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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
Eye in GSC
Eyes open 4: spontaneously 3: to voice 2: to pain 1: none
26
Verbal response in GCS
5: Answers questions properly 4: Confused and disoriented 3: Inappropriate words 2: incomprehensible sounds 1: none
27
Motor response in GCS
6: Obeys commands 5: localizes to pain 4: Withdraws from pain 3: decorticate 2: decerebrate 1: none
28
Exposure/Environment in primary survey
``` Assess entire body Log roll DRE Keep pt warm (blanket, radiant heat) Warm IV fluids/blood Keep provider safe ```
29
3:1 rule for saline crystaloids
30% remains in IV space, so give 3x estimated blood loss
30
Fluid resuscitation
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)
31
If unilateral dilated, non-reactive pupil, DDx?
Focal mass Epidural hematoma Subdural hematoma
32
Resuscitation components
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
33
Contraindications to foley insertion
Blood at urethra meatus Scrotal hematoma High-riding prostate on DRE
34
NG tube contraindications
Basal skull fracture | Significant mid-face trauma
35
Airway for CPR
Head tilt-chin lift For all ages (If C-spine stable)
36
Breaths for CPR
2 breaths at 1 s/breath | Stop once see chest rise
37
Foreign-body airway obstruction
>8 y: abdominal thrust | <1 y: back slaps, chest thrusts
38
Compression landmarks in CPR
>1 y: chest centre, between nipples | <1 y: just below nipple line
39
Compression method in CPR
>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
40
Compression rate in CPR
100-120/ min | Allow complete chest wall recoil
41
Compression to ventilation ratio
30 compression to 2 ventilations
42
Defibrillation
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)
43
When is secondary survey done?
Once patient is hemodynamically and neurologically stabilized
44
Secondary survey components
Hx Full physical exam X-rays (C-spine,chest, pelvis), Consider T-spine and L-spine if indicated
45
History taking during secondary survey
``` SAMPLE S: signs and symptoms A: allergies M: medications P: past medical history L: last meal E: events related to injury ```
46
Physical exam during secondary survey
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
47
Initial imaging during secondary survey
Non-contrast CT head/face/C-spine CXR FAST or CT abd/pel (if stable) Pelvis x-ray
48
Signs of increasing ICP in trauma patient
``` Deteriorating LOC Deteriorating respiratory pattern Cushing reflex Lateralizing CNS signs Seizures Papilledema (late) N/V and headache ```
49
Golden hour in trauma
4-6 h
50
Height of fall considered high risk injury
>12 ft (3.6 m)
51
Typical vault skull fx
Linear: temporal bone, middle meningeal artery area
52
The most common cause of epidural hematoma
Linear skull vault fx in middle meningeal artery area
53
Typical basal skull fx
Floor of anterior cranial fossa | Longitudinal
54
Best method if diagnosing basal skull fx
Clinical Dx superior to CT
55
High risk injuries in MVC
Ejection from vehicle Motorcycle collisions Vehicle versus pedestrian crashes Fall from height Ford and 12 feet
56
Concussion
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
57
Diffuse axonal injury
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
58
Focal brain injuries
Contusion | Intracranial hemorrhage
59
Cushing response to increased ICP
Bradycardia HTN irregular respirations
60
Traumatic brain injury severity
Mild: GCS:13-15 Mod: 9-12 Severe: 3-8
61
Significant anisocoria in trauma
> 1mm in pt with altered LOC
62
Hx in assessment of brain injury in trauma pt
Pre-hospital status | Mechanism of injury
63
PEx in assessment of brain injury in trauma pt
``` C-spine: assume injured V/S: shock (infants), Cushing response LOC Pupils: size, anisocoria, response to light Lateralizing signs (motor/sensory) Reassess frequently ```
64
Investigations in assessment of brain injury in trauma pt
CBC, lytes, toxicology screen, PTT/INR, glucose CT of head and neck C-spine imaging
65
Goal of Mx of brain injury in ED
Reducing secondary injury by: | Avoiding hypoxia, ischemia, decreased cerebral perfusion pressure, seizure
66
Head injury Mx in ED
``` General: ABC Intubate, prevent hypercarbia sBP > 90 Treat other injuries Neurosurgical consultation Seizure Tx/Prophylaxis: BDZ, Phenytoin, phenobarbital ``` Treat suspected raised ICP
67
Treatment of raised ICP
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
68
Contraindications to manittol
Shock | RF
69
Mx of minor head injuries not requiring admission
24 h head injury protocol to competent caregiver | F/U with neurology
70
Indications of CT had in minor head injury
``` 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) ```
71
Definition of minor head injury
Witnessed loss of consciousness, definite amnesia, or witnessed disorientation in a patient with a GCS score of 13-15
72
Warning signs of severe head injury
GCS<8 Deteriorating GCS Unequal pupils Lateralizimg signs
73
Signs of mild traumatic brain injury
Somatic: Headache, sleep disturbance, N/V, blurred vision Cognitive dysfunction: Attentional impairment, reduced processing speed, drowsiness, amnesia Emotion and behavior: Impulsivity, irritability, depression
74
Signs of severe concussion
Seizure, bradycardia, hypotension, sluggish pupils
75
Tx of mild traumatic brain injury
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
76
C-spine collar indications
``` Midline tenderness Neurological symptoms or signs Significant distracting injuries Head injury Intoxication Dangerous mechanism Hx of altered LOC ```
77
When to assume cord injury?
