Emergency Medicine Exam 2 Flashcards
5 Life threatening causes of dyspnea
Upper airway obstruction
Tension pneumothorax
Pulmonary Embolism
Myasthenia gravix/GB/C-Bot
Fat embolism
MC causes of dyspnea (not necessarily life threatening)
Obstructive airway disease - COPD/Asthma
HF
Anxiety
ACS
Pneumonia
Presentation of Cardiac Dyspnea
Hx of MI
Paroxysmal nocturnal dyspnea
DOE
S3/S4, JVD
Lung crackles
Initial management goal for dyspnea
Maintain oxygenation
Goal O2 sat for dyspnea
90% is general rules of thumb
Depends on baseline
CO2 retainer patients and oxygenation
Chronic COPD patients who baseline sat at 88 or similar. Giving oxygen will suppress respiratory drive
Oxygen per minute available in cannula and non-rebreather mask
Cannula - ~6
Non-rebreather Mask - 10-15
Why use a BiPAP rather than a CPAP
BiPAP lowers pressure for an exhale - makes the patient not feel like they are suffocating
Laryngotracheomalacia
Weak larynx d/t weak larynx - need to rule out other things
Laryngotracheal foreign body presentation
Stridor, hoarseness or complete apnea
Bronchial foreign body presentation
Unilateral wheezing and decreased breath sounds
MC foods for choking in children
Peanuts
Sunflower seeds
Carrots
Rasins
Grapes
Hot dogs
Imaging for airway foreign body
NOT DONE IF ACTIVELY CHOKING
Soft tissue of neck
Lateral CXR and PA
Inspiratory and expiratory views for radioluscent objects - air stuck in obstructed lung
Atelectasis and foreign bodies
Hazy area of the lung with no air - blocked off by foreign body
Coin in trachea on XR
Circular face in lateral view
Management for foreign body
BLS
Laryngoscopy for FB
Prep for intubation if unable to remove or tracheostomy
Croup presentation
Inspiratory stridor with barking or seal like cough
Stridor at rest
Low grade fever
Croup on XR
Steeple sign
Mild, Mod, and Severe coup
Mild - No stridor at rest
Mod - Stridor at rest with mild retractions
Severe - Stridor at rest with severe retractions - anxious and agitated
Management for mild croup
1 dose of steroids only - oral is preferred
IM/Neb if not able
Mod/Severe Croup Managment
Steroids
Recemic Epinephrine - Nebulized
Give up to three times with a 3 hour space
Heliox or intubate if fail
6 Discharge criteria for croup
Must meet all:
Nontoxic
No signs of dehydration
O2 sat over 90
Reliable caregiver
Improvement for 3 hours after last epi tx
f/u with PCP in 24-48 hours
Indications for Croup admission
Persistent stridor at rest
Tachypnea
Retractions
Hypoxia
2+ doses of nebulized epi needed
Bacterial tracheitis
Croup but bacterial rather than viral
Presentation of bacterial tracheitis
Sore throat
Toxic appearing
Tender to tracheal palpation - not seen with croup
Thick secretions of bronchoscopy blocking airway
Steeple sign
Management for bacterial tracheitis
Vancomycin PLUS (Unasyn or Rocephin)
FQ for b-lactam allergy
Kidney vs. Lung acid/base compensation
Kidneys take time, lungs take minutes
Elements of an ABG
pH
PaCO2
PaO2
HCO3
O2Sat
Normal pH, CO2 and Bicarb levels
pH - 7.35-7.45
CO2 - 35-45
Bicarb - 22-26
Causes of respiratory acidosis
Drop in respiratory rate and gas exchange
COPD
Resp depression from narcotics
OSA
Causes of resp alkalosis
Hyperventilation
3 Types of abdominal pain
Visceral - organs being stretched
Parietal - Generalized to localized as the peritoneum becomes inflamed
Referred - Pain distant to location of underlying cause (ie. to scapula, etc.)
Red flag abdominal pain for ischemia, dissection, or perforation
Maximal intensity onset pain
Red flag pain for inflammation, infection, or obstruction
Gradual onset pain
Abdominal pain that worsens over 6 hours
Likely surgical etiology
Abdominal pain that improves after eating
PUD
Abdominal pain that is worse with eating
Biliary colic
Abdominal pain that improves when upright and is worse when supine
Pancreatitis
Abdominal pain that worsens with sudden movements and improves with stillness
Peritonitis
Abdominal pain to the point that a patient can’t sit still
Renal colic suggestive
How long must you listen to say that bowel sounds are absent
2 minutes
Effect of blood on peristalsis
Increases peristalsis
Peritoneal testing
Rebound, Heel tap, jumping produce pain as well as bumps in the road
Carnett sign
Differentiate abdominal wall pain from intrabdominal wall
Positive=pain persists with tightened muscles
Murphy sign
Pressure on right upper quadrant leads to a cessation in breathing
Indicates cholecystitis
Psoas sign
Put on left side of bed and extend right leg back - Pain indicative of retrocecal appendicitis
Obturator sign
Internal rotation of the hip on the right elicits pain - appendicitis
Rovsing sign
Pain in RLQ on LLQ palpation - appendicitis
CVA tenderness
Pyelonephritis indicative
When to do pelvic/testicular exam
With any lower GI pain
Rectal exam for abdominal pain
Always look for FOB
Cullen and Gray turner signs
Pain around umbilicus and on flanks respectively, indicate peritoneal rupture
When is oral contrast needed in abdomen patients
BMI less than 23
Conditions for which to use oral contrast in the abdomen
Abcess, Appendicitis, Diferticulitis, Perforation, Fistula
Contraindication for IV contrast
CR 1.5+ GFR under 60
Caution in metformin use
General abdominal pain management
NPO with maintainance fluids - NS bolus
Maintainance NS rate
75-125 ml/hr if normotensive
May need K+
Antiemetics for acute abdomen management
Ondansetron or metaclopramide (extrapyramidal symptoms with meta)
Goal for pain management in acute abdomen
Make pain tolerable not zero
Pain management agents for acute abdomen
Morphine
Toradol
Renal Colic (as long as no peritonitis)
NG tube for abdominal pain management
Flush out stomach to avoid blood induced peristalsis
Decompress GI tract
3 purposes of a foley catheter for acute abdominal pain
Relieve obstruction
Monitor I/O
Assess renal perfusion
Abx for empiric acute abdomen
1 - Zosyn
2 - Gentamycin and Metronidazole
Monitoring of abdominal pain patients
Periodic checks for worsening
Disposition of abdominal pain patient - 7 reasons to admit
Elderly, Non-communicative, Demetia, Unable to comply, Immune compromised, Intractable pain and vomiting, Lack support
Good samaritain law
Good faith, voluntary, immediate
Not liable
Defer to EMS when they arrive
Don’t go out of your comfort level
