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Emergency Medicine > Emergency Medicine Exam 1 > Flashcards

Emergency Medicine Exam 1 Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Number one goal in the emergency room

A

Figure out if the patient has a life or limb threatening condition

Rule out all the things that could kill this patient

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2
Q

Role of ER provider

A

Make medical decisions quickly with limited time and information
Act as a patient advocate for admission, transfer, etc.

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3
Q

Triage levels 1-5

A

1 - Requires immediate life saving intercention
2 - High risk situation incl. chest pain, lethargy
3,4,5 - Danger zone vitals, one resource, or no resources needed

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4
Q

Danger zone vitals adults

A

HR over 100 RR over 20 satting under 92%

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5
Q

3 things we can generally give safely

A

Dextrose, Narcan, Thiamine

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6
Q

How soon should a patient see a provider after an ER visit

A

Within 2-3 days
Make sure they have the resources to follow up or return to the ER!!

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7
Q

Things to do when a death occurs

A

Self reflect
Why did patient die
Medical risk to community? (ie. Neisseria)
Organ donation
Be straightforward, empathetic, and have security nearby for delivering bad news

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8
Q

EMTALA

A

1985 Law
Emergency room must treat must be appropriately examined and evaluated - must be treated for an emergent condition even if they can’t pay
Recieving facility can’t deny transfer of patient under EMTALA if they can accomodate and treat them

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9
Q

Elements of informed consent

A

Patient’s diagnosis
Purpose of treatment
Risks of expected treatment
Expected outcome of treatment
Alternatives to tx
Consequence of no tx

All non emergent conditions must be agreed to by MPOA of pt

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10
Q

Exceptions to informed consent

A

Unable to communicate, no one is available, no time to obtain consent
Recurrent treatment
Patient waves right to consent
Non-emancipated minors cannot give consent

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11
Q

Who obtains informed consent from pt

A

Whoever is performing the procedure

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12
Q

Things that may make a patient incompetent

A

Altered mental status, intoxication, deemed incompetent,

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13
Q

Police custody patients and consent

A

Are still competent

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14
Q

Minor patients in emergencies

A

Do not need parental consent

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15
Q

Naloxone half life

A

1-1.5 hours (shorter than some narcotics)

EDUCATE

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16
Q

Psych eval for ER patients

A

Hold patients, potentially against their will, fi they are a threat to self or others until psych eval

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17
Q

JWs and blood products

A

Adults can refuse but can’t refuse lifesaving transfusion for their kids

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18
Q

Unique additions to an ER record

A

Time and means of arrival - how long ago
Appropriate use of “acute distress” don’t say for anxiety or pain
Any emergent treatment from EMS
ER COurse - What happened IN the ER
Differential - Med Decision Making
Final Disposition
Condition on Discharge

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19
Q

Performing an exam in a painful eye

A

Use a topical anistetic

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20
Q

Visual acuity worse that 200/20

A

Use fingers - numbers
Test for light perception

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21
Q

Normal intraocular pressure

A

10 to 20 mmHg

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22
Q

Orbital cellulitis presentation

A

Proptosis
Fever
Warm and swollen
Chemosis -inflammation of conjunctiva
Pain WITH extraocular movements

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23
Q

Orbital cellulitis diagnostics

A

Orbital CT with contrast - shows bulging

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24
Q

Complications of orbital cellulitis

A

Cavernous sinus thrombosis

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25
Q

Tx of periorbital cellulitis

A

Admit periorbital IF toxic for IV Rocephin or amp sulbactam plus vanc (PCN allergy: Cipro and Flagyl OR Clinda)

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26
Q

Tx for orbital cellulitis

A

EMERGENCY
IV abx Rocephin or amp sulbactam plus vanc (PCN allergy: Cipro and Flagyl OR Clinda)
Cathotomy if IOP increase or optic neuropathy

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27
Q

Hordeolum/Chalazion management

A

Warm moist compresses - do not squeeze or pop

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28
Q

Conjunctivitis approach

A

Fluoroscene to r/o HSV
Trimethprim polymixin B topical
FQ or Tobramycin for contact wearers
Admit infants and those with acute onset - IV therapy
Acyclovir for viral

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29
Q

Allergic conjunctivitis

A

Cobblestoning of conjunctiva
check for HSV

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30
Q

Iritis
5sx
1dx
2tx

A

Ciliary flush - unilateral and bilateral
Keratitic percipitates
Consensual photophobia
Miosis
Slit lamp diagnosis
Hypopyon
Cycloplegia for 2-4 days - cyclogyl or cyclopentylate
Steroids

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31
Q

Corneal Ulcer
One dx
Four tx

A

FLuoroscene stain to diagnose
Consult ophthalmology
Topical FQ - Ofloxacin/Cipro
Cycloplegic for pain
Avoid eye patch or steroids

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32
Q

HSV keratoconjunctivitis
One sx
One dx
Five tx

A

Painful, red, preauricular lymphadenopathy
Fluoroscene stain to dx
Under 1 mo - admit
Eyelid involved - Oral antiviral
Conjunctival involvement - Topical trifluridine with erythromycin
Corneal - Ophthomology
Avoid steroids