Fall > 12 ft Deceleration injury Blunt trauma to head, beck or back
78
The most important film of cervical spine
Lateral cervical x-ray
79
Indication of MRI in traumatic brain injury
If worsening symptoms despite normal CT
80
Spinal cord injury Hx
``` Mechanism Previous deficits SAMPLE neck pain Paralysis/weakness Paresthesia ```
81
Spinal cord injury PEx
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
82
Investigations for spine injury
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)
83
Level of injury for cauda equina syndrome
Below T10
84
Cauda equina symptoms
``` Incontinence Anterior thigh pain Quadriceps weakness Abnormal sacral sensation Decreased rectal tone Variable reflexes ```
85
Indications for spine imaging
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
86
The canadian C-spine rule:
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
87
Insications for C-spine X-ray
``` 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 ```
88
Indications for C-spine CT scan
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
89
If normal C-spine films but abnormal neurological exam
Perform an MRI | C-spine cleared if normal
90
If normal C-spine films but neck pain
Order flexion/extension films If normal, C-spine cleared If abnormal, remain immobilized and consult spine service
91
Mx of cord injury
``` 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 ```
92
Cervical cord injury and respiration
C5-T1: abdominal breathing | Higher level injury: May require intubation and ventilation
93
Unable to rule out dens fx by odontoid view
``` Repeat view Or CT Or Plain film tomography ```
94
Physiologic spine subluxations
Children < 8y C2 on C3 C3 on C4 Spino-laminal lines are maintained
95
Fanning of spinous processes
Posterior lugament disruption
96
Widening of predental space
3 mm or higher in adults 5 mm or higher in children Suggests C1 or C2 injury
97
Anterior/ posterior wedging of intervertebral disc spaces
Vertebral compression
98
Normal retropharyngeal width
<7 mm at C1-C4 | Wide in children <2 y on expiration
99
Normal retrotracheal space width
<22 mm at C6-T1 | <14 mm in children < 5 y
100
Neurogenic shock level
``` T6 or higher Within 30 min Loss of vasomotor tone, SNS tone Lasts up to 6 wk Hypotension, bradycardia, poikilotherma ```
101
Spinal shock
Absence of all voluntary and reflex activities below level of injury No sensation Flaccid paralysis Lasts days to months
102
Autonomic dysreflexia
``` 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
103
Airway obstruction investigation and Mx
Primary survey Inv: none Mx: Definitive airway management Remove foreign body if visible with laryngoscope prior to intubation
104
Tension pneumothorax investigations and management
Primary survey Investigation: none Management: Needle Thoracostomy, large bore needle, 2nd ICS, mid-clavicular line Then: Chest tube in 5th ICS, anterior axillary line
105
Open pneumothorax Mx
Primary survey Air-tight dressing sealed on 3 sides Chest tube Surgery Inv: decreased pO2 on ABG
106
Massive hemothorax Mx
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 ```
107
Flail chest Mx
Primary survey ABG: decreased pO2, increased pCO2 CXR: rib fx, lung contusion Mx: O2+ fluid+ pain control Positive pressure ventilation +/- intubation and ventilation
108
Cardiac tamponade Mx
Primary survey Echo FAST Mx: IV fluid Pericardiocentesis Open thoracotomy
109
Pulmonary contusion Mx
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 ```
110
Ruptured diaphragm Mx
``` Secondary survey CXR: abn diaphragm/ lower lung fields NGTube CT Endoscopy ``` Mx: laparotomy
111
Esophageal injury
Secondary survey CXR: mediastinal air Esophagogram Flexible esophagoscopy Mx: all require repair (improved outcome if within 24h)
112
Aortic tear
``` Secondary survey CXR CT TEE aortography ``` Mx: thoracotomy
113
Blunt myocardial injury
Secondary survey ECG: dysrhythmias, ST changes If normal ECG and hemodynamics, pt never gets dysrhythmia Mx: O2 Antidysrhythmic Analgesic
114
Aortic tear on X-ray
``` 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 ```
115
Penetrating neck trauma
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
116
Triad of larynx injury
Hoarseness SQ emphysema Palpable fx Other: hemoptysis Dyspnea Dysphonea
117
Inv in larynx injury
CXR CT Arteriography (if penetrating)
118
Management of larynx injury
Airway: manage early because of Edema C-spine protection Surgery: tracheotomy vs repair
119
Injury to trachea or bronchus
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
120
The most common solid organ injury in blunt abdominal trauma
Spleen | Liver is the second most common
121
The most common are organ injury in penetrating abdominal trauma
Liver | And hollow organs
122
Investigations in abdominal trauma
``` CBC Lytes Coagulation Cross/type Glucose Cr CK lipase Amylase Liver enzyme ABG blood EtOH B-HCG U/A Toxicology ```
123
Indication of foley in abdominal trauma
Unconscious Patient with multiple injuries who cannot void spontaneously
124
Indications for NG tube in abdominal trauma
To decompress the stomach and proximal small bowel Contra: face/skull base fx
125
Seatbelt abdominal injuries
Retroperitoneal duodenal trauma Intraperitoneal bowel transection Mesentric injury L-spine injury
126
X-ray and abdominal trauma
``` CXR Pelvis C-spine Thoracic Lumbar ```
127
CT scan in abdominal trauma
Most specific test Cannot be used if hemodynamic instability
128
Diagnostic peritoneal lavage
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
129
FAST
Rapid <5min False positive in ascites
130
Positive DPL
``` Gross blood > 10cc Bile Bacteria Foreign material RBC > 100,000/microliter WBC > 500 Amylase > 175 IU ```
131
Indications for abdominal imaging
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
132
Management of blunt abdominal trauma
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
133
Penetrating abdominal trauma Mx
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
134
PEx in abdominal trauma
``` Inspection Palpation Auscultation NG Foley DRE ```
135
Intraperitoneal bladder rupture if:
Full bladder Acute abdomen presentation
136
