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01 Family Medicine > Emergency Medicine > Flashcards

Emergency Medicine Flashcards

AAFP Board Review lecture: Emergency Medicine Parts 1 & 2

1
Q

What are the two Nonshockable rhythms?

A

  1. Asystole
  2. Pulseless Electrial Activity (PEA)
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2
Q

Per ACLS protocol what are the steps of managment for nonshockable heart rhythms?

A
  1. Continue CPR for 2 minutes, establish an airway and provide oxygen
  2. Give Epinephrine 1 mg IV/IO every 3-5 minutes
  3. Evaluate heart rhythm
  4. If no VT or VF, evaluate and treat reversible causes (5Ts and 6Hs); still continue CPR and epinephrine
  5. If no return of circulation, repeat all steps
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3
Q

What are the 5 T’s and 6 H’s to consider with nonshockable rhythms?

A
  1. Toxins
  2. Tamponade
  3. Tension pneumothorax
  4. Thrombosis (cardiac)
  5. Thrombosis (PE)
  6. H+ (acidosis)
  7. Hypothermia
  8. Hypokalemia
  9. Hyperkalemia
  10. Hypovolemia
  11. Hypoxia
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4
Q

What are the Shockable Rhythms?

A

Ventricular fibrillation

Ventricular Tachycardia

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5
Q

Per ACLS, What are the mangement steps for a shockable rhythm?

A
  1. CPR for 2 minutes
  2. Epinephrine 1 mg IV/IO every 3-5 minutes
  3. Evaluate rhythm, If VT/VF, Defibrillate 200J x1
  4. CPR for 2 minutes, 5 times
  5. Evaluate rhythm, If VT/VF, Defibrillate again and give epinephrine 1mg
  6. CPR for 2 minutes, 5 times
  7. Evaluate rhythm, if VT/VF defibrillate agian and give amiodarone or lidocaine
  8. If no ROSC, repeat all steps
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6
Q

Which 3 unstable rhythms are treated with synchronized cardioversion?

A

SVT

Atrial flutter/fibrillation

Monomorphic VT

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7
Q

What are the general principles of the Good Samartian Law?

A
  1. No legal obligation to provide aid (outside of hospital/clinical setting)
  2. Immunity from malpractive suit*

*except if actions were willful negligence or lack of good faith

*Immunity removed if payment is accepted for aid provided

3.Recipient of aid must not object to aid rendered

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8
Q

Where does the Good Samaritan law apply?

A

In all 50 states and on airlines

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9
Q

What is the definition of SIRS?

A

2 or more of the following:

Temperature < 36 C (96.8 F) or >38 C (100.4 F)

Respiratory Rate >20

Pulse >90

WBC < 4,000 or >12,000 or >10% immature cells

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10
Q

Define sepsis, severe sepsis and septic shock

A

Sepsis: SIRS + source of infection

Severe sepsis: sepsis + lactate >2 or organ dysfunction

Septic shock: severe sepsis + lactate >4 or hypotension despite fluid resuscitation

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11
Q

How is septic shock managed and within what time frame?

A

All steps should be completed within 3 hours of presentation

  • Measure Lactate
  • Obtain cultures
  • Administer antibiotics (within 1 hour of presentation)
  • Administer 30 mL/kg of cystalloid for hypotension or lactate >4
  • If hypotensive (MAP <65) after fluids, start norepinephrine
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12
Q

What is the #1 and #2 causes of trauma deaths in adults?

A
  1. Firearms
  2. Motor vehicle accident
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13
Q

What is the #1 and #2 causes of trauma deaths in kids?

A
  1. Motor vehicle accident
  2. Firearms
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14
Q

At what age can children safely sit in the front seat of a car?

A

13 and older

12 and under always in the backseat

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15
Q

Are car seats based off of age or weight/height recommendations?

A

Weight and height

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16
Q

Which is associated with the poorest outcome in drowning cases?