Bee/Wasp sting anaphylaxis presentation
Hypotension, bradycardia, bradypnea
Tx for bee/wasp sting anaphylaxis
Epi pen
Pens have extra doses that can be gotten out
Make sure to use the right end of the needle
Dosing for epi pen
0.3 for over 66lbs
0.15 over 33 lbs
0.1 under 33lbs
Presentation of carbon monoxide poisoning
Headache, Nausea, Vomiting, Weakness, confusion and syncope
Classic cherry red skin
Normal pulse ox
Tx for CO poisoning
320 minutes at RA
74 min on 100% O2
23 min in hyperbaric oxygen
Indication to treat lactic acidosis in CO poisoning
pH under 7.15
Indication for hyperbaric O2 in CO pisoning
Carboxyhemoglobin over 25%
Heat edema presentation
No core body temp chenge
Ankle swelling
Diuretic if really bothering
Heat syncope presentation
Like heat edema due to intravasculkar redistribution
Normal core temp and hypernatremic
Heat cramps
Muscles not getting enough electrolyted
Core temp okay
Electrolytes with 6% carbs max
Heat exhaustion
Elevated core temp up to 104 (rectal thermometer)
Hyper or hyponatremic
Heat stroke
Body is redlined w/ organ damage and CV collapse
Core temp over 104
Tissue most sensitive to heat
Neural, hepatic, nephrons, vasc. endothelium
Presentation of sepsis
Temp over 100.5 or under 96.8
HR over 90
RR over 20
WBC over 12,000 or under 4,000 10% immature bands
Thyroid storm
Increase in t4/T3
Shaking/flapping of hands
Nausea, diarrhea, anxiety, tachycardia
Serotonin syndrome
Due to an SSRI
106 body temp
agitation, dilated pupils, seizures
Meds that can cause serotonin syndrome
SSRI, SNRI, MOAIs, Tramadol, St. John’s Wort
Tumor lysis syndrome
Tumor releases contents into bloodstream
Metabolic abnormalities leading to arrhythmias, seizures, organ failure
Tx for tumor lysis syndrome
Hydration
Allopurinol
Rasburicase
Signs of true heat stroke
Petechia, Dizzy, nausea
Tx for heat stroke
Recheck electrolytes every hour
Monitor temp until in the 101.5-102 zone
Rapid cooling
Rapid cool - evap is fastest
Tx for heat stroke unresponsive to initial therapy
Peritoneal, gastric, bladder, rectal, cool the brain
IV fluid for heat stroke
NS or lactated ringers
Goal is urine output of 50-100 mL/hour
Five ICU criteria for heat stroke
Hemodynamically unstable
Rhabdo
LFT elevation
Severe electrolyte abnormalities
Unknown dx
Trench foot
Painful condition from standing in cold water - militarym agriculture, homeless
Pain never really resolves after rewarming
Does not have to be freezing
Frostbite
Damage to tissue due to contact with freezing temperatures
Presentation of frostbite
Paresthesias, pruritis, loss of sensation and fine motor control
Stinging, burning, aching, throbbing AFTER rewarming
Tissue discoloration
4 degrees of frostbite
1 - Gets cold
2 - Blisters
3 - Hemorrhagic blisters
4 - Necrosis
Rewarming frostbite
Don’t rewarm and then freeze
Rapid rewarming in circulating water 98.6-102.2 F for 15-60 minutes
Avoid trauma
NSAID or Opiate for pain
Fluids
Mild hypothermia
COnscious and shivering
Core temp 89.6-95 F
Able to rewarm on own
Moderate hypothermia
Decrease in cognition with loss of shivering
82.4-89.6 temp
Requires external rewarming
Severe hypothermia
Unconscious with cardiac arrhythmia
Under 82.4 F
Progression of hypothermic arrhythmias
Brady>Afib>vfib>asystole
Dire hypothermia
Absent vital signs
Temp under 75.2 F
CPR and internal-external rewarm
Tx for hypothermia
Insulate from the ground
Wet clothing off and dry skin
Keep supine in ALL CASES - d/t BP drop
Warm liquids
ABCs
Defibrillation in hypothermia
You only get one shot - it will not work after that
Acute Mountain Sickness
Occurs above 9,000 feet
Decrease in PO2
Presentation of acute mountain sickness
Initially a HA followed by at least one of the following:
Anorexia, insomnia, weakness, dizzyness, oliguria, dyspnea, altered mental status
High altitude sickness
Beginning
Renal excretion of bicarb
Capillary stability weakens - edema
Pulm vasoconstriction increased erythropoietin, hemoglobin oxygen affinity
Prevention and tx of altitude sickness
Hike up slow and sleep lower than play
Ginko Balboa and Acetazolamide
Descent to cure
Hyperbaric chamber, sack, steroids to delay
Adjunct tx to acute altitude sickness
Tylenol and NSAID for HA
Ondansetron for nausea
High altitude pulmonary edema
Due to hypoxic vasoconstriction and increased right heart pressures`
Descent to treat
Onset of pulmonary edema
Onset on second day of ascent
Presentation of high altitude pulmonary edema
Cough, rales, tachypnea, chest tightness, tachycardia, dyspnea at rest
High altitude cerebral edema
Thickening at “arrow points” seen on CT
Bleeding on ophthalmoscopic exam
Looks like astroke
Management for HACE
Descent, dexamethasone 8mg followed 4mg q6
Admit if symptomatic 2hrs after descent
Copperhead/Rattlesnake antivenom
CroFab
Pit viper bite management - things NOT to do
Copperhead/Rattlesnake
Restrict, suck venom
Pit viper bite things to do
Immobilize, measure every 30 minutes
Watch for compartment syndrome
Dry bite
No symptoms after 12 hours monitoring
Symptoms of a pit viper bite
Nausea, Vomiting, Hemolysis, THrombocytopenia, Coagulopathy
Cardiopulmonary collapse
Coral snake bite treatment
Red touch yellow
Different than pit viper bite
Tick bite tx
Doxy 100mg BID
1-3 day tx, 10 day tx for positive IgM titer
Treat until 3 days after fever subsides
“Spider bite” bacteria
Treat as MRSA
Brown recluse spider bite presentation
Extreme pain and skin erosion
Lightning injuries presentation
Electrical asystole - responds to CPR almost 100%
Burns worse near bones
Non-fatal pneumomediastinum
Cataracts
Management of drowning
CPR is critical
High flow oxygen - goal is 95%
Monitor acid base status and UDS
Something to evaluate for in fire burns
CO poisoning
Fluid to use for those with burns
Lactated ringers
Inhalation burn presentation
Facial burns, singed nasal hair, soot in mouth
Hoarse, carbonaceous sputum, wheezing
Hypoxemia
Management of inhalation burns
100% oxygen
Potential intubation
Bronchodilators
Lactated ringers IV
Management for external burns
Removed burned clothes
Poor cool water over burns (NO ICE)
Remove jewelry
Lactated ringers via parkland or Modified Brooke formula
Rule of nines for burns
9% - Head+Neck; One arm
18% - One leg
36% - Trunk
1% - Groin
