Emergency objectives Flashcards
Components of glasgow coma score
Eye opening 1-4
Verbal response 1-5
Motor response 1-6
Severe: 3-8
Moderate: 9-13
Mild: 14-15
Types of shock
Hypovolemic: blood loss, fluids, third spacing
Cardiogenic: dysrrhythmias, MI
Obstructive: tension pneumo, pericardial disease, pulmonary blockages
Distributive: Septic shock, anaphylactic shock, neurogenic shock, vasodilatory drugs
Hypocalcemia
Eti, S/s, workup, manage
Eti: Renal, vit D, increase Phos, low mag, hypoPara, sequestration by pancrease, alkalosis, malabsorb
S/s: tetany, cramps, arrhythmias (long QT), hyperreflexia
Test: Chvostek and Trousseau’s
Workup: Mg, PTH, Vit D, phos, albumin, ionized Ca
Tx: Give Ca and Vit D
Hypercalcemia
Eti, S/s, workup, manage
Eti: HyperPTH, malignancy, thyrotoxicosis, Inc Vit D, bone destruction…
S/s: Renal stones, bone pain (moans), abdominal (groans), MS changes (psychiatric overtones).
Dx: PTH, phos, vit d, albumin, Ionized Ca, CXR, TSH
Tx: Urine excretion
Comp: cardiac arrhythmias
Hypokalemia
Eti, S/s, workup, manage
Eti: Diuretics