A) Below freezing water

B) Saltwater aspiration

C) >6 minute submersion

A

C) >6 minute submersion

Water temperatue has no correlation with outcome

No difference in fresh water v. salt water aspiration

*4 sided fencing is the best prevention measure

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17
Q

What is the most common cause of unintentional death in infants and how can it be prevented?

A

Suffocation

  • remove soft bedding and toys from sleeping area
  • have newborns sleep on their back
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18
Q

Name 4 types of head trauma

A

Intracerebral hemorrhage

Epidural hematoma

Subdural hematoma

Concussion

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19
Q

What causes epidural hematomas?

A

Usually due to middle meningeal artery rupture

  • associated with skull fracture
  • can present during a “lucid interval” then deteriorate
  • Convex bleed on CT
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20
Q

Which type of head trauma may not be seen on initial CT?

A

Intracerebral hemorrhage

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21
Q

What causes subdural hematomas?

A

Tearing of bridging veins between dura and arachnoid

  • Common in elderly and alcoholics
  • Concave, crescent shape bleed on CT
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22
Q

Name and Rank the order of INR reversal agents from longest to fastest

A

Vitamin K (12-24 hours)

FFP (13-48 hours)

Prothrombin Complex Concentrate (3-15 minutes)

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23
Q

What is the ideal treatment for life threatening bleeding in a patient on warfarin?

A

Vitamin K 10mg IV

and

prothrombin complex concentrate (dose based on INR)

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24
Q

Why is FFP used more but less ideal?

A

Cheaper, available in more hospitals

Requires ABO testing

Takes 30-45 minutes to thaw

Takes 12-48 hours to have effect

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25
Q

What is the treatment for corneal abrasion?

A

Topical NSAIDs

Topical antibiotics (Grade C)

If wearing contacts remove and add pseudomonas abx coverage

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26
Q

What treatments are not proven to be beneficial in corneal abrasion?

A

Topical cycloplegics and mydriatics (no pain relief or benefit)

Eye patch (may delay healing)

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27
Q

“I got punched in the eye” What are three eye injuries to look out for?

A

Orbital fracture, Traumatic iritis, Hyphema

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28
Q

What common physical exam findings can be found with orbital fractures?

A

Restricted upward gaze

numbness of lower eyelid, lateral side of nose, anterior cheek, upper lip (infraorbital nerve)

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29
Q

What is traumatic iritis and how to treat it?

A

Inflammation of iris and ciliary muscle

Analgesia: mydriatics (help with ciliary spasm and light sensitivity)

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30
Q

What is this? How to treat?

A

Hyphema-blood in anterior chamber

Elevate bed to 30 degrees, call ophtho

Avoid NSAIDs/ASA

[https://en.wikipedia.org/wiki/Hyphema]

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31
Q

What is the diagnosis and treatment?

A

Not an emergency, provide reassurance

Avoid straining

[https://en.wikipedia.org/wiki/Subconjunctival_bleeding]

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32
Q

Differential for Non-traumatic painful eye problem?

What intervention can help narrow your differential?

A

Relieved by proparacaine: conjunctivitis, keratitis, corneal ulcer

Not relieved by proparacaine: iritis, uveitis, acute glaucoma

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33
Q

Differential for Non-traumatic painless eye problem with vision changes?

A

Posterior vitreous detachment

Rretinal detachment

Retinal artery/vein occlusion

Ischemic optic neuropathy (temporal arteritis)

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34
Q

Differential for blunt chest trauma?

A

Rib fractures, flail chest

hemothorax, pneumothorax

pulmonary contusion

aortic tear

cardiac tamponade

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35
Q

What is commotio cordis?

A

Blunt chest trauma just as the T wave begins before the peak -> Causes Vfib

Classic example: kid hit in chest during baseball game

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36
Q

What is Kehr’s sign? In what common situation is it seen?

A

Left shoulder pain due to blood irritating the diaphragm.

Seen with spleen hemorrhage, abdominal trauma

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37
Q

What vaccines are needed post splenectomy?

A

Pneumococcal, HIB, meningococcal

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38
Q

What are some causes of Rhabdomylolysis?

