variable reflexes
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85
Q

Indications for spine imaging

A

C-spine injury
Unconscious patient with appropriate mechanism of injury
Neurological symptoms or findings
Deformities that are palpable when patient is log rolled
Back pain
Bilateral calcaneal fractures due to fall from height
Consider CT for subtle bone injuries, MRI for soft tissue injuries if appropriate

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86
Q

The canadian C-spine rule:

A

Radiology performed if:

Any of:

  • age > 65
  • dangerous mechanism
  • paresthesia in limbs

Or

None of:
Simple rear-end MCV
Sitting in ED
Ambulatory at any time
Delayed onset of neck pain

Or

Not able to actively rotate neck > 45 degrees

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87
Q

Insications for C-spine X-ray

A 
Midline neck pain
Numbness or paresthesia
Presence of distracting pain
Head injury
Intoxication
Loss of consciousness
Past history of spinal mobility disorder
Posterior neck spasm
Tenderness or crepitus
Any neurologic deficit
Autonomic dysfunction
Altered mental status
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88
Q

Indications for C-spine CT scan

A

Inadequate plain film survey
Suspicious plain film findings
To better delineate injuries seen on plane films
Any clinical suspicion of Atlanto-axial subluxation
High clinical suspicion of injury despite normal x-ray
To include C1-C3 when head city is indicated in head trauma

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89
Q

If normal C-spine films but abnormal neurological exam

A

Perform an MRI

C-spine cleared if normal

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90
Q

If normal C-spine films but neck pain

A

Order flexion/extension films

If normal, C-spine cleared
If abnormal, remain immobilized and consult spine service

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91
Q

Mx of cord injury

A 
Immobilized
Evaluate ABC
Treat neurogenic shock (maintain SBP> 100)
NG
Foley
High-dose steroid within 6-8h
Complete imaging of the spine
Consult spine service
Continually re-assessed high cord injuries
Watch for respiration if cervical cord injury
Warm blanket
Trendelenburg position
Volume infusion
Consider vasopressors
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92
Q

Cervical cord injury and respiration

A

C5-T1: abdominal breathing

Higher level injury: May require intubation and ventilation

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93
Q

Unable to rule out dens fx by odontoid view

A 
Repeat view
Or
CT
Or
Plain film tomography
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94
Q

Physiologic spine subluxations

A

Children < 8y
C2 on C3
C3 on C4
Spino-laminal lines are maintained

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95
Q

Fanning of spinous processes

A

Posterior lugament disruption

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96
Q

Widening of predental space

A

3 mm or higher in adults
5 mm or higher in children

Suggests C1 or C2 injury

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97
Q

Anterior/ posterior wedging of intervertebral disc spaces

A

Vertebral compression

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98
Q

Normal retropharyngeal width

A

<7 mm at C1-C4

Wide in children <2 y on expiration

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99
Q

Normal retrotracheal space width

A

<22 mm at C6-T1

<14 mm in children < 5 y

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100
Q

Neurogenic shock level

A 
T6 or higher
Within 30 min
Loss of vasomotor tone, SNS tone
Lasts up to 6 wk 
Hypotension, bradycardia, poikilotherma
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101
Q

Spinal shock

A

Absence of all voluntary and reflex activities below level of injury
No sensation
Flaccid paralysis

Lasts days to months

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102
Q

Autonomic dysreflexia

A 
Level T6 or higher
Chronic phase of spinal cord injuryg
Pounding headache
Nasal congestion
Apprehension
Anxiety
Visual changes
Dangerously increased SBP or DBP

Triggers
Bladder distention, UTI, kidney stone
Fecal impaction, bowel distension

Tx: monitoring, BP control, then: underlying

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103
Q

Airway obstruction investigation and Mx

A

Primary survey
Inv: none

Mx:
Definitive airway management
Remove foreign body if visible with laryngoscope prior to intubation

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104
Q

Tension pneumothorax investigations and management

A

Primary survey
Investigation: none
Management:
Needle Thoracostomy, large bore needle, 2nd ICS, mid-clavicular line
Then: Chest tube in 5th ICS, anterior axillary line

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105
Q

Open pneumothorax Mx

A

Primary survey
Air-tight dressing sealed on 3 sides
Chest tube
Surgery

Inv: decreased pO2 on ABG

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106
Q

Massive hemothorax Mx

A

Primary survey
>1500 cc blood

Only able to do supine CXR (entire lung radioopaque)

Mx: 
Restore blood volume
Chest tube
Thoracotomy if:
>1500 total blood loss
> 200cc/h continued drainage
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107
Q

Flail chest Mx

A

Primary survey
ABG: decreased pO2, increased pCO2
CXR: rib fx, lung contusion

Mx: O2+ fluid+ pain control
Positive pressure ventilation
+/- intubation and ventilation

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108
Q

Cardiac tamponade Mx

A

Primary survey
Echo
FAST

Mx: IV fluid
Pericardiocentesis
Open thoracotomy

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109
Q

Pulmonary contusion Mx

A

Secondary survey

CXR: area of opacification of lung within 6 h

Mx: 
Adequate ventilation
Monitor with: ABG, oximeter, ECG
Chest physiotherapy
If severe: positive pressure ventilation
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110
Q

Ruptured diaphragm Mx

A 
Secondary survey
CXR: abn diaphragm/ lower lung fields
NGTube
CT
Endoscopy

Mx: laparotomy

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111
Q

Esophageal injury

A

Secondary survey
CXR: mediastinal air
Esophagogram
Flexible esophagoscopy

Mx: all require repair (improved outcome if within 24h)

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112
Q

Aortic tear

A 
Secondary survey
CXR
CT
TEE
aortography

Mx: thoracotomy

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113
Q

Blunt myocardial injury

A

Secondary survey

ECG: dysrhythmias, ST changes
If normal ECG and hemodynamics, pt never gets dysrhythmia

Mx: O2
Antidysrhythmic
Analgesic

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114
Q

Aortic tear on X-ray

A 
Depressed left mainstem bronchus
Pleural cap
Wide mediastinum (The most consistent feature)
Hemothorax
Indistinct aortic knuckle
Tracheal deviation to right
Esophagus (NG) deviated to right
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115
Q

Penetrating neck trauma

A

Do not explore except in OR
If injury deep to platysma: angiography, contrast CT, surgery

Do not clamp structures
Do not probe
Do not insert NG
Do not remove weapon/impaled object

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116
Q

Triad of larynx injury

A

Hoarseness
SQ emphysema
Palpable fx

Other: hemoptysis
Dyspnea
Dysphonea

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117
Q

Inv in larynx injury

A

CXR
CT
Arteriography (if penetrating)

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118
Q

Management of larynx injury

A

Airway: manage early because of Edema
C-spine protection
Surgery: tracheotomy vs repair

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119
Q

Injury to trachea or bronchus

A

Dyspnea, hemoptysis
SQ air
Hamman’s sign: Crunching sound synchronous with heartbeat
CXR: mediastinal air, persistent pneumothorax or persistent air leak after chest tube inserted for pneumothorax

Mx: if > 1/3 circumference, surgical repair

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120
Q

The most common solid organ injury in blunt abdominal trauma

A

Spleen

Liver is the second most common

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121
Q

The most common are organ injury in penetrating abdominal trauma

A

Liver

And hollow organs

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122
Q

Investigations in abdominal trauma

A 
CBC
Lytes
Coagulation
Cross/type
Glucose
Cr
CK
lipase
Amylase
Liver enzyme
ABG
blood EtOH
B-HCG
U/A
Toxicology
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123
Q

Indication of foley in abdominal trauma

A

Unconscious

Patient with multiple injuries who cannot void spontaneously

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124
Q

Indications for NG tube in abdominal trauma

A

To decompress the stomach and proximal small bowel

Contra: face/skull base fx

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125
Q

Seatbelt abdominal injuries

A

Retroperitoneal duodenal trauma
Intraperitoneal bowel transection
Mesentric injury
L-spine injury

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126
Q

X-ray and abdominal trauma

A 
CXR
Pelvis
C-spine
Thoracic 
Lumbar
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127
Q

CT scan in abdominal trauma

A

Most specific test

Cannot be used if hemodynamic instability

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128
Q

Diagnostic peritoneal lavage

A

Most sensitive test for interperitoneal bleed

Cannot test for retroperitoneal bleed or diaphragmatic ruptures

Cannot distinguish lethal from trivial bleed

Results take up to one hour

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129
Q

FAST

A

Rapid <5min

False positive in ascites

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130
Q

Positive DPL

A 
Gross blood > 10cc
Bile
Bacteria
Foreign material
RBC > 100,000/microliter 
WBC > 500
Amylase > 175 IU
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131
Q

Indications for abdominal imaging

A

Equivocal abdominal examination
Altered sensorium
Distracting injuries (head trauma, spinal cord injury resulting abdominal anesthesia)
Unexplained shock or hypotension
Patients with multiple trauma who must undergo general anesthesia
Fracture of lower ribs, pelvis, spine
Positive FAST

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132
Q

Management of blunt abdominal trauma

A

ABC
Fluid

Surgical: watchful waiting vs. laparotomy

If solid organ injury: decision based on hemodynamic stability not the specific injuries

If hemodynamically unstable or persistently high transfusion requirements: Laparotomy

If hollow organ injury: laparotomy

If low suspicion of injury: admit and observe for 24 h

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133
Q

Penetrating abdominal trauma Mx

A

ABC
Fluid
Local wound exploration under direct vision to determine peritoneal perforation
Except: thoracoabdominal region, back/flanks
If gunshot: always laparotomy

If shock: laparotomy

If peritonitis: laparotomy

If evisceration: laparotomy

If free air in abdomen: laparotomy

If blood in NG: laparotomy

If blood in foley: laparotomy

If blood on DRE: laparotomy

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134
Q

PEx in abdominal trauma

A 
Inspection
Palpation
Auscultation
NG
Foley
DRE
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135
Q

Intraperitoneal bladder rupture if:

A

Full bladder

Acute abdomen presentation

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136
Q

Extraperitoneal bladder rupture

A

From pelvic fx

Pelvis instability, suprapubic tenderness

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137
Q

Gross hematuria in abdominal trauma suggests:

A

Bladder injury

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138
Q

Investigations for GU teauma

A

Urethra: retrograde urethrography

Bladder: U/A, CT, urethrogram +/- retrograde cystoscopy +/- cystogram (dilated bladder, post-void

Ureter: retrograde ureterogram

Renal: CT (if stable hemodynamic), IVP

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139
Q

In case of gross hematuria

A

GU investigated from distal to proximal

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140
Q

Mx of renal trauma

A

Minor:
Conservative: bed rest, hydration, analgesic, AB

Major:
Admit
Conservative: frequent assessments, serial U/A +/- re-imaging

If hemodynamically unstable: surgery

If continued bleeding > 48h: surgery

If major urine extravasation: surgery

Renal pedicle injury: surgery

Penetrating wound: surgery

Major laceration: surgery

Infection: surgery

Renal artery thrombosis: surgery

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141
Q

Mx of ureter trauma

A

Ureterouretostomy

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142
Q

Mx of bladder trauma

A

Extraperitoneal:
If minor rupture, Foley x 10-14 d
If major rupture, surgical repair

Intraperitoneal:
Drain abdomen and surgical repair

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143
Q

Urethra trauma Mx

A

Anterior:
Conservative, if cannot void, Foley/suprapubic cystostomy and AB

Posterior:
Suprapubic cystostomy (avoid cath) +/- surgical repair
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144
Q

Open fx management

A 
Remove gross debris
Irrigate
Cover with sterile dressing
OR: irrigation, debridement
Control bleeding with pressure
Splint
AB
Definitive surgical Mx within 6 h
Tetanus prophylaxis
Neurovascular status before and after reduction

Do not clamp

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145
Q

If vascular compromise in fx

A

Realign limb/ apply longitudinal traction
Reassess pulse with doppler
Surgical comsult

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146
Q

Pain out of proportion to injury

A

Esophageal rupture
Compartment syndrome
Ischemia of mesentry
Necrotizing fasciitis

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147
Q

Compartment syndrome Mx

A

Prompt decompression
Remove constrictive cast and dressings
+/- emergent fasciotomy

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148
Q

Anterior shoulder dislocation Mx

A

X-ray (lateral, fx?)
Reduction (traction, scapular manipulation)
Repeat x-ray
F/U with ortho

Nerve injury: lateral aspect of shoulder (axillary nerve), extensor of forearm (musculocutaneous)

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149
Q

Coll’s fx

A

X-ray: radial deviation, dorsal displacement

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150
Q

Scaphoid fx symptoms

A

Tenderness in anatomical snuffbox
Pain on scaphoid tubercle
Pain on axial loading of thumb

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151
Q

Scaphoid fx Mx

A

Negative X-ray: thumb spica splint, repeat x-ray in 1 wk +/- CT, bone scan

Positive x-ray: thumb spica splint x 6-8 wk, repeat x-ray in 2wk

Outpt F/U

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152
Q

Avulsion of the base of 5th metatarsal

A

Occurs with inversion injury

Supportive tensor or below knee walking cast x 3wk

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153
Q

Ankle radiograph series indications in malleolus trauma:

A

Pain in malleolar zone and any of:

Bony tenderness atposterior edge or tip of lateral malleolus
Or
Bony tenderness at posterior edge or tip of medial malleolus
Or
Inability to bear wt both immediately and in ED

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154
Q

Ankle radiograph series indications in midfoot trauma:

A

Pain in midfoot zone and any of:

Bony tenderness at base of 5th metatarsal
Or
Bony tenderness at navicular bone
Or inability to bear wt both immediately and in ED

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155
Q

Wounds requiring tetanus prophylaxis

A 
Dirt, soil, feces, saliva contamination
Puncture wound
Avulsion
Resulting from missile
Crushing
Burn
Frostbite
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156
Q

Abrasion management

A

Clean thoroughly with brush
Local anesthetic antiseptic oint (if facial or complex abrasion
Tetanus prophylaxis

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157
Q

Acute treatment of contusions

A 
RICE
Rest
Ice
Compression
Elevation
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158
Q

High risk factors for infection

A 
Puncture
Crush
>12h
Hand or foot
Age> 50
Prosthetic joint/valve
Immunocompromised
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159
Q

Suture size and duration

A 
Face: 6-0 x 5d
Joints: 3-0 x 10d
Not joints: 4-0 x 7d
Scalp: 4-0 x 7d
Mucous membranes: absorbable
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160
Q

Laceration Mx

A 
Tendon function against resistance
Neurovascular status
Clean
Explore under local anesthesia
X-ray or U/S if suspicion of foreign body or if suspect intra-articular involvement
Disinfect skin
Sterile techniques
Analgesia +/- anesthesia 
Secure hemostasis
Evacuate hematoma
Debride non-viable tissue, remove hair and foreign body
AB for prophylaxis
Suture
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161
Q

Maximum dose of lidocain

A

With epinephrine: 7 mg/ kg

Without epinephrine: 5 mg/kg

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162
Q

Indications for prophylactic AB in lacerations

A

Animal bite
Human bite
Intra-oral lesions
Puncture wounds to the foot

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163
Q

Exception to perform suture

A 
Presentation > 6-8 h
Puncture wound
Mammalian bite
Crush injury
Retained foreign body
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164
Q

The most important factor in decreasing wound infection risk is:

A

Early irrigation and debridement

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165
Q

Metabolic reasons of stomachache

A

Emergent:
DKA, Sickle cell crisis, toxin, addisonian crisis

Less emergent:
Lead poisoning, porphyria

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166
Q

Investigations in abdominal pain

A 
ABC
CBC
Lytes
BG
BUN/Cr, U/A
Liver enzymes, LFT
Lipase
Lactate, VBG
ECG, troponins
B-hCG
AXR, CXR, U/S, CT
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167
Q

Pts with atypical presentations of abdominal pain

A

Very young
Elderly
Alcoholics
Immunocompromised

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168
Q

Peritoneal findings blunted if:

A

Old age
Pregnancy T3
Chronic CS use

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169
Q

Disposition of abdominal pain pt

A

Admit if:
Surgical abdomen, w/u of significant abdominal findings, need for IV AB or pain control

Discharge if: negative lab, negative imaging who improve clinically

Return if: fever, increasing pain, persistent vomiting

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170
Q

Most common cause of pelvic pain

A

Ruptured ovarian cyst

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171
Q

Acute pelvic pain inv

A

B-hCG
CBC, diff, lytes, BG, Cr, BUN, G&S, PTT/INR, U/A, vaginal/cervical swabs for C&S,
Abdominal/pelvis U/S
Doppler flow studies for ovarian torsion

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172
Q

Pelvic pain referral indications:

A

If requiring surgery
If requiring admission
If oncologic

Admit if: requiring surgery, IV AB/pain control

Discharge if: negative w/u, improving symptoms

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173
Q

Ovarian cyst Mx

A

If unruptured: analgesia, f/u
If ruptured but stable hemodynamic: analgesic and f/u
If unstable hemodynamic or significant bleeding: surgery

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174
Q

Preferred imaging modality and assessment of pelvic pain

A

U/S

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175
Q

Lethargy, Stupor, Coma

A

Lethargy: wakeful but decreased awareness and alertness

Stupor: unresponsive but rousable

Coma: unresponsive, not rousable to consciousness

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176
Q

Abrupt onset of coma suggests

A

CNS hemorrhage/ischemia

Cardiac cause

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177
Q

Onset of coma over hours to days

A

Progressive CNS lesion
Toxic
Metabolic

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178
Q

PEx in altered LOC

A 
ABC
LOC, eye examination
vitals
Cardiac/respiratory/abdominal exams
Complete neurologic exam
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179
Q

Investigations for altered LOC

A 
CBC
Lytes
BUN, Cr, U/A
LFT
Glucose
INR/PTT
Serum osmolality, VBG
Troponins
Serum EtOH, acetaminophen, salicylate
CXR, CT head
ECG, UTox
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180
Q

Finding suggestive of toxic or metabolic coma

A

Dysfunction at lower levels of the brain stem

Respiratory depression in association with an intact opera brainstem (equal and reactive pupils)

Extraocular movements and motor findings are symmetric or absent

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181
Q

Findings suggestive of structural coma

A

Lateralizing abnormalities

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182
Q

Lucid interval

A

Epidural hematoma

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183
Q

Universal antidotes

A

Thiamine 100 mg IV ( if Hx of EtOH or malnourished)

D50W IV 1 ampule (if hypoglycemic on fingerprick)

Naloxane 0.4-2 mg IV or IM (if opiate overdose suspected)

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184
Q

Toxic or metabolite causes of fixed dilated pupils

A 
Anoxia
Anticholinergic (atropine, TCA...)
Methanol
Cocaine
Opioid withdrawal
Amphetamine
Hallucinogen
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185
Q

Toxic or metabolic causes of fixed constricted pupils

A

Opiates (except meperidine)

Cholinergics (organophosphates)

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186
Q

Metabolic/toxic causes of normal to dilated fixed pupils

A

Hypothermia
Barbiturates
Antipsychotics

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187
Q

Chest pain investigations

A

CBC, lytes, BUN, Cr, BG, PTT/INR, CK, troponins

ECG, CXR, CT

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188
Q

Mx of acute chest pain

A 
ABC
O2
Cardiac monitoring
IV access
Underlying, consultation
Observation/monitoring if unknown cause
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189
Q

When to discharge a pt with acute chest pain

A

If low probability of life-threatening illness: resolving symptoms, negative w/u

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190
Q

Typical angina

A

Retrosternal
Provoked by exertion
Relieved by rest/nitroglycerin

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191
Q

When to take a 15 lead EKG in MI

A

If hypotensive
If AV node involvement
If inferior MI

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192
Q

When is troponin sensitive for MI?