Extraperitoneal bladder rupture
From pelvic fx Pelvis instability, suprapubic tenderness
137
Gross hematuria in abdominal trauma suggests:
Bladder injury
138
Investigations for GU teauma
Urethra: retrograde urethrography Bladder: U/A, CT, urethrogram +/- retrograde cystoscopy +/- cystogram (dilated bladder, post-void Ureter: retrograde ureterogram Renal: CT (if stable hemodynamic), IVP
139
In case of gross hematuria
GU investigated from distal to proximal
140
Mx of renal trauma
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
141
Mx of ureter trauma
Ureterouretostomy
142
Mx of bladder trauma
Extraperitoneal: If minor rupture, Foley x 10-14 d If major rupture, surgical repair Intraperitoneal: Drain abdomen and surgical repair
143
Urethra trauma Mx
Anterior: Conservative, if cannot void, Foley/suprapubic cystostomy and AB ``` Posterior: Suprapubic cystostomy (avoid cath) +/- surgical repair ```
144
Open fx management
``` 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
145
If vascular compromise in fx
Realign limb/ apply longitudinal traction Reassess pulse with doppler Surgical comsult
146
Pain out of proportion to injury
Esophageal rupture Compartment syndrome Ischemia of mesentry Necrotizing fasciitis
147
Compartment syndrome Mx
Prompt decompression Remove constrictive cast and dressings +/- emergent fasciotomy
148
Anterior shoulder dislocation Mx
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)
149
Coll’s fx
X-ray: radial deviation, dorsal displacement
150
Scaphoid fx symptoms
Tenderness in anatomical snuffbox Pain on scaphoid tubercle Pain on axial loading of thumb
151
Scaphoid fx Mx
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
152
Avulsion of the base of 5th metatarsal
Occurs with inversion injury Supportive tensor or below knee walking cast x 3wk
153
Ankle radiograph series indications in malleolus trauma:
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
154
Ankle radiograph series indications in midfoot trauma:
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
155
Wounds requiring tetanus prophylaxis
``` Dirt, soil, feces, saliva contamination Puncture wound Avulsion Resulting from missile Crushing Burn Frostbite ```
156
Abrasion management
Clean thoroughly with brush Local anesthetic antiseptic oint (if facial or complex abrasion Tetanus prophylaxis
157
Acute treatment of contusions
``` RICE Rest Ice Compression Elevation ```
158
High risk factors for infection
``` Puncture Crush >12h Hand or foot Age> 50 Prosthetic joint/valve Immunocompromised ```
159
Suture size and duration
``` Face: 6-0 x 5d Joints: 3-0 x 10d Not joints: 4-0 x 7d Scalp: 4-0 x 7d Mucous membranes: absorbable ```
160
Laceration Mx
``` 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 ```
161
Maximum dose of lidocain
With epinephrine: 7 mg/ kg | Without epinephrine: 5 mg/kg
162
Indications for prophylactic AB in lacerations
Animal bite Human bite Intra-oral lesions Puncture wounds to the foot
163
Exception to perform suture
``` Presentation > 6-8 h Puncture wound Mammalian bite Crush injury Retained foreign body ```
164
The most important factor in decreasing wound infection risk is:
Early irrigation and debridement
165
Metabolic reasons of stomachache
Emergent: DKA, Sickle cell crisis, toxin, addisonian crisis Less emergent: Lead poisoning, porphyria
166
Investigations in abdominal pain
``` ABC CBC Lytes BG BUN/Cr, U/A Liver enzymes, LFT Lipase Lactate, VBG ECG, troponins B-hCG AXR, CXR, U/S, CT ```
167
Pts with atypical presentations of abdominal pain
Very young Elderly Alcoholics Immunocompromised
168
Peritoneal findings blunted if:
Old age Pregnancy T3 Chronic CS use
169
Disposition of abdominal pain pt
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
170
Most common cause of pelvic pain
Ruptured ovarian cyst
171
Acute pelvic pain inv
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
172
Pelvic pain referral indications:
If requiring surgery If requiring admission If oncologic Admit if: requiring surgery, IV AB/pain control Discharge if: negative w/u, improving symptoms
173
Ovarian cyst Mx
If unruptured: analgesia, f/u If ruptured but stable hemodynamic: analgesic and f/u If unstable hemodynamic or significant bleeding: surgery
174
Preferred imaging modality and assessment of pelvic pain
U/S
175
Lethargy, Stupor, Coma
Lethargy: wakeful but decreased awareness and alertness Stupor: unresponsive but rousable Coma: unresponsive, not rousable to consciousness
176
Abrupt onset of coma suggests
CNS hemorrhage/ischemia | Cardiac cause
177
Onset of coma over hours to days
Progressive CNS lesion Toxic Metabolic
178
PEx in altered LOC
``` ABC LOC, eye examination vitals Cardiac/respiratory/abdominal exams Complete neurologic exam ```
179
Investigations for altered LOC
``` CBC Lytes BUN, Cr, U/A LFT Glucose INR/PTT Serum osmolality, VBG Troponins Serum EtOH, acetaminophen, salicylate CXR, CT head ECG, UTox ```
180
Finding suggestive of toxic or metabolic coma
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
181
Findings suggestive of structural coma
Lateralizing abnormalities
182
Lucid interval
Epidural hematoma
183
Universal antidotes
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)
184
Toxic or metabolite causes of fixed dilated pupils
``` Anoxia Anticholinergic (atropine, TCA...) Methanol Cocaine Opioid withdrawal Amphetamine Hallucinogen ```
185
Toxic or metabolic causes of fixed constricted pupils
Opiates (except meperidine) | Cholinergics (organophosphates)
186
Metabolic/toxic causes of normal to dilated fixed pupils
Hypothermia Barbiturates Antipsychotics
187
Chest pain investigations
CBC, lytes, BUN, Cr, BG, PTT/INR, CK, troponins | ECG, CXR, CT
188
Mx of acute chest pain
``` ABC O2 Cardiac monitoring IV access Underlying, consultation Observation/monitoring if unknown cause ```
189
When to discharge a pt with acute chest pain
If low probability of life-threatening illness: resolving symptoms, negative w/u
190
Typical angina
Retrosternal Provoked by exertion Relieved by rest/nitroglycerin
191
When to take a 15 lead EKG in MI
If hypotensive If AV node involvement If inferior MI
192
When is troponin sensitive for MI?