Chemical burn presentation
Acid - Tans skin, limits depth
Alkaline burns - Goes deep and saponifies lipids
Heavy metals - Flush with water to get oxygen away
Barotrauma of descent
Rupture of TM or of the Oval Window
Sinus bleeding
Rupture of ascent
Same as descent but high pressure comes from the inside pushing out
Burst lung from diving
Expanding air from ascent causes over expansion and rupture
Tx for blood gas expansion
Pressurized chamber or back underwater
Presentation of bends
Tissues full of air, extreme knee pain from air in the joints
Extraction of injured party
Stabilize injury, Hard hat, sunglasses if looking up, protect from cold
Need to clear ANY debris from helicopter landing site
Cardiogenic shock
Heart not working - MI, etc.
Cardiac monitor and access fluid bolus and pressors
PCI and Cabbage
Septic shock
Infection response causing shock
SIRS criteria - tachycardic, tachypneic, febrile
Lactic over 4
TX for septic shock
Start BS abx
Give fluids - Lactated ringers
Central line for bigger pipe
Frequently recheck pressure
Amount of fluid needed in septic shock
Often 3-5 liters for first 6 hours
Balanced after 2-3 liters
Neurogenic shock
Presents with a spinal cord injury
Hypotensive and bradycardic with good perfusion - warm
Fluid is just sitting there
Manage w/ Vasopressors
CPR compressions to breaths
30:2
Intubation position
Forward flexion of neck with extension “sniffing position” - place towel under patients occiput
DO NOT ATTEMPT IN C-SPINE INJURY
Oropharyngeal airway
Smallest and least invasive - keeps the tongue out of the way
Nasopharyngeal airway
More invasive - failed shotgun suicide - easier than oropharyngeal
Optimal bag valve mask delivery
75% oxygen, make sure you get a good seal with two people if possible
6 INdications for intubation
Respiratory failure low O2 high CO2
Apnea
GCS 8 or below
Airway injury
Aspiration risk
Trauma to larynx
Mallampati class system
I-IV - DOcumentation tool for ease of intubation
IV uvulacome down more
Preoxygenation for intubation
Done for everyone to give more time for successful intubation
Give 100% oxygen on a 15 mL/min non-rebreather mask for 3 minutes
Intubation blades
Mac - 3,4 Curved, helps to lift tongue, goes into the valecula
Miller - 2,3 Straight, pushes stuff out of the way
Glidescope - Easier to use
ET tube sizes
7.5-8 for women
8-8.5 for men
Rapid sequence intubation
Paralytic and sedative w/ the sedative first, may not paralyze with large body habitus, no sedative with drug overdose
Common sedatives for intubation
Etomidate
Propofol - not in hypotensive
Ketamine - Good for asthma
Paralytics for intubation
Succinylcholine - Avoid in hyperkalemia and burns
Rocuronium - Do not use in myasthenia gravis
What to do if intubation fails
Use bag mask to keep sats above 90% after failure
Consider a cric.if 3 failed attempts
Steps for using a glide scope for intubation
Put in scope, check on camera, put in tube, check on camera remove stylette (scope)
Hand used to place the stylette in incubation
Always left hand
Confirmation for ET tube placement
Breath sounds first
Capnography second
Places not to get IV access
Infection, injury, burns, fistula, vascular disruption
CI to Peripheral access
Sclerosing, Chemotherapy, Concentrated electrolytes or glucose
Indications for central IV access
Can’t get peripheral access
Need access to central circulation
Measurement of CVP
Sclerosing, chemo drugs, Concentrated solutions
Femoral access
Easiest access, don’t need US
Dirty area - needs changed more often
Jugular access
Visualize with US
Commonly done
Must be careful to avoid carotid artery
Subclavian central line
Not near the artery, risk of popping a lung
Use US, can be somewhat easier
Defibrillation for Vfib
200 J Biphasic
360 J Monophasic
Epi administration in ACLS
every 3-5 minutes if no rhythm
Pulse checks for CPR
Every 2 minutes
Tx for asystole or Pulseless Electrical Activity (PEA)
NON-shockable
COmpressions with Epinephrine
Tx for supraventricular rhythms Sinus tachy, SVT, A fib
Sinus tach -find underlying cause and treat
SVT -Vagal maneuvers to rule out or adenosine (not fun)
A fib/flutter - BB or CCB, Cardiovert
Vtach with a pulse tx
Procainamide or Amiodarone
Pulseless V tach tx
Defibrillate 360 J Mono, 200 J Bi
Indications for emergent treatment of bradyarrhythmia
HR under 50-60 with hypotension and hypoperfusion
Tx for acutely symptomatic heart block
Transcutaneous pacing
Resuscitation for pediatrics
15:2 compressions to breaths if two rescuers - usually problems are respiratory rather than cardiovascular
IV access in peds
Intraosseus is often easier to do
BRUE
Brief Resolved Unexplained Event
Cyanosis or pallor
Absent decreased or irregular breathing
Loss of tone
ALtered responsiveness
Only applied if now asymptomatic infant
Risk factors for BRUE
Feeding difficulties
Recent URI/symptoms
Under 2 months
Previous episodes - suspect abuse
Warning signs in an apparent end of life event or BRUE
Still symptomatic
LOC or CPR needed
Trauma
Hx in last 24 hours
Unexpected sibling death
Inconsistent description - abuse
Low risk peds apparent end of life event or BRUE
Over 60 days
Born at gestational age 32+
No prior hx
Less than 1 minute BRUE
No CPR required
No concerning hx or PE findings
Risk factors for SIDS
Smoking
Sleeping on tummy
Resuscitation for SIDS
May be tried if the baby is warm, or has suffered known hypothermia
Other reasons not to resuscitate in SIDS
Low core temp w/o hypothermia
Livedo reticularis
pH under 6
Indication for termination of peds resuscitation efforts
Arrest over 20 minutes
Core temp of 30 degrees C reached in hypothermic pts
What counts as physical trauma
Anyone with multiple injuries - MVA or senior who fell
Primary survey for trauma patient
ABCDE
A - Airway maintainance
B - Breathing compromise
C - Circulation and Hemorrhage control
D - Disbility/Neuro traits
E - Exposure and environmental control
Airway maintainance in trauma patient
Suction and inspect for foreign bodies
Look for surrounding fractures
Assume C spine injury in blunt trauma and altered LOC - C collar
Breathing managment in the trauma patient
Auscultate lungs for flow
Inspect and palpate chest
Inspect for JVD and tracheal position
Circulation management in trauma patient
Look at BP to estimate