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33
Q

Herpes Zoster Ophthalmacus
Two sx
One dx
Four tx

A

Painful vescicular rash down face - hutchinson sign
Light sensitivity
Fluroscene stain - psudodendrite - no terminal bulbs
Consult Optho
Oral antivirals (acyclovir), topical antibiotics (bacitracin or erythromycin)
Ocular involvement - use abx eye drops
Pts. under 40 workup for immune compromise

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34
Q

Subconjunctival hemorrhage

A

Clinical diagnosis
Goes away on own
Consider coags if warranted
Looks scarier than it is

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35
Q

Ultraviolet keratitis
Three sx
One dx
Two tx

A

Death of corneal epithelial cells
Foreign body sensation and sensitivity that gets worse
Blepharospasm
Corneal abrasions on slit lamp
Consult optho
Cycloplegic

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36
Q

Corneal abrasion (trauma)
Three tx

A

Anesthetize eye
Search for foreign body
Kotorolac with abx (Erythromycin or FQ+tobra if contact lens wearer

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37
Q

Corneal foreign bodies

A

Was it high velocity?
Edema and sensation
Find foreign body - evert eyelid
Hyphema suggests perforation - Sidel test for glow perforation
Consult optho, CT orbit if rupture suspected
Remove with anestetic in BOTH eyes
f/u if rust ring

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38
Q

f/u for eye foreign body

A

24 hours if rust ring, central line of vision, deep
48 hours if symptoms don’t improve

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39
Q

Lid laceration approach

A

Evaluate extent of injury - tetanus, what structures affected, ptosis for muscles
Oculoplastic surgeon
Under 1mm heals on own
Use 7-0 suture to repar
Keflex and erythromycin ointment

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40
Q

Indications for an oculoplastic surgeon consult for a lid laceration

A

Involving lid margin
6-8 mm from medial canthus
inner eyelid
Ptosis
Involving tarsal plate
Involving levator palpbrae muscles

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41
Q

Globe rupture approach
Four sx
One dx
Two tx

A

Taerdrop pupil, hyphema, reduced visual acuity, sidell test, small anterior chamber
CT of orbit
Eye shield, upright and NPO
Vanc and Ceftazidime (FQ if allergic)

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42
Q

Blunt eye trauma approach

A

Use a retractor NOT fingers to examine
If no globe rupture - complete exam (nerve damage, slit lamp, IOP)
Look for orbital blowout fracture - restriction of upward and lat gaze
CT of face
Discharge home IF normal EOM and Visual Acuity
Prednisolone acetate and cycloplegic by optho for iritis

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43
Q

Chemical ocular injury approach

A

Treat before exam - irrigate eye
Apply anisthetic via Morgan lend - contact with tube
Irrigate until pH of 74 for 30 minutes
Cycloplegic, Potential erythro and Td
Consult optho

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44
Q

Acute vision loss - Gloucoma approach

A

Cupping of optic disk on fundoscopic exam
Follows hx of event leading to pupillary dilation
Sudden onset monocular vision loss
Blurring and halos around lights
Injected conjunctiva high IOP
Gonioscopy to diagnose with immediate referral
Acetazolamide IV if IOP over 50
Topical timolol (block production), Manitol (reduce AH)
Laser iridotomy is def dx

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45
Q

Optic neuritis approach

A

Often painless with reduction of color vision or all vision
Affected eye sees objects as redder
+ afferent pupillary defect
Swollen optic disk
Emergency consult

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46
Q

Central retinal artery occlusion

A

Hx of amaurosis fujax (transient vision loss)
Sudden painless monocular vision loss
Positive afferent pupillary defect
Cherry red spot and boxcars
Pale infarcted retina
Optho consult and neuro -stroke risk
Permanent 4 hours after onset

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47
Q

Central Retinal Vein occlusion

A

Afferent pupillary defect
Blurring to rapid vision loss
Compare right and left
Blood and thunder fundus
Consult opthalmology - see within a day

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48
Q

Retinal detachment

A

Flashes and floaters, curtain
Visual fields by confrontation may be abnormal
Urgent call to optho
Bedside US may assist in dx

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49
Q

Otitis externa

A

Itching, ear pain, tenderness, otorrhea
Swelling of external canal
Pain of tragus and auricle
Give tyleno/motrin
Ofloxin drops (perforation)
Cipro (no perforation)

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50
Q

Malignant otitis externa approach

A

Otalgia and edema
Granulation tissue in canal
Bone erosion on CT WITH contrast
Urgent ENT consult
Trobramycin IV plus one of three (Piperacillin, ceftriaxone, cipro)
Opiate for pain control

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51
Q

Otitis media approach

A

Otalgia with or without fever
TM erythema - red, may be perforated, bulging
Amox DOC
Zithromax or Cefdinir are also options, Augmentin
TYlenol/Motrin

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52
Q

Acute mastoiditis approach

A

Infection to mastoid
Protrusion of auricle
History of OM
Fever
Clouding on CT w/ contrast
Mastoidectomy w/ IV vancomycin and Ceftriaxone

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53
Q

Bullous myringitis

A

OM complication
Severe pain w/ otorrhea and hearing loss
Treat like OM

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54
Q

Auricular hematoma

A

Swelling pain and eccymosis of auricle
Ear block
Immediate I&D to avoid permanent damage

