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Emergency Medicine > Emergency Medicine Exam 2 > Flashcards

Emergency Medicine Exam 2 Flashcards

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1
Q

5 Life threatening causes of dyspnea

A

Upper airway obstruction
Tension pneumothorax
Pulmonary Embolism
Myasthenia gravix/GB/C-Bot
Fat embolism

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2
Q

MC causes of dyspnea (not necessarily life threatening)

A

Obstructive airway disease - COPD/Asthma
HF
Anxiety
ACS
Pneumonia

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3
Q

Presentation of Cardiac Dyspnea

A

Hx of MI
Paroxysmal nocturnal dyspnea
DOE
S3/S4, JVD
Lung crackles

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4
Q

Initial management goal for dyspnea

A

Maintain oxygenation

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5
Q

Goal O2 sat for dyspnea

A

90% is general rules of thumb
Depends on baseline

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6
Q

CO2 retainer patients and oxygenation

A

Chronic COPD patients who baseline sat at 88 or similar. Giving oxygen will suppress respiratory drive

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7
Q

Oxygen per minute available in cannula and non-rebreather mask

A

Cannula - ~6
Non-rebreather Mask - 10-15

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8
Q

Why use a BiPAP rather than a CPAP

A

BiPAP lowers pressure for an exhale - makes the patient not feel like they are suffocating

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9
Q

Laryngotracheomalacia

A

Weak larynx d/t weak larynx - need to rule out other things

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10
Q

Laryngotracheal foreign body presentation

A

Stridor, hoarseness or complete apnea

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11
Q

Bronchial foreign body presentation

A

Unilateral wheezing and decreased breath sounds

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12
Q

MC foods for choking in children

A

Peanuts
Sunflower seeds
Carrots
Rasins
Grapes
Hot dogs

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13
Q

Imaging for airway foreign body

A

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

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14
Q

Atelectasis and foreign bodies

A

Hazy area of the lung with no air - blocked off by foreign body

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15
Q

Coin in trachea on XR

A

Circular face in lateral view

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16
Q

Management for foreign body

A

BLS
Laryngoscopy for FB
Prep for intubation if unable to remove or tracheostomy

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17
Q

Croup presentation

A

Inspiratory stridor with barking or seal like cough
Stridor at rest
Low grade fever

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18
Q

Croup on XR

A

Steeple sign

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19
Q

Mild, Mod, and Severe coup

A

Mild - No stridor at rest
Mod - Stridor at rest with mild retractions
Severe - Stridor at rest with severe retractions - anxious and agitated

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20
Q

Management for mild croup

A

1 dose of steroids only - oral is preferred
IM/Neb if not able

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21
Q

Mod/Severe Croup Managment

A

Steroids
Recemic Epinephrine - Nebulized
Give up to three times with a 3 hour space
Heliox or intubate if fail

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22
Q

6 Discharge criteria for croup

A

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

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23
Q

Indications for Croup admission

A

Persistent stridor at rest
Tachypnea
Retractions
Hypoxia
2+ doses of nebulized epi needed

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24
Q

Bacterial tracheitis

A

Croup but bacterial rather than viral

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25
Q

Presentation of bacterial tracheitis

A

Sore throat
Toxic appearing
Tender to tracheal palpation - not seen with croup
Thick secretions of bronchoscopy blocking airway
Steeple sign

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26
Q

Management for bacterial tracheitis

A

Vancomycin PLUS (Unasyn or Rocephin)
FQ for b-lactam allergy

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27
Q

Kidney vs. Lung acid/base compensation

A

Kidneys take time, lungs take minutes

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28
Q

Elements of an ABG

A

pH
PaCO2
PaO2
HCO3
O2Sat

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29
Q

Normal pH, CO2 and Bicarb levels

A

pH - 7.35-7.45
CO2 - 35-45
Bicarb - 22-26

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30
Q

Causes of respiratory acidosis

A

Drop in respiratory rate and gas exchange
COPD
Resp depression from narcotics
OSA

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31
Q

Causes of resp alkalosis

A

Hyperventilation

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32
Q

3 Types of abdominal pain

A

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.)

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33
Q

Red flag abdominal pain for ischemia, dissection, or perforation

A

Maximal intensity onset pain

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34
Q

Red flag pain for inflammation, infection, or obstruction

A

Gradual onset pain

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35
Q

Abdominal pain that worsens over 6 hours

A

Likely surgical etiology

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36
Q

Abdominal pain that improves after eating

A

PUD

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37
Q

Abdominal pain that is worse with eating

A

Biliary colic

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38
Q

Abdominal pain that improves when upright and is worse when supine

A

Pancreatitis

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39
Q

Abdominal pain that worsens with sudden movements and improves with stillness

A

Peritonitis

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40
Q

Abdominal pain to the point that a patient can’t sit still

A

Renal colic suggestive

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41
Q

How long must you listen to say that bowel sounds are absent

A

2 minutes

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42
Q

Effect of blood on peristalsis

A

Increases peristalsis

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43
Q

Peritoneal testing

A

Rebound, Heel tap, jumping produce pain as well as bumps in the road

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44
Q

Carnett sign

A

Differentiate abdominal wall pain from intrabdominal wall
Positive=pain persists with tightened muscles

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45
Q

Murphy sign

A

Pressure on right upper quadrant leads to a cessation in breathing
Indicates cholecystitis

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46
Q

Psoas sign

A

Put on left side of bed and extend right leg back - Pain indicative of retrocecal appendicitis

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47
Q

Obturator sign

A

Internal rotation of the hip on the right elicits pain - appendicitis

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48
Q

Rovsing sign

A

Pain in RLQ on LLQ palpation - appendicitis

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49
Q

CVA tenderness

A

Pyelonephritis indicative

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50
Q

When to do pelvic/testicular exam

A

With any lower GI pain

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51
Q

Rectal exam for abdominal pain

A

Always look for FOB

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52
Q

Cullen and Gray turner signs

A

Pain around umbilicus and on flanks respectively, indicate peritoneal rupture

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53
Q

When is oral contrast needed in abdomen patients

A

BMI less than 23

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54
Q

Conditions for which to use oral contrast in the abdomen

A

Abcess, Appendicitis, Diferticulitis, Perforation, Fistula

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55
Q

Contraindication for IV contrast

A

CR 1.5+ GFR under 60

Caution in metformin use

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56
Q

General abdominal pain management

A

NPO with maintainance fluids - NS bolus

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57
Q

Maintainance NS rate

A

75-125 ml/hr if normotensive

May need K+

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58
Q

Antiemetics for acute abdomen management

A

Ondansetron or metaclopramide (extrapyramidal symptoms with meta)