Alert = Good brain perfusion
Pallor and Pulses
Bleeding - remember airway bleeding
Bruising and low BP indicates internal bleed
How long can a tourniquet be on
3 hours
Disability/Neuro management for trauma patient
Consider alcohol, narcotics and hypoglycemia - naloxone, glucose thiamine
Take GCS
Exposure management in trauma patient
Undress patient and then cover in warm blankets - they may not notice pain from some injuries
Airway resuscitation in trauma patient
Jaw thrust and chin tilt - less than 8 intubate
Breathing resuscitation in trauma patient
Supplemental oxygen
Circulation resuscitation in trauma patient
Hemostasis and IV fluids (2 large bore IV) or Blood products
Surgery
Four areas of a fast exam
Cardiac subxyphoid
RUQ
LUQ
Suprapubic
E fast also looks at lung apices
Secondary survey for trauma
Constantly reevaluating primary
EENT - Fluid, pupilreaction, palpate, Jaw ROM
Traumatic head injuries - Epidural hematoma
- young person hit in the head
May pass out after trauma with convex area
Arterial bleed
Tx for an epidural hematoma
BP above 100 older and 110 younger
Subdural hematoma
Goes slower because venous bleed
MC in older people and alcoholics
CT scan to dx, not always acute - crescent sign
TX for subdural hematoma
Watch BP and coagulation, surgery not required
Cervical spine and neck inspection for trauma
Look for anyseat belt mark, tenderness, SQ emphysema, tracheal deviation
Always stabilize with a C collar
Tx for cervical spine fracture
Head CT to identify
Always admit
Spinal precautions
Associated injury stabilization
Watch for deterioration
Tx for cervical spine and neck soft tissue penetration
Clavicles-Cricoid cartilage (zone 1) always needs surgical intervention
Watch for airway and exsanguination (will kill faster than airway)
Non superficial penetrating neck trauma
Injury of the platysma - more likely to have airway compromise
Dx for spinal cord injury
CT followed by MRI
Presentation of anterior cord syndrome - intact vs. preserved sensations
Loss of motor function, pain and temperature sensation distal to the lesion
Intact vibration, position, and tactile sensation
Central cord syndrome presentation
Due to spinal hyperextension
Decreased strength in upper extremities but okay in lower extremities
Bilateral
Brown sequard syndrome presentation
Direct penetration to the spine
Ipsilateral loss of motor function and contralateral loss of pain and temperature sensation
Cauda equina presentation
Bowel or bladder dysfunction - retention and then overflow incontinence
Low sphincter tone
Saddle numbness
Motor and sensory loss in lower extremities
Chest inspection in trauma
Look for open pneumothorax and flail chest
Listen for crackles
Look for hemothroax
Hemothorax dx
Blood in lungs on CXR or FAST exam
Treat with thoracostomy if 300+mL of blood (half the lung
Pneumothorax management
No breath sounds and collapsed on CXR
Thoracostomy if large enough to treat
Pneumothorax too small to treat
Under 1cm wide, confined to upper third of the chest
You’ll probably still treat if symptomatic
Presentation of a tension pneumothorax
Pleural pressure transferred to the mediastinum
Tachypneic, Tachycardic, Devation, No breath sounds
Tx for tension pneumothorax
Needle decompression at 4th AICS in the midclavicular line above rib with angiocatherter then thoracostomy
Exam of traumatic abdomen
Distension - may be bleeding out
Tenderness and guarding - voluntery or involuntary
FAST
Solid abdominal organ injury trauma treatment
Laparotomy - dx with FAST and CT - urgent if peritonitis is diffuse or pt is unstable
Hollow viscus injury
Bowel or mesenteric injury from blunt trauma
More minimal symptoms
Blood loss and contamination
Rare
Tx for extremity fx
Splint and ABX and tetanus if open fx (Ancef for abx)
Rhabdomyolysis presentation
Crush injury - MVA hard to extract or overdose laying for a long time
Muscle pain, CK to dx 3x upper limit
Coca Cola Urine
Tx for rhabdomyolysis
Treat with fluids
COmpartment syndrome
Pressure in leg compartment
MC in calf
5 P’s
Tx for compartment syndrome
Dx with compartment pressure
Tx with fasciotomy
Red flags of non-accidental trauma in peds
No hx of trauma
Description not consistent with development
Delay in seeking care
Bruises suggestive of child abuse
Torso, neck, ears, back
Larger and more symmetrical pattern
Burns suggestive of child abuse
Well demarcated -often from hot water when intentional - stocking glove
Fractures that may indicate abuse
Rib fracture
Sheer injury
Spiral fracture
Presentation of viral gastroenteritis
Rapid onset of WATERY diarrhea
Cramping and abdominal pain that improves with relieving self
Look for volume loss
PE for viral gastroenteritis
Dry mucous membranes
Benign abdominal exam
Diffuse tenderness
Lack of tear production
Dx for viral gastroenteritis
Check glucose and BMP with Mag - stool studies not needed if symptoms less than two weeks
Tx for mild/moderate viral gastroenteritis
Oral fluid challenge - 15 minutes rest followed by 30mL electrolyte fluid intake repeat with a goal of 30-100 mL in 4 hours
Tx for moderate - severe viral gastroenteritis
IV NS or LR
500-1000mL bolus in adults
20mL/kg in children
Antiemetic use in viral gastroenteritis
Only used if patient fails oral fluid challenge but meets discharge criteria
Zophran
Antidiarrheal use in viral gastroenteritis
Only if diarrhea leads to dehydration
Adults only - Imodium/Lomotil for antimotility and Bismuth for antisecretory
Contraindications for antidiarrheal use
Pediatrics, IBD, pregnancy for bismuth salicylate
Patient education for viral gastroenteritis
BRAT diet - low in fat and soft, avoid dairy, raw fruit, caffeine
Probiotics to reduce duration of symptoms
Five Admission criteria for viral gastroenteritis
Toxic appearing
Severe dehydration -electrolytes or renal function impacted)
Comorbid conditions
Extreme youth or age
Symptoms over 1 week
2 Processes of bacterial gastroenteritis
Toxin-mediated - Secretory
Invasive - Inflammatory
Clinical presentation of bacterial gastroenteritis
Large amount of either watery or bloody mucopurulent diarrhea
Cramping and tenderness
Fever
Hemolytic uremic syndrome
MC in elderly and under 10 years
Associated with EHEC, renal failure, anemia, thrombocytopenia
Abx can make this problem WORSE!!