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55
Q

Ear foreign body approach

A

Visualize on otoscope
Immobilize insect with lidocaine
Irrigation for non-organic material
Can also use foreceps or suction if necessary

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56
Q

Tympanic membrane perforation approach

A

Trauma or lightning strike
Visualize
Usually heals on own with ENT in next 1 or 2 weeks
abx only if foreign bodies have gotten inside
Patch for larger injuries

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57
Q

Epistaxis approach

A

Anterior - MC kesselbach’s plexus and Posterior - MC palatine artery, bilateral bleed!!
Blood type, place in sniffing position - leaned forward
Apply direct pressure
Phenylephrine or Oxymetazoline to constrict vessels
Pinch nose for 10-15 minutes
Chemical cauterization - Anterior ONLY after 2 attempts - Numb mucosa and apply silver nitrate stick, electrocautery
If cautery fails apply a gel if that fails - packing

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58
Q

Nasal Packing

A

Pack all posterior bleeds - Rapid rhino balloon - remove in 24-48 hours, tampons, ribbon gauze
Can also put baloon in nasopharynx for a posterior bleed
Augmentin prescription

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59
Q

Pharyngitis/Tonsilitis approach

A

Fever cough, rhinorrhea
Centor criteria!!
Exudates and lymphadenopathy for pharyngitis bacterial, ulcers are VIRAL, Petichiase are strep
Sterp test if two or more centor criteria met
Mono or flu consider
Antipyretics only for viral
PCN, Amoxil, Keflex, Zmax
Change toothbrush after 24 hours

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60
Q

Peritonsilar abcess approach
Six sx
One dx
Two tx

A

Hot potato voice
Sore throat, fever, dysphagia
Drool, Uvula deviated AWAY from the abcess
Itraoral US confirms CT of neck possible
I&D with PCN and flagyl
Sepsis workup with Pip n’ Taz for toxic patients

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61
Q

Retropharyngeal abcess
Three sx
Two dx
Three tx

A

Base of skull to tracheal bifurcation
Strido, torticollis, cervical LAD
Soft tissue XR
CT with contrast = GOLD - edema, fat stranding; later necrotic lymph nodes and ring enhancement
Airway placement, NPO with IV fluids
IV clinda or cefoxitin or zosyn/unasin

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62
Q

Egiglottitis
Eight sx
Two dx
Four tx

A

Drool, stridor fever, tripod position
Cervical lymphadenopathy
Dysphagia, odynophagia, dyspnea
Worse when supine
Tachycardia
H flu B
Lateral soft tissue XR with thumbprint sign
Laryngoscopy = GOLD
Emergent airway placement
Cardiopulmonary monitoring
IV cefotaxime PLUS vancomycin - FQ if allergic
IV methylprednisilone to reduce inflammation and edema

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63
Q

Odontogenic abcess

A

Hx of dental abcess
Swelling of lip and gingiva
Dyspnea if severe and retropharyngeal
Superficial - US
Deep - CT
Oral PCN or amoxil in non-toxic (clinda if allergic
Urgent consult - amp/sul + clinda +cipro for toxic appearing, deep space infection

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64
Q

Ludwigs angina

A

Complication of odontogenic abcess
Cellulitis of sublingual and submaxillary space

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65
Q

Necrotizing infection

A

Complication of odontogenic abcess
Toxic appearing with hemodynamic instability, skin discoloration, crepitus, fever
Immediate fasciotomy

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66
Q

Approach to ingested foreign bodies

A

Meat mc food that gets stuck in esophagous
Gagging, choking, stridor, inability to eat
Foreign body film XR
Coins in esophagus are coronal, coins in trachea are saggital
CT without contrast for non-radio opaque objects
Objects that pass the pylorus are usually okay - risk with objects over 2.5 cm wide or 6cm long
Assess for airway compromise
Endoscopy if obstruction - URGENT
Serial X ray and let pass, IV glucagon to relax esophageal sphincter

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67
Q

DANGER items - endoscopy if swallowed

A

Sharp, elongated objects
Multiple foreign bodies
Button batteries
Evidence of perforation
Coin at cricopharyngeus muscle - preferred to remove coins
Airway compromise
Present for over 24 hours
Full food obstruction

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68
Q

Narotic ingestion approach

A

No endoscopy, admit for observation until packet (narcotics in condom) reach rectum

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69
Q

Red flag HA symptoms

A

Under five (any) or over 50 (new or worsening)
Head trauma
Sudden onset
During exertion
During valsalva and bearing down
Different than previous HAs
Fever
Anticoagulant use
Abx use
Papilledema - increased ICP
Altered mental status

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70
Q

Indications for getting a CT scan before a lumbar puncture

A

Immune compromise
Hx of CNS disease
New onset seizure
Papilledema
Altered LOC
Focal neurologic deficits

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71
Q

When might an LP be indicated

A

Suspicion includes:
Meningitis
Encephalitis
Intracranial hypotension
Pseudotumor cerebri
Subarachnoid hemorrhage (Negative CT)

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72
Q

When is a subarachnoid visible on a CT scan?