A

After 6-8 h

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193
Q

Westermark sign

A

Abrupt tapering of a vessel on chest film

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194
Q

Rate of normal CXR in PE

A

50%

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195
Q

Pericarditis pain relieved by

A

Sitting up and leaning forward

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196
Q

ECG in acute pericarditis

A

II,III,aVF,V4-V6: ST elevation, PR depression

aVR, V1: ST depression and PR elevation (reciprocal)

Sinus tachycardia

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197
Q

sBP in arms in aortic dissection

A

Difference > 20 mmHg

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198
Q

CXR in aortic dissection

A

Wide mediastinum
Left pleural effusion
Indistinct aortic knob
>4mm separation of intimal calcification from aortic shadow

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199
Q

Aortic dissection Tx

A

ABC
reduce BP and HR

Type A (ascending): urgent surgery

Type B (descending): medical

Urgent consult

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200
Q

Esophageal rupture symptoms

A 
Sudden onset
Severe pain
After: endoscopy, forceful vomiting, labour, convulsion, corrosive injury, cancer
Sepsis
Subcutaneous emphysema
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201
Q

Imaging esophageal ruptur

A

CXR:
Pleural effusion
Pneumomediastinum

CT, water soluble contrast esophagogram

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202
Q

Tx of esophageal rupture

A 
ABC
early AB
Thoracics consult
NPO
Consider chest tube
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203
Q

Abnormal skin sensation in herpes zoster precedes rash by

A

1-5 d

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204
Q

Reproduction of symptoms with movement or palpation is found in what percent of MI patients?

A

25% (similar to MSK)

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205
Q

Long QT syndrome

A

QT interval > 1/2 of cardiac cycle

206
Q

ECG in dig toxicity

A

Gradual downward curve of ST

At risk for AV block, ventricular irritability

207
Q

Abortive treatment for migrain

A

Fluids: 1 L bolus of NS
NSAID: ketorolac 30 mg IV
Antiemetic: prochlorprazine 10 mg IV, diphenhydramine 25 mg IV
Antiepileptic
Vasoactive medications
Dexa 10 mg IV
Halopridol, metoclopramide, ergotamine, sumatriptan…

Family doctor to consider prophylactic treatment

208
Q

Tx of tension headache

A

Modify stressors
Local measures
NSAIDs
TCA

209
Q

Migraine headache increases by

210
Q

Tension or muscular headache aggravated by

A

Stress, sleep deprivation

211
Q

SAH headache increases by

212
Q

Hyperattenuated signal around circle of willis on CT

213
Q

If suspected SAH bu normal CT after 6 h of onset,

214
Q

Mx of SAH

A

Urgent neurosurgery consult

215
Q

High-risk variables for SAH

A 
Age 40 and higher
Neck pain/stiffness
Witnessed loss of consciousness
Onset during exertion
Thunderclap headache (instantly peaking pain)
Limited neck flexion on examinatio
216
Q

Eye exam in temporal arthritis

A

Relative afferent pupillary defect

Optic disc edema

217
Q

Admission for headache

A 
If:
Underlying diagnosis is critical
Underlying diagnosis is emergent
Abnormal neurological findings
Elderly
Immunocompromised
Pain is refractory to oral medications
218
Q

Discharging headache

A

Most patients can be discharged
Assessed for risk of narcotic missuse
Instruct patient to return for fever, vomiting, neurology changes, or increasing pain

219
Q

Morning Stiffness in inflammatory arthritis

220
Q

Midday fatigue is in favor of which type of arthritis

A

Inflammatory

221
Q

Investigation for arthritis

A

CBC, ESR, CRP, INR/PTT, blood cultures, urate
Joint x-ray +/- contralateral joint for comparison
Bedside U/S to identify effusion

222
Q

Emergency vascular conditions needed to be ruled out in back pain

A 
Aortic dissection
AAA
PE
MI
Retroperitoneal bleeding
223
Q

Indications of imaging in back pain

A

Suspicion of emergencies, metastasis, high risk of fracture, infection, cancer or vascular causes

224
Q

Use of dexamethasone for abortive treatment of migraine

A

26% reduction in headache recurrence within 72 hours

225
Q

Red flags for back pain

A 
Bowel or bladder dysfunction
Anesthesia, saddle
Constitutional symptoms
Chronic disease
Constant pain 
Paresthesia
Age>50 and mild trauma
IV drug use
Neuromotor deficit
226
Q

Status epilepticus

A

Continuous or intermittent seizure activity for greater than five minutes without regaining consciousness

227
Q

immediate Mx of status epilepticus

A

Protect airway: positioning, ETT (if compromised or if increased ICP)

Monitor: V/S, ECG, oximetry, bedside BG

IV access

BDZ: IV lorazepam (0.1 mg/kg, max: 4 mg, 2mg/min) preferred over diazepam, repeat at 5 min if ineffective

Fluid

Thiamine 100 mg IM (adults), then

50% glucose, 50 mL

Blood sample: CBC, Lytes, Ca, Mg, BG, toxicology, AED levels, consider: B-hCG, PRL

Vasopressor if sBP<90, or MAP <70

228
Q

Urgent management of status epilepticus

A

Second IV line

Foley

If status persists: phenytoin 20 mg/kg IV, an additional 10 mg/kg after 10 min

AED to prevent recurrence

EEG monitoring for non-convulsive status epilepticus

229
Q

Mx of refractory status epilepticus

A

Consult ICU

Phenobarbital 20mg/kg IV, at 50 mg/min
Midazolam 0.2 mg/kg IV, then 0.05-0.5 mg/kg/h
Propofol
2-5 mg/kg IV then 2-10 mg/kg/h

230
Q

Post-seizure Mx of status epilepticus

A 
Investigate underlying:
CT
LP
MRI
ICP monitoringg
231
Q

Minimum work up in an adult with first time seizure

A

CBC and diff
Electrolytes including Ca, Mg, PO4
Head CT

232
Q

Control of seizures in adults without IV access

A

Midazolam 0.2 mg/kg up to 10 mg

233
Q

When to discharge patients in status epilepticus

A

Patient returns to baseline function and is neurologically intact

Outpatient follow-up

Complete notification form for appropriate authorities regarding ability to drive

Warn regarding other safety concerns: no swimming, bathing children alone…

234
Q

Anti-epileptic drug requiring cardiac monitoring

235
Q

Investigations for dyspnea

A 
CBC, diff
Lyte
VBG
Serial cardiac enzymes
ECG
WELL’s score
CXR
236
Q

Findings in favor of cardiogenic syncope

A

Sudden loss of consciousness with no warning or prodrome

Syncope accompanied by chest pain

237
Q

Investigations for syncope

A 
ECG
Bedside BG
CBC
Lytes
BUN/Cr
ABG
Troponin
Ca
Mg
B-hCG
D-dimertoxicology
238
Q

Mx of syncope

A

ABC
IV
O2
Monitoring

If cardiogenic: admit

If low risk: discharge with F/U

Educate about avoiding orthostatic or situational syncope
Evaluate a patient for fitness to drive or work
If recurrent syncope, should avoid high-risk activities

239
Q

General approach to sexual assault

A

ABC

Treat acute serious injuries

Ongoing emotional support

Obtain consent for: medical exam and treatment, evidence collection, disclosure to police

Sexual assault kit (if < 72h)

Label samples immediately and pass directly to police

Offer community crisis resources

Do not report unless pt requests or is <16 y

240
Q

How long does the sperm remain motile in female genital?

A

6-12 h in vagina

5 d in cervix

241
Q

Lab in sexual assault

A

VDRL, repeat in 3 mo if negative
Serum B-hCG
ABO group, Rh
Baseline serology (HIV, Hepatitis…)

242
Q

Mx of sexual assault

A

Involve local/regional sexual assault team

Suture lacerations, tetanus prophylaxis

Gynecology consult if: foreign body, complex lacerations

Azithromycin 1 g (alt: doxy bid 7 d) + cefixime 800 mg PO x 1dose ( alt: ceftriaxone 250 IM)

+/- prophylaxis for hepatitis B and HIV

Pre and post counseling for HIV testing

Offer pregnancy prophylaxis: Plan B

Psychological support

Have the pt change and shower after exam

243
Q

Disposition

A

Discharge if injuries/social situation permit

F/U with physician in rape crisis centre in 24 h

Best if pt does not leave ED alone

244
Q

The most common STD after rape

A

Gonorrhea> chlamydia> syphilis > HIV

245
Q

Suspicion about domestic violence

A

Suggestive injuries, often inconsistent with history provided

Somatic symptoms, chronic and vagie

Psychosocial symptoms

Clinical impression for example overbearing partner that won’t leave the patient’s side

246
Q

Management of domestic violence

A 
Treat injuries
Document findings
Ask about sexual assault
Ask about children at home 
Encourage notification of police 
Safety plan
Good follow up With family physician or social worker
Be supportive and assess danger
Patient must consent to follow-up investigation or reporting unless for children
247
Q

Most common triggers for anaphylaxis

A

Foods, stings, drugs, radiographic contrast media, blood products, latex

248
Q

Drugs causing anaphylaxis

A

Penicillin
NSAIDs
ACEI

249
Q

Angioedema versus anaphylaxis

A

Angioedema does not tend to improve with standard anaphylaxis treatment

250
Q

Management of moderate anaphylaxis

A

Epinephrine: 1:1000, 0.3-0.5 IM, lateral thigh q 5-15 min

Antihistamine: diphenhydramine, 25-50 mg IM

Salbutamol: 1cc via MDI

Symptomes: Generalized Urticaria, Angioedema, wheezing, tachycardia

251
Q

Management of severe angioedema

A

ABC, may need ETT

Epinephrine: 1:1000, 0.1-0.3 mg, IV (or via ETT), repeat as needed

Antihistamines: diphenhydramine, 50 mg IV

Steroids: hydrocortisone 100 mg IV OR methylprednisolone 1mg/kg IV q 6h x 24 h

Large volume of crystalloid

Symptom: severe wheezing, laryngeal/pulmonary edema, shock

252
Q

Second phase of anaphylaxis can happen within

A

Up to 48 hours

253
Q

Disposition of anaphylaxis patient

A

Monitor for at least 4 to 6 hours in ED

Arrange follow-up with family physician in 24 to 48 hours

May need to be supervised

Educat patient on avoidance of allergens

Medications:
H1 antagonist, x3d
H2 antagonist, x3d
CS (prednisone 50 mg PO OD x 5d) to prevent secondary reaction