A

Trauma, seizures, burns, drug overdose, exertion, toxins

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39
Q

What labs results are seen in rhabdomylolysis?

A

Urine dipstick (+) blood, UA RBCs 0-2

CPK (2-3x above upper limit of normal)

elevated Cr

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40
Q

What is the treatment of rhabdomyolysis?

A

Fluids- crystalloid 500 cc/hour

goal urine output 200-300 cc/hour

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41
Q

When does compartment syndrome occur?

A

When perfusion pressure falls below tissue pressure in any anatomic space

Pressure >30 mm Hg

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42
Q

What are the signs of Compartment Syndrome?

A

Pain (first sign)

parenthesia

poikilothermia (affected limb is colder)

Paralysis

Pallor

Pulselessness

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43
Q

When irrigating wounds should sterile or tap water be used?

A

Irrigation with tap water has been shown to have comparable (or lower) rates of infection compared to sterile water

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44
Q

When should tetanus prophylaxis be given in the setting of a new wound?

A

Give if clean wound and greater than 10 years since last dose

Give if dirty wound and greater than 5 years since last dose

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45
Q

Can non sterile gloves be used in wound care?

A

Yes, does not increase infection rate

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46
Q

Up to how many hours after the incident can non infected wounds caused by clean objects be closed up?

A

Up to 18 hours

If on face/scalp 24 hours

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47
Q

Can lidocaine with epinephrine be used on digits?

A

Yes if no concern for vascular compromise

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48
Q

What is the next step in management if you are concerned about glass in a wound?

A

X-ray

Can identify any glass 2mm or greater

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49
Q

Which wounds need prophylactic antibiotics?

A

High risk site- hand, foot

High risk mechanism- bites

High risk patient-immunocompromised, prosthetic valve

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50
Q

4 month old with diffuse cerebral injury with edema +/- intracerebral bleed and retinal hemorrhages, diagnosis?

A

Shaken baby syndrome

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51
Q

What are 3 principles to remember about child abuse?

A
  1. If they don’t cruise they don’t bruise
  2. 82% of rib fractures in kids less than 3 years old are abuse
  3. Undiagnosed abuse had a 25% mortality in 2 years
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52
Q

20 month old with spiral fracture of the distal tibia, diagnosis? Treatment?

A

Toddler’s fracture

Below knee walking cast for 3 weeks

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53
Q

What age range is toddler’s fracture seen most commonly?

A

9 months to 3 years

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54
Q

Radial nerve sensory and motor function?

A

Sensory- posterior hand thumb to radial half of ring finger

Motor-wrist and finger extension

55
Q

Median nerve sensory and motor function?

A

Sensory- palmer surface thumb to radial half of ring finger

Motor- flexion of wrist and fingers

Test with OK sign

56
Q

Ulnar nerve sensory and motor function?

A

Sensory- Anterior and posterior sides of little finger and ulnar half of ring finger

Motor- interossesous muscles intrinsically- abduction

Test with star trek sign

57
Q

Diagnosis?

A

Community acquired MRSA

58
Q

What bugs cause non purulent cellulitis?

A

Strep pyogenes

MSSA

59
Q

Common treatments for non purulent cellulitis?

A

Dicloxacillin, Cephalexin, Doxycycline, Clindamycin

60
Q

Common treatment for purulent cellulitis?

A

TMP-SMX, Doxycycline, Clindamycin

61
Q

Why do face injuries rarely get infected?

A

Due to high vascularization

62
Q

What type of bite has the highest risk on infection?

A

Cat bites

Puncture wound that is hard to wash out

Higher risk of bone/joint infection

63
Q

Human bite or closed fist injury treatment?

A

Polymicrobial

Copious irrigation, avoid closure, Augmentin x5 days

64
Q

What is the rate of infection in dog bites?

A

About 5%

Higher if bite is on the hands or a deep puncture or an elderly patient

65
Q

Treatment of dog bites?

A

+/- Augmentin

Ok to close

66
Q

Most common bacteria and treatment for Cat bite?

A

Pasteurella multocida

Amoxicillin- Clavulanate

67
Q

Most common bacteria and treatment for Dog bite?