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59
Q

Goal for pain management in acute abdomen

A

Make pain tolerable not zero

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60
Q

Pain management agents for acute abdomen

A

Morphine
Toradol
Renal Colic (as long as no peritonitis)

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61
Q

NG tube for abdominal pain management

A

Flush out stomach to avoid blood induced peristalsis
Decompress GI tract

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62
Q

3 purposes of a foley catheter for acute abdominal pain

A

Relieve obstruction
Monitor I/O
Assess renal perfusion

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63
Q

Abx for empiric acute abdomen

A

1 - Zosyn
2 - Gentamycin and Metronidazole

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64
Q

Monitoring of abdominal pain patients

A

Periodic checks for worsening

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65
Q

Disposition of abdominal pain patient - 7 reasons to admit

A

Elderly, Non-communicative, Demetia, Unable to comply, Immune compromised, Intractable pain and vomiting, Lack support

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66
Q

Good samaritain law

A

Good faith, voluntary, immediate
Not liable
Defer to EMS when they arrive
Don’t go out of your comfort level

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67
Q

Bee/Wasp sting anaphylaxis presentation

A

Hypotension, bradycardia, bradypnea

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68
Q

Tx for bee/wasp sting anaphylaxis

A

Epi pen
Pens have extra doses that can be gotten out
Make sure to use the right end of the needle

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69
Q

Dosing for epi pen

A

0.3 for over 66lbs
0.15 over 33 lbs
0.1 under 33lbs

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70
Q

Presentation of carbon monoxide poisoning

A

Headache, Nausea, Vomiting, Weakness, confusion and syncope
Classic cherry red skin
Normal pulse ox

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71
Q

Tx for CO poisoning

A

320 minutes at RA
74 min on 100% O2
23 min in hyperbaric oxygen

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72
Q

Indication to treat lactic acidosis in CO poisoning

A

pH under 7.15

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73
Q

Indication for hyperbaric O2 in CO pisoning

A

Carboxyhemoglobin over 25%

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74
Q

Heat edema presentation

A

No core body temp chenge
Ankle swelling
Diuretic if really bothering

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75
Q

Heat syncope presentation

A

Like heat edema due to intravasculkar redistribution
Normal core temp and hypernatremic

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76
Q

Heat cramps

A

Muscles not getting enough electrolyted
Core temp okay
Electrolytes with 6% carbs max

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77
Q

Heat exhaustion

A

Elevated core temp up to 104 (rectal thermometer)
Hyper or hyponatremic

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78
Q

Heat stroke

A

Body is redlined w/ organ damage and CV collapse
Core temp over 104

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79
Q

Tissue most sensitive to heat

A

Neural, hepatic, nephrons, vasc. endothelium

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80
Q

Presentation of sepsis

A

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

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81
Q

Thyroid storm

A

Increase in t4/T3
Shaking/flapping of hands
Nausea, diarrhea, anxiety, tachycardia

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82
Q

Serotonin syndrome

A

Due to an SSRI
106 body temp
agitation, dilated pupils, seizures

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83
Q

Meds that can cause serotonin syndrome

A

SSRI, SNRI, MOAIs, Tramadol, St. John’s Wort

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84
Q

Tumor lysis syndrome

A

Tumor releases contents into bloodstream
Metabolic abnormalities leading to arrhythmias, seizures, organ failure

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85
Q

Tx for tumor lysis syndrome

A

Hydration
Allopurinol
Rasburicase

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86
Q

Signs of true heat stroke

A

Petechia, Dizzy, nausea

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87
Q

Tx for heat stroke

A

Recheck electrolytes every hour
Monitor temp until in the 101.5-102 zone
Rapid cooling
Rapid cool - evap is fastest

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88
Q

Tx for heat stroke unresponsive to initial therapy

A

Peritoneal, gastric, bladder, rectal, cool the brain

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89
Q

IV fluid for heat stroke

A

NS or lactated ringers
Goal is urine output of 50-100 mL/hour

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90
Q

Five ICU criteria for heat stroke

A

Hemodynamically unstable
Rhabdo
LFT elevation
Severe electrolyte abnormalities
Unknown dx

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91
Q

Trench foot

A

Painful condition from standing in cold water - militarym agriculture, homeless
Pain never really resolves after rewarming
Does not have to be freezing

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92
Q

Frostbite

A

Damage to tissue due to contact with freezing temperatures

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93
Q

Presentation of frostbite

A

Paresthesias, pruritis, loss of sensation and fine motor control
Stinging, burning, aching, throbbing AFTER rewarming
Tissue discoloration

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94
Q

4 degrees of frostbite

A

1 - Gets cold
2 - Blisters
3 - Hemorrhagic blisters
4 - Necrosis

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95
Q

Rewarming frostbite

A

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

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96
Q

Mild hypothermia

A

COnscious and shivering
Core temp 89.6-95 F
Able to rewarm on own

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97
Q

Moderate hypothermia

A

Decrease in cognition with loss of shivering
82.4-89.6 temp
Requires external rewarming

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98
Q

Severe hypothermia

A

Unconscious with cardiac arrhythmia
Under 82.4 F

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99
Q

Progression of hypothermic arrhythmias

A

Brady>Afib>vfib>asystole

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100
Q

Dire hypothermia

A

Absent vital signs
Temp under 75.2 F
CPR and internal-external rewarm

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101
Q

Tx for hypothermia

A

Insulate from the ground
Wet clothing off and dry skin
Keep supine in ALL CASES - d/t BP drop
Warm liquids
ABCs

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102
Q

Defibrillation in hypothermia

A

You only get one shot - it will not work after that

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103
Q

Acute Mountain Sickness

A

Occurs above 9,000 feet
Decrease in PO2

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104
Q

Presentation of acute mountain sickness

A

Initially a HA followed by at least one of the following:
Anorexia, insomnia, weakness, dizzyness, oliguria, dyspnea, altered mental status

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105
Q

High altitude sickness

A

Beginning
Renal excretion of bicarb
Capillary stability weakens - edema
Pulm vasoconstriction increased erythropoietin, hemoglobin oxygen affinity

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106
Q

Prevention and tx of altitude sickness

A

Hike up slow and sleep lower than play
Ginko Balboa and Acetazolamide
Descent to cure
Hyperbaric chamber, sack, steroids to delay

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107
Q

Adjunct tx to acute altitude sickness

A

Tylenol and NSAID for HA
Ondansetron for nausea

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108
Q

High altitude pulmonary edema

A

Due to hypoxic vasoconstriction and increased right heart pressures`
Descent to treat