254
Q

Investigations for asthma in ED

A

Peak flow meter
ABG: if severe respiratory distress
CXR: if Dx in doubt

255
Q

Definition of hypotension

A

sBP > 30% decrease from baseline
Or
Adults: <90

11y and older: <90

1-10 yr: < 70+ 2 x age

1mo-1yr: < 70

256
Q

Asthma pt with silent chest

A

Medical emergency

May require emergency intubation

257
Q

Elements of well-controlled asthma

A

Daytime symptoms < 4x/wk

Nocturnal symptoms <1x/wk

No limitation in activity

No absence from work or school

Rescue inhaler use < 4x/wk

FEV1 > 90% personal best

PEF <10-15% diurnal variation

Mild infrequent exacerbations

258
Q

Mild asthma symptoms and characteristics

A

FEV1 > 80%

Exertional SOB/cough + some nocturnal symptoms

Difficulty finishing sentences

259
Q

Mild asthma management in ED

A

B-agonist

Monitor FEV1

Consider steroid (MDI or PO)

260
Q

Moderate asthma symptoms and features in ED

A

FEV1: 50-80%

SOB at rest

Cough

Congestion

Chest tightness

Speaking in phrases

Inadequate relief from B-agonists

261
Q

Moderate asthma management in ED

A

O2 to achieve O2 sat > 92%

SABA (ventolin): MDI or nebulizer q 5min

Short-acting anticholinergic (atrovent): MDI or nebs x3

Steroids: prednisone 40-60 mg PO

262
Q

Severe asthma theaters in ED

A

FEV1 < 50%

O2 sat <90%

Agitated

Diaphoretic

Labored respirations

Speaking in words

No relief from B-agonist

263
Q

Severe asthma management in ED

A

100% O2 to achieve O2 sat >90%

Anticipate need for intubation

Cardiac monitoring

IV access

SABA: nebulizer, 5 mg, continually

Short-acting anticholinergic: nebulizer, 0.5 mg x 3

IV steroids: methylprednisolone 125 mg

MgSO4 2g IV

264
Q

Characteristics of asthma with imminent respiratory arrest

A

O2 sat <90%

Decreased HR

RR> 30

pCO2> 45

Exhausted
Confused
Diaphoretic
Cyanotic
Silent chest
Ineffective respiratory effort
265
Q

Management of asthma with Imminent respiratory arrest

A

100% O2 to achieve O2 sat >90%

Intubate (consider ketamine)

Cardiac monitoring

IV access

SABA: nebulizer, 5 mg, continually

Short-acting anticholinergic: nebulizer, 0.5 mg x 3

IV steroids: methylprednisolone 125 mg

266
Q

Disposition of patient with exacerbated asthma

A

Discharge safe if:
FEV1 or PEF >60% predicted (may be safe if 40-60% predicted)

B-agonist MDI with aerochamber: 2-4 puffs q 2-4 h until symptoms are controlled. Then PRN

Inhaled CS aerochamber

Prednisone 30-60 mg/d x 7 d (if mod-sev)

Counsel on medication adherence

F/U with Primary care physician or asthma specialist

267
Q

Risk factors for recurrence of exacerbation of asthma

A 
Frequent ED visits
Frequent hospitalizations
Recent steroid use
Recent exacerbation
Poor medication compliance
Prolonged use of high dose B-agonists
268
Q

Tx of Mobitz II and 3rd degree block

A

ED:
Atropine with caution
Transcutaneous pacing
If failed, IV dopamine, epinephrine

Long-term:
Internal pacemaker

269
Q

Tx of sinus bradycardia

A

Indication: if symptomatic

ED: atropine, transcutaneous pacing

Sick sinus node: transcutaneous pacing

Drug-induced: D/C or reduce offending drug, antidotes

270
Q

Sinus tachycardia treatment

A

Treat underlying

BB if symptomatic

271
Q

Supraventicular tachycardia with narrow QRS

Next step?

A

Is rhythm regular or irregular?

272
Q

If SVT with regular rhythm?

A

Vagal maneuvers
Adenosine 6 mg IV -> 12 mg -> 12 mg

If rhythm converts: probable re-entry tachycardia (AVNRT»>AVRT)
Next step: monitor.
If recurred: adenosine, longer acting meds

If no rhythm conversion: atrial flutter, ectopic atrial tachycardia, junctional tachycardia
Next step: rate control, cardiology consult

273
Q

If SVT with irregular rhythm

A

A Fib, atrial flutter, MAT

Next step: rate control (diltiazem, BB)

274
Q

If pt with tachydysrrhythmia is unstable:

A

Immediate synchronized cardioversion

275
Q

Most common

276
Q

Holiday heart

277
Q

Treatment principles in AF

A

Stroke prevention
Symptom control
Identification and treatment of underlying disease

278
Q

How much does cardiac output decrease and AF?

279
Q

Treatment of AF

A

Unstable: immediate synchronized cardioversion

Onset> 48h or unknown:
Rate control
Anticoagulate for 3 weeks prior to and 4 weeks after cardioversion or TEE to R/O clot
Then: cardioversion

Onset <48h or already anticoagulated:
Cardiovert:
-electrical: synchronized DC
-chemical: procainamide, flecainide, propafenone

Long-term Mx:
Rate or rhythm control, consider anticoagulation (CHADS2 score)

280
Q

VTach definition

A

3 or more consecutive ventricular beats at > 100 bpm

281
Q

The most common cause of VTach

A

CAD with MI

282
Q

Sustained VTach Tx

A

> 30 sec
Emergency

Hemodynamic compromise:
synchronized DC cardioversion

No hemodynamic compromise:
Synchronized DC cardioversion
Amiodarone
Procainamide

283
Q

VFib Mx

A

Call code blue

ACLS

284
Q

Torsades de pointes Tx

A

IV Mg
Isoprotrenol
Correct cause

285
Q

Causes of torsades de pointes

A 
Erythromycin
TCA
quinidine
Quinolones
Hypokalemia
Hypomagnesimia
286
Q

If WPW with AF

A

Amiodarone
Procainamide

Avoid AV blocking agents

287
Q

COPD exacerbation cardinal symptoms

A

Increased dyspnea
Increased cough
Increased sputum
Purulence of sputum

288
Q

Investigations in COPD

A 
CBC
Lytes
ABG
CXR
ECG

NO PFT

289
Q

Physical findings in COPD

A 
Wheezing
Laryngeal height 4 cm or less
Forced expiratory time 6 sec or more
Decreased breath sounds
Decreased cardiac dullness
290
Q

In COPD exacerbation R/O:

A 
exacerbated CHF
MI
PE
pneumonia
Other infections
Pneumothorax
291
Q

COPD exacerbation Tx

A

O2 (keep O2 sat between 88-92%)

Bronchodilators:
SABA 4-8 puff with MDI q 15 min x 3
Short acting anticholinergic 4-8 puff with MDI q 15’ x 3

Steroid:
Prednisone 40-60 mg PO x 7-14 d
Or
Methylpred 125 mg IV bid-qid if severe/unable to take PO

AB:
TMP-SMX
Cephalosporins
Respiratory Q

Ventilation:
If, severe distress, signs of fatigue, hypercapnic, arterial pH < 7.35
CPAP, BiPAP

ICU:
If life-threatening, ICU admission for intubation and ventilation

292
Q

Disposition of COPD

A

Low admission threshold if comorbidities

If discharge:
Taper steroid
Up to 4-6 puffs of ipratropium and salbutamol
F/U

293
Q

Investigations for heart failure

A 
CBC 
Lytes
AST, ALT, Bil
Cr, BUN
Cardiac enzymes
Brain natriuretic peptide
CXR
ECG
ABG: if severe and refractory
Echo: not usually used in ED
R/O serious differentials
294
Q

Mx of CHF

A

ABC

Sit upright

Cardiac monitoring

Continuous pulse oximetry

Saline lock IV

Foley

100% O2 by mask

May require BiPAP, ETT

Meds:
-diuretics: if volume overload:furosemide

  • vasodilators: if sBP> 100: NTG SL q5 min, Nitrodur patch. If no response/signs of ischemia NTG IV. If severe/refractory HTN: nitroprusside
  • ionotropes/vasopressors: if sBP < 90. With shock: dopamine, without shock: dobutamine
  • treat precipitating factors
  • cardiology or medicine consult
295
Q

CHF on CXR

A

Pulmonary vascular redistribution

Perihilar infiltrates

Interstitial edema, Kerley B lines

Alveolar edema, bilateral infiltrates

May: cardiomegaly, pleural effusion

Peribronchial cuffing

Fissural thickening (fluid in fissure)

296
Q

Hospital Mx of CHF required if:

A

Acute MI
Pulmonary edema or severe respiratory distress
Severe complicating medical illness such as pneumonia
Anasarca
Symptomatic hypotension or syncope
Refractory to outpatient therapy
Thromboembolic complications requiring intervention
Clinically significant dysrhythmia
Inadequate social support for safe outpatient management
Persistent hypoxia requiring supplemental oxygen

297
Q

Well,s Criteria for DVT

A

Active cancer 1

Paralysis, paresis, recent immobilization of leg 1

Recently bedridden x3d or major surgery within 4 weeks 1

Local tenderness 1

Entire leg swollen 1

Calf swelling 3 cm> asymptomatic leg 1

Unilateral pitting edema 1

Collateral superficial veins 1

Alternative Dx more likely -2

298
Q

Well’s criteria for DVT scoring

A

0: low probability
1-2: moderate probability
3 and higher: high probability

299
Q

The first step in suspicion for DVT

A

Compression U/S

303
Q

Mx of DVT

A

LMWH

Warfarin started at same time

LMWH D/C when INR 2-3 for 2 consecutive days

  • can use DOAC (rivaroxaban, apixaban) in acute Mx of symptomatic DVT
  • thrombolysis if: extensive DVT and limb compromise
  • IVC filter if: anticoagulation is contraindicated
304
Q

Duration of anticoagulation therapy

A

If transient coagulopathy: 3 mo

If unprovoked coagulopathy: 6 mo

If ongoing coagulopathy: life-long

305
Q

Well’s criteria for PE

A

Previous history of DVT/PE 1.5

HR> 100 1.5

Recent immobility or surgery 1.5

Clinical signs of DVT 3

Alternative diagnosis less likely than PE 3

Hemoptysis 1

Cancer 1

306
Q

Interpretation of Well’s criteria for PE

A

<2 low probability

2-6: intermediate probability

> 6: High probability

307
Q

ECG in PE

A

S1Q3T3
Sinus tachycardia
T wave inversion in anterior and inferior leads

308
Q

If PE suspicion, next step?