A

Pasteurella multocida, Capnocytophaga sp, Fuscobacterium, S. aureus, eikenella, EF-4

Amoxicillin- Clavulanate

68
Q

Most common bacteria and treatment for Human bite?

A

Viridans Streptococci, Bacteroides

Amoxicillin- Clavulanate

69
Q

Most common bacteria and treatment for Animal hides, carcasses?

A

Bacillus anthracis (Anthrax) - skin and lung infection

Ciprofloxacin, doxycycline, PCN

70
Q

Most common bacteria and treatment for Fresh water injury?

A

Aeromonas sp

TMP-SMX, Fluroquinolones

71
Q

Most common bacteria and treatment for Salt water injury?

A

Vibrio fulnificus- skin and GI infection

3rd gen cephalosporin + minocycline/doxycycline or fluoroquinolone

72
Q

Most common bacteria and treatment for Fish tank exposure?

A

Mycobacterium marinum

Hot compresses, minocycline, clarithromycin

73
Q

Most common bacteria and treatment for Hot tube exposure?

A

Pesudomonas aeruginosa

Self limiting, acetic acid compresses, ciprofloxacin

74
Q

What is the characteristic finding in Cat Scratch Disease?

A

Regional lymphadenopathy: Axillary/epitrochlear, Cervical, inguinal

10% suppurative

75
Q

How is Cat Scratch Disease diagnosed?

A

Serologic IgG antibodies to bartonella henselae

76
Q

What is the treatment of Cat Scratch Disease?

A

Self limiting (1-2 months)

Do NOT I&D

No antibiotics needed

Unless immocompromised, use azithromycin

77
Q

Name the rash and associated illness:

A flat, oval, large rash with central clearing, no fluctuance, non tender

Hx of travel to the NE

A

Erythema Migrans

Lyme disease

78
Q

How is Lyme disease transmitted?

A

Deer tick

Bacteria: borrelia burgdorferi

79
Q

What are the early stages of Lyme disease?

A

Erythema migrans

Cranial nerve 7 neuropathy, radiculopathy, lymphocytic meningitis

A-V block

80
Q

What are the late stages of Lyme disease?

A

Lyme arthritis (mainly large joints like knees)

Encephalopathy, peripheral neuropathy

81
Q

Treatment of early Lyme disease?

A

Doxycycline 100 mg BID x 10 days

Other options: Amoxicillin, Cefuroxime, Azithromycin

82
Q

Who should be tested for Lyme disease?

A

Bell’s palsy with questionable hx

Presenting with large swollen joints

83
Q

How does treatment for Lyme disease change if signs of early neurological disease are present?

A

7th CN palsy - oral tx for 14-21 days

Meningitis, radiculopathy- parenteral tx for 10-28 days

84
Q

Treatment length of Lyme carditis?

A

Oral or parenteral for 21-28 days

85
Q

Treatment length of Lyme arthritis?

A

Oral tx for 28 days

86
Q

Patient presents with fever, chills, myalgias, headache after starting antibiotic treatment for Lyme disease, what is the best treatment plan?

A

Contine same antibiotics and treat symptomatically

This is Jarisch-Herxheimer Reaction

87
Q

Who needs antibiotic prophylaxis for Lyme disease?

A

If all of the following are met:

Attached tick reliably identified

Estimated that tick was attached for more than 36 hours

Prophylaxis can be started within 72 hours of tick removal

Local rate of infection in these ticks with B. Burgdorferi is greater than 20%

Doxycycline not contraindicated

88
Q

What is the regiment for Lyme disease prophylaxis?

A

One dose of doxycycline (200 mg)

89
Q

Other than Lyme disease, what other 2 illness are transmitted by deer ticks?

A

Anaplasmosis

Babesiosis

90
Q

What is the presentation of human granulocytic anaplasmosis?

A

Fever, chills, headache

Thrombocytopenia, leukopenia, elevated LFTs

Symptoms within 3 weeks of tick bite

91
Q

What is the presentation of Babesiosis?