Diagnostics for bacterial gastroenteritis
+FOB
CBC if HUS suspected, BMP for hypokalemia or AKI
CT for obstruction
Indications for stool studies in bacterial gastroenteritis
Severe dehydration or Toxic appearing w/ dysenterry
Immune compromised
Prolonged diarrhea (over 3 days)
Bacteria to culture for in gastroenteritis
Salmonella, Shigella, Campylobacter
Management for bacterial gastroenteritis
Fluid resuscitation w/ glucose/K+ if indicated
Abx for bacterial gastroenteritis
Cipro or Azithromycin
Not recommended in children until pathogen identified
Caution in geriatrics
Antidiarrheals in bacterial gastroenteritis
Avoid lamotil and imodium
May use bismuth salicylate but it is contraindicated in children
Landmar separating upper and lower GI tractk
Ligament of trietz
3 substances that can simulate hematochezia or melena
Iron and Bismuth - Melena
Beets - Hematochezia
PE for GI bleed
Increased bowel sounds
Tenderness = Infectious etiology
Nontender = Vascular etiology
Rectal exam if LGI bleed suspected
Diagnostics for GI bleed
Type and crossmatch
CBC may be normal before resucitation in acute patients- monitor CBC every 2-8 hours
CMP - BUN:Cr 30+ = UGI
PT/INR
INR for endoscopy
Must be under 2.5
NG tube for UGI bleed
Blood will be seen if bleed with proximal to pylorus
Management for GI bleed
Stable - Consult GI/Syrgery
Unstable -NPO, O2, 2 large bore IV sites give up to 2L NS or LR
Blood transfusion in GI bleed
1 unite of FFP for every 4 units of PRBC
INdicated if:
Hemodynamically unstable
No response to 2L NS or LR
Hgb under 7 or older, comorbid under 9
GI bleed complicated by anticoagulant
INR>2.0
Hold and potentially reverse
Reversal agents for anticoagulants
Andexxa for Xarelto/Eliquis
Praxbind for Pradaxa
Vit. K for warfarin
Additional management for UGI bleed
PPI for acid suppression -pantoprazole
Octreotide for verceal bleeding
Additional Management for lower GI bleed
Consider EGD to r/o UGI bleed
Colonoscopy or angiography
Discharge criteria for lower GI bleed
Hx of mild bleeding (ie. from hemmorhoid)
BRBPR (bright red blood) on DRE
No melanotic stool
Stable vitals
No comorbidities
Admit ALL others
Esophageal ulcer presentation
Hx of GERD and odynophagia
Presentation of PUD
H. pylori, NSAIDs, Smoking in hx
Assoc. abdominal pain
Presentation of ruptured esophageal varices
Liver disease, alcoholism, jaundice, ascites present
Presentation of UGI bleed d/t malignancy
Hx of smoking, alcohol, H pylori, Early satiety, weight loss chachexia
Presentation of UGI bleed due to marginal ulcers
Ulcer at gastroenteric bypass
Hx of Rouz-en-Y gastric bypass
Presentation of GI bleed due to aorto-enteric aneurism
AAA hx or aortic graft
Presentation of UGI due to angiodysplasia
Renal disease, AS, Hereditary hemorrhagic telangiectasia
Presentation of perforated GI bleed
Severe abdominal pain with rebound tenderness and involuntary guarding
Gastric outlet obstruction
Nausea and vomiting because stomach contents can’t move the other way
Succision splash heard
Tx for PUD/Gastritis
d/c NSAIDs
PPI, H2RA
Refer to GI
PUD alarm symptoms
Age over 50 with new onset symptoms
Unexplained weight loss
Persistent vomiting
Dysphagia or odynophagia
Anemia or bleeding
Mass or lymphadenopathy
Fam hx of GI malignancy
Disposition for PUD
f/u with PCP if uncomplicated
Complicated - Consult general surgery for peroration, place NG tube for gastric outlet obstruction
Presentation of kidney stone
Only causes problems when in ureter or bladder
Worst pain of life - fluctuant
Flank to RLQ to Groin
UTI, Hematuria, Dysuria
Kidney stones and age
New onset in over 60 is rare - should suspect something else!! - ie. AAA
Dx for nephrolithiasis
UA, HcG, CBC, CMP
CT scanning for nephrolithiasis
Non contrast of abdomen and pelvis
Sensitive and specific
Can detect stones 1mm+
Can also detect AAA
Other imaging for nephrolithasis
US of kidneys or KUB X-ray
Management for nephrolithiasis
Toradol - opiates if inadequate
Zophran
IV/PO fluids
a-blocker - Tamsulosin (flowmax)QD for 2 weeks
Admission criteria for nephrolithiasis
Intractable pain/emesis
Coexisting pyelonephritis
Stone 6+mm or anatomic abnormality
Renal dysfunction
Disposition of non-admitted nephrolithiasis patients
f/u in 24-48 hours with urology
Drink 2-3 L fluid per day
Strain urine for stone
Pyelonephritis presentation
Dysuria, Urgency, Frequency
CVA tenderness
Hematuria with +leukocyte esterase and WBC casts
Pyelonephritis dx
hCG for females
Urine C&S
BMP/CBC
General management for pyelonephritis
IV fluids
Tylenol or ibuprofen
Zofran
Toradol or opiate if needed
Outpatient abx for pyelonephritis
Cipro, Initial IV Rocephin recommended
Alt: Bactrim
Inpatient abx for pyelonephritis
Cipro, Rocephin, Gent/Amp, Zosyn, -Penem
Choice depends on local resistance data
Pyelonephritis admission criteria
Unable to keep pills down
Severe illness
Comorbid
Pregnancy or Stone
Compliance concerns
Outpatient f/u for pyelonephritis
1-2 days
Educate to increase fluid intake
Presentation of hepatitis
MC is viral but can be alcohol or tylenol toxicity
Fever, RUG pain, Ascites, High AST/ALT
Interpretation of AST/ALT ratio
2.5+ = Alcoholoc
Under 1 = Other causes
AST and ALT over 1000 is a tylenol poisoning
Admission criteria for hepatitis patients
Elderly or Pregnant
No response to supportive care
Billirubin 20+mg/dL