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109
Q

Onset of pulmonary edema

A

Onset on second day of ascent

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110
Q

Presentation of high altitude pulmonary edema

A

Cough, rales, tachypnea, chest tightness, tachycardia, dyspnea at rest

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111
Q

High altitude cerebral edema

A

Thickening at “arrow points” seen on CT
Bleeding on ophthalmoscopic exam
Looks like astroke

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112
Q

Management for HACE

A

Descent, dexamethasone 8mg followed 4mg q6
Admit if symptomatic 2hrs after descent

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113
Q

Copperhead/Rattlesnake antivenom

A

CroFab

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114
Q

Pit viper bite management - things NOT to do

A

Copperhead/Rattlesnake
Restrict, suck venom

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115
Q

Pit viper bite things to do

A

Immobilize, measure every 30 minutes
Watch for compartment syndrome

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116
Q

Dry bite

A

No symptoms after 12 hours monitoring

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117
Q

Symptoms of a pit viper bite

A

Nausea, Vomiting, Hemolysis, THrombocytopenia, Coagulopathy
Cardiopulmonary collapse

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118
Q

Coral snake bite treatment

A

Red touch yellow
Different than pit viper bite

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119
Q

Tick bite tx

A

Doxy 100mg BID
1-3 day tx, 10 day tx for positive IgM titer
Treat until 3 days after fever subsides

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120
Q

“Spider bite” bacteria

A

Treat as MRSA

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121
Q

Brown recluse spider bite presentation

A

Extreme pain and skin erosion

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122
Q

Lightning injuries presentation

A

Electrical asystole - responds to CPR almost 100%
Burns worse near bones
Non-fatal pneumomediastinum
Cataracts

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123
Q

Management of drowning

A

CPR is critical
High flow oxygen - goal is 95%
Monitor acid base status and UDS

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124
Q

Something to evaluate for in fire burns

A

CO poisoning

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125
Q

Fluid to use for those with burns

A

Lactated ringers

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126
Q

Inhalation burn presentation

A

Facial burns, singed nasal hair, soot in mouth
Hoarse, carbonaceous sputum, wheezing
Hypoxemia

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127
Q

Management of inhalation burns

A

100% oxygen
Potential intubation
Bronchodilators
Lactated ringers IV

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128
Q

Management for external burns

A

Removed burned clothes
Poor cool water over burns (NO ICE)
Remove jewelry
Lactated ringers via parkland or Modified Brooke formula

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129
Q

Rule of nines for burns

A

9% - Head+Neck; One arm
18% - One leg
36% - Trunk
1% - Groin

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130
Q

Chemical burn presentation

A

Acid - Tans skin, limits depth
Alkaline burns - Goes deep and saponifies lipids
Heavy metals - Flush with water to get oxygen away

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131
Q

Barotrauma of descent

A

Rupture of TM or of the Oval Window
Sinus bleeding

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132
Q

Rupture of ascent

A

Same as descent but high pressure comes from the inside pushing out

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133
Q

Burst lung from diving

A

Expanding air from ascent causes over expansion and rupture

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134
Q

Tx for blood gas expansion

A

Pressurized chamber or back underwater

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135
Q

Presentation of bends

A

Tissues full of air, extreme knee pain from air in the joints

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136
Q

Extraction of injured party

A

Stabilize injury, Hard hat, sunglasses if looking up, protect from cold
Need to clear ANY debris from helicopter landing site

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137
Q

Cardiogenic shock

A

Heart not working - MI, etc.
Cardiac monitor and access fluid bolus and pressors
PCI and Cabbage

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138
Q

Septic shock

A

Infection response causing shock
SIRS criteria - tachycardic, tachypneic, febrile
Lactic over 4

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139
Q

TX for septic shock

A

Start BS abx
Give fluids - Lactated ringers
Central line for bigger pipe
Frequently recheck pressure

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140
Q

Amount of fluid needed in septic shock

A

Often 3-5 liters for first 6 hours
Balanced after 2-3 liters

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141
Q

Neurogenic shock

A

Presents with a spinal cord injury
Hypotensive and bradycardic with good perfusion - warm
Fluid is just sitting there
Manage w/ Vasopressors

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142
Q

CPR compressions to breaths

A

30:2

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143
Q

Intubation position

A

Forward flexion of neck with extension “sniffing position” - place towel under patients occiput
DO NOT ATTEMPT IN C-SPINE INJURY

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144
Q

Oropharyngeal airway

A

Smallest and least invasive - keeps the tongue out of the way

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145
Q

Nasopharyngeal airway

A

More invasive - failed shotgun suicide - easier than oropharyngeal

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146
Q

Optimal bag valve mask delivery

A

75% oxygen, make sure you get a good seal with two people if possible

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147
Q

6 INdications for intubation

A

Respiratory failure low O2 high CO2
Apnea
GCS 8 or below
Airway injury
Aspiration risk
Trauma to larynx

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148
Q

Mallampati class system

A

I-IV - DOcumentation tool for ease of intubation
IV uvulacome down more

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149
Q

Preoxygenation for intubation

A

Done for everyone to give more time for successful intubation
Give 100% oxygen on a 15 mL/min non-rebreather mask for 3 minutes

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150
Q

Intubation blades

A

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

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151
Q

ET tube sizes

A

7.5-8 for women
8-8.5 for men

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152
Q

Rapid sequence intubation

A

Paralytic and sedative w/ the sedative first, may not paralyze with large body habitus, no sedative with drug overdose

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153
Q

Common sedatives for intubation

A

Etomidate
Propofol - not in hypotensive
Ketamine - Good for asthma

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154
Q

Paralytics for intubation

A

Succinylcholine - Avoid in hyperkalemia and burns
Rocuronium - Do not use in myasthenia gravis

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155
Q

What to do if intubation fails

A

Use bag mask to keep sats above 90% after failure
Consider a cric.if 3 failed attempts

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156
Q

Steps for using a glide scope for intubation

A

Put in scope, check on camera, put in tube, check on camera remove stylette (scope)

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157
Q

Hand used to place the stylette in incubation

A

Always left hand

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158
Q

Confirmation for ET tube placement

A

Breath sounds first
Capnography second

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159
Q

Places not to get IV access

A

Infection, injury, burns, fistula, vascular disruption

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160
Q

CI to Peripheral access

A

Sclerosing, Chemotherapy, Concentrated electrolytes or glucose

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161
Q

Indications for central IV access

A

Can’t get peripheral access
Need access to central circulation
Measurement of CVP
Sclerosing, chemo drugs, Concentrated solutions