After 6-8 h
193
Westermark sign
Abrupt tapering of a vessel on chest film
194
Rate of normal CXR in PE
50%
195
Pericarditis pain relieved by
Sitting up and leaning forward
196
ECG in acute pericarditis
II,III,aVF,V4-V6: ST elevation, PR depression aVR, V1: ST depression and PR elevation (reciprocal) Sinus tachycardia
197
sBP in arms in aortic dissection
Difference > 20 mmHg
198
CXR in aortic dissection
Wide mediastinum Left pleural effusion Indistinct aortic knob >4mm separation of intimal calcification from aortic shadow
199
Aortic dissection Tx
ABC reduce BP and HR Type A (ascending): urgent surgery Type B (descending): medical Urgent consult
200
Esophageal rupture symptoms
``` Sudden onset Severe pain After: endoscopy, forceful vomiting, labour, convulsion, corrosive injury, cancer Sepsis Subcutaneous emphysema ```
201
Imaging esophageal ruptur
CXR: Pleural effusion Pneumomediastinum CT, water soluble contrast esophagogram
202
Tx of esophageal rupture
``` ABC early AB Thoracics consult NPO Consider chest tube ```
203
Abnormal skin sensation in herpes zoster precedes rash by
1-5 d
204
Reproduction of symptoms with movement or palpation is found in what percent of MI patients?
25% (similar to MSK)
205
Long QT syndrome
QT interval > 1/2 of cardiac cycle
206
ECG in dig toxicity
Gradual downward curve of ST At risk for AV block, ventricular irritability
207
Abortive treatment for migrain
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
Tx of tension headache
Modify stressors Local measures NSAIDs TCA
209
Migraine headache increases by
Activity
210
Tension or muscular headache aggravated by
Stress, sleep deprivation
211
SAH headache increases by
Exertion
212
Hyperattenuated signal around circle of willis on CT
SAH
213
If suspected SAH bu normal CT after 6 h of onset,
LP
214
Mx of SAH
Urgent neurosurgery consult
215
High-risk variables for SAH
``` 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
Eye exam in temporal arthritis
Relative afferent pupillary defect | Optic disc edema
217
Admission for headache
``` If: Underlying diagnosis is critical Underlying diagnosis is emergent Abnormal neurological findings Elderly Immunocompromised Pain is refractory to oral medications ```
218
Discharging headache
Most patients can be discharged Assessed for risk of narcotic missuse Instruct patient to return for fever, vomiting, neurology changes, or increasing pain
219
Morning Stiffness in inflammatory arthritis
>30 min
220
Midday fatigue is in favor of which type of arthritis
Inflammatory
221
Investigation for arthritis
CBC, ESR, CRP, INR/PTT, blood cultures, urate Joint x-ray +/- contralateral joint for comparison Bedside U/S to identify effusion
222
Emergency vascular conditions needed to be ruled out in back pain
``` Aortic dissection AAA PE MI Retroperitoneal bleeding ```
223
Indications of imaging in back pain
Suspicion of emergencies, metastasis, high risk of fracture, infection, cancer or vascular causes
224
Use of dexamethasone for abortive treatment of migraine
26% reduction in headache recurrence within 72 hours
225
Red flags for back pain
``` Bowel or bladder dysfunction Anesthesia, saddle Constitutional symptoms Chronic disease Constant pain Paresthesia Age>50 and mild trauma IV drug use Neuromotor deficit ```
226
Status epilepticus
Continuous or intermittent seizure activity for greater than five minutes without regaining consciousness
227
immediate Mx of status epilepticus
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
Urgent management of status epilepticus
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
Mx of refractory status epilepticus
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
Post-seizure Mx of status epilepticus
``` Investigate underlying: CT LP MRI ICP monitoringg ```
231
Minimum work up in an adult with first time seizure
CBC and diff Electrolytes including Ca, Mg, PO4 Head CT
232
Control of seizures in adults without IV access
Midazolam 0.2 mg/kg up to 10 mg
233
When to discharge patients in status epilepticus
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
Anti-epileptic drug requiring cardiac monitoring
Phenytoin
235
Investigations for dyspnea
``` CBC, diff Lyte VBG Serial cardiac enzymes ECG WELL’s score CXR ```
236
Findings in favor of cardiogenic syncope
Sudden loss of consciousness with no warning or prodrome Syncope accompanied by chest pain
237
Investigations for syncope
``` ECG Bedside BG CBC Lytes BUN/Cr ABG Troponin Ca Mg B-hCG D-dimertoxicology ```
238
Mx of syncope
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
General approach to sexual assault
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
How long does the sperm remain motile in female genital?
6-12 h in vagina | 5 d in cervix
241
Lab in sexual assault
VDRL, repeat in 3 mo if negative Serum B-hCG ABO group, Rh Baseline serology (HIV, Hepatitis...)
242
Mx of sexual assault
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
Disposition
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
The most common STD after rape
Gonorrhea> chlamydia> syphilis > HIV
245
Suspicion about domestic violence
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
Management of domestic violence
``` 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
Most common triggers for anaphylaxis
Foods, stings, drugs, radiographic contrast media, blood products, latex
248
Drugs causing anaphylaxis
Penicillin NSAIDs ACEI
249
Angioedema versus anaphylaxis
Angioedema does not tend to improve with standard anaphylaxis treatment
250
Management of moderate anaphylaxis
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
Management of severe angioedema
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
Second phase of anaphylaxis can happen within
Up to 48 hours
253
Disposition of anaphylaxis patient
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
Investigations for asthma in ED
Peak flow meter ABG: if severe respiratory distress CXR: if Dx in doubt
255
Definition of hypotension
sBP > 30% decrease from baseline Or Adults: <90 11y and older: <90 1-10 yr: < 70+ 2 x age 1mo-1yr: < 70
256
Asthma pt with silent chest
Medical emergency | May require emergency intubation
257
Elements of well-controlled asthma
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
Mild asthma symptoms and characteristics
FEV1 > 80% Exertional SOB/cough + some nocturnal symptoms Difficulty finishing sentences
259
Mild asthma management in ED
B-agonist Monitor FEV1 Consider steroid (MDI or PO)
260
Moderate asthma symptoms and features in ED
FEV1: 50-80% SOB at rest Cough Congestion Chest tightness Speaking in phrases Inadequate relief from B-agonists
261
Moderate asthma management in ED
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
Severe asthma theaters in ED
FEV1 < 50% O2 sat <90% Agitated Diaphoretic Labored respirations Speaking in words No relief from B-agonist
263
Severe asthma management in ED
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
Characteristics of asthma with imminent respiratory arrest
O2 sat <90% Decreased HR RR> 30 pCO2> 45 ``` Exhausted Confused Diaphoretic Cyanotic Silent chest Ineffective respiratory effort ```
265
Management of asthma with Imminent respiratory arrest
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
Disposition of patient with exacerbated asthma
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
Risk factors for recurrence of exacerbation of asthma
``` Frequent ED visits Frequent hospitalizations Recent steroid use Recent exacerbation Poor medication compliance Prolonged use of high dose B-agonists ```
268
Tx of Mobitz II and 3rd degree block
ED: Atropine with caution Transcutaneous pacing If failed, IV dopamine, epinephrine Long-term: Internal pacemaker
269
Tx of sinus bradycardia
Indication: if symptomatic ED: atropine, transcutaneous pacing Sick sinus node: transcutaneous pacing Drug-induced: D/C or reduce offending drug, antidotes
270
Sinus tachycardia treatment
Treat underlying BB if symptomatic
271
Supraventicular tachycardia with narrow QRS | Next step?
