Emergency Medicine Exam 1 Flashcards
Number one goal in the emergency room
Figure out if the patient has a life or limb threatening condition
Rule out all the things that could kill this patient
Role of ER provider
Make medical decisions quickly with limited time and information
Act as a patient advocate for admission, transfer, etc.
Triage levels 1-5
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
Danger zone vitals adults
HR over 100 RR over 20 satting under 92%
3 things we can generally give safely
Dextrose, Narcan, Thiamine
How soon should a patient see a provider after an ER visit
Within 2-3 days
Make sure they have the resources to follow up or return to the ER!!
Things to do when a death occurs
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
EMTALA
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
Elements of informed consent
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
Exceptions to informed consent
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
Who obtains informed consent from pt
Whoever is performing the procedure
Things that may make a patient incompetent
Altered mental status, intoxication, deemed incompetent,
Police custody patients and consent
Are still competent
Minor patients in emergencies
Do not need parental consent
Naloxone half life
1-1.5 hours (shorter than some narcotics)
EDUCATE
Psych eval for ER patients
Hold patients, potentially against their will, fi they are a threat to self or others until psych eval
JWs and blood products
Adults can refuse but can’t refuse lifesaving transfusion for their kids
Unique additions to an ER record
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
Performing an exam in a painful eye
Use a topical anistetic
Visual acuity worse that 200/20
Use fingers - numbers
Test for light perception
Normal intraocular pressure
10 to 20 mmHg
Orbital cellulitis presentation
Proptosis
Fever
Warm and swollen
Chemosis -inflammation of conjunctiva
Pain WITH extraocular movements
Orbital cellulitis diagnostics
Orbital CT with contrast - shows bulging
Complications of orbital cellulitis
Cavernous sinus thrombosis
Tx of periorbital cellulitis
Admit periorbital IF toxic for IV Rocephin or amp sulbactam plus vanc (PCN allergy: Cipro and Flagyl OR Clinda)
Tx for orbital cellulitis
EMERGENCY
IV abx Rocephin or amp sulbactam plus vanc (PCN allergy: Cipro and Flagyl OR Clinda)
Cathotomy if IOP increase or optic neuropathy
Hordeolum/Chalazion management
Warm moist compresses - do not squeeze or pop
Conjunctivitis approach
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
Allergic conjunctivitis
Cobblestoning of conjunctiva
check for HSV
Iritis
5sx
1dx
2tx
Ciliary flush - unilateral and bilateral
Keratitic percipitates
Consensual photophobia
Miosis
Slit lamp diagnosis
Hypopyon
Cycloplegia for 2-4 days - cyclogyl or cyclopentylate
Steroids
Corneal Ulcer
One dx
Four tx
FLuoroscene stain to diagnose
Consult ophthalmology
Topical FQ - Ofloxacin/Cipro
Cycloplegic for pain
Avoid eye patch or steroids
HSV keratoconjunctivitis
One sx
One dx
Five tx
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
Herpes Zoster Ophthalmacus
Two sx
One dx
Four tx
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
Subconjunctival hemorrhage
Clinical diagnosis
Goes away on own
Consider coags if warranted
Looks scarier than it is
Ultraviolet keratitis
Three sx
One dx
Two tx
Death of corneal epithelial cells
Foreign body sensation and sensitivity that gets worse
Blepharospasm
Corneal abrasions on slit lamp
Consult optho
Cycloplegic
Corneal abrasion (trauma)
Three tx
Anesthetize eye
Search for foreign body
Kotorolac with abx (Erythromycin or FQ+tobra if contact lens wearer
Corneal foreign bodies
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
f/u for eye foreign body
24 hours if rust ring, central line of vision, deep
48 hours if symptoms don’t improve
Lid laceration approach
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
Indications for an oculoplastic surgeon consult for a lid laceration
Involving lid margin
6-8 mm from medial canthus
inner eyelid
Ptosis