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162
Q

Femoral access

A

Easiest access, don’t need US
Dirty area - needs changed more often

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163
Q

Jugular access

A

Visualize with US
Commonly done
Must be careful to avoid carotid artery

164
Q

Subclavian central line

A

Not near the artery, risk of popping a lung
Use US, can be somewhat easier

165
Q

Defibrillation for Vfib

A

200 J Biphasic
360 J Monophasic

166
Q

Epi administration in ACLS

A

every 3-5 minutes if no rhythm

167
Q

Pulse checks for CPR

A

Every 2 minutes

168
Q

Tx for asystole or Pulseless Electrical Activity (PEA)

A

NON-shockable
COmpressions with Epinephrine

169
Q

Tx for supraventricular rhythms Sinus tachy, SVT, A fib

A

Sinus tach -find underlying cause and treat
SVT -Vagal maneuvers to rule out or adenosine (not fun)
A fib/flutter - BB or CCB, Cardiovert

170
Q

Vtach with a pulse tx

A

Procainamide or Amiodarone

171
Q

Pulseless V tach tx

A

Defibrillate 360 J Mono, 200 J Bi

172
Q

Indications for emergent treatment of bradyarrhythmia

A

HR under 50-60 with hypotension and hypoperfusion

173
Q

Tx for acutely symptomatic heart block

A

Transcutaneous pacing

174
Q

Resuscitation for pediatrics

A

15:2 compressions to breaths if two rescuers - usually problems are respiratory rather than cardiovascular

175
Q

IV access in peds

A

Intraosseus is often easier to do

176
Q

BRUE

A

Brief Resolved Unexplained Event
Cyanosis or pallor
Absent decreased or irregular breathing
Loss of tone
ALtered responsiveness
Only applied if now asymptomatic infant

177
Q

Risk factors for BRUE

A

Feeding difficulties
Recent URI/symptoms
Under 2 months
Previous episodes - suspect abuse

178
Q

Warning signs in an apparent end of life event or BRUE

A

Still symptomatic
LOC or CPR needed
Trauma
Hx in last 24 hours
Unexpected sibling death
Inconsistent description - abuse

179
Q

Low risk peds apparent end of life event or BRUE

A

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

180
Q

Risk factors for SIDS

A

Smoking
Sleeping on tummy

181
Q

Resuscitation for SIDS

A

May be tried if the baby is warm, or has suffered known hypothermia

182
Q

Other reasons not to resuscitate in SIDS

A

Low core temp w/o hypothermia
Livedo reticularis
pH under 6

183
Q

Indication for termination of peds resuscitation efforts

A

Arrest over 20 minutes
Core temp of 30 degrees C reached in hypothermic pts

184
Q

What counts as physical trauma

A

Anyone with multiple injuries - MVA or senior who fell

185
Q

Primary survey for trauma patient

A

ABCDE

A - Airway maintainance
B - Breathing compromise
C - Circulation and Hemorrhage control
D - Disbility/Neuro traits
E - Exposure and environmental control

186
Q

Airway maintainance in trauma patient

A

Suction and inspect for foreign bodies
Look for surrounding fractures
Assume C spine injury in blunt trauma and altered LOC - C collar

187
Q

Breathing managment in the trauma patient

A

Auscultate lungs for flow
Inspect and palpate chest
Inspect for JVD and tracheal position

188
Q

Circulation management in trauma patient

A

Look at BP to estimate
Alert = Good brain perfusion
Pallor and Pulses
Bleeding - remember airway bleeding
Bruising and low BP indicates internal bleed

189
Q

How long can a tourniquet be on

A

3 hours

190
Q

Disability/Neuro management for trauma patient

A

Consider alcohol, narcotics and hypoglycemia - naloxone, glucose thiamine
Take GCS

191
Q

Exposure management in trauma patient

A

Undress patient and then cover in warm blankets - they may not notice pain from some injuries

192
Q

Airway resuscitation in trauma patient

A

Jaw thrust and chin tilt - less than 8 intubate

193
Q

Breathing resuscitation in trauma patient

A

Supplemental oxygen

194
Q

Circulation resuscitation in trauma patient

A

Hemostasis and IV fluids (2 large bore IV) or Blood products
Surgery

195
Q

Four areas of a fast exam

A

Cardiac subxyphoid
RUQ
LUQ
Suprapubic

E fast also looks at lung apices

196
Q

Secondary survey for trauma

A

Constantly reevaluating primary
EENT - Fluid, pupilreaction, palpate, Jaw ROM

197
Q

Traumatic head injuries - Epidural hematoma

A
  • young person hit in the head
    May pass out after trauma with convex area
    Arterial bleed
198
Q

Tx for an epidural hematoma

A

BP above 100 older and 110 younger

199
Q

Subdural hematoma

A

Goes slower because venous bleed
MC in older people and alcoholics
CT scan to dx, not always acute - crescent sign

200
Q

TX for subdural hematoma

A

Watch BP and coagulation, surgery not required

201
Q

Cervical spine and neck inspection for trauma

A

Look for anyseat belt mark, tenderness, SQ emphysema, tracheal deviation
Always stabilize with a C collar

202
Q

Tx for cervical spine fracture

A

Head CT to identify
Always admit
Spinal precautions
Associated injury stabilization
Watch for deterioration

203
Q

Tx for cervical spine and neck soft tissue penetration

A

Clavicles-Cricoid cartilage (zone 1) always needs surgical intervention
Watch for airway and exsanguination (will kill faster than airway)

204
Q

Non superficial penetrating neck trauma

A

Injury of the platysma - more likely to have airway compromise

205
Q

Dx for spinal cord injury

A

CT followed by MRI

206
Q

Presentation of anterior cord syndrome - intact vs. preserved sensations

A

Loss of motor function, pain and temperature sensation distal to the lesion
Intact vibration, position, and tactile sensation

207
Q

Central cord syndrome presentation

A

Due to spinal hyperextension
Decreased strength in upper extremities but okay in lower extremities
Bilateral

208
Q

Brown sequard syndrome presentation

A

Direct penetration to the spine
Ipsilateral loss of motor function and contralateral loss of pain and temperature sensation

209
Q

Cauda equina presentation

A

Bowel or bladder dysfunction - retention and then overflow incontinence
Low sphincter tone
Saddle numbness
Motor and sensory loss in lower extremities

210
Q

Chest inspection in trauma

A

Look for open pneumothorax and flail chest
Listen for crackles
Look for hemothroax

211
Q

Hemothorax dx

A

Blood in lungs on CXR or FAST exam
Treat with thoracostomy if 300+mL of blood (half the lung