A 
PERC score:
Age > 50yr
HR > 100
O2 sat <94%
Prior Hx DVT/PE
Recent trauma/surgery
Hemoptysis
Exogenous estrogen
Clinical signs suggesting DVT
309
Q

PERC interpretation

A

0/8: PE excluded

1-8/8: proceed to Well’s

310
Q

How to proceed according well’s score in PE

A

If low probability:
Check D-dimer
- if < 500, PE excluded
-if > 500, CT pulmonary angiogram

If moderate-high probability: CT-PA

  • if negative: PE excluded
  • if positive: PE confirmed

V/Q scan if CT-PA unavailable or contraindicated

311
Q

PE in pregnancy

A

Use PERC with caution

V/Q scan instead of CT-PA

312
Q

Mx of PE

A

The same as DVT

Thrombolysis if: extensive PE causing hemodynamic compromise/cardiogenic shock
-catheter-directed thrombolysis or surgical thrombectomy if contraindication to thrombolysis

Often can be treated as outpatien

Analgesia for chest pain

Referral to medicine for coagulopathy and malignancy w/u

313
Q

When to admit PE pt?

A 
Hemodynamically unstable
Require supplemental O2
Major comorbidities
Lack of sufficient social support
Unable to ambulate
Need invasive therapy
314
Q

Respiration in DKA

315
Q

Investigations fo DKA

A

CBC, electrolytes, Ca, Mg, PO4, BUN, Cr, glucose, ketones, osmolality, AST/ALT/ALP, amylase, troponin
Urine glucose and ketones
ABG or VBG
ECG

316
Q

Mx of DKA

A

Rehydration:
Bolus of NS, then high rate NS

K:
KCl
(20 mEq/L if adequate renal function and initial K < 5.5)

Cardiac monitoring if K: Nl or low

Insuline:
Not if K < 3.3
Initial bolus of 5-10 unit, regular, IV
Then continuous infusion at 5-10/h
Once glucose < 14, subcutaneous injection, D/C IV
Once glucose <15, add D5W to IV fluids

Bicarbonate: if pH < 7

317
Q

How to correct pseudohyponatremia

A

Add 3 Na per 10 glucose over 5.5

318
Q

Triad of DKA

A

Hyperglycemia
Ketosis
Acidosis
Also: ketonuria

319
Q

Investigations for HHS

A 
CBC
Lytes, Ca, Mg, PO4
BUN, Cr
Blood glucose
Ketones
Osmolality
Urine: glucose and ketones
ABG/VBG
Investigations for underlying causes: CXR, ECG, blood/urine C/S
320
Q

Mx of HHS

A 
Rehydration
IV NS
(Total deficit: 100 cc/kg body weight)
O2
Cardiac monitoring
Insuline (controversial)
Treat underlying ( Ischemia, Infarction, Infection, Insulin missed, Intoxication)
321
Q

Mx of hypoglycemia

A

IV access
Rapid blood glucose measurement
D50W 50 mL IV push
PO glucose if mental status permits

If IV access not possible, glucagon 1-2 mg IM, repeat once in 10-20 min

O2 monitoring

Cardiac monitoring

Frequent blood glucose monitoring

Thiamine 100 IM

Full meal ASAP

Watch for prolonged hypoglycemia due to long-acting insulins or sulfunylurea

Search for cause (insulin, alcohol, OHA)

322
Q

The most common reason for hypoglycemia

A

Excessive insulin use in setting of poor PO intake

323
Q

Levels of Na causing seizures and coma

324
Q

Tx of hypernatremia

A

Salt restrict
Give free water
No more correction than 12 /24 h

325
Q

Hyponatremia Mx

A

Water restrict/NPO

Seizure/coma: 100cc 3% NaCl

If hypovolemia: ringer lactate

If hypervolumia: furosemide

Limit total rise to 8/ 24h

326
Q

Mx of hyperkalemia

A

Protect heart: Ca gluconate

Shift K into cells:
D50W+ insulin
NaHCO3
Salbutamol

Remove K:
Fluid+ furosemide
Dialysis

327
Q

Hypokalemia Mx

A

K-Dur

K sparing diuretics

IV solutions with 20-40 mEq/L KCl over 3-4 h

May need to restor Mg

328
Q

Hypercalcemia Mx

A 
Isotonic saline (usually dehydrated)
\+ furosemide if hypervolemic
Bisphosphonate
Dialysis
Chelation (EDTA, oral PO4)
329
Q

Hypocalcemia Mx

A 
If acute ( ionized Ca < 0.7): immediate treatment:
IV calcium gluconate
330
Q

EOD in hypertensive crisis

A

CNS:
Stroke/TIA, headache, altered mental status, seizures, hemorrhage

Retinal:
Visual changes, hemorrhage, exudates, papilledema

Renal:
Nocturia, elevated Cr, proteinuria, hematuria, oliguria

Cardiovascular:
Ischemia/angina, infarction, dissection (back pain), CHF

Gastrointestinal:
N/V, abdominal pain, elevated liver enzymes

331
Q

Investigations in hypertension crisis

A

CBC, Lytes, BUN, Cr
U/A
PBS
CXR (if SOB, back pain)
ECG, troponin, CK (if chest pain)
CT head (if neurological findings or severe headache)
Toxicology screen (if sympathomineric overdose suspected)

332
Q

Management of hypertensive crisis (emergency)

A

Aim: Lower BP gradually and progressively in 24 to 48 hours
Lower BP by 25% during first 60 minutes.

Nitroprusside
Labetalol

Establish arterial line
Transfer to ICU for further reduction

333
Q

Management of hypertension crisis in Ischemic stroke

A

maintain BP> 150/100 for 5 d

334
Q

In case of aortic dissection and hypertension crisis

A

Rapid reduce of BP to 110-120 STAT

Do not resuscitate with IV fluid

335
Q

In case of excessive catecholamines in hypertension crisis

A

Do not use BB (except labetalol)

336
Q

In case of ACS and hypertension crisis

A

First address ischemia, then BP

337
Q

Hypertensive urgency

A

Severely elevated BP > 180/110

No evidence of EOD

338
Q

The most common reason for hypertension urgency

A

Not adherence with medications

339
Q

Tx of HTN urgency

A

Goal: differentiate hypertension urgency from emergency
Initiate/adjust antihypertensive therapy
Monitor in ED (up to 6 h)
Discharge with F/U for 48-72 h

340
Q

1st line treatment in HTN crisis

A

Sodium Nitroprusside

341
Q

Na nitroprusside adverse effects

A

N/V, muscle twitching, sweating, cyanide intoxication, coronary steal syndrome

342
Q

Caution with nitroprusside

A

High ICP

Azotemia

343
Q

Caution with nicardipine

344
Q

Special hypertensive indication for NTG

A

MI/pulmonary edema

345
Q

Caution in fenoldopam

346
Q

HTN with catecholamine excess

A

Phentolamine

347
Q

Investigations for ACS

A

ECG STAT
Troponin (2-6 h after onset)
CXR to R/O other causes

348
Q

Mx of ACS

A

Stabilize:
ABC, O2, IV access, cardiac monitoring, oximetry

ASA 162-325 chewed

NTG 0.3 SL q5min x 3 (IV if persistent pain, CHF, HTN)

Anticoagulation (UH, LMWH, fondaparinux)

Early cardiology consult for reperfusion therapy

Atorvastatin 80 mg (to stabilize plaque)

BB (if no sign of CHF, hemodynamic compromise, bradycardia, severe reactive airway disease)

ACEI (within 24h)

349
Q

NTG contraindications

A

Hypotension
PDE-inhibitor use
Right ventricular infarction (1/3 of inferior MIs)

350
Q

Reperfusion strategy

A

UA/NSTEMI:
Early coronary angiography recommended if high TIMI score

STEMI:
Preferred: primary PCI (within 90 min)
If unavailable within 120 min of medical contact, symptoms <12 h and no contra: thrombolysis

351
Q

Sepsis definition

A

Life-threatening organ dysfunction (by a dysregulated host response to infection)

A change in baseline SOFA score equal or higher than 2

352
Q

Septic shock definition

A

Profound circulatory, cellular, metabolic abnormalities.

Require vasopressors to maintain MAP 65 or higher
Serum lactate 2 or higher without hypovolemia

353
Q

Mx of septic shock

A 
ABC
Monitors
Lines
Aggressive fluid
Ventilatory/inotropic support
Cultures
Early empiric ABs- broad spectrum and atypical coverage
Source control
Monitor adequate resuscitation: V/S, serial lactate, IVC on U/S
354
Q

TIA duration

A

<24 h

Typically <1h

355
Q

VBA stroke

A

Loss of pain and temprature in ipsilateral face and contralateral body

Cranial nerves palsy

Cerebellar/brainstem deficits: vertigo, nystagmus, diplopia, visual field deficit, dysphasia, facial hyposthesia, syncope, ataxia

356
Q

ACA stroke

A

Contralateral hemianesthesia and hemiparesis (legs > arms/face)
Gait apraxia, altered mental status, impaired judgement

357
Q

MCA stroke

A

Contralateral hemianesthesia and hemiparesis (arms/face > legs)

Contralateral homonymous hemianopsia,

Ipsilateral gaze

358
Q

PCA stroke

A

Contralateral homonymous hemianopsia

Cortical blindness

Impaired memory

359
Q

Investigations for stroke

A 
CBC
Lytes
BG
Coagulation studies
\+/- cardiac biomarkers
\+/- toxicology screen
Non-contrast CT head
ECG
\+/- echo
\+/- carotid doppler, CTA, MRA
360
Q

Mx of stroke

A

ABC

Intubate if GCS<9, rapidly decreasing GCS, inadequate airway protection reflexes

Thrombolysis (<4.5 h)

elevate head of bed (if risk of elevated ICP, aspiration, worsening cardiopulmonary status)

NPO

IV

+/- cardiac monitoring

Fluid: careful judging

BP control

Glycemic control (keep fasting glucose <6.5 in first 5 d)

Cerebral edema control: hyperventilation, mannitol

Consult: neurosurgery, neurology, medicine

361
Q

Requirements for thrombolysis

A 
Need acute onset
<4.5 h from drug administration time
Compatible physical findings
Normal CT with no bleed
>60 min without improvement
362
Q