A

Within 6 hours of onset

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73
Q

Migraine HA approach

A

Slow onset, throbbing HA with photophobia and no other PE findings

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74
Q

ER treatment for migraine

A

Ketorolac
Prochloperazine
Diphenydramine
All IV

Dexamethasone to reduce risk of recurrence

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75
Q

Alternative ER treatments for migraine HA

A

Triptan - If they haven’t used at home, CI in pregnancy
Ergot with antiemetic/antihistamine - CI in pregnant

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76
Q

Migraine in pregnancy tx

A

Acetominophen, Opioids, Metaclopramide and Corticosteroids
NSAIDS only in 1st or 2nd trimester
NO Triptans, ergotamines, caffeine

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77
Q

Discharge for migraine HA in ER

A

Most can be dischared to PCP or Neurologist
Can prescribe sumatriptan

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78
Q

Cluster HA approach in the ER

A

Intense pain - behind or around the eye
Daily attacks for a wkk+ then remission
One side with ipsilateral lacrimation, injection, congestion, ptosis, miosis
Precipitated by EtOH or vasodilators
Normal neuro exam

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79
Q

Cluster HA treatment in the ER

A

High flow O2 through a non-rebreather
Try sumatriptan if failed

IN lidocaine, Ergotamine, Dihydroergotamine as alternatives

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80
Q

Transitional therapy that can be started in the ER for cluster HAs

A

Corticosteroids - taper over 2 weeks to prevent recurrence
Naratriptan BID
Ergotamine BID

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81
Q

Approach to a tension HA in the ER

A

Gradual onset lasting hours and present the next day
Underlying stressor
NSAID treatment - Ketorolac (inject) with compazine and benadryl
Excedrin for outpatient use
Muscle relaxant

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82
Q

Brain tumor presentation

A

Progessive, deep aching HA
Begins to have neurologic deficits
Worse upon awakening and with valsalva

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83
Q

Approach to brain tumor

A

CT with IV contrast
Emergent neurological/Surgical consult - Large problematic tumors
IV glucocorticoids to reduce swelling
Secondary prevention of seizures - Levitiracetam, topiramate, lamotrigine

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84
Q

Post traumatic HA syndrome

A

After some kind of trauma
Fatigue, dizziness, vertigo - followed by psych symptoms
Should have a CT scan if they have not already had one for the same trauma
Discharge home must have social support
Tylenol and NSAIDS
AVOID a second brain injury - slow return to activity

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85
Q

Idopathic intercranial HTN Presentation

A

Headache
Visual changes
Scotoma - black spot
Scintillation
Back pain
Papilledema
Abducens nerve palsy

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5
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86
Q

Workup for idiopathic intercranial HTN

A

CT - Normal no enlarged ventricles like hydrocephalus
LP in left lateral decubitis for opening pressure
Normal CSF analysis

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87
Q

Target CSF pressure for idopathic intercranial HTN

A

10-20 cm H2O

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88
Q

Management for idiopathic intercranial HTN

A

1 mL of CSF removed will reduce pressure by 1cm H2O
Acetazolamide for visual symptoms + thiazide diuretic if needed
Admit new diagnoses

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89
Q

Intercranial hypotension HA

A

Usually d/t an LP or epidural. Can be d/t trauma
HA worse in upright position 24-48 hours after procedure
Audiovisual changes

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90
Q

Work up and management for intercranial hypotension

A

Dx based on PE
Opening pressure under 6
May see enhanced meninges on CT
IV fluidss with NSAIDs, Tylenol or recumbency
Epidural blood patch for refrectory

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91
Q

Brain abcess workup

A

CT with contrast is diagnostic
Blood cultures - twice for children and once for adults
NO LP

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92
Q

Brain abcess abx

A

Odontogenic - PCN G OR (Ceftriaxone plus metronidazole)
Post neuro procedure - Vanc plus ceftazidime
All others - Cefotaxime (or ceftriaxone) plus metronidazole

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93
Q

Steroids and brain abcess

A

Use if significant peri-abcess edema and associated mass effect and impending herniation

Steroids will break down brain abcess

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94
Q

Other mangement of brain abcess

A

Aspirate surgically and culture

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95
Q

Spinal epidural abcess

A

Infection between the dura and bone or elsewhere in spinal cord
Spinal tenderness and back pain and fever
Pain with percussion
May have bowel or bladder changes - pay attention to rectal sphincter

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96
Q

Tx for spinal abcess

A

Vanc and Ceftazidime - if surgery delayed
URGENT surgery consult

97
Q

Temperature sites to subtract one degree

A

Orifices - Rectal and Oral and Tympanic

98
Q

Temperature sites to add a degree

A

Axillary and Temporal

99
Q

Time to take oral temp after eating

A

15 minutes

100
Q

Fever of unknown origin

A

3 week fever with no known cause
Often autoimmune

101
Q

Two things to look for in an adult who “feels fine”

A

Pneumonia and UTI

102
Q

SIRS criteria

A

For Sepsis
HR over 90
Resp over 20
Temp under 96.8 or over 100.4

103
Q

Sepsis criteria

A

SIRS plus Source of infection

104
Q

Severe sepsis

A

Sepsis and Organ dysfunction

105
Q

Septic shock

A

Persistent hypotension after bolus
LDH 4.0+

106
Q

Fever management

A

Acetominophen for pediatrics
Ibuprofen (Toradol IV/IM in the ER)