212
Q

Pneumothorax management

A

No breath sounds and collapsed on CXR
Thoracostomy if large enough to treat

213
Q

Pneumothorax too small to treat

A

Under 1cm wide, confined to upper third of the chest

You’ll probably still treat if symptomatic

214
Q

Presentation of a tension pneumothorax

A

Pleural pressure transferred to the mediastinum
Tachypneic, Tachycardic, Devation, No breath sounds

215
Q

Tx for tension pneumothorax

A

Needle decompression at 4th AICS in the midclavicular line above rib with angiocatherter then thoracostomy

216
Q

Exam of traumatic abdomen

A

Distension - may be bleeding out
Tenderness and guarding - voluntery or involuntary
FAST

217
Q

Solid abdominal organ injury trauma treatment

A

Laparotomy - dx with FAST and CT - urgent if peritonitis is diffuse or pt is unstable

218
Q

Hollow viscus injury

A

Bowel or mesenteric injury from blunt trauma
More minimal symptoms
Blood loss and contamination
Rare

219
Q

Tx for extremity fx

A

Splint and ABX and tetanus if open fx (Ancef for abx)

220
Q

Rhabdomyolysis presentation

A

Crush injury - MVA hard to extract or overdose laying for a long time
Muscle pain, CK to dx 3x upper limit
Coca Cola Urine

221
Q

Tx for rhabdomyolysis

A

Treat with fluids

222
Q

COmpartment syndrome

A

Pressure in leg compartment
MC in calf
5 P’s

223
Q

Tx for compartment syndrome

A

Dx with compartment pressure
Tx with fasciotomy

224
Q

Red flags of non-accidental trauma in peds

A

No hx of trauma
Description not consistent with development
Delay in seeking care

225
Q

Bruises suggestive of child abuse

A

Torso, neck, ears, back
Larger and more symmetrical pattern

226
Q

Burns suggestive of child abuse

A

Well demarcated -often from hot water when intentional - stocking glove

227
Q

Fractures that may indicate abuse

A

Rib fracture
Sheer injury
Spiral fracture

228
Q

Presentation of viral gastroenteritis

A

Rapid onset of WATERY diarrhea
Cramping and abdominal pain that improves with relieving self
Look for volume loss

229
Q

PE for viral gastroenteritis

A

Dry mucous membranes
Benign abdominal exam
Diffuse tenderness
Lack of tear production

230
Q

Dx for viral gastroenteritis

A

Check glucose and BMP with Mag - stool studies not needed if symptoms less than two weeks

231
Q

Tx for mild/moderate viral gastroenteritis

A

Oral fluid challenge - 15 minutes rest followed by 30mL electrolyte fluid intake repeat with a goal of 30-100 mL in 4 hours

232
Q

Tx for moderate - severe viral gastroenteritis

A

IV NS or LR
500-1000mL bolus in adults
20mL/kg in children

233
Q

Antiemetic use in viral gastroenteritis

A

Only used if patient fails oral fluid challenge but meets discharge criteria
Zophran

234
Q

Antidiarrheal use in viral gastroenteritis

A

Only if diarrhea leads to dehydration
Adults only - Imodium/Lomotil for antimotility and Bismuth for antisecretory

235
Q

Contraindications for antidiarrheal use

A

Pediatrics, IBD, pregnancy for bismuth salicylate

236
Q

Patient education for viral gastroenteritis

A

BRAT diet - low in fat and soft, avoid dairy, raw fruit, caffeine
Probiotics to reduce duration of symptoms

237
Q

Five Admission criteria for viral gastroenteritis

A

Toxic appearing
Severe dehydration -electrolytes or renal function impacted)
Comorbid conditions
Extreme youth or age
Symptoms over 1 week

238
Q

2 Processes of bacterial gastroenteritis

A

Toxin-mediated - Secretory
Invasive - Inflammatory

239
Q

Clinical presentation of bacterial gastroenteritis

A

Large amount of either watery or bloody mucopurulent diarrhea
Cramping and tenderness
Fever

240
Q

Hemolytic uremic syndrome

A

MC in elderly and under 10 years
Associated with EHEC, renal failure, anemia, thrombocytopenia

Abx can make this problem WORSE!!

241
Q

Diagnostics for bacterial gastroenteritis

A

+FOB
CBC if HUS suspected, BMP for hypokalemia or AKI
CT for obstruction

242
Q

Indications for stool studies in bacterial gastroenteritis

A

Severe dehydration or Toxic appearing w/ dysenterry
Immune compromised
Prolonged diarrhea (over 3 days)

243
Q

Bacteria to culture for in gastroenteritis

A

Salmonella, Shigella, Campylobacter

244
Q

Management for bacterial gastroenteritis

A

Fluid resuscitation w/ glucose/K+ if indicated

245
Q

Abx for bacterial gastroenteritis

A

Cipro or Azithromycin
Not recommended in children until pathogen identified
Caution in geriatrics

246
Q

Antidiarrheals in bacterial gastroenteritis

A

Avoid lamotil and imodium
May use bismuth salicylate but it is contraindicated in children

247
Q

Landmar separating upper and lower GI tractk

A

Ligament of trietz

248
Q

3 substances that can simulate hematochezia or melena

A

Iron and Bismuth - Melena
Beets - Hematochezia

249
Q

PE for GI bleed

A

Increased bowel sounds
Tenderness = Infectious etiology
Nontender = Vascular etiology
Rectal exam if LGI bleed suspected

250
Q

Diagnostics for GI bleed

A

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

251
Q

INR for endoscopy

A

Must be under 2.5

252
Q

NG tube for UGI bleed

A

Blood will be seen if bleed with proximal to pylorus

253
Q

Management for GI bleed

A

Stable - Consult GI/Syrgery
Unstable -NPO, O2, 2 large bore IV sites give up to 2L NS or LR

254
Q

Blood transfusion in GI bleed

A

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

255
Q

GI bleed complicated by anticoagulant

A

INR>2.0
Hold and potentially reverse

256
Q

Reversal agents for anticoagulants

A

Andexxa for Xarelto/Eliquis
Praxbind for Pradaxa
Vit. K for warfarin

257
Q

Additional management for UGI bleed

A

PPI for acid suppression -pantoprazole
Octreotide for verceal bleeding

258
Q

Additional Management for lower GI bleed

A

Consider EGD to r/o UGI bleed
Colonoscopy or angiography

259
Q

Discharge criteria for lower GI bleed

A

Hx of mild bleeding (ie. from hemmorhoid)
BRBPR (bright red blood) on DRE
No melanotic stool
Stable vitals
No comorbidities