Prothrombin 50% above normal
Hypoglycemia
GI bleed
Presentation of rupturing or dissecting AAA
Severe ripping pain
Hypotension if ruptured
Pulses often normal and symmetrical
Pulsitile mass
LOOK for abnormal vitals
Management for dissecting or dissecting AAA
Type and crossmatch
Two largebore catheters
O2 and Pain
CBC, CMP
Management of unstable patient with potential AAA
Immediate US and referral to vascular surgery - don’t wait for imaging
Management of stable AAA
CT scan aortagram or full CT scan
Rapidly growing is at risk for rupture
Consult vascular with 24-72 hour follow up
Hypertensive patients with potential aneurism
Esmolol, add nitroprusside if BP remains uncontrolled
Size of AAA
5+ cm = Surgery consult within 2-3 days
3-5 - Less likely rupture, follow with PCP or vascular surgeon;’/
Presentation of appendicitis
Malaise and indigestion followed by periumbilical discomfort localizing to McBurney’s point
N/V may be seen
Sudden improvement with perforation
Diagnostics for appendicitis
Elevated WBC is earliest finding
UA may see hematuria and pyria
hCG to r/o ectopic pregnancy
Imaging for appendicitis
US - Indicated in children, pregnant women, thin adults
Specific more than sensitive
CT - IV contrast, oral if BMI under 23
Males and non-gravid females
Appendicitis dx in pregnancy
US as initial study, may follow up with CT/MRI
Management of appendicitis
NPO with fluids
Paincontrol
Antiemetics
Surgical consult
Perioperative abx for appendicitis
Unasyn, Zosyn, Flagyl, or Cefoxitin
4 Presentations of cholecystitis
MC - billiary colic
If gallstone stays in plays = inflamed gallbladder
Pancreatitis if obstructed pancreas
Ascending cholangitis
General presentation of cholecystitis
RUQ or epigastric pain radiating to right scapula
May have fatty food intolerance
+Murphy sign may have fever
Charcot’s triad
Cholecystitis:
Fever
RUQ pain
Jaundice
DX for cholecystitis
Elevated LFTs in choledocholithiasis (emergency)
Lipase for pancreatitis
US - Stones, sonographic murphy’s sign
CBD enlrgement indicative of choledocholithiasis
Over 5-7 mm
Management for cholecystitis
NPO with IV fluids NS or LR
1-2 L bolus
Zophran and NG tube
Morphine or Toradol
Abx for cholecystitis or cholangitis
Uncomplicated cholecystitis - Ceftriaxone and Metronidazole
Ascending cholangitis (emergent) - Ampacillin, Gentamycin and, Clinda
Ascending cholangitis substitution drugs for allergies
Ampicilling - Rocephin or FQ
Clinda - Flagyl
Disposition of cholecystitis patient
Urgent surgical consult in acute
Refer for ERCP and Sphincterotomy in ascending cholangitis
Indications for discharge in cholecystitis
Symptoms resolve in 4-6 hours of supportive therapy
Tolerate oral hydration
Always admit: Acute cholecystitis, cholangitis, choledocolithiasis
Presentation of diverticulitis
LLQ pain, intermittent or constant with leukocytosis
Tenderness, mass, or distended abdomen
Rebound tenderness and guarding
Dx for diverticulitis
Imaging not needed in pts with a hx of diverticulitis with similar presentation
Lipase, CRP, UA
CT of abd/pelvis with IV contrast
CT findings for diverticulitis
Increased soft tissue density within pericolic fat
Presence of diverticula
Bowel wall thickening of 4mm+
Pericolic fluid collections representing abcesses
Uncomplicated diverticulitis
Isolated inflammation of diverticula wall w/ or w/o phlegmon, or abcess confined to bowel wall
Complicated diverticulitis
Associated with abcess, stricture, onstruction, fistula, or perforation
Therapy for diverticulitis
NPO and fluids, abx
Abx for moderate diverticulitis
Flagyl and cipro
ALT: Flagyl and Ceftriaxone
Alt: Zosyn
Abx for severe diverticulitis
Zosyn
ALT: Azytreonam and Flagyl
Surgical consult for diverticulitis
Emergent if perforated
Within 24 hours for all othe complicated cases
Out patient management if diverticulitis
Abx and conservative therapy
Liquid diet and avoidance of dairy
F/u in 2-3 days with PCP
Flagyl and FQ
ALT: Flgyl and Bactrim
ALT Augmentin
ALT: Moxifloxacin
2 MCC of pancreatitis
Gallstones and Alcohol consumption
Presentation of Pancreatitis
Acute, severe, persistent epigastric abdominal pain, may radiate to back, chest, flanks
Worse with oral intake or lying supine
Better sitting up with knees flexed
Nausea, anorexia, distension, tenderness
Signs of nectrotizing pancreatitis
Cullen (periumbilical) or Gray Turner (bilateral flank) signs
Erythematous skin nodules
Dx for pancreatitis
2 of 3 required
Consistent clinical presentation
Elevated Serum LIPASE (may also use amylase but lipase is BETTER)
Characteristic imaging
Imaging suggestive of pancreatitis
CT with contrast or US showing enlargement of the pancreas
Workup for pancreatitis
ALT over 150 w/i 48 hours indicates gallstone
Elevated Alk phos indicates gallstone
US for gallstone
CXR for respiratory complaints
CT if uncertain
Management for pancreatitis
NPO
Fluids - NS or LR
O2 sat over 95%
IV opiate for pain
Zofran
Fluid rate and amount for pancreatitis
2.5 to 4 L of fluid for 12 to 24 hours
5-10 mL/kg per hour if okay with CV or Renal health
Abx for pancreatitis with infection
Imipenem-cilastatin
Meropenem
Cipro with metronidazole
Disposition for pancreatitis - indications for discharge (4)
May be discharge if:
No evidence of billiary involvement
Pain and vomiting with oral agents
Able to tolerate clrear liquids