Indications of BP control in stroke

A

If severe HTN > 200/120 or MAP >140

HTN associated with hemorrhagic stroke transformation

Cardiac ischemia

Aortic dissection

Renal damage

Use: IV nitroprusside or labetalol

363
Q

U/S for Dx of DVT

A

High sensitivity and specificity for proximal clot
Lower sensitivity for calf DVT

If positive: treat DVT

If negative and low-risk: rule out DVT
If negative and moderate-high risk: repeat in 5-7 d

If inconclusive/inadequate: Venography or MRI

365
Q

D-dimer value in DVT

A

Only useful at ruling out DVT if it’s negative and low-moderate risk patients

367
Q

False positive D-dimer in:

A 
Elderly
Infection
Recent surgery
Trauma
Hemorrhage
Late in pregnancy
Liver disease
Cancer
368
Q

Medications in TIA/Stroke

A

Thrombolysis

Antiplatelet agents: to prevent recurrent stroke or stroke after TIA:
1st line: ASA
2nd line: clopidogrel, aggrenox

Anticoagulation: if immobile or AFib

F/U: endarterectomy, cardiovascular risk optimization

369
Q

4 types of dizziness

A

Vertigo (spinning)

Lightheadedness (disconnect from environment)

Presyncope (almost blacking out)

Dysequilibrium (unstable, off-balance)

370
Q

Indications of CT head in earache

A

Mastoiditis

Malignant otitis externa

371
Q

Sudden SNHL

A

Emergency
High dose steroid
Urgent referal

372
Q

Unilateral tinnitus in elderly

A

Acoustic neuroma until proven otherwise

373
Q

Absolute contra to thrombolytics

A 
Suspected SAH
Previous ICH
Cerebral infarct/severe head trauma within the past 3 month
Recent LP
Recent arterial puncture at non-compressible site
Brain tumor
Metastatic cancer 
BP > 185/110
Bleeding diathesis
PTT> 15s or INR >1.7
Plt <100,000
BG <2.8 or >22
ICH on CT
Large volume infarct
Previously ADL dependent
Seizures at onset causing postictal impairment
374
Q

Relative contra to thrombbolysis

A

Minor symptoms

Rapidly improving

Very severe symptoms/ coma

Major surgery within past 14 days

GI or urinary hemorrhage within the past 21 d

375
Q

The most common reason for epistaxis

376
Q

Inv for epistaxis

A

CBC
PT/PTT
X-ray, CT as needed

377
Q

Tx of epistaxis

A

Aim: localize bleeding and achieving hemostasis

ABC

Clear clots (blowing nose, suction)

Lean forward!

Pinch cartilaginous portion for 20 min, twice

Assess blood loss: vitals, IV NS, crossmatch 2 units of pRBC

If fail twice, proceed to packing

Prophylactic AB if packing both nares

If controlled with anterior pressure: cautery with silver nitrate if the site identified (one side only)

If suspected posterior bleeding or anterior packing does not provide hemostasis: consult ENT for posterior packing

378
Q

Posterior packing issues

A

Requires monitoring

Can you cause significant vagal response

Can lead to significant blood loss

Usually requires admission

379
Q

Packing procedure

A

Clear nose

Topical anesthesia/vasoconstrictors

Insert vaseline gauze pack/ nasal tampon/ nasal balloons

Resorbable pack for thrombocytopenia

If bleeding stops: arrange F/U in 48-72 h: reassess, remove pack

If packing does not provide hemostasis: ENT consult

380
Q

Disposition of epistaxis

A

Discharge upon stabilization

Appropriate F/U

Educate pt: 
Humidifiers
Saline spray
Topical ointment
Avoiding irritants
Control HTN
381
Q

Complications of nasal packing

A

Hypoxemia

TSS

Aspiration

Pharyngeal fibrosis/stenosis

Alar/septal necrosis

382
Q

The most common cause of bleeding during first and second trimesters of pregnancy

A

Friable cervix

383
Q

Inv in vaginal bleeding

A 
B-hCG
CBC
PTT/INR
Blood type and Rh
Type and cross if significant blood loss
Transvaginal U/S
Abdominal U/S
384
Q

Mx of vaginal bleeding

A

ABC
if unstable: cardiac monitoring, oximetry
If pregnant and Rh - : Rhogam

If 1st/2nd T:
If EP: surgery/MTX
If intrauterine pregnancy: F/U with OB/GYNG
If U/S indeterminate: further W/U with OB
Complete abortion: discharge if stable
All other abortions: consult GYN

If 2nd/3rd T: consult

Postparum: ABC, 2large bore IVs, rapid infusion, type and cross 4 units of blood, consult

If non-pregnant:
Unstable: admit to gyn: IV hormonal therapy, possible D&C
If stable non-structural: tranexamic acid, Provera x 10d
If stable structural: outpatient gynecology referral

385
Q

Vaginal bleeding in IVF

A

EP cannot be ruled out by intrauterine pregnancy by bedside U/S

386
Q

The most common type of nephrolithiasis

A

Calcium oxalate 80%

387
Q

Inv for nephrolithiasis

A

CBC

Lytes
BUN, Cr

U/A:R&M, C&S

Non-contrast spiral CT (choice)

Abdominal U/S (if childbearing age)

AXR: initial investigation in pts who have a Hx of radioopaque stone and similar episodes, perform CT if negative AXR

Stone analysis

388
Q

Stones found on AXR

A

Calcium, struvite, cystine

Stones missed on AXR: small, uric acid, overlying bones

389
Q

Mx of nephrolithiasis

A

Ketorolac
Antiemetics
IV fluids
a-blocker in selected cases

Urology consult if stone>5 mm, obstruction, infection

390
Q

Disposition of nephrolithiasis pt

A

Most can be discharged:
Stable
Adequate analgesia
Able to tolerate oral meds

Advise: 
Hydration
Limit protein
Limit Na
Limit oxalate
Limit alcohol
391
Q

Admission of nephrolithiasis if:

A 
Intractable pain
Fever
Evidence of pyelonephritis
Single kidney with your ureteral obstruction
Bilateral obstructing stones
Intractable vomiting
Compromised renal function
392
Q

If high velocity injury to eye suspected

A 
X-ray
Or
U/S
Or
CT

To exclude presence of inteaocular metallic foreign body

393
Q

Mx of ophthalmologic foreign body

A

Copious irrigation with saline

Remove foreign body under slit lamp exam with cotton swab or sterile needle

Antibiotic drops qid until healed

No patching, especially for contact lens wearers

Tetanus prophylaxis

Ophthalmology consult if glob penetration suspected

Topical anesthetics only for examination

394
Q

Contraindications to pupil dilation

A

Shallow anterior chamber

Iris-supported lens implant

Potential neurological abnormalities requiring pupillary evaluation

Caution with Cardiovascular disease as mydriatics can cause tachycardia

395
Q

Inv for rash presenting to ED

A

CBC
Lytes
Cr
AST, ALT, ALP, B/C, skin biopsy, serum Ig levels (IgE)

396
Q

Mx of skinlesions

A

Judicious IV fluid
Lyte control
Vasopressors
Prevention of infection

397
Q

DDx of fixed pupils with red eye

A

Acute angle glucoma

Iritis

398
Q

Acute angle closure glaucoma Tx

A

Consult

Topical:
BB
Adrenergics
Cholinergics

Systemic:
Carbonic anhydrase inhibitors
Hyperosmotic agents

399
Q

Chemical burn of eyes

A 
Irrigate at site of accident
IV NS drip in ED with eyelid retracted
Swab fornices
Cycloplegic drops
Topical AB
Patching
400
Q

Orbital cellulitis treatment

A 
Admission
Ophthalmology consult
Blood culture
Orbital CT
IV antibiotics (ceftriaxone+vanco)
Drainage of abscess
401
Q

Treatment of retinal artery occlusion

A 
Restore blood flow <2h
Massage globe
Decrease IOP:
-topical BB
-inhaled O2/CO2 mix
-IV Diamox (acetazolamide) 
-IV mannitol
-drain aqueous fluid
402
Q

Retinal detachment treatment

A

Consults for scleral buckle/pneumatic retinoplexy

403
Q

Loss of red reflex

A

Retinal detachment

404
Q

Heat exhaustion

A

Loss of circulatory volume

Water depletion: if fluid not adequately replaced
Salt depletion: if fluid replaced with hypotonic fluid

Malaise, headache, fatigue, T <40.5 (usually normal)
Dehydration (HR, orthostatic hypotension)

Tx: rest, cool environment, IV NS if orthostatic hypotension, otherwise slow oral replacement of fluid loss

405
Q

Heat stroke

A

Failure of compensatory heat shedding mechanisms
Subtypes: classical, exertional

Classical:
high ambient temperatures
Often older, poor, sedentary, immobile
Dry, hot skin, temp > 40.5, altered mental status, seizures, delirium, coma. May have elevated AST,ALT

Exertional:
High endogenous heat production that overwhelms homeostatic mechanisms.
Often: younger, active
Diaphoretic, hot skin, temp > 40.5, altered mental status, seizures, delirium, coma. May have DIC, ARF, rhabdomyolysis, marked lactic acidosis

406
Q

Tx of heat stroke

A

Cool body temperature

Monitor temp closely

Secure airway (risk of seizures/aspiration)

Fluid resuscitation if still hypotensive

Avoid B-agonists/peripheral vasoconstriction/antipyretics

If no response to Tx, DDx: meningitis, thyroid storm, delirium tremens, anticholinergic poisoning, other infections

407
Q

Complications of hypothermia

A 
Coagulopathy
Acidosis
Ventricular dysrhythmia
Asystole
Volume and electrolyte depletion
408
Q

Inv in hypothermia

A 
CBC
Lytes, Mg, Ca
Glucose
BUN/Cr
Coagulation profile
Amylase
CXR
ECG
Rectal thermometer
Foley
NG
Monitor metabolic status frequently
409
Q

Symptoms of hypothermia

A

Mild (32-34.9):
Tachycardia, tachypnea, shivering
Ataxia, dysarthria

Moderate (28-31.9):
Dysrhythmia, asborne (J) wave,
Loss of shivering, muscle rigidity
Decreased LOC, Combative behavior, dilated pupils