A

Malaria-like illness

Hemolytic anemia, thrombocytopenia, elevated LFTs

Caused by intracellular protozoa

92
Q

What is Rocky Mountain Spotted Fever and how does it present?

A

Organism: Rickettsia rickettsia

Transmitted by American dog tick, Rocky Mountain wood tick

Flu-like illness, rash within 5-10 days of tick bite, can progress to multisystem involvement

93
Q

What occurs during a Nonimmunologic (Non- IgE) reaction?

A

Direct release of granules from mast cells and basophils

Not a true allergy- does not require sensitization (1st exposure)

(contrast, opioids, ASA/NSAIDs)

94
Q

A patient has used their EPi-pen following an allergic reaction, what should you advise them to do next?

A

Go to ED for follow up

Due to concern for “second wave” biphasic reaction (very rare)

95
Q

How does epinephrine treat allergic reaction?

A

Causes vasoconstriction

(Dose 0.3-0.5 cc of 1:1000 IM)

96
Q

How do H1/H2 antagonists treat allergic reaction?

A

Antihistamine effects - decreases itch

97
Q

How do steroids treat allergic reaction?

A

They do NOTHING for an acute episode

Unclear benefit in preventing recurrence

98
Q

What causes ACE induced angioedema?

A

Possibly accumulation of bradykinin

Not an allergic reaction

Can occur day 1 or year 12 (anytime while on ACEi)

More common in African Americans and women more than men

99
Q

What is the treatment of ACE induced angioedema?

A

Supportive

(will likely get EPI and steroids in the ED but not necessary)

100
Q

Patient has facial flushing, diaphoresis, hives, edema, diarrhea and peppery taste about 1-2 hours after eating Tuna and mackerel. Diagnosis?

A

Scombroid poisoning, “Psuedo” Fish allergy

Bacteria in contaminated fish converts histidine to histamine

101
Q

How is Scombroid poisoning treated?

A

H1/H2 blockers

Self limiting illness

Lasts about 4- 6 hours

102
Q

Your patient reports that hot water feels cold and cold water feels hot along with GI upset for the past several weeks. He notes that he recently went on a tropical vacation to the Great Barrier reef. Diagnosis?

A

Ciguatera Poisoning

Caused by eating reef fish that have accumulated dinoflagellate

(barracuda, amberjack, grouper, snapper, sturgeon, king mackerel)

Symptoms start 1-6 hours after consumption

Can last weeks to months

Mixed GI, neurological symptoms, cold sensation reversal

103
Q

What is chilblains/pernio?

A

Abnormal vascular response to cold

Inflammation of skin with pruritus, painful erythematous or violaceous acral lesions

104
Q

What is the difference between frostnip and frostbite?

A

Frostnip- no ice crystal formation or tissue loss, Pale, painful tissue

Frostbite- ice crystal formation, tissue loss

Tx: rapid rewarding in circulating water (104-108 F)

105
Q

What is the difference between heat exhaustion and heat stroke?

A

Heat exhaustion- Temp normal to 104 F, normal Neuro exam, non specific dizzy, headache, weakness, N/V, diaphoresis

Heat stroke- Temp > 105 F with CNS dysfunction, delirium, seizures, looking septic, elderly may have anhydrosis and a more gradual presentation

106
Q

Treatment for heat stroke?

A

Evaporative cooling, immersion cooling

Antipyretics do not work

107
Q

What are the risk factors for heat exhuastion/stroke?

A

Exogenous heat gain

Increased heat production

Decreased heat dispersion-dehydration: CVD, very young or old, obesity, improper clothing, skin disease, drugs, anticholinergics

108
Q

For toxic ingestion, what is the best option for gastric decontamination?

A

Charcoal- decreases absorption by 70% if taken less than 30 minutes from ingestion

Decreases by 30 % if taken 30-60 min after ingestion

109
Q

For toxic ingestion what should NOT be used?

A

Syrup of ipecac

Gastric lavage

110
Q

What is the max daily dosing of acetaminophen?