Good social support
Indications for pancreatitis admission
Not meeting discharge criteria
First episode of pancreatitis
Surgery consult for pancreatitis
General surgery for biliary involvement - needs cholecystectomy
Gallstone involved needs ERCP and sphincterotomy
Four classifications of small bowel obstruction
Partial obstruction - Gas and liquid stool can pass
Complete obstruction - No substance can pass
Simple - No loss of blood flow
Strangulated - Loss of blood flow
MCC of small bowel obstruction and second MCC
1 - Adhesions post surgery
2 - Incarceration of a hernia
Ileus v. obstruction
Ileus = Paralyzed
Obstruction = Not paralyzed
Clinical presentation of small bowel obstruction
Crampy intermittent abdominal pain
Bilious Vomiting with proximal obstructions, Fecalant in distal
Change in bowel habits - constipation
High pitched bowel sounds diminish over time
Dx for small bowel obstruction
Nonspecific labs - WBC over 20,000 in gangrene, 40,000 suggests mesenteric ischemia
XR to r/o perforation
CT w/ contrast is diagnostic of choice - dilated bowel
Management of partial small bowel obstruction
NPO with IV fluids
NG tube with light suction
Antiemetic, analgesics
Most resolve w/o surgery in 72 hours
Management of complete small bowel obstruction
NPO, IV fluids, NG tube with light suction
Surgical consult
Zosyn if surgery indicated
Spontaneous primary pneumothorax
Tall, thin males 10 to 40 with hx of smoking
No previous hx of lung disease
Spontaneous secondary pneumothorax
Complication of preexisting diseas - COPD, asthma, etc.
Often more severe presenting symptoms
Iatrogenic pneumothorax
D/t PPV and interventional procedures
Tension pneumpthorax
Air enters pleural space but cannot escape
MCC - CPR or PPV
Presentation of pneumothorax
Pleuritic chest pain, onset at rest
RR over 24
O2 under 90
Tachycardia
Deminished or absent breath sounds with decreased tactile fremitus
Tracheal deviation away from tension pntx
Dx for pneumothorax
PA CXR usually diagnostic
US for unstable patients
CT to ID associated pathology
Management of primary spontaneous pneumothorax - indication for supplemental oxygen with observation
Indicated if
Under 3cm at apex or under 2cm at hilum
First PSP
2-6L with goal of 96% saturation
4-6 hr f/u XR - d/c if improved
Management of primary spontaneous pneumothorax with needle or catheter - indications
Indicated if:
First but large (3+cm at apex 2+ cm at hilum)
Stable vital signs and expert provider
Pneumothorax needle decompression method
2 inch needle 14G adults 16G children
Aspirate via syringe - remove air until resistance
Care after needle aspiration of pneumothorax
Remove catheter if stable after 4 hours and d/c if CXR okay 3=2 hours after that
Needle placement for PSPT decompression
Anterior - midclavicular line, second intercostal space
Lateral - Anterior axillary line 4-5th ICS
Management for pneumothorax with a chest tube or thoracostomy - indications
Indicated in: Failed aspiration (more than 4 L pulled)
Large, recurrent, bilateral, Unstable, severe dyspnea
Pneumothorax chest tube/thoracostomy placement method
10-14 French in atraumatic cases and 14-22 in larger traumatic leaks
4th or 5th ICS in the anterior axillary or midaxillary line
Attach to water seal suction or to wall suction
Admit
Management for secondary spontaneous pneumothorax
Maintain airway
Supplemental oxygen - caution in O2 induced hypercapnic individuals
Tube/Catheter thoracostomy and admission
Definitive tx with pleurodeisis
Management of tension pneumothorax
Needle decompression with 14-16 guage needle at the anterior 2-3 ICS at the midclavicular line or 5th ICS midaxillary
Leave needle in place until thoracostomy
Large amount of escaping gas is diagnostic for tension pneumothorax
Presentation of pulmonary embolism
MC - Chest pain and dyspnea
Tachycardia, signs of DVT, HR over 100 may have a fever
Lungs CLEAR!
Wells criteria with point values
Risk of PE
Suspected DVT - 3
Alt dx les likely than PE - 3
HR over 100bpm - 1.5
Prior venous thromboembolism - 1.5
Surgery or immbilazation in past week - 1.5
Active malignancy - 1
Hemoptysis - 1
Well’s score interpretation
Over 6 - high risk
2-6 moderate risk
Under 2 - low risk
PERC criteria - 9
All must be present to rule out PE
Clinical low probability
Under 50 y/o
Pulse under 100bpm for entire stay
Pulse oximetry over 94% near sea level or over 92% near 5,000 feet
No hemoptysis
Nor prior venous thromboembolic hx
No surgery or trauma needing endotracheal or epidural anesthesia in past 4 weeks
No estrogen use
No unilateral leg swelling
Diagnostics for PE
Pulse oximetry may be low
Abnormal to nonspecific findings
Westermark’s sign
Uncommon indicator of PE
Wedge shaped area of lung oligemia
Hampton’s hump
Uncommon indicator of PE
Peripheral dome shaped opacification
EKG of pulmonary embolism
Pulmonary hypertension
T wave inversion in V1 and V4
Incomplete RBBB
S1-Q3-T3 pattern
D-dimer for PE dx
Only used in low-moderate probability cases
CT imaging for PE
CTA - segment or larger filling defects
Safe in pregnancy
V/Q scanning for PE
Can identify defect when ventilation is normal
Indicated in renal insufficiency or other issues with contrast
Management for PE in presence of instability
UFH or fibrinolytic
Management for PE - stable
LMHW or Factor X Agonist (eliquis, xarelto, etc.)