Severe (<28):
Hypotension, apnea, VFib, asystole
Acidemia, flaccidity
Coma

410
Q

Tx of hypothermia

A

Gentle fluid and electrolyte replacement

Passive external rewarming:
If stable and T> 32.2
Insulating blanket

Active external rewarming:
Heating blanket
Possibility of after-drop. Safe if in conjunction with core rewarming

Active core rewarming:
(Pts with T<32.2 or cardiovascular instability)
Warn humidified oxygen
Warm IV fluids
Peritoneal dialysis with warm fluids
Gastric/colonic/pleural irrigation with warm fluids

411
Q

Passive external warming only suitable for T:

412
Q

Approach to VFib due to hypothermia

A

Do all procedures gently

Check pulse for 1 min

DO NOT CPR if any pulse at all

If in VFib: defibrilate up to 3 times if coreT<30)

Intubate if needed

Ventilate with warm humidified O2

Meds: vasopressors/antidysrhythmic: may try one dose

Focus of treatment: rewarming

413
Q

Frostbite classification

A

First degree:
Paresthesia, pruritus
Erythema, edema, hyperemia

Second degree:
Numbness
Clear blisters, erythema, edema

Third degree:
Pain, burning, painless if severe, throbbing on thawing
Hemorrhagic blisters, skin necrosis, edema, no movement

Fourth degree:
Extension into subcuticular, osseous, muscle tissue

414
Q

Mx of frostbite

A

Treat hypothermia:
O2, IV fluids, body rewarming

Remove wet and constrictive clothing

Immerse in 40-42° C agitated water for 10-30 min
(Needs adequate analgesia)

Clean injured area and leave it open to air

Aspiration/debridement of blisters (contraversial)

Debride skin

Tetanus prophylaxis

Consider penicillin G (high risk of infection)

Surgical intervention to release restrictive eschars

Never allow a thawed area re-chill

415
Q

Burn classification

A

1st degree:
Only epiderm

2nd degree:
Superficial partial thickness:
Blister, very painful
Deep partial thickness:
Hair follicles, sebaceous glands, blister, white-yellow exposed dermis, absent sensation

3rd degree:
Epiderm and all dermal layers:
Pale, insensate, charred, leathery

4th degree:
Fat, muscle, bone

416
Q

Mx of burns

A

Remove noxious agent, stop burning process

Airway (esp if >40% or smoke inhalation)

2 large bore IVs

Resuscitate for 2nd and 3rd degree burns:
Parkland: Ringer’s lactate: 4x wt x % of burnt area (excluding 1st degree burn). Half in first 8h, half in next 16 h.
+ maintenance if no oral tolerance

Pain relief: continuous morphine with breakthrough bolus

Investigations, wound care, escharotomy/fasciotomy for circumferential burns

Topical AB

Tetanus prophylaxis

417
Q

Best measure of resuscitation is:

A

Urine output:
40-50 cc/h (0.5 cc/kg/h)
Avoid diuretics

418
Q

Burn wound care

A 
Prevent infection
Clean/debride with mild soap and water
Sterile dressing
Topical AB
Tetanus prophylaxis (if deeper than superficial dermis)
419
Q

Disposition of burn patient

A 
Admit if:
2nd degree > 10% BSA
Any significant 3rd degree burn
Electrical burn
Chemical burn
Inhalation injury
Underlying medical problems
ImSup
420
Q

Direct thermal injury in inhalation injury

A

Limited to upper airway, above vical cords

421
Q

Investigations in burn

A 
CBC
Lytes
U/A
CXR
ECG
ABG
Carboxyhemoglobin
422
Q

Investigations for inhalation injury

A 
Hb-CO
Co-oximetry
ABG
CXR
\+/- bronchoscopy
423
Q

If high pO2 but low O2 sat

A

CO poisoning

424
Q

Mx of CO poisoning

A

100% O2

+/- hyperbaric O2

425
Q

Mx of direct thermal injury to upper airways

A 
Humidified O2
Early intubation
Pulmonary toilet
Bronchodilators
Mucolytics: NAC
426
Q

What type of bite has hepatitis B or HIV risk?

A

Human bite

427
Q

Bite investigations

A

If bony injury/infection suspected:
X-ray to check for fx and gas in tissue

If child with scalp bite wound:
Skull film +/- CT to R/O skull perforation

If radiolucent foreign body suspected: U/S

If abscess suspected: U/S

428
Q

Mx of bite

A

Wound cleansing:
Copious irrigation
Puncture wounds: irrigate/debride if feasible but not if sealed or very small opening.
Don’t hydrodissect

Debride:
Esp in crush injuries

Culture wounds:
If signs of infection
Anaerobic culture if: foul smelling, necrotizing, abscess

Suturing:
For face and scalp (vascular)
Secondary intention healing for hand, foot, pretinial

AB prophylaxis

Tetanus prophylaxis

429
Q

AB for bite

A

3-5 d
For all bite wounds to the hands.
For other high-risk bites.

Cat»>Dog bites:
Amoxicillin-clavulanate

Human bite:
Amoxicillin-clavulanic acid

Rabies:
Post exposure vaccine and Ig

430
Q

Insect bite Mx

A

ABC

If shock: epinephrine

Antihistamines

Cimetidine 300 mg, IV/IM/PO

Steroids

If SOB/wheezing: B-agonists nebulizer

431
Q

When to admit pt with bite injury?

A 
Mod-sev infection
Infection in ImCompr
Not responding to oral AB
Penetrating injuries to tendons, joints, CNS
Open fx
432
Q

Complications of near drowning experience

A 
Volume shifts
Electrolyte abnormalities
Hemolysis
Rhabdomyolysis
Renal 
DIC
433
Q

Investigations for near drowning

A 
CBC
Lytes
ABG
BUN,Cr
INR, PTT
U/A (drug screen, myoglobin)
CXR
C-spine imaging
ECG
434
Q

Mx of near drowning

A

ABC (trauma, hypothermia, shock): always initiate CPR in drowning-induced cardiac arrest, even if hypothermic. Ckntinue until fully rewarmed

Cardiac and O2 monitors

Intensive respiratory care:
Ventilator (if pO2 <60, pCO2>50, decreased respiration)
+/- ETT
Hugh flow O2/CPAP/BiPAP

Dysrhythmias (usually respond to correction of hypoxemia, acidemia, hypothermia)

Vomiting: NG

Convulsion: O2 (if no response, diazepam)

Bronchospasm: bronchodilators

Prophylactic AB if: contaminated water, hot tub

435
Q

Disposition of drowning pt

A

If non-significant submersion:
discharge after short observation

If significant submersion:
Long period (24h) of observation, even if asymptomatic (pulmonary edema can appear late)

If CNS symptoms/hypoxemia:
Admit

If severe hypoxemia, decreased LOC: ICU

Anticipate secondary drowning

436
Q

ABCD3EFG of toxicology

A 
Airway
Breathing
Circulation
Drugs (ACLS, universal antidotes)
Draw blood
Decontamination (decrease absorption)
Expose/Examine
Full vitals, ECG monitor, Foley, X-rays
Give specific antidotes/ Tx
437
Q

Universal antidotes

A

O2:
If hypoxic
Exceptio: paraquat, diquat

Naloxone

Dextrose:
To any pt with altered LOC
Measure BG first

Thiamine (must give before dextrose):
All pts
100 mg IV/IM
Necessary for glucose metabolism

438
Q

Blood tests in intoxication

A 
CBC
Lytes
BUN/Cr
BG
INR/PTT
Osmolality
ABG, O2 sat
ASA, acetaminophen, EtOH
\+/-
Drug levels
Ca, Mg, PO4
Protein, Alb, lactate, ketones, liver enzymes, CK
439
Q

AG formula and normal amount

A

Na - (HCO3 + Cl)

Normal: 12 or less

440
Q

Radioopaque pills or objects

A 
Calcium
Chloral hydrate
CCl4
Heavy metals
Iron
Potassium
Enteric coated salicylate
Some foreign bodies
441
Q

Electrolyte abnormality caused by digitalis glycosides

A

Hyperkalemia

442
Q

Electrolyte abnormality caused by fluoride

A

Hyperkalemia

443
Q

Electrolyte abnormality caused by theophylline

A

Hypokalemia

444
Q

Electrolyte abnormality caused by BB

A

Hyperkalemia

445
Q

Electrolyte abnormality caused by B-adrenergic agents

A

Hypokalemia

446
Q

Electrolyte abnormality caused by caffeine

A

Hypokalemia

447
Q

Electrolyte abnormalities caused by soluble barium salts

A

Hypokalemia

448
Q

The effects of ASA on blood glucose

A

Hypoglycemia

449
Q

The effects of ethanol on blood glucose

A

Hypoglycemia

450
Q

The affect of salicylates on ventilation

A

Hyperventilation

451
Q

The effect of TCA on QRS complex

452
Q

The effect of Quinidine on QRS

453
Q

The effect of class Ia and Ic antiarhythmics on QRS

454
Q

The effect of antipsychotics on ECG

A

Prolonged QT interval

455
Q

Contraindications to charcoal

A

Caustics
Small bowel obstruction
Perforation

456
Q

Dosage of charcoal

A

10 g/g drug ingested
Or
1 g/kg

457
Q

Whole bowel irrigation indications

A

Polyethylene glycol
By mouth

Indications:
Awake, alert, can be nursed upright
OR
Intubated
Delayed release product
Drug/toxin not bound to charcoal
Drug packages
Recent toxin ingestion
458
Q

Contraindications to bowel irrigation

A

Evedence of ileus
Perforation
Obstruction

459
Q

Indications for surgical removal in intoxication

A

Drugs that are toxic
Drugs that form concretions
Drugs that cannot be removed by conventional means
Evidence of drug packages breakage

460
Q

Indications for urine alkalinization

A

ASA
MTX
Phenobarbital
Chlorpropamide

Urine pH >7.5

461
Q

Indications for multidoes activated charcoal

A 
Carbamazepine
Phenobarbital
Quinine
Theophylline
Toxins which undergo enterohepatic recirculation
462
Q

Indications for hemodialysis in intoxication

A

Toxins that have:
High water solubility, Low protein binding, Low molecular weight, adequate concentration gradient, small volume of distribution, rapid plasma equilibration