Is rhythm regular or irregular?
272
If SVT with regular rhythm?
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
If SVT with irregular rhythm
A Fib, atrial flutter, MAT | Next step: rate control (diltiazem, BB)
274
If pt with tachydysrrhythmia is unstable:
Immediate synchronized cardioversion
275
Most common
AF
276
Holiday heart
AF
277
Treatment principles in AF
Stroke prevention Symptom control Identification and treatment of underlying disease
278
How much does cardiac output decrease and AF?
20-30%
279
Treatment of AF
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
VTach definition
3 or more consecutive ventricular beats at > 100 bpm
281
The most common cause of VTach
CAD with MI
282
Sustained VTach Tx
>30 sec Emergency Hemodynamic compromise: synchronized DC cardioversion No hemodynamic compromise: Synchronized DC cardioversion Amiodarone Procainamide
283
VFib Mx
Call code blue | ACLS
284
Torsades de pointes Tx
IV Mg Isoprotrenol Correct cause
285
Causes of torsades de pointes
``` Erythromycin TCA quinidine Quinolones Hypokalemia Hypomagnesimia ```
286
If WPW with AF
Amiodarone Procainamide Avoid AV blocking agents
287
COPD exacerbation cardinal symptoms
Increased dyspnea Increased cough Increased sputum Purulence of sputum
288
Investigations in COPD
``` CBC Lytes ABG CXR ECG ``` NO PFT
289
Physical findings in COPD
``` Wheezing Laryngeal height 4 cm or less Forced expiratory time 6 sec or more Decreased breath sounds Decreased cardiac dullness ```
290
In COPD exacerbation R/O:
``` exacerbated CHF MI PE pneumonia Other infections Pneumothorax ```
291
COPD exacerbation Tx
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
Disposition of COPD
Low admission threshold if comorbidities If discharge: Taper steroid Up to 4-6 puffs of ipratropium and salbutamol F/U
293
Investigations for heart failure
``` 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
Mx of CHF
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
CHF on CXR
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
Hospital Mx of CHF required if:
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
Well,s Criteria for DVT
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
Well’s criteria for DVT scoring
0: low probability 1-2: moderate probability 3 and higher: high probability
299
The first step in suspicion for DVT
Compression U/S
303
Mx of DVT
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
Duration of anticoagulation therapy
If transient coagulopathy: 3 mo If unprovoked coagulopathy: 6 mo If ongoing coagulopathy: life-long
305
Well’s criteria for PE
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
Interpretation of Well’s criteria for PE
<2 low probability 2-6: intermediate probability >6: High probability
307
ECG in PE
S1Q3T3 Sinus tachycardia T wave inversion in anterior and inferior leads
308
If PE suspicion, next step?
``` PERC score: Age > 50yr HR > 100 O2 sat <94% Prior Hx DVT/PE Recent trauma/surgery Hemoptysis Exogenous estrogen Clinical signs suggesting DVT ```
309
PERC interpretation
0/8: PE excluded | 1-8/8: proceed to Well’s
310
How to proceed according well’s score in PE
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
PE in pregnancy
Use PERC with caution V/Q scan instead of CT-PA
312
Mx of PE
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
When to admit PE pt?