Involving tarsal plate
Involving levator palpbrae muscles
Globe rupture approach
Four sx
One dx
Two tx
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)
Blunt eye trauma approach
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
Chemical ocular injury approach
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
Acute vision loss - Gloucoma approach
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
Optic neuritis approach
Often painless with reduction of color vision or all vision
Affected eye sees objects as redder
+ afferent pupillary defect
Swollen optic disk
Emergency consult
Central retinal artery occlusion
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
Central Retinal Vein occlusion
Afferent pupillary defect
Blurring to rapid vision loss
Compare right and left
Blood and thunder fundus
Consult opthalmology - see within a day
Retinal detachment
Flashes and floaters, curtain
Visual fields by confrontation may be abnormal
Urgent call to optho
Bedside US may assist in dx
Otitis externa
Itching, ear pain, tenderness, otorrhea
Swelling of external canal
Pain of tragus and auricle
Give tyleno/motrin
Ofloxin drops (perforation)
Cipro (no perforation)
Malignant otitis externa approach
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
Otitis media approach
Otalgia with or without fever
TM erythema - red, may be perforated, bulging
Amox DOC
Zithromax or Cefdinir are also options, Augmentin
TYlenol/Motrin
Acute mastoiditis approach
Infection to mastoid
Protrusion of auricle
History of OM
Fever
Clouding on CT w/ contrast
Mastoidectomy w/ IV vancomycin and Ceftriaxone
Bullous myringitis
OM complication
Severe pain w/ otorrhea and hearing loss
Treat like OM
Auricular hematoma
Swelling pain and eccymosis of auricle
Ear block
Immediate I&D to avoid permanent damage
Ear foreign body approach
Visualize on otoscope
Immobilize insect with lidocaine
Irrigation for non-organic material
Can also use foreceps or suction if necessary
Tympanic membrane perforation approach
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
Epistaxis approach
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
Nasal Packing
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
Pharyngitis/Tonsilitis approach
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
Peritonsilar abcess approach
Six sx
One dx
Two tx
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
Retropharyngeal abcess
Three sx
Two dx
Three tx
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
Egiglottitis
Eight sx
Two dx
Four tx
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
Odontogenic abcess
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
Ludwigs angina
Complication of odontogenic abcess
Cellulitis of sublingual and submaxillary space
Necrotizing infection
Complication of odontogenic abcess
Toxic appearing with hemodynamic instability, skin discoloration, crepitus, fever
Immediate fasciotomy
Approach to ingested foreign bodies
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
DANGER items - endoscopy if swallowed
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
Narotic ingestion approach
No endoscopy, admit for observation until packet (narcotics in condom) reach rectum
Red flag HA symptoms
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
Indications for getting a CT scan before a lumbar puncture
Immune compromise
Hx of CNS disease
New onset seizure
Papilledema
Altered LOC
Focal neurologic deficits
When might an LP be indicated
Suspicion includes:
Meningitis
Encephalitis
Intracranial hypotension
Pseudotumor cerebri
Subarachnoid hemorrhage (Negative CT)
When is a subarachnoid visible on a CT scan?
Within 6 hours of onset
Migraine HA approach
Slow onset, throbbing HA with photophobia and no other PE findings
ER treatment for migraine
Ketorolac
Prochloperazine
Diphenydramine
All IV
Dexamethasone to reduce risk of recurrence
Alternative ER treatments for migraine HA
Triptan - If they haven’t used at home, CI in pregnancy
Ergot with antiemetic/antihistamine - CI in pregnant
Migraine in pregnancy tx
Acetominophen, Opioids, Metaclopramide and Corticosteroids