107
Q

Fever patients not to give empiric antimicrobials to

A

Neutropenic
Unstable
Asplenic
Immune suppressed

108
Q

Admission criteria for fever

A

VItal sign abnormalities
End organ damage
Temp over 105.8 F 41 C
Assoc seizure or other mental status change
UNderlying condition requires it - ie. pneumonia

109
Q

Follow up for fever

A

In 2-3 days

110
Q

Pediatric fever

A

Easily jumps from system to system making a good PE critical

111
Q

3 pediatric age categories

A

0-28 days (neonate)
1-3 months
3 to 36 months

112
Q

Emergent fever criteria in children

A

100.4 under 3 months
102.2 3-36 months

113
Q

Origins of roseola and measles

A

Roseola - Abdomen
Measles - Head

114
Q

First place to look for source of pediatric fever

A

Urine

Then CXR for pneumonia, LP for meningitis

115
Q

Criteria for sending febrile neonate home

A

Well appearing with no hx of prematurity or perinatal complications
No immunizations within 48 hours
WBC 5,000-15,000 (bands 1500 or less
UA less than 10 WBCs per HPF
CSF under 5 WBCs per HPF
Stool with under 5 WBCs per HPF
Normal CXR

Check for vaccination hx

116
Q

Follow up for febrile infant

A

24 hours

117
Q

Management for pediatric fever -high risk

A

Admit if high risk
Antibiotics!! - Ampicillin and Cefotaxime with blood cultures first!

118
Q

Low risk management for febrile child

A

Assess for social needs - admit anyone who is ill appearing, unable to maintain fluids, or unlikely to follow up
UA with C&S and Blood cultures if they look sick
Abx

119
Q

Who to get a UA on for pediatric fever

A

Girls under 24m, Uncircusised boys under 12m, Circumcised girls under 6m

OR if you feel the need

120
Q

What to do if blood cultures come back +

A

Admit if sick
Don’t admit if okay
ALL on abx

121
Q

Neutropenic fever presentation

A

Patient with cancer
100.4 for an hour or single temp 101
Absolute Neutrophil count under 1000 cells/mm (severe 500)

122
Q

When do neutropenic fevers most often happen

A

10-15 days after last chemo treatment

123
Q

Management for neutropenic fever

A

Vanc plus Cefepime
This is a hematologic emergency
MASCC score 20+ means you can send them home - get onc on board

124
Q

Sign of a seizure that is nearly a 100% guarantee

A

Tongue biting

125
Q

Assessment for seizures

A

Check glucose
Assess for injuries
Full neuro exam - LOC, mentation, walk, eye movements

126
Q

Todd’s paralysis

A

Transient unilateral focal deficit after a simple or complex seizure
Work up as if it is a stroke

127
Q

What an actual seizure should look like

A

Sudden start
Loss of memory
Post-ictal confusion

Soto saline sign for fakers

128
Q

Diagnostic eval for Seizures

A

If hx - Serum anti-convulsant drug level, glucose, hcg for females
No hx - Glucose, BMP, Mag, Hcg, Toxicology

CT without contrast (unless concerned about tumor) if new or different seizures
LP for febrile patients

129
Q

Active seizure management

A

Maintain airway
Turn on side and suction
IV access
Pulse and O2 monitors
EEG for first time seizures

130
Q

Pharm for status epilepticus

A

Lorazepam - repeat in 5 minutes

Fosphenytoin or Phenytoin - second line
Can also give levetiracetam

Coma induction with Midazolam, Propofol, Pentobarbital

131
Q

Management for patients with hx of seizures

A

Check serum drug levels - discuss with neuro what you want to do depending on levels

132
Q

Discharge for first time seizures

A

Ensure return to baseline
No driving
Follow up with Neuro

133
Q

Suspected eclampsia management

A

IV magnesium sulfate

134
Q

Workup for febrile seizures

A

Only absolutely necessary if it’s status epilepticus - consult peds

135
Q

Syncope - primary cause and technical definition

A

Not enough blood to brain
Out for seconds with no resuscitation
Loss of postural tone and consciousness

136
Q

Workup for syncope vs. presyncope

A

SAME WORKUP

137
Q

Differential and workup for syncope

A

Cardiac - Start with this
Neuro - Consider after
Ask to describe dizziness for vertigo vs. lightheadedness

138
Q

Seizure vs. True Syncope

A

Seizure has a post-ictal phase, true syncope does not

139
Q

Presentation of vasovagal syncope

A

Fainting after seeing blood, etc., w/ prodrome (pallor, nausea, warmth, diaphoresis, blurred vision)
60% of patients with a heart condition

140
Q

Presentation of cardiac syncope

A

No prodrome and w/ exercise
Syncope while supine

141
Q

Presentation of reflex syncope

A

After exercise with a drop in HR and BP

142
Q

Presentation of psychogenic syncope

A

Long lasting, no post ictal phase - suspect

143
Q

3 potential associated signs of syncope

A

HA - SAH
Chest Pain - MI, PE
Fever - Sepsis

144
Q

Syncope and diabetics

A

Due to autonomic neuropathy of diabetes

145
Q

QT and syncope

A

Check for meds - Zophran, Psych, Macrolides, FQ, Antipsychotics, Diuretics, nDHP-CCB
May have gone into torsades
EKG of 450+ is concerning