``` Hemodynamically unstable Require supplemental O2 Major comorbidities Lack of sufficient social support Unable to ambulate Need invasive therapy ```
314
Respiration in DKA
Kussmaul
315
Investigations fo DKA
CBC, electrolytes, Ca, Mg, PO4, BUN, Cr, glucose, ketones, osmolality, AST/ALT/ALP, amylase, troponin Urine glucose and ketones ABG or VBG ECG
316
Mx of DKA
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
How to correct pseudohyponatremia
Add 3 Na per 10 glucose over 5.5
318
Triad of DKA
Hyperglycemia Ketosis Acidosis Also: ketonuria
319
Investigations for HHS
``` 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
Mx of HHS
``` Rehydration IV NS (Total deficit: 100 cc/kg body weight) O2 Cardiac monitoring Insuline (controversial) Treat underlying ( Ischemia, Infarction, Infection, Insulin missed, Intoxication) ```
321
Mx of hypoglycemia
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
The most common reason for hypoglycemia
Excessive insulin use in setting of poor PO intake
323
Levels of Na causing seizures and coma
> 158
324
Tx of hypernatremia
Salt restrict Give free water No more correction than 12 /24 h
325
Hyponatremia Mx
Water restrict/NPO Seizure/coma: 100cc 3% NaCl If hypovolemia: ringer lactate If hypervolumia: furosemide Limit total rise to 8/ 24h
326
Mx of hyperkalemia
Protect heart: Ca gluconate Shift K into cells: D50W+ insulin NaHCO3 Salbutamol Remove K: Fluid+ furosemide Dialysis
327
Hypokalemia Mx
K-Dur K sparing diuretics IV solutions with 20-40 mEq/L KCl over 3-4 h May need to restor Mg
328
Hypercalcemia Mx
``` Isotonic saline (usually dehydrated) + furosemide if hypervolemic Bisphosphonate Dialysis Chelation (EDTA, oral PO4) ```
329
Hypocalcemia Mx
``` If acute ( ionized Ca < 0.7): immediate treatment: IV calcium gluconate ```
330
EOD in hypertensive crisis
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
Investigations in hypertension crisis
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
Management of hypertensive crisis (emergency)
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
Management of hypertension crisis in Ischemic stroke
maintain BP> 150/100 for 5 d
334
In case of aortic dissection and hypertension crisis
Rapid reduce of BP to 110-120 STAT Do not resuscitate with IV fluid
335
In case of excessive catecholamines in hypertension crisis
Do not use BB (except labetalol)
336
In case of ACS and hypertension crisis
First address ischemia, then BP
337
Hypertensive urgency
Severely elevated BP > 180/110 | No evidence of EOD
338
The most common reason for hypertension urgency
Not adherence with medications
339
Tx of HTN urgency
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
1st line treatment in HTN crisis
Sodium Nitroprusside
341
Na nitroprusside adverse effects
N/V, muscle twitching, sweating, cyanide intoxication, coronary steal syndrome
342
Caution with nitroprusside
High ICP | Azotemia
343
Caution with nicardipine
Acute CHF
344
Special hypertensive indication for NTG
MI/pulmonary edema
345
Caution in fenoldopam
Glaucoma
346
HTN with catecholamine excess
Phentolamine
347
Investigations for ACS
ECG STAT Troponin (2-6 h after onset) CXR to R/O other causes
348
Mx of ACS
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
NTG contraindications
Hypotension PDE-inhibitor use Right ventricular infarction (1/3 of inferior MIs)
350
Reperfusion strategy
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
Sepsis definition
Life-threatening organ dysfunction (by a dysregulated host response to infection) A change in baseline SOFA score equal or higher than 2
352
Septic shock definition
Profound circulatory, cellular, metabolic abnormalities. Require vasopressors to maintain MAP 65 or higher Serum lactate 2 or higher without hypovolemia
353
Mx of septic shock
``` 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
TIA duration
<24 h | Typically <1h
355
VBA stroke
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
ACA stroke
Contralateral hemianesthesia and hemiparesis (legs > arms/face) Gait apraxia, altered mental status, impaired judgement
357
MCA stroke
Contralateral hemianesthesia and hemiparesis (arms/face > legs) Contralateral homonymous hemianopsia, Ipsilateral gaze
358
PCA stroke
Contralateral homonymous hemianopsia Cortical blindness Impaired memory
359
Investigations for stroke
``` CBC Lytes BG Coagulation studies +/- cardiac biomarkers +/- toxicology screen Non-contrast CT head ECG +/- echo +/- carotid doppler, CTA, MRA ```
360
Mx of stroke
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
Requirements for thrombolysis
``` Need acute onset <4.5 h from drug administration time Compatible physical findings Normal CT with no bleed >60 min without improvement ```
362
Indications of BP control in stroke
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
U/S for Dx of DVT
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
D-dimer value in DVT
Only useful at ruling out DVT if it’s negative and low-moderate risk patients
367
False positive D-dimer in:
``` Elderly Infection Recent surgery Trauma Hemorrhage Late in pregnancy Liver disease Cancer ```
368
Medications in TIA/Stroke
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
4 types of dizziness
Vertigo (spinning) Lightheadedness (disconnect from environment) Presyncope (almost blacking out) Dysequilibrium (unstable, off-balance)
370
Indications of CT head in earache
Mastoiditis | Malignant otitis externa
371
Sudden SNHL
Emergency High dose steroid Urgent referal
372
Unilateral tinnitus in elderly
Acoustic neuroma until proven otherwise
373
Absolute contra to thrombolytics
``` 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
Relative contra to thrombbolysis
Minor symptoms Rapidly improving Very severe symptoms/ coma Major surgery within past 14 days GI or urinary hemorrhage within the past 21 d
375
The most common reason for epistaxis
Trauma
376
Inv for epistaxis
CBC PT/PTT X-ray, CT as needed
377
Tx of epistaxis
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
Posterior packing issues
Requires monitoring Can you cause significant vagal response Can lead to significant blood loss Usually requires admission
379
Packing procedure
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
Disposition of epistaxis
Discharge upon stabilization Appropriate F/U ``` Educate pt: Humidifiers Saline spray Topical ointment Avoiding irritants Control HTN ```
381
Complications of nasal packing
Hypoxemia TSS Aspiration Pharyngeal fibrosis/stenosis Alar/septal necrosis
382
The most common cause of bleeding during first and second trimesters of pregnancy
Friable cervix
383
Inv in vaginal bleeding
``` B-hCG CBC PTT/INR Blood type and Rh Type and cross if significant blood loss Transvaginal U/S Abdominal U/S ```