NSAIDS only in 1st or 2nd trimester
NO Triptans, ergotamines, caffeine
Discharge for migraine HA in ER
Most can be dischared to PCP or Neurologist
Can prescribe sumatriptan
Cluster HA approach in the ER
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
Cluster HA treatment in the ER
High flow O2 through a non-rebreather
Try sumatriptan if failed
IN lidocaine, Ergotamine, Dihydroergotamine as alternatives
Transitional therapy that can be started in the ER for cluster HAs
Corticosteroids - taper over 2 weeks to prevent recurrence
Naratriptan BID
Ergotamine BID
Approach to a tension HA in the ER
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
Brain tumor presentation
Progessive, deep aching HA
Begins to have neurologic deficits
Worse upon awakening and with valsalva
Approach to brain tumor
CT with IV contrast
Emergent neurological/Surgical consult - Large problematic tumors
IV glucocorticoids to reduce swelling
Secondary prevention of seizures - Levitiracetam, topiramate, lamotrigine
Post traumatic HA syndrome
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
Idopathic intercranial HTN Presentation
Headache
Visual changes
Scotoma - black spot
Scintillation
Back pain
Papilledema
Abducens nerve palsy
Workup for idiopathic intercranial HTN
CT - Normal no enlarged ventricles like hydrocephalus
LP in left lateral decubitis for opening pressure
Normal CSF analysis
Target CSF pressure for idopathic intercranial HTN
10-20 cm H2O
Management for idiopathic intercranial HTN
1 mL of CSF removed will reduce pressure by 1cm H2O
Acetazolamide for visual symptoms + thiazide diuretic if needed
Admit new diagnoses
Intercranial hypotension HA
Usually d/t an LP or epidural. Can be d/t trauma
HA worse in upright position 24-48 hours after procedure
Audiovisual changes
Work up and management for intercranial hypotension
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
Brain abcess workup
CT with contrast is diagnostic
Blood cultures - twice for children and once for adults
NO LP
Brain abcess abx
Odontogenic - PCN G OR (Ceftriaxone plus metronidazole)
Post neuro procedure - Vanc plus ceftazidime
All others - Cefotaxime (or ceftriaxone) plus metronidazole
Steroids and brain abcess
Use if significant peri-abcess edema and associated mass effect and impending herniation
Steroids will break down brain abcess
Other mangement of brain abcess
Aspirate surgically and culture
Spinal epidural abcess
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
Tx for spinal abcess
Vanc and Ceftazidime - if surgery delayed
URGENT surgery consult
Temperature sites to subtract one degree
Orifices - Rectal and Oral and Tympanic
Temperature sites to add a degree
Axillary and Temporal
Time to take oral temp after eating
15 minutes
Fever of unknown origin
3 week fever with no known cause
Often autoimmune
Two things to look for in an adult who “feels fine”
Pneumonia and UTI
SIRS criteria
For Sepsis
HR over 90
Resp over 20
Temp under 96.8 or over 100.4
Sepsis criteria
SIRS plus Source of infection
Severe sepsis
Sepsis and Organ dysfunction
Septic shock
Persistent hypotension after bolus
LDH 4.0+
Fever management
Acetominophen for pediatrics
Ibuprofen (Toradol IV/IM in the ER)
Fever patients not to give empiric antimicrobials to
Neutropenic
Unstable
Asplenic
Immune suppressed
Admission criteria for fever
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
Follow up for fever
In 2-3 days
Pediatric fever
Easily jumps from system to system making a good PE critical
3 pediatric age categories
0-28 days (neonate)
1-3 months
3 to 36 months
Emergent fever criteria in children
100.4 under 3 months
102.2 3-36 months
Origins of roseola and measles
Roseola - Abdomen
Measles - Head
First place to look for source of pediatric fever
Urine
Then CXR for pneumonia, LP for meningitis
Criteria for sending febrile neonate home
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
Follow up for febrile infant
24 hours
Management for pediatric fever -high risk
Admit if high risk
Antibiotics!! - Ampicillin and Cefotaxime with blood cultures first!