146
Q

Normal QRS

A

80-100

147
Q

Physical exam for syncope

A

Head and Neck Trauma
Skin Turgor
Abdomen for AAA
Rectal exam for bleed

148
Q

Who gets a CT for syncope

A

Neuro deficit
Trauma to head - Canadian CT rules

149
Q

Required workup for syncope

A

EKG
All other test based on presentation

150
Q

PERC criteria

A

R/O PE
Must answer NO to all questions
Age 50+
HR 100+
O2 95+
No unilateral leg swelling
Hemoptysis
Recent surgery/Trauma
Prior PE or DVT
Hormone use

151
Q

HCG for syncope

A

Any female of child bearing age with syncope - could be an ectopic pregnancy

152
Q

Risk stratification for syncope

A

San Francisco and Canadian
Help us decide whether to admit or not

153
Q

Canadian syncope positive risk factors

A

Heart disease hx
SBP >180 or <90
Elevated troponin
Abnormal QRS axis
QRS >130
QTc >480

154
Q

Negative risk factors for canadian syncope rule

A

Anything to suggest a vsovagal etiology

155
Q

Reasons not to use canadian syncope rule

A

LOC >5 minutes
Change in mental status
Obvious seizure
Head trauma
Intoxication
Language barrier

156
Q

San Francisco Syncope Rule

A

CHESS
CHF hx
HCT <30%
ECG Abnormal
SOB hx
SBP <90

157
Q

Normal EKG axis

A

Look at I and AVF
Should both be going UP

158
Q

Moderate canadian syncope score

A

1-3
6 hours of observation and 15 days of monitoring

159
Q

How long should syncope last

A

Less than a minute

160
Q

Reflex syncope ddx

A

Vasovagal, Situational, Carotid sinus

161
Q

Exam of vasovagal syncope

A

Labs, ekg, PE normal
Use to r/o bad stuff

162
Q

Orthostatic syncope presentation

A

Change in position causes BP to drop causing a reflexive tachycardic response

163
Q

Orthostatic hypotension diagnostic criteria

A

Decrease of 20 SBP OR 10DBP OR Increase of HR 20 bpm from supine to standing
Only one needed to diagnose

164
Q

Dx for orthostatic hypotension

A

Ask nerve to do orthostatic readings - standing and supine

165
Q

Patient ed for orthostatic hypotension

A

Hydrate
Wait between standing up and walking

166
Q

Carotid sinus syncope

A

Tight collar, Head turn, Shaving - leading to push on artery
Hx of atherosclerosis
Use carotid massage to dx
Midodrine

167
Q

Positive dx for carotid sinus syncope

A

Decrease of SBP by 50+ upon carotid sinus massage

168
Q

Presentation of aortic stenosis syncope

A

Chest pain, Syncope, Dyspnea
Systolic murmur rad. to carotids
Echo and Valve replacement

169
Q

Use of carotid sinus massage for dysrhythmias

A

SVT

170
Q

ED care for aortic stenosis

A

Avoid: Nitro, BB, CCB
Admit for TAVR

171
Q

Subclavian Steal Syndrome

A

Must have a stenosis in the subclavian
Blood flows to the brain but gets diverted back to the arm via the vertebral artery

172
Q

Presentation of Subclavian Steal Syndrome

A

Pale, cool, arm
Right arm is more common
Low BP on one arm
Syncope!!
Get a CTA

173
Q

Tx for SSS

A

Statin
ASA + Plavix
Admit

174
Q

Basilar Artery insufficiency

A

Posterior Stroke - Syncope
Not normal stroke syndromes - vertigo, nausea, weakness, dysarthria, vision changes
CTA of head and neck to dx

175
Q

Time to treat stroke from presentation

A

4.5 hours to use tPA
24 hours for manual clot removal

176
Q

HINTS exam

A

Distinguish between BPPV and Stroke
Use Dix-Hallpike if you think it’s BPPV
Horizontal Head Impulse Testing
Nystagmus
Vertical skew

177
Q

Presentation of Subarachnoid hemorrhage

A

Sudden onset, thunderclap headache - worst of life
Neck stiffness, possible positive meningeal signs
Syncope, neurodefecits

178
Q

CT scan for stroke

A

Non-contrast
Most sensitive in the first 6 hours

179
Q

Ottowa SAH rule

A

For patients with a new non-trauma HA
6 criteria - evaluate for SAH in any of them
Neck pain or stiffness
Age 40+
Witnessed LOC
Onset with exertion
THunderclap HA
Limited neck flexion

180
Q

LP for Subarachnoid hemorrhage

A

Xanthocromia indicates blood in CSF for 2+ hours
Use if CT is negative and suspicion is high OR patient presents after 6 hours

181
Q

What to do in high suspiscion of SAH with a negative CT and LP

A

CT angiogram or MRA/MRI

182
Q

Management for subarachnoid hemorrhage

A

Gradual BP reduction for SBP over 180 (160 reduces risk)
Use lebatolol, nicardipine, clevidipine, or enalapril with conversion to nimodipine after stabilization
d/c anticoagulants