384
Mx of vaginal bleeding
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
Vaginal bleeding in IVF
EP cannot be ruled out by intrauterine pregnancy by bedside U/S
386
The most common type of nephrolithiasis
Calcium oxalate 80%
387
Inv for nephrolithiasis
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
Stones found on AXR
Calcium, struvite, cystine Stones missed on AXR: small, uric acid, overlying bones
389
Mx of nephrolithiasis
Ketorolac Antiemetics IV fluids a-blocker in selected cases Urology consult if stone>5 mm, obstruction, infection
390
Disposition of nephrolithiasis pt
Most can be discharged: Stable Adequate analgesia Able to tolerate oral meds ``` Advise: Hydration Limit protein Limit Na Limit oxalate Limit alcohol ```
391
Admission of nephrolithiasis if:
``` Intractable pain Fever Evidence of pyelonephritis Single kidney with your ureteral obstruction Bilateral obstructing stones Intractable vomiting Compromised renal function ```
392
If high velocity injury to eye suspected
``` X-ray Or U/S Or CT ``` To exclude presence of inteaocular metallic foreign body
393
Mx of ophthalmologic foreign body
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
Contraindications to pupil dilation
Shallow anterior chamber Iris-supported lens implant Potential neurological abnormalities requiring pupillary evaluation Caution with Cardiovascular disease as mydriatics can cause tachycardia
395
Inv for rash presenting to ED
CBC Lytes Cr AST, ALT, ALP, B/C, skin biopsy, serum Ig levels (IgE)
396
Mx of skinlesions
Judicious IV fluid Lyte control Vasopressors Prevention of infection
397
DDx of fixed pupils with red eye
Acute angle glucoma | Iritis
398
Acute angle closure glaucoma Tx
Consult Topical: BB Adrenergics Cholinergics Systemic: Carbonic anhydrase inhibitors Hyperosmotic agents
399
Chemical burn of eyes
``` Irrigate at site of accident IV NS drip in ED with eyelid retracted Swab fornices Cycloplegic drops Topical AB Patching ```
400
Orbital cellulitis treatment
``` Admission Ophthalmology consult Blood culture Orbital CT IV antibiotics (ceftriaxone+vanco) Drainage of abscess ```
401
Treatment of retinal artery occlusion
``` Restore blood flow <2h Massage globe Decrease IOP: -topical BB -inhaled O2/CO2 mix -IV Diamox (acetazolamide) -IV mannitol -drain aqueous fluid ```
402
Retinal detachment treatment
Consults for scleral buckle/pneumatic retinoplexy
403
Loss of red reflex
Retinal detachment
404
Heat exhaustion
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
Heat stroke
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
Tx of heat stroke
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
Complications of hypothermia
``` Coagulopathy Acidosis Ventricular dysrhythmia Asystole Volume and electrolyte depletion ```
408
Inv in hypothermia
``` CBC Lytes, Mg, Ca Glucose BUN/Cr Coagulation profile Amylase CXR ECG Rectal thermometer Foley NG Monitor metabolic status frequently ```
409
Symptoms of hypothermia
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
Tx of hypothermia
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
Passive external warming only suitable for T:
>32.2
412
Approach to VFib due to hypothermia
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
Frostbite classification
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
Mx of frostbite
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
Burn classification
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
Mx of burns
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
Best measure of resuscitation is:
Urine output: 40-50 cc/h (0.5 cc/kg/h) Avoid diuretics
418
Burn wound care
``` Prevent infection Clean/debride with mild soap and water Sterile dressing Topical AB Tetanus prophylaxis (if deeper than superficial dermis) ```
419
Disposition of burn patient
``` Admit if: 2nd degree > 10% BSA Any significant 3rd degree burn Electrical burn Chemical burn Inhalation injury Underlying medical problems ImSup ```
420
Direct thermal injury in inhalation injury
Limited to upper airway, above vical cords
421
Investigations in burn
``` CBC Lytes U/A CXR ECG ABG Carboxyhemoglobin ```
422
Investigations for inhalation injury
``` Hb-CO Co-oximetry ABG CXR +/- bronchoscopy ```
423
If high pO2 but low O2 sat
CO poisoning
424
Mx of CO poisoning
100% O2 | +/- hyperbaric O2
425
Mx of direct thermal injury to upper airways
``` Humidified O2 Early intubation Pulmonary toilet Bronchodilators Mucolytics: NAC ```
426
What type of bite has hepatitis B or HIV risk?
Human bite
427
Bite investigations
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
Mx of bite
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
AB for bite
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
Insect bite Mx
ABC If shock: epinephrine Antihistamines Cimetidine 300 mg, IV/IM/PO Steroids If SOB/wheezing: B-agonists nebulizer
431
When to admit pt with bite injury?
``` Mod-sev infection Infection in ImCompr Not responding to oral AB Penetrating injuries to tendons, joints, CNS Open fx ```
432
Complications of near drowning experience
``` Volume shifts Electrolyte abnormalities Hemolysis Rhabdomyolysis Renal DIC ```
433
Investigations for near drowning
``` CBC Lytes ABG BUN,Cr INR, PTT U/A (drug screen, myoglobin) CXR C-spine imaging ECG ```
434
Mx of near drowning
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
Disposition of drowning pt
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
ABCD3EFG of toxicology
``` 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
Universal antidotes
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
Blood tests in intoxication
``` 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
AG formula and normal amount
Na - (HCO3 + Cl) Normal: 12 or less
440
Radioopaque pills or objects
``` Calcium Chloral hydrate CCl4 Heavy metals Iron Potassium Enteric coated salicylate Some foreign bodies ```
441
Electrolyte abnormality caused by digitalis glycosides
Hyperkalemia
442
Electrolyte abnormality caused by fluoride
Hyperkalemia
443
Electrolyte abnormality caused by theophylline
Hypokalemia
444
Electrolyte abnormality caused by BB
Hyperkalemia
445
Electrolyte abnormality caused by B-adrenergic agents
Hypokalemia
446
Electrolyte abnormality caused by caffeine
Hypokalemia
447
Electrolyte abnormalities caused by soluble barium salts
Hypokalemia
448
The effects of ASA on blood glucose
Hypoglycemia
449
The effects of ethanol on blood glucose
Hypoglycemia
450
The affect of salicylates on ventilation
Hyperventilation
451
The effect of TCA on QRS complex
Wide QRS
452
The effect of Quinidine on QRS
Wide QRS
453
The effect of class Ia and Ic antiarhythmics on QRS