Low risk management for febrile child
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
Who to get a UA on for pediatric fever
Girls under 24m, Uncircusised boys under 12m, Circumcised girls under 6m
OR if you feel the need
What to do if blood cultures come back +
Admit if sick
Don’t admit if okay
ALL on abx
Neutropenic fever presentation
Patient with cancer
100.4 for an hour or single temp 101
Absolute Neutrophil count under 1000 cells/mm (severe 500)
When do neutropenic fevers most often happen
10-15 days after last chemo treatment
Management for neutropenic fever
Vanc plus Cefepime
This is a hematologic emergency
MASCC score 20+ means you can send them home - get onc on board
Sign of a seizure that is nearly a 100% guarantee
Tongue biting
Assessment for seizures
Check glucose
Assess for injuries
Full neuro exam - LOC, mentation, walk, eye movements
Todd’s paralysis
Transient unilateral focal deficit after a simple or complex seizure
Work up as if it is a stroke
What an actual seizure should look like
Sudden start
Loss of memory
Post-ictal confusion
Soto saline sign for fakers
Diagnostic eval for Seizures
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
Active seizure management
Maintain airway
Turn on side and suction
IV access
Pulse and O2 monitors
EEG for first time seizures
Pharm for status epilepticus
Lorazepam - repeat in 5 minutes
Fosphenytoin or Phenytoin - second line
Can also give levetiracetam
Coma induction with Midazolam, Propofol, Pentobarbital
Management for patients with hx of seizures
Check serum drug levels - discuss with neuro what you want to do depending on levels
Discharge for first time seizures
Ensure return to baseline
No driving
Follow up with Neuro
Suspected eclampsia management
IV magnesium sulfate
Workup for febrile seizures
Only absolutely necessary if it’s status epilepticus - consult peds
Syncope - primary cause and technical definition
Not enough blood to brain
Out for seconds with no resuscitation
Loss of postural tone and consciousness
Workup for syncope vs. presyncope
SAME WORKUP
Differential and workup for syncope
Cardiac - Start with this
Neuro - Consider after
Ask to describe dizziness for vertigo vs. lightheadedness
Seizure vs. True Syncope
Seizure has a post-ictal phase, true syncope does not
Presentation of vasovagal syncope
Fainting after seeing blood, etc., w/ prodrome (pallor, nausea, warmth, diaphoresis, blurred vision)
60% of patients with a heart condition
Presentation of cardiac syncope
No prodrome and w/ exercise
Syncope while supine
Presentation of reflex syncope
After exercise with a drop in HR and BP
Presentation of psychogenic syncope
Long lasting, no post ictal phase - suspect
3 potential associated signs of syncope
HA - SAH
Chest Pain - MI, PE
Fever - Sepsis
Syncope and diabetics
Due to autonomic neuropathy of diabetes
QT and syncope
Check for meds - Zophran, Psych, Macrolides, FQ, Antipsychotics, Diuretics, nDHP-CCB
May have gone into torsades
EKG of 450+ is concerning
Normal QRS
80-100
Physical exam for syncope
Head and Neck Trauma
Skin Turgor
Abdomen for AAA
Rectal exam for bleed
Who gets a CT for syncope
Neuro deficit
Trauma to head - Canadian CT rules
Required workup for syncope
EKG
All other test based on presentation
PERC criteria
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
HCG for syncope
Any female of child bearing age with syncope - could be an ectopic pregnancy
Risk stratification for syncope
San Francisco and Canadian
Help us decide whether to admit or not
Canadian syncope positive risk factors
Heart disease hx
SBP >180 or <90
Elevated troponin
Abnormal QRS axis
QRS >130
QTc >480
Negative risk factors for canadian syncope rule
Anything to suggest a vsovagal etiology
Reasons not to use canadian syncope rule
LOC >5 minutes
Change in mental status
Obvious seizure
Head trauma
Intoxication
Language barrier
San Francisco Syncope Rule
CHESS
CHF hx
HCT <30%
ECG Abnormal
SOB hx
SBP <90
Normal EKG axis
Look at I and AVF
Should both be going UP
Moderate canadian syncope score
1-3
6 hours of observation and 15 days of monitoring
How long should syncope last
Less than a minute
Reflex syncope ddx
Vasovagal, Situational, Carotid sinus
Exam of vasovagal syncope
Labs, ekg, PE normal
Use to r/o bad stuff
Orthostatic syncope presentation
Change in position causes BP to drop causing a reflexive tachycardic response
Orthostatic hypotension diagnostic criteria
Decrease of 20 SBP OR 10DBP OR Increase of HR 20 bpm from supine to standing
Only one needed to diagnose
Dx for orthostatic hypotension
Ask nerve to do orthostatic readings - standing and supine
Patient ed for orthostatic hypotension
Hydrate
Wait between standing up and walking
Carotid sinus syncope
Tight collar, Head turn, Shaving - leading to push on artery
Hx of atherosclerosis
Use carotid massage to dx
Midodrine
Positive dx for carotid sinus syncope
Decrease of SBP by 50+ upon carotid sinus massage
Presentation of aortic stenosis syncope
Chest pain, Syncope, Dyspnea
Systolic murmur rad. to carotids
Echo and Valve replacement
Use of carotid sinus massage for dysrhythmias
SVT
ED care for aortic stenosis
Avoid: Nitro, BB, CCB
Admit for TAVR
Subclavian Steal Syndrome
Must have a stenosis in the subclavian
Blood flows to the brain but gets diverted back to the arm via the vertebral artery
Presentation of Subclavian Steal Syndrome
Pale, cool, arm
Right arm is more common
Low BP on one arm
Syncope!!