183
Q

Tx for seizures and increased ICP with SAH

A

Elevate HOB 30 degrees
Active seizure control with lorazepam
Secondary with Phenytoin
Primary prevention not recommended

184
Q

Presentation of Giant Cell/Temporal Arteritis

A

50+ with hx of polymyalgia rheumatica
Unilateral HA with jaw claudication
May have fever and vision changes
Temporal artery tenderness

185
Q

Labs for Temporal Arteritis

A

Elevated ESR and CRP
US with a halo sign

186
Q

Management for giant cell arteritis

A

PO Prednisone if no visual disturbance
IV Methylprednisone if visual disturbance - admit - can worsen to complete vision loss
Optho consult always

187
Q

Presentation of trigeminal neuralgia

A

Unilateral, electric facial pain along a trigeminal nerve branch
Pain free intervals, women more than men

188
Q

Management of trigeminal neuralgia

A

Imaging not needed in the ED - only for bilateral pain to r/o MS
Phenytoin off label for acute attack BBW for fast administration (HTN, arrhythmias)
Carbamazepime first line - alt. lamictal

189
Q

Presentation of adult meningitis

A

Continuous, throbbing, generalized HA, Worse with movement and valsalva
Fever and nuchal rigidity
Petechial rash may be present
Altered LOC, meningeal signs, photophobia

190
Q

Presentation of Meningitis in Kids

A

Fever, Lethargy, Poor feeding
Seizures and Bulging fontanells
Young children may LACK meningeal signs

191
Q

7 HX red flags for meningitis

A

Recent exposure to similar illness
Recent illness or abx tx
Recent travel to Africa/India/etc.
Penetrating head trauma
CSF leak from nose/ears
Cochlear implants
Recent neuro procedure

192
Q

Diagnostic eval for meningitis

A

CBC w/ culture
Liver/Kidney func.
PT/PTT before LP
LP w/ CSF analysis and PCR

193
Q

7 Indications for a head CT before an LP

A

Immunocompromised
Hx of CNS disease
Mass lesion, Stroke, Or Focal infection
New onset seizure
Papilledema
Abnormal level of consciousness
Focal neuro defecit

194
Q

CSF in bacterial meningitis

A

Cloudy
200-300mmH2O
High protein, Low glucose

195
Q

CSF in viral meningitis

A

Clear
90-200 mmH2O
Increased Lymphocytes

196
Q

Supportive management for meningitis

A

Maintain airway, monitor for seizures
Analgesics/Antipyretics
IV fluids

197
Q

Management for bacterial meningitis

A

Dexamethasone before abx
Ceftriaxone+Vancomycin (Cefotaxin in children)

198
Q

Other abx for bacterial meningitis

A

Acyclovir - In case of HSV
Doxycycline - TIck borne disease
Ampicillin (or Bactrim for allergy) in <1mo and >50 and immune comp.
Metronidazole if ENT infection or brain abcess
Moxifloxacin - Severe cephalosporin and penecillin allergy
Aztreonam - Immune compromised on Moxifloxacin

199
Q

Management for Viral meningitis

A

Enteroviruses -MC
Symptomatic therapy with acyclovir for HSV, VZV
Empiric abx in immune compromised

200
Q

Presentation of Encephalitis (and how it might differ from meningitis)

A

Fever and HA
Focal Neuro Deficits - more than meningitis
Negative meningeal signs
Altered LOC
HSV, VZV, EBV

201
Q

Diagnostics for encephalitis

A

LP with same findings as viral meningitis
CT prior for same conditions as with meningitis
MRI more sensitive
Viral culture of any lesion/Tzank smear

202
Q

Management for encephalitis

A

Support
IV lorazepam for acute seizures
Neuro checks
Abx until confirmed
Acyclovir by 30 minutes after arrival

203
Q

Clinical presentation of a brain abcess

A

HA, Focal neuro defecits
Increased ICP, Papilledema, change in LOC
Fever, new onset seizure

204
Q

Diagnostics for brain abcess

A

CBC - Elevated WBC
CMP - Usually normal
ESR, CRP - Usually elevated
Blood cultures before abx if possible
CT/MRI WITH Contrast!

205
Q

Management for brain abcess

A

Neurosurgical drainage
Ceftriaxone and Metronidazole
Add for head trauma or recent procedure: (Ceftazidime OR Meropenem) PLUS Vanc
Steroids for periabcess edema and mass effect

206
Q

History suggestive of ACS

A

Non-sharp/stabbing pain - more like squeezing radiating to arm, neck, jaw
Brought on by exercise, stress, cold
Short duration, improving with rest and NTG
May have nausea, vomitingm diaphoresis, dyspnea

207
Q

Physical exam suggestive of ACS

A

Uncomfortable, pale, or cyanotic
Heart Failure Acute
May hear S3 and S4
PE may be mostly normal

208
Q

EKG interpretations for STEMI

A

STEMI - 1mm plus ST elevation in 2+ contiguous leads
Or new LBBB

209
Q

EKG for NSTEMI

A

New horizontal or down sloping ST depression .5mm+ in two contiguous leads
T wave inversion in two contig. leads with prominent R