Admit ALL others

260
Q

Esophageal ulcer presentation

A

Hx of GERD and odynophagia

261
Q

Presentation of PUD

A

H. pylori, NSAIDs, Smoking in hx
Assoc. abdominal pain

262
Q

Presentation of ruptured esophageal varices

A

Liver disease, alcoholism, jaundice, ascites present

263
Q

Presentation of UGI bleed d/t malignancy

A

Hx of smoking, alcohol, H pylori, Early satiety, weight loss chachexia

264
Q

Presentation of UGI bleed due to marginal ulcers

A

Ulcer at gastroenteric bypass
Hx of Rouz-en-Y gastric bypass

265
Q

Presentation of GI bleed due to aorto-enteric aneurism

A

AAA hx or aortic graft

266
Q

Presentation of UGI due to angiodysplasia

A

Renal disease, AS, Hereditary hemorrhagic telangiectasia

267
Q

Presentation of perforated GI bleed

A

Severe abdominal pain with rebound tenderness and involuntary guarding

268
Q

Gastric outlet obstruction

A

Nausea and vomiting because stomach contents can’t move the other way
Succision splash heard

269
Q

Tx for PUD/Gastritis

A

d/c NSAIDs
PPI, H2RA
Refer to GI

270
Q

PUD alarm symptoms

A

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

271
Q

Disposition for PUD

A

f/u with PCP if uncomplicated
Complicated - Consult general surgery for peroration, place NG tube for gastric outlet obstruction

272
Q

Presentation of kidney stone

A

Only causes problems when in ureter or bladder
Worst pain of life - fluctuant
Flank to RLQ to Groin
UTI, Hematuria, Dysuria

273
Q

Kidney stones and age

A

New onset in over 60 is rare - should suspect something else!! - ie. AAA

274
Q

Dx for nephrolithiasis

A

UA, HcG, CBC, CMP

275
Q

CT scanning for nephrolithiasis

A

Non contrast of abdomen and pelvis
Sensitive and specific
Can detect stones 1mm+
Can also detect AAA

276
Q

Other imaging for nephrolithasis

A

US of kidneys or KUB X-ray

277
Q

Management for nephrolithiasis

A

Toradol - opiates if inadequate
Zophran
IV/PO fluids
a-blocker - Tamsulosin (flowmax)QD for 2 weeks

278
Q

Admission criteria for nephrolithiasis

A

Intractable pain/emesis
Coexisting pyelonephritis
Stone 6+mm or anatomic abnormality
Renal dysfunction

279
Q

Disposition of non-admitted nephrolithiasis patients

A

f/u in 24-48 hours with urology
Drink 2-3 L fluid per day
Strain urine for stone

280
Q

Pyelonephritis presentation

A

Dysuria, Urgency, Frequency
CVA tenderness
Hematuria with +leukocyte esterase and WBC casts

281
Q

Pyelonephritis dx

A

hCG for females
Urine C&S
BMP/CBC

282
Q

General management for pyelonephritis

A

IV fluids
Tylenol or ibuprofen
Zofran
Toradol or opiate if needed

283
Q

Outpatient abx for pyelonephritis

A

Cipro, Initial IV Rocephin recommended
Alt: Bactrim

284
Q

Inpatient abx for pyelonephritis

A

Cipro, Rocephin, Gent/Amp, Zosyn, -Penem

Choice depends on local resistance data

285
Q

Pyelonephritis admission criteria

A

Unable to keep pills down
Severe illness
Comorbid
Pregnancy or Stone
Compliance concerns

286
Q

Outpatient f/u for pyelonephritis

A

1-2 days
Educate to increase fluid intake

287
Q

Presentation of hepatitis

A

MC is viral but can be alcohol or tylenol toxicity
Fever, RUG pain, Ascites, High AST/ALT

288
Q

Interpretation of AST/ALT ratio

A

2.5+ = Alcoholoc
Under 1 = Other causes
AST and ALT over 1000 is a tylenol poisoning

289
Q

Admission criteria for hepatitis patients

A

Elderly or Pregnant
No response to supportive care
Billirubin 20+mg/dL
Prothrombin 50% above normal
Hypoglycemia
GI bleed

290
Q

Presentation of rupturing or dissecting AAA

A

Severe ripping pain
Hypotension if ruptured
Pulses often normal and symmetrical
Pulsitile mass
LOOK for abnormal vitals

291
Q

Management for dissecting or dissecting AAA

A

Type and crossmatch
Two largebore catheters
O2 and Pain
CBC, CMP

292
Q

Management of unstable patient with potential AAA

A

Immediate US and referral to vascular surgery - don’t wait for imaging

293
Q

Management of stable AAA

A

CT scan aortagram or full CT scan
Rapidly growing is at risk for rupture
Consult vascular with 24-72 hour follow up

294
Q

Hypertensive patients with potential aneurism

A

Esmolol, add nitroprusside if BP remains uncontrolled

295
Q

Size of AAA

A

5+ cm = Surgery consult within 2-3 days
3-5 - Less likely rupture, follow with PCP or vascular surgeon;’/

296
Q

Presentation of appendicitis

A

Malaise and indigestion followed by periumbilical discomfort localizing to McBurney’s point
N/V may be seen
Sudden improvement with perforation

297
Q

Diagnostics for appendicitis

A

Elevated WBC is earliest finding
UA may see hematuria and pyria
hCG to r/o ectopic pregnancy

298
Q

Imaging for appendicitis

A

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

299
Q

Appendicitis dx in pregnancy

A

US as initial study, may follow up with CT/MRI

300
Q

Management of appendicitis

A

NPO with fluids
Paincontrol
Antiemetics
Surgical consult

301
Q

Perioperative abx for appendicitis

A

Unasyn, Zosyn, Flagyl, or Cefoxitin

302
Q

4 Presentations of cholecystitis

A

MC - billiary colic
If gallstone stays in plays = inflamed gallbladder
Pancreatitis if obstructed pancreas
Ascending cholangitis

303
Q

General presentation of cholecystitis

A

RUQ or epigastric pain radiating to right scapula
May have fatty food intolerance
+Murphy sign may have fever

304
Q

Charcot’s triad

A

Cholecystitis:
Fever
RUQ pain
Jaundice

305
Q

DX for cholecystitis

A

Elevated LFTs in choledocholithiasis (emergency)
Lipase for pancreatitis
US - Stones, sonographic murphy’s sign

306
Q

CBD enlrgement indicative of choledocholithiasis

A

Over 5-7 mm

307
Q

Management for cholecystitis

A

NPO with IV fluids NS or LR
1-2 L bolus
Zophran and NG tube
Morphine or Toradol

308
Q

Abx for cholecystitis or cholangitis

A

Uncomplicated cholecystitis - Ceftriaxone and Metronidazole
Ascending cholangitis (emergent) - Ampacillin, Gentamycin and, Clinda