Get a CTA
Tx for SSS
Statin
ASA + Plavix
Admit
Basilar Artery insufficiency
Posterior Stroke - Syncope
Not normal stroke syndromes - vertigo, nausea, weakness, dysarthria, vision changes
CTA of head and neck to dx
Time to treat stroke from presentation
4.5 hours to use tPA
24 hours for manual clot removal
HINTS exam
Distinguish between BPPV and Stroke
Use Dix-Hallpike if you think it’s BPPV
Horizontal Head Impulse Testing
Nystagmus
Vertical skew
Presentation of Subarachnoid hemorrhage
Sudden onset, thunderclap headache - worst of life
Neck stiffness, possible positive meningeal signs
Syncope, neurodefecits
CT scan for stroke
Non-contrast
Most sensitive in the first 6 hours
Ottowa SAH rule
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
LP for Subarachnoid hemorrhage
Xanthocromia indicates blood in CSF for 2+ hours
Use if CT is negative and suspicion is high OR patient presents after 6 hours
What to do in high suspiscion of SAH with a negative CT and LP
CT angiogram or MRA/MRI
Management for subarachnoid hemorrhage
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
Tx for seizures and increased ICP with SAH
Elevate HOB 30 degrees
Active seizure control with lorazepam
Secondary with Phenytoin
Primary prevention not recommended
Presentation of Giant Cell/Temporal Arteritis
50+ with hx of polymyalgia rheumatica
Unilateral HA with jaw claudication
May have fever and vision changes
Temporal artery tenderness
Labs for Temporal Arteritis
Elevated ESR and CRP
US with a halo sign
Management for giant cell arteritis
PO Prednisone if no visual disturbance
IV Methylprednisone if visual disturbance - admit - can worsen to complete vision loss
Optho consult always
Presentation of trigeminal neuralgia
Unilateral, electric facial pain along a trigeminal nerve branch
Pain free intervals, women more than men
Management of trigeminal neuralgia
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
Presentation of adult meningitis
Continuous, throbbing, generalized HA, Worse with movement and valsalva
Fever and nuchal rigidity
Petechial rash may be present
Altered LOC, meningeal signs, photophobia
Presentation of Meningitis in Kids
Fever, Lethargy, Poor feeding
Seizures and Bulging fontanells
Young children may LACK meningeal signs
7 HX red flags for meningitis
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
Diagnostic eval for meningitis
CBC w/ culture
Liver/Kidney func.
PT/PTT before LP
LP w/ CSF analysis and PCR
7 Indications for a head CT before an LP
Immunocompromised
Hx of CNS disease
Mass lesion, Stroke, Or Focal infection
New onset seizure
Papilledema
Abnormal level of consciousness
Focal neuro defecit
CSF in bacterial meningitis
Cloudy
200-300mmH2O
High protein, Low glucose
CSF in viral meningitis
Clear
90-200 mmH2O
Increased Lymphocytes
Supportive management for meningitis
Maintain airway, monitor for seizures
Analgesics/Antipyretics
IV fluids
Management for bacterial meningitis
Dexamethasone before abx
Ceftriaxone+Vancomycin (Cefotaxin in children)
Other abx for bacterial meningitis
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
Management for Viral meningitis
Enteroviruses -MC
Symptomatic therapy with acyclovir for HSV, VZV
Empiric abx in immune compromised
Presentation of Encephalitis (and how it might differ from meningitis)
Fever and HA
Focal Neuro Deficits - more than meningitis
Negative meningeal signs
Altered LOC
HSV, VZV, EBV
Diagnostics for encephalitis
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
Management for encephalitis
Support
IV lorazepam for acute seizures
Neuro checks
Abx until confirmed
Acyclovir by 30 minutes after arrival
Clinical presentation of a brain abcess
HA, Focal neuro defecits
Increased ICP, Papilledema, change in LOC
Fever, new onset seizure
Diagnostics for brain abcess
CBC - Elevated WBC
CMP - Usually normal
ESR, CRP - Usually elevated
Blood cultures before abx if possible
CT/MRI WITH Contrast!