210
Q

EKG for USA

A

Normal or nonspecific changes

211
Q

Lead groups

A

Inferior - II, III, aVF
Anteroseptal - V1-V2
Anteroapical - V3-V4
Anterolateral - V5-V6
Lateral - I, aVL

212
Q

Cardiac enzymes in ACS

A

Rise in STEMI, NSTEMI, not in USA increases in 2-6 hours and stays elevated for 7-10 days
Specific for ANY cardiac muscle injury

213
Q

Initial management for all ACS

A

Cardiac monitoring
2 large bore IV lines
Oxygen if under 94%
ASA 325 or Clopidogrel if allergic

214
Q

Initial management for all ACS: NTG

A

.4 mg SL - repeat if no effect in 5 minutes
Give IV if NTG SL fails twice and SBP 100+
CI in inferior STEMI, hypotension, or severe aortic stenosis
Not diagnostic for ACS

215
Q

Initial management for all ACS: Morphine

A

Use only if pain is not sufficiently relieved by NTG
IV therapy

216
Q

Initial management for all ACS: Beta blocker and Statin

A

Started within 24 hours - doesn’t have to be in the ED
Consider for refractory HTN or ongoing ischemia
Prevents arrhythmias and reaccurance
CI: CHF, Bradycardia, Conduction block, Hypotension
Metoprolol, Atenolol

217
Q

Meds for ACS with refractory HTN

A

Clevidipine, Nicardipine, Metoprolol, Esmolol

218
Q

Manaement specific to USA or NSTEMI

A

Cardio consult
Conservative approach
Dual antiplatelet therapy: ASA and P2Y12
LMWH

Early invasive approach
PCI or CABG
Unfractionated Heparin

219
Q

STEMI specific management: PCI

A

90 minute reperfusion goal at PCI facility
120 at non-PCI facility

220
Q

STEMI specific management: Fibrinolytics

A

For those unable to get to PCI in 120 minutes with symptoms less than 12 hours
30 minute reperfusion goal
tPA and informed consent

221
Q

Monitoring for fibrinolytic therapy

A

BP - 15 minutes
EKG
Bleeding
12L EKG Q4 hours
Troponin Q4 hours

222
Q

Disposition of ICS patient

A

PCI to cath lab
Fibrinolytics to the ICU

223
Q

Presentation and Tx of stable angina

A

Precipitating factors the same for 3 months for 1-15 minutes
Relieved by NTG -Tx
Call 911 if no improvement in 5 minutes
Take up to three NTG in five min intervals if not working

224
Q

Presentation and Treatment of Prinzmetal angina

A

Occurs w/o precipitating event, wakes pt at night
May have ST elevation or depression
Tx - Nitroglycerin SL

225
Q

Type A aortic dissection

A

Involves ascending aorta

226
Q

Type B aortic dissection

A

Does NOT involve ascending aorta

227
Q

Where do 90% of aortic dissections occur

A

Right lateral wall of proximal ascending aorta

228
Q

Risk factors for aortic dissection

A

Male Sex
Age over 50
Poorly controlled HTN
Cocaine of Meth use
Bicuspid aortic valve
Marfans
Pregnancy

229
Q

Presentation of Aortic dissection

A

Often atypical ezp. in older patients
Sharp, w/ ripping or tearing sensation - Abrupt!!
Often non-migratory
SOB, Limb ischemia, syncope, Neuro

230
Q

Physical exam for aortic stenosis

A

May have aortic regurg ( diastolic decresendo murmur)
May see unilateral pulse defecit or BP difference

231
Q

Diagnostics for Aortic dissection

A

CXR - Widened mediastinum
EKG - May show nonspecific or ischemic changes
D-dimer over 500
CTA is preferred method
TEE is highly sensitive

232
Q

d-Dimer and Aortic dissection

A

Can almost always r/o if under 500
Us if ADD-RS is 0 or 1

233
Q

ADD-RS

A

Asesses whetehr we should use D-dimer for aortic dissection dx
Score conditions, pain features and exam features 1-3

234
Q

Management of aortic dissection

A

Resuscitate as needed
BB - Esmolol or Labetalol
Vasodilator if not controlled w/ BB - Nicardipine, clevidipine, NTG, Nitroprusside
Fentanyl for pain
Emergent vasc. surg. consult

235
Q

Goal HR and BP for aortic disstection

A

HR - 60
SBP - 120-130

236
Q

Presentation of Pericarditis

A

Sudden, severe, constant substernal pain
Radiation to back/shoulders
Worse lying back and breathing
Better sitting up and leaning forwards
Fever, dyspnea, dysphagia
Friction rub!

237
Q

Diagnostics for pericarditis

A

Diffuse ST elevation
CXR - Can see any secondary HF
TTE - Normal, may have effusion
Labs for complications

238
Q

Management for pericarditis

A

May discharge home if stable
Ibuprofen TID for 7-10 days PO - Colchicene for adjunct

239
Q

Indications for pericarditis admission

A

Fever
Slow onset
Immune compromise
Myocarditis
Failure to respond after 1 week
Effusion over 20mm
Tamponade
Uremic pericarditis

Emergency Medicine (4 decks)

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