A

4 grams

(toxic dose 150 mg/kg)

111
Q

What are the 4 clinical phases of acetaminophen toxicity?

A

Stage 1: 0-24 hours, asymptomatic or N/V

Stage 2: 18-72 hours, RUQ pain, N/V, LFTs elevated

Stage 3: 72-96 hours, Abdominal pain, N/V, jaundice, encephalopathy, renal failure, death

Stage 4: 4-14 days, resolution

112
Q

How to diagnose and treat acetaminophen toxicity?

A

Draw level 4 hours after ingestion

Rumack-Matthew nomogram

113
Q

Name the antidote: Acetaminophen

A

N-acetylcysteine

114
Q

Name the antidote: Aspirin

A

Alkaline diuresis

115
Q

Name the antidote: Beta blocker

A

Glucagon

116
Q

Name the antidote: Calcium channel blocker

A

Glucagon

117
Q

Name the antidote: Digitalis

A

Fab antibodies

118
Q

Name the antidote: Heparin

A

Protamine Sulfate

119
Q

Name the antidote: Isoniazid (INH)

A

Pyridoxine (Vit B6)

120
Q

Name the antidote: Opiates

A

Naloxone (Narcan)

121
Q

Name the antidote: Organophosphates

A

Atropine

122
Q

Name the antidote: TCA

A

Sodium bicarb

123
Q

Describe the toxidrome of anticholinergic overdose

A

Hot as a hare- hyperthermia

Blind as a bat- Mydriasis

Dry as a bone- thirsty, decreased salivation

Red as a beet- flushing, vasodilation

Mad as a hatter- delirium, agitation, confusion

124
Q

What medications have anticholinergic effects?

A

Antihistamines

Antiparkinson

Antipsychotics

Antiemetics (phenothiazines)

Antidepressants (TCAs)

Antispasmodics

125
Q

Describe the toxidrome of serotonin syndrome

A

Cognitive- agitation, anxiety, drowsy, delirium, headache, seizures

Autonomic dysfunction- tachycardia, arrhythmia, HTN, hyperthermia, diaphoresis, diarrhea, nausea

Neuromuscular- restless, tremor, hyperreflexia, dysarthria, ataxia, myoclonic jerk/twitching

126
Q

What medications have serotonergic effects?

A

SSRIs, MAOIs

Higher risk of serotinin syndrome if combined with meperidine, cocaine, dextromethorphan, venlafaxine, amphetamine, linezolid

127
Q

What is the treatment of serotonin syndrome?

A

Cyproheptadine

128
Q

Compare serotonin syndrome, anticholinergic toxicity, neuroleptic malignant syndrome: Skin exam

A

SS- diaphoretic

AC- dry

NMS- diaphoretic, pallor

129
Q

Compare serotonin syndrome, anticholinergic toxicity, neuroleptic malignant syndrome: muscular tone

A

SS- increased tone

AC- normal tone

NMS- lead pipe rigidity

130
Q

Compare serotonin syndrome, anticholinergic toxicity, neuroleptic malignant syndrome: reflexes

A

SS- hyperreflexia

AC- normal

NMS- bradyreflexia

131
Q

Describe Type I hypersensitivity reactions

A

Immediate hypersensitivity

IgE mediated

Effects within hours

Ex: anaphylaxis

Antigen binds to IgE on mast cells and basophils -> degranulation -> increased vascular permeability, smooth muscle constriction

132
Q

Describe Type II hypersensitivity reactions

A

IgG, IgM, cytotoxic mediated

Effects from hours to days

IgG and IgM antibodies react to antigens on cells surfaces

Ex: blood transfusion reactions, ITP, hemolytic anemias

133
Q

Describe Type III hypersensitivity reactions

A

Immune complex mediated

Effects days to weeks

antigen-antibody complex triggers complement system

Ex: post streptococcal glomerulonephritis, serum sickness

134
Q

Describe Type IV hypersensitivity reactions

A

T cell mediated

Effects days to weeks

Ex: PPD, poison ivy

01 Family Medicine (16 decks)

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