Management for brain abcess
Neurosurgical drainage
Ceftriaxone and Metronidazole
Add for head trauma or recent procedure: (Ceftazidime OR Meropenem) PLUS Vanc
Steroids for periabcess edema and mass effect
History suggestive of ACS
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
Physical exam suggestive of ACS
Uncomfortable, pale, or cyanotic
Heart Failure Acute
May hear S3 and S4
PE may be mostly normal
EKG interpretations for STEMI
STEMI - 1mm plus ST elevation in 2+ contiguous leads
Or new LBBB
EKG for NSTEMI
New horizontal or down sloping ST depression .5mm+ in two contiguous leads
T wave inversion in two contig. leads with prominent R
EKG for USA
Normal or nonspecific changes
Lead groups
Inferior - II, III, aVF
Anteroseptal - V1-V2
Anteroapical - V3-V4
Anterolateral - V5-V6
Lateral - I, aVL
Cardiac enzymes in ACS
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
Initial management for all ACS
Cardiac monitoring
2 large bore IV lines
Oxygen if under 94%
ASA 325 or Clopidogrel if allergic
Initial management for all ACS: NTG
.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
Initial management for all ACS: Morphine
Use only if pain is not sufficiently relieved by NTG
IV therapy
Initial management for all ACS: Beta blocker and Statin
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
Meds for ACS with refractory HTN
Clevidipine, Nicardipine, Metoprolol, Esmolol
Manaement specific to USA or NSTEMI
Cardio consult
Conservative approach
Dual antiplatelet therapy: ASA and P2Y12
LMWH
Early invasive approach
PCI or CABG
Unfractionated Heparin
STEMI specific management: PCI
90 minute reperfusion goal at PCI facility
120 at non-PCI facility
STEMI specific management: Fibrinolytics
For those unable to get to PCI in 120 minutes with symptoms less than 12 hours
30 minute reperfusion goal
tPA and informed consent
Monitoring for fibrinolytic therapy
BP - 15 minutes
EKG
Bleeding
12L EKG Q4 hours
Troponin Q4 hours
Disposition of ICS patient
PCI to cath lab
Fibrinolytics to the ICU
Presentation and Tx of stable angina
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
Presentation and Treatment of Prinzmetal angina
Occurs w/o precipitating event, wakes pt at night
May have ST elevation or depression
Tx - Nitroglycerin SL
Type A aortic dissection
Involves ascending aorta
Type B aortic dissection
Does NOT involve ascending aorta
Where do 90% of aortic dissections occur
Right lateral wall of proximal ascending aorta
Risk factors for aortic dissection
Male Sex
Age over 50
Poorly controlled HTN
Cocaine of Meth use
Bicuspid aortic valve
Marfans
Pregnancy
Presentation of Aortic dissection
Often atypical ezp. in older patients
Sharp, w/ ripping or tearing sensation - Abrupt!!
Often non-migratory
SOB, Limb ischemia, syncope, Neuro
Physical exam for aortic stenosis
May have aortic regurg ( diastolic decresendo murmur)
May see unilateral pulse defecit or BP difference
Diagnostics for Aortic dissection
CXR - Widened mediastinum
EKG - May show nonspecific or ischemic changes
D-dimer over 500
CTA is preferred method
TEE is highly sensitive
d-Dimer and Aortic dissection
Can almost always r/o if under 500
Us if ADD-RS is 0 or 1
ADD-RS
Asesses whetehr we should use D-dimer for aortic dissection dx
Score conditions, pain features and exam features 1-3
Management of aortic dissection
Resuscitate as needed
BB - Esmolol or Labetalol
Vasodilator if not controlled w/ BB - Nicardipine, clevidipine, NTG, Nitroprusside
Fentanyl for pain
Emergent vasc. surg. consult
Goal HR and BP for aortic disstection
HR - 60
SBP - 120-130
Presentation of Pericarditis
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!
Diagnostics for pericarditis
Diffuse ST elevation
CXR - Can see any secondary HF
TTE - Normal, may have effusion
Labs for complications
Management for pericarditis
May discharge home if stable
Ibuprofen TID for 7-10 days PO - Colchicene for adjunct
Indications for pericarditis admission
Fever
Slow onset
Immune compromise
Myocarditis
Failure to respond after 1 week
Effusion over 20mm
Tamponade
Uremic pericarditis