Removal of toxins will lead to clinical improvement

Advantage is shown over other modes of therapy

Predicted that drug or metabolite will have toxic effects

Impairment of normal routes of elimination

Clinical deterioration despite maximal medical support

463
Q

Substances for which hemodialysis is useful

A 
Methanol
Ethylene glycol
Salicylate
Lithium
Phenobarbital
Chloral hydrate
Theophylline
Carbamazepine
Valproate
MTX
464
Q

Anticholinergic overdose signs and symptoms

A 
Hyperthermia
Dilated pupils
Dry skin
Vasodilation
Agitation/hallucination
Ileus
Urinary retention
Tachycardia
465
Q

Cholinergic toxicity signs and symptoms

A 
Diaphoresis
Diarrhea
Decreased BP
Urination
Miodis
Bronchospasm
Bronchorrhea
Bradycardia
Emesis
Excitation of skeletal muscle
Lacrimation
Salivation
Seizures
466
Q

Extrapyramidal toxidrome signs and symptoms

A 
Dysphonia
Dysphagia
Rigidity
Tremor
Motor restlessness
Akathisia (crawling sensation)
Dyskinesia (constant movements)
Dystonia
467
Q

Hb deranging toxidromes signs and symptoms

A 
Increased respiratory rate
Decreased LOC
Seizures
Cyanosis unresponsive to O2
Lactic acidosis
468
Q

Intoxication with opioids, sedatives, hypnotics, EtOH signs and symptoms

A 
Hypothermia
Hypotension
Respiratory depression
Dilated or constricted pupils
CNS depression
469
Q

Medications causing serotonin syndrome

A 
MAOI
TCA
SSRI
opiate analgesics
Cough medicine
Wt reduction medications
470
Q

Examples of cholinergics

A 
Mushrooms
Trumpet flower
Physostigmine
Organophosphates
Carbamates
Nerve gas
471
Q

Examples of anticholinergics

A 
TCA (antidepressants)
Carbamazepine
Diphenhydramine (antihistamines)
Antiparkinsonism
Antipsychotics
Antispasmodics
Belladona (atropine)
472
Q

Urine alkalization method for ASA treatment

A

Fluid resuscitate first
3 amps of NaHCO3/L of D5W at 1.5 x maintenance
Add 20-40 mEq/L KCL if pt is able to urinate

473
Q

Protocol for warfarin overdose

A

INR < 5:
Cessation of warfarin, observation, serial INR/PT

5.1 -9.0:
If no RF for bleeding, hold 1-2 d, reduce dose
If increased risk of bleeding, VitK 1-2 mg PO

9.1-20.0:
Hold, vitK 2-4 mg PO, serial INT, aditional vitK if necessary

> 20:
Hold, vit K 10 mg IV over 10 min. Increase dosing q4h if needed

Any INR with life-threatening bleeding or surgical plan within 6h: PCC

474
Q

Tx of acetaminophen overdose

A

Activated charcoal

NAC

475
Q

Tx of acute dystonic reaction

A

Benztropine

Diphenhydramine

476
Q

Tx of anticholinergic intoxication

A

Charcoal

Supportive

477
Q

Tx of ASA intoxication

A

Charcoal
Urine alkalinization
Hemodialysis if: intractable metabolic acidosis, very high levels, EOD

478
Q

Tx of BDZ intoxication

A

Charcoal
Flumazenil
Supportive

479
Q

Tx of BB overdose

A

Charcoal
High dose insuline euglycemic therapy
Dialysis
Intralipids

480
Q

Tx of CCB intoxication

A 
Charcoal
CaCl2
High dose insulin euglycemic therapy
Inotropes
Intralipids
481
Q

Tx of cocaine intoxication

A

Charcoal if oral
Supportive
Intralipid if life-threatening

BB CONTRAINDICATED

482
Q

CO poisoning

A

Supportive

100% O2

483
Q

Tx of cyanide intoxication

A

Hydroxycobalamin

484
Q

Tx of dig toxicity

A

Charcoal

Digoxin-specific Ab fragments

485
Q

Tx of ethanol toxicity

A

Thiamin 100

Check glucose esp in children

486
Q

Tx of intoxication with methanol or ethylen glycol

A 
Fomepizole or
Ethanol 10%
Urgent hemodialysis required
Folic acid for methanol
B1 and B6 for ethylene glycol
487
Q

Tx of heparin toxicity

A

Prothamine sulfate

488
Q

Tx of MDMA intoxication

A

Charcoal

Supportive

489
Q

Tx of TCA intoxication

A 
Charcoal
Supportive
NaHCO3 if wide QRS/seizures
intralipid
FLUMAZENIL CONTRAINDICATED
490
Q

Correlation of alcohol levels and symptoms

491
Q

Effect of alcohol on blood pressure

A

Hypotension if acute consumption

HTN if chronic

492
Q

Tx of alcohol withdrawal

A

Diazepam/Lorazepam
Thiamine
MgSO4 (if hypomagnesemic)

Admit if: DT or multiple seizures

493
Q

Common deficiencies with alcohol

A 
Thiamine B1
Niacin B3
Folate
Glycogen
Mg
K
Hypophosphatemia
Hypocalcemia
494
Q

Alcoholic ketoacidosis

A 
AG metabolic acidosis
Urine ketones
Low glucose
Normal osmolality
Hx of chronic alcohol intake with abrupt decrease/cessation
Malnourished
Abdominal pain
N/V
Tx
Dextrose
Thiamine prior to dextrose
Volume repletion
Resolves in 12-24 h
495
Q

Methanol, ethylene glycol acid-base derangement

A

AG metabolic acidosis with osmolar gap

496
Q

AST/ALT ratio suggestive of alcohol misuse

A

> 2

Also increased GGT with acute ingestion

497
Q

Disposition of alcohol withdrawal pt

A 
Discharge when:
Stable V/S
Walk unassisted
Oriented
Can obtain medications
Can F/U

Offer social services

498
Q

Disposition of TCA intoxication

A

If prolonged/delayed cardiotoxicity: ICU

If asymptomatic and no clinical signs:
Proper decontamination + normal ECG + 6h observation, then discharge

If sinus tachycardia alone: observe in ED

most common finding in TCA toxicity: sinus tachycardia

499
Q

ASA/Acetaminophen toxicity disposition

A

If borderline levels, check again in 2-4 h after first level

For ASA: discharge if at least 2 downward levels (3 levels minimum)

500
Q

Oral hypoglycemics intoxication disposition

A

Admit all hypoglycemics for at least 24 h and 12 h if last octreotide dose

If asymptomatic, observe for at least 8 h

octreotide is considered for glyburide

501
Q

Mx of acute psychosis

A 
Violence prevention:
Remain calm, empathic, reassuring
Ensure safety of staff and pts
Have extra staff/ security on hand
\+/- physical restraint, chemical tranquilizer

BDZ: lorazepam
Antipsychotics: olanzapine, halopridol

Treat underlying medical condition
Psychiatry consult

502
Q

Mx of suicidal pt

A

Ensure pt safety

Assess thoughts, means, action, previous attempt

Admit if:
Evidence of active intent
Organized plan
Access to lethal means
Psychiatric disorder
Intoxication

Do not start long-term meds in ED

Psychiatry consult

503
Q

Infant < 1 yr with large boggy scalp hematoma due to trauma, next step?

504
Q

Mx of croup

A

Dexa x 1 dose

If mod-sev: nebulized epinephrine

If no response: other DDx

505
Q

Bacterial tracheitis Mx

A

Intubation, ICU
ENT consult
AB (cloxacillin,…)
C&S

506
Q

Epiglotitis Mx

A

DO NOT EXAMINE OROPHARYNX

immediate anesthesia, ENT call, intubate

Then IV fluids

AB

B/C

507
Q

Mx of children asthma

A

O2 (if sat < 90% or PaO2 < 60%)

Salbutamol (by mask x3)

Steroid (systemic prednisolone/ dexa x 2 doses 24 h apart)

Ipratropium (if severe. Add to first 3 salbutamol doses)

MgSO4 ( if critically ill, not responding to bronchodilator/CS)

IV B2-agonist (if critically ill and not responding to above)

508
Q

Mx of Febrile infant Without obvious focus

A

<28 d:
Admit
Full sepsis W/U
Treat empirically

28-90 d:
As above
But if meets Rochester criteria, partial sepsis w/u

> 90 d:
If toxic: admit, treat, full sepsis w/u
If non-toxic: investigate as indicated by Hx and PEx

509
Q

Rochester criteria:

A 
Non-toxic
Previously well:
(Term
Home with mother
No hyperbil
No prior AB or hospitalization
No chronic/ underlying illness)
No focus of infection
WBC 5000-15000
Bands <1500
Urine <10 WBC
Stool <5 WBC
510
Q

Full vs partial sepsis w/u

A

Full:
CBC, diff, blood C/S, urine C/S, LP
+/- stool C/S, CXR

Partial:
CBC, diff, blood C/S, urine C/S
+/- CXR

511
Q

Febrile seizure features

A 
6mo-6yr
Fever Or Hx of recent fever
Often positive FHx
Normal neurological exam afterward
No evidence of intracranial infection
No Hx of previous non-febrile seizures
Relatively well-looking after seizure
512
Q

Mx of febrile seizure

A

Treat fever

Look for source of fever

513
Q

Head and neck findings in favor of child abuse

A 
Torn frenulum
Dental injuries
Bilateral black eyes
Traumatic hair loss
Diffuse severe CNS injury
Retinal hemorrhage
514
Q

Shaken baby syndrome

A

Diffuse brain injury
Subdural hemorrhage, SAH
Retinal hemorrhage
Minimal/no evidence of external trauma or associated bony fx

515
Q

Skin injuries

A 
Bites
Bruises/burns in shape of an object
Glove/stocking distribution of burns
Bruises of various ages
Bruises in protected areas
516
Q

Bone injuries suggestive of child abuse

A 
Rib fx without major trauma
Femur fx < 1yr
Spiral fx of long bones in non-ambulatory children
Metaphyseal fx in infants
Multiple fx of various ages
Complex/multiple skull fractures
517
Q

GI/GU injuries suggestive of child abuse

A

Chronic abdominal/perineal pain
Injury to genitals/rectum
STI/pregnancy
Recurrent vomiting or diarrhea

Med (25 decks)

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