Wide QRS
454
The effect of antipsychotics on ECG
Prolonged QT interval
455
Contraindications to charcoal
Caustics Small bowel obstruction Perforation
456
Dosage of charcoal
10 g/g drug ingested Or 1 g/kg
457
Whole bowel irrigation indications
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
Contraindications to bowel irrigation
Evedence of ileus Perforation Obstruction
459
Indications for surgical removal in intoxication
Drugs that are toxic Drugs that form concretions Drugs that cannot be removed by conventional means Evidence of drug packages breakage
460
Indications for urine alkalinization
ASA MTX Phenobarbital Chlorpropamide Urine pH >7.5
461
Indications for multidoes activated charcoal
``` Carbamazepine Phenobarbital Quinine Theophylline Toxins which undergo enterohepatic recirculation ```
462
Indications for hemodialysis in intoxication
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
Substances for which hemodialysis is useful
``` Methanol Ethylene glycol Salicylate Lithium Phenobarbital Chloral hydrate Theophylline Carbamazepine Valproate MTX ```
464
Anticholinergic overdose signs and symptoms
``` Hyperthermia Dilated pupils Dry skin Vasodilation Agitation/hallucination Ileus Urinary retention Tachycardia ```
465
Cholinergic toxicity signs and symptoms
``` Diaphoresis Diarrhea Decreased BP Urination Miodis Bronchospasm Bronchorrhea Bradycardia Emesis Excitation of skeletal muscle Lacrimation Salivation Seizures ```
466
Extrapyramidal toxidrome signs and symptoms
``` Dysphonia Dysphagia Rigidity Tremor Motor restlessness Akathisia (crawling sensation) Dyskinesia (constant movements) Dystonia ```
467
Hb deranging toxidromes signs and symptoms
``` Increased respiratory rate Decreased LOC Seizures Cyanosis unresponsive to O2 Lactic acidosis ```
468
Intoxication with opioids, sedatives, hypnotics, EtOH signs and symptoms
``` Hypothermia Hypotension Respiratory depression Dilated or constricted pupils CNS depression ```
469
Medications causing serotonin syndrome
``` MAOI TCA SSRI opiate analgesics Cough medicine Wt reduction medications ```
470
Examples of cholinergics
``` Mushrooms Trumpet flower Physostigmine Organophosphates Carbamates Nerve gas ```
471
Examples of anticholinergics
``` TCA (antidepressants) Carbamazepine Diphenhydramine (antihistamines) Antiparkinsonism Antipsychotics Antispasmodics Belladona (atropine) ```
472
Urine alkalization method for ASA treatment
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
Protocol for warfarin overdose
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
Tx of acetaminophen overdose
Activated charcoal | NAC
475
Tx of acute dystonic reaction
Benztropine | Diphenhydramine
476
Tx of anticholinergic intoxication
Charcoal | Supportive
477
Tx of ASA intoxication
Charcoal Urine alkalinization Hemodialysis if: intractable metabolic acidosis, very high levels, EOD
478
Tx of BDZ intoxication
Charcoal Flumazenil Supportive
479
Tx of BB overdose
Charcoal High dose insuline euglycemic therapy Dialysis Intralipids
480
Tx of CCB intoxication
``` Charcoal CaCl2 High dose insulin euglycemic therapy Inotropes Intralipids ```
481
Tx of cocaine intoxication
Charcoal if oral Supportive Intralipid if life-threatening BB CONTRAINDICATED
482
CO poisoning
Supportive | 100% O2
483
Tx of cyanide intoxication
Hydroxycobalamin
484
Tx of dig toxicity
Charcoal | Digoxin-specific Ab fragments
485
Tx of ethanol toxicity
Thiamin 100 | Check glucose esp in children
486
Tx of intoxication with methanol or ethylen glycol
``` Fomepizole or Ethanol 10% Urgent hemodialysis required Folic acid for methanol B1 and B6 for ethylene glycol ```
487
Tx of heparin toxicity
Prothamine sulfate
488
Tx of MDMA intoxication
Charcoal | Supportive
489
Tx of TCA intoxication
``` Charcoal Supportive NaHCO3 if wide QRS/seizures intralipid FLUMAZENIL CONTRAINDICATED ```
490
Correlation of alcohol levels and symptoms
Poor
491
Effect of alcohol on blood pressure
Hypotension if acute consumption HTN if chronic
492
Tx of alcohol withdrawal
Diazepam/Lorazepam Thiamine MgSO4 (if hypomagnesemic) Admit if: DT or multiple seizures
493
Common deficiencies with alcohol
``` Thiamine B1 Niacin B3 Folate Glycogen Mg K Hypophosphatemia Hypocalcemia ```
494
Alcoholic ketoacidosis
``` 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
Methanol, ethylene glycol acid-base derangement
AG metabolic acidosis with osmolar gap
496
AST/ALT ratio suggestive of alcohol misuse
>2 Also increased GGT with acute ingestion
497
Disposition of alcohol withdrawal pt
``` Discharge when: Stable V/S Walk unassisted Oriented Can obtain medications Can F/U ``` Offer social services
498
Disposition of TCA intoxication
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
ASA/Acetaminophen toxicity disposition
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
Oral hypoglycemics intoxication disposition
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
Mx of acute psychosis
``` 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
Mx of suicidal pt
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
Infant < 1 yr with large boggy scalp hematoma due to trauma, next step?
U/S Or CT
504
Mx of croup
Dexa x 1 dose If mod-sev: nebulized epinephrine If no response: other DDx
505
Bacterial tracheitis Mx
Intubation, ICU ENT consult AB (cloxacillin,...) C&S
506
Epiglotitis Mx
DO NOT EXAMINE OROPHARYNX immediate anesthesia, ENT call, intubate Then IV fluids AB B/C
507
Mx of children asthma
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
Mx of Febrile infant Without obvious focus
<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
Rochester criteria:
``` 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
Full vs partial sepsis w/u
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
Febrile seizure features
``` 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
Mx of febrile seizure
Treat fever | Look for source of fever
513
Head and neck findings in favor of child abuse
``` Torn frenulum Dental injuries Bilateral black eyes Traumatic hair loss Diffuse severe CNS injury Retinal hemorrhage ```
514
Shaken baby syndrome
Diffuse brain injury Subdural hemorrhage, SAH Retinal hemorrhage Minimal/no evidence of external trauma or associated bony fx
515
Skin injuries
``` Bites Bruises/burns in shape of an object Glove/stocking distribution of burns Bruises of various ages Bruises in protected areas ```
516
Bone injuries suggestive of child abuse
``` 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
GI/GU injuries suggestive of child abuse
Chronic abdominal/perineal pain Injury to genitals/rectum STI/pregnancy Recurrent vomiting or diarrhea

Med (25 decks)

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