2 Indications for UFH instead of LMWH
Renal insufficiency and instability
Indications for fibrinolytic use for PE
SBP <90mmHg for >15 minutes (under 100 w/ hx of HTN) or greater than 40mmHg drop from baseline. Elevated troponin or BNP, persistent hypoxemia with distress
CI for fibrinolytic therapy - 4
Intercranial disease
Uncontrolled hypertension at presentation
Recent major surgery or trauma (3 weeks
Metastatic cancer
Tx post thrombolytic infusion
UFH started after infusion, switch to LMWH after 24 hours
Surgical embolectomy for PE
Young patients with large proximal PE accompanied by hypotension
Simplified PE severity Index score criteria - 6
Only need one for high risk
Age >80
Hx of cancer
Hx of heart failure or chronic lung disease
Pulse >110 bpm
SBP <100mmHg
Sat under 90%
Presentation of Heart Failure - 7
Dyspnea on exertion
Orthopnea
Frothy sputum
Edema
HTN and Tachycardia
S3 heart sound
JVD
Diagnostics for HF in the ED
CXR - Pulmonary venous congestion, enlarged heart, edema
Elevated BNP/NT-pro-BNP
Renal function b/c we will be using diuretics
LVH on EKG
Indication for echo in HF
New or acutely changing CHF
Airway management for unstable CHF patients
Keep O2 sat above 95% - oxygen
BiPAP/CPAP
Intubate if extremely ill
Management for normotensive acute heart failure
Lasix IV
Monitor for improvement and double dose if none
If still none, add a vasodilator
Management for hypertensive acute HF
BP over 150/100
Reduce afterload IF NO EVIDENCE OF HYPOPERFUSION nitroglycerin or nitroprusside (if NTG doesn’t work)
Lasix AFTER BP becomes controlled (Lasix won’t work in the setting of severe HTN)
Presentation of cardiogenic shock
Signs of hypoperfusion with SBP under 90mmHg
Management of cardiogenic shock
Give O2 to sat above 91% - intubate if failing
IV NS/LR 250-500mL if no pulmonary congestion or RV infart
If no improvement with fluids or pulmonary congestion present give pressors
5 Vasopressors for cardiogenic shock
Dobutamine
Dopamine
Norepinephrine
Epinephrine
Milirone
Presentation and Dx for pneumonia
Presence of fever, cough, rales/rhonchi with radiographic infiltrate
May order additional tests if admitting patient
Airway management in pneumonia patients
Keep saturation above 90%
Noninvasive PPV
Intubate if extremely ill
CURB-65 criteria
COnfusion
Uremia (BUN over 19mg/dL)
RR 30+ per miute
SBP <90mmHg OR DBP Under 60 mmHg
65+ y/o
Admit for 2+ criteria met
Comorbidities of pneumonia that inform abx use (8 chronic conditions and 4 other considerations)
Chronic pulm, liver, heart, cancer, diabetes, CHF, alcohol dependance, immuneosuppression
Abx use in past 3 months
Smoker
65+ age
Alcohol dependance
Management of outpatient CAP w/ no comorbidities and uncomplicated
Amoxil 1g TID OR DOxycycline 100mg BID
5 days minimum tx
ALT: Azithromycin or Clarithromycin if resistance low
Management of outpatient CAP WITH comorbidities
Augmentin PLUS one of (macrolide or doxycycline
ALT: Moxi/Levofloxacin if unable to tolerate, severe COPD and NO myasthenia gravis
Non-ICU inpatient management of Pneumonia - Initial
ROcephin and Z-Max
OR
Respiratory FQ alone
MRSA and pseudomonas coverage for inpatient pneumonia
Vanc for MRSA
Zosyn for pseudomonas
ICU inpatient management for penumonia
Beta-lactam and macrolide
OR
Beta lactam and resp FQ (Moxi or Levo)
Presentation of Asthma or COPD exacerbation
May lack wheezing d/t lack of flow
Forward posturing with pursed lips
Cyanosis, apprehension, tachypnea, confusion
Indications for a CXR in asthma
A complicating cardiopulmonary process is suspected - ie. elevated temp (38.3+) unexplained chest pain, leukocytosis, hypoxemia, hospitalization needed.
Oxygen management in asthma or COPD exacerbation
Keep spO2>90% and PaO2 at 60-70mmHg
Measure end tidal CO2, ABG/VBG
Beta agonist use in COPD/Asthma exacerbation
First line in asthma and COPD bronchospasm
Albuterol 2.5-5mg via neb every 20-60 minutes x 3 doses followed by 2.5-10mg every 1-4 hours or continuous
Titrate to clinical response or toxicity
Signs of albuterol toxicity
Tachycardia, hypertension, palpitation
MC if doses given close together
Anticholinergic use for asthma/COPD exacerbation
Add if severe (FEV1 or PEFR <40%)
Ipratropium bromide (Duo neb is comined with albuterol)
Dry mouth and metallic taste
Tx for COPD/Asthma if aerosolized therapy not tolerated or status asthmaticus
Terbutaline or epinephrine - SQ
Corticosteroid use in asthma/COPD exacerbation
Indicated in all patients except easily fully reversed episodes
Any route okay
Prednisone PO or Methylprednisone IV
5-10 day treatment without tapering
IV magnesium sulfate for Asthma/COPD exacerbation
Only for severe exacerbations (FEV1<25% predicted), not responding to albuterol
Bronchodilates to releive symptoms
Monitor BP and reflexes
Additional options for treatment of status asthmaticus
Epinephrine SC or IM
Mechanical ventillation for resp muscle fatigue, acidosis, altered mental status, refractory hypoxia
BIPAP/CPAP
Indications for intubation in status asthmaticus
Uncooperative, Obtunded, unstable, unable to clear airway
Abx use for COPD exacerbation - Indications
Increased sputum purulence or dyspnea, patients who need vantilatory assistance
First line abx for COPD exacerbation
Macrolide, Bactrim, Cefdinir
Augmentin or FQ in high risk patients
Asthma disposition
Good response = FEV or PEFR 70+ after 60 minutes = d/c
Incomplete response = FEV or PEFR 40-69% = Admit, O2 therapy, SABA every 1-4 hours
Poor response = FEV1 or PEFR under 40 or PCO2 over 42mmHg = Admit to ICU, Hourly SABA