309
Q

Ascending cholangitis substitution drugs for allergies

A

Ampicilling - Rocephin or FQ
Clinda - Flagyl

310
Q

Disposition of cholecystitis patient

A

Urgent surgical consult in acute
Refer for ERCP and Sphincterotomy in ascending cholangitis

311
Q

Indications for discharge in cholecystitis

A

Symptoms resolve in 4-6 hours of supportive therapy
Tolerate oral hydration

Always admit: Acute cholecystitis, cholangitis, choledocolithiasis

312
Q

Presentation of diverticulitis

A

LLQ pain, intermittent or constant with leukocytosis
Tenderness, mass, or distended abdomen
Rebound tenderness and guarding

313
Q

Dx for diverticulitis

A

Imaging not needed in pts with a hx of diverticulitis with similar presentation
Lipase, CRP, UA
CT of abd/pelvis with IV contrast

314
Q

CT findings for diverticulitis

A

Increased soft tissue density within pericolic fat
Presence of diverticula
Bowel wall thickening of 4mm+
Pericolic fluid collections representing abcesses

315
Q

Uncomplicated diverticulitis

A

Isolated inflammation of diverticula wall w/ or w/o phlegmon, or abcess confined to bowel wall

316
Q

Complicated diverticulitis

A

Associated with abcess, stricture, onstruction, fistula, or perforation

317
Q

Therapy for diverticulitis

A

NPO and fluids, abx

318
Q

Abx for moderate diverticulitis

A

Flagyl and cipro

ALT: Flagyl and Ceftriaxone
Alt: Zosyn

319
Q

Abx for severe diverticulitis

A

Zosyn

ALT: Azytreonam and Flagyl

320
Q

Surgical consult for diverticulitis

A

Emergent if perforated
Within 24 hours for all othe complicated cases

321
Q

Out patient management if diverticulitis

A

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

322
Q

2 MCC of pancreatitis

A

Gallstones and Alcohol consumption

323
Q

Presentation of Pancreatitis

A

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

324
Q

Signs of nectrotizing pancreatitis

A

Cullen (periumbilical) or Gray Turner (bilateral flank) signs
Erythematous skin nodules

325
Q

Dx for pancreatitis

A

2 of 3 required
Consistent clinical presentation
Elevated Serum LIPASE (may also use amylase but lipase is BETTER)
Characteristic imaging

326
Q

Imaging suggestive of pancreatitis

A

CT with contrast or US showing enlargement of the pancreas

327
Q

Workup for pancreatitis

A

ALT over 150 w/i 48 hours indicates gallstone
Elevated Alk phos indicates gallstone
US for gallstone
CXR for respiratory complaints
CT if uncertain

328
Q

Management for pancreatitis

A

NPO
Fluids - NS or LR
O2 sat over 95%
IV opiate for pain
Zofran

329
Q

Fluid rate and amount for pancreatitis

A

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

330
Q

Abx for pancreatitis with infection

A

Imipenem-cilastatin
Meropenem
Cipro with metronidazole

331
Q

Disposition for pancreatitis - indications for discharge (4)

A

May be discharge if:
No evidence of billiary involvement
Pain and vomiting with oral agents
Able to tolerate clrear liquids
Good social support

332
Q

Indications for pancreatitis admission

A

Not meeting discharge criteria
First episode of pancreatitis

333
Q

Surgery consult for pancreatitis

A

General surgery for biliary involvement - needs cholecystectomy
Gallstone involved needs ERCP and sphincterotomy

334
Q

Four classifications of small bowel obstruction

A

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

335
Q

MCC of small bowel obstruction and second MCC

A

1 - Adhesions post surgery
2 - Incarceration of a hernia

336
Q

Ileus v. obstruction

A

Ileus = Paralyzed
Obstruction = Not paralyzed

337
Q

Clinical presentation of small bowel obstruction

A

Crampy intermittent abdominal pain
Bilious Vomiting with proximal obstructions, Fecalant in distal
Change in bowel habits - constipation
High pitched bowel sounds diminish over time

338
Q

Dx for small bowel obstruction

A

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

339
Q

Management of partial small bowel obstruction

A

NPO with IV fluids
NG tube with light suction
Antiemetic, analgesics
Most resolve w/o surgery in 72 hours

340
Q

Management of complete small bowel obstruction

A

NPO, IV fluids, NG tube with light suction
Surgical consult
Zosyn if surgery indicated

341
Q

Spontaneous primary pneumothorax

A

Tall, thin males 10 to 40 with hx of smoking
No previous hx of lung disease

342
Q

Spontaneous secondary pneumothorax

A

Complication of preexisting diseas - COPD, asthma, etc.
Often more severe presenting symptoms

343
Q

Iatrogenic pneumothorax

A

D/t PPV and interventional procedures

344
Q

Tension pneumpthorax

A

Air enters pleural space but cannot escape
MCC - CPR or PPV

345
Q

Presentation of pneumothorax

A

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

346
Q

Dx for pneumothorax

A

PA CXR usually diagnostic
US for unstable patients
CT to ID associated pathology

347
Q

Management of primary spontaneous pneumothorax - indication for supplemental oxygen with observation

A

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

348
Q

Management of primary spontaneous pneumothorax with needle or catheter - indications

A

Indicated if:
First but large (3+cm at apex 2+ cm at hilum)
Stable vital signs and expert provider

349
Q

Pneumothorax needle decompression method

A

2 inch needle 14G adults 16G children
Aspirate via syringe - remove air until resistance

350
Q

Care after needle aspiration of pneumothorax

A

Remove catheter if stable after 4 hours and d/c if CXR okay 3=2 hours after that

351
Q

Needle placement for PSPT decompression

A

Anterior - midclavicular line, second intercostal space
Lateral - Anterior axillary line 4-5th ICS

352
Q

Management for pneumothorax with a chest tube or thoracostomy - indications

A

Indicated in: Failed aspiration (more than 4 L pulled)
Large, recurrent, bilateral, Unstable, severe dyspnea

353
Q

Pneumothorax chest tube/thoracostomy placement method

A

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

354
Q

Management for secondary spontaneous pneumothorax

A

Maintain airway
Supplemental oxygen - caution in O2 induced hypercapnic individuals
Tube/Catheter thoracostomy and admission
Definitive tx with pleurodeisis

355
Q

Management of tension pneumothorax

A

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

356
Q

Presentation of pulmonary embolism

A

MC - Chest pain and dyspnea
Tachycardia, signs of DVT, HR over 100 may have a fever
Lungs CLEAR!

357
Q

Wells criteria with point values

A

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

358
Q

Well’s score interpretation

A

Over 6 - high risk
2-6 moderate risk
Under 2 - low risk

359
Q

PERC criteria - 9

A

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

360
Q

Diagnostics for PE

A

Pulse oximetry may be low
Abnormal to nonspecific findings

361
Q

Westermark’s sign

A

Uncommon indicator of PE
Wedge shaped area of lung oligemia

362
Q

Hampton’s hump

A

Uncommon indicator of PE
Peripheral dome shaped opacification

363
Q

EKG of pulmonary embolism

A

Pulmonary hypertension
T wave inversion in V1 and V4
Incomplete RBBB
S1-Q3-T3 pattern

364
Q

D-dimer for PE dx

A

Only used in low-moderate probability cases

365
Q

CT imaging for PE

A

CTA - segment or larger filling defects
Safe in pregnancy

366
Q

V/Q scanning for PE

A

Can identify defect when ventilation is normal
Indicated in renal insufficiency or other issues with contrast

367
Q

Management for PE in presence of instability

A

UFH or fibrinolytic

368
Q

Management for PE - stable

A

LMHW or Factor X Agonist (eliquis, xarelto, etc.)

369
Q

2 Indications for UFH instead of LMWH

A

Renal insufficiency and instability

370
Q

Indications for fibrinolytic use for PE

A

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

371
Q

CI for fibrinolytic therapy - 4

A

Intercranial disease
Uncontrolled hypertension at presentation
Recent major surgery or trauma (3 weeks
Metastatic cancer

372
Q

Tx post thrombolytic infusion

A

UFH started after infusion, switch to LMWH after 24 hours

373
Q

Surgical embolectomy for PE

A

Young patients with large proximal PE accompanied by hypotension

374
Q

Simplified PE severity Index score criteria - 6

A

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%

375
Q

Presentation of Heart Failure - 7

A

Dyspnea on exertion
Orthopnea
Frothy sputum
Edema
HTN and Tachycardia
S3 heart sound
JVD

376
Q

Diagnostics for HF in the ED

A

CXR - Pulmonary venous congestion, enlarged heart, edema
Elevated BNP/NT-pro-BNP
Renal function b/c we will be using diuretics
LVH on EKG

377
Q

Indication for echo in HF

A

New or acutely changing CHF

378
Q

Airway management for unstable CHF patients

A

Keep O2 sat above 95% - oxygen
BiPAP/CPAP
Intubate if extremely ill

379
Q

Management for normotensive acute heart failure

A

Lasix IV
Monitor for improvement and double dose if none
If still none, add a vasodilator

380
Q

Management for hypertensive acute HF

A

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)

381
Q

Presentation of cardiogenic shock

A

Signs of hypoperfusion with SBP under 90mmHg

382
Q

Management of cardiogenic shock

A

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

383
Q

5 Vasopressors for cardiogenic shock

A

Dobutamine
Dopamine
Norepinephrine
Epinephrine
Milirone

384
Q

Presentation and Dx for pneumonia

A

Presence of fever, cough, rales/rhonchi with radiographic infiltrate
May order additional tests if admitting patient

385
Q

Airway management in pneumonia patients

A

Keep saturation above 90%
Noninvasive PPV
Intubate if extremely ill

386
Q

CURB-65 criteria

A

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

387
Q

Comorbidities of pneumonia that inform abx use (8 chronic conditions and 4 other considerations)

A

Chronic pulm, liver, heart, cancer, diabetes, CHF, alcohol dependance, immuneosuppression

Abx use in past 3 months
Smoker
65+ age
Alcohol dependance

388
Q

Management of outpatient CAP w/ no comorbidities and uncomplicated

A

Amoxil 1g TID OR DOxycycline 100mg BID
5 days minimum tx
ALT: Azithromycin or Clarithromycin if resistance low

389
Q

Management of outpatient CAP WITH comorbidities

A

Augmentin PLUS one of (macrolide or doxycycline

ALT: Moxi/Levofloxacin if unable to tolerate, severe COPD and NO myasthenia gravis

389
Q

Non-ICU inpatient management of Pneumonia - Initial

A

ROcephin and Z-Max
OR
Respiratory FQ alone

390
Q

MRSA and pseudomonas coverage for inpatient pneumonia

A

Vanc for MRSA
Zosyn for pseudomonas

391
Q

ICU inpatient management for penumonia

A

Beta-lactam and macrolide
OR
Beta lactam and resp FQ (Moxi or Levo)

392
Q

Presentation of Asthma or COPD exacerbation

A

May lack wheezing d/t lack of flow
Forward posturing with pursed lips
Cyanosis, apprehension, tachypnea, confusion

393
Q

Indications for a CXR in asthma

A

A complicating cardiopulmonary process is suspected - ie. elevated temp (38.3+) unexplained chest pain, leukocytosis, hypoxemia, hospitalization needed.

394
Q

Oxygen management in asthma or COPD exacerbation

A

Keep spO2>90% and PaO2 at 60-70mmHg
Measure end tidal CO2, ABG/VBG

395
Q

Beta agonist use in COPD/Asthma exacerbation

A

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

396
Q

Signs of albuterol toxicity

A

Tachycardia, hypertension, palpitation
MC if doses given close together

397
Q

Anticholinergic use for asthma/COPD exacerbation

A

Add if severe (FEV1 or PEFR <40%)
Ipratropium bromide (Duo neb is comined with albuterol)
Dry mouth and metallic taste

398
Q

Tx for COPD/Asthma if aerosolized therapy not tolerated or status asthmaticus

A

Terbutaline or epinephrine - SQ

399
Q

Corticosteroid use in asthma/COPD exacerbation

A

Indicated in all patients except easily fully reversed episodes
Any route okay
Prednisone PO or Methylprednisone IV
5-10 day treatment without tapering

400
Q

IV magnesium sulfate for Asthma/COPD exacerbation

A

Only for severe exacerbations (FEV1<25% predicted), not responding to albuterol
Bronchodilates to releive symptoms
Monitor BP and reflexes

401
Q

Additional options for treatment of status asthmaticus

A

Epinephrine SC or IM
Mechanical ventillation for resp muscle fatigue, acidosis, altered mental status, refractory hypoxia
BIPAP/CPAP

402
Q

Indications for intubation in status asthmaticus

A

Uncooperative, Obtunded, unstable, unable to clear airway

403
Q

Abx use for COPD exacerbation - Indications

A

Increased sputum purulence or dyspnea, patients who need vantilatory assistance

404
Q

First line abx for COPD exacerbation

A

Macrolide, Bactrim, Cefdinir

Augmentin or FQ in high risk patients

405
Q

Asthma disposition

A

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

Emergency Medicine (4 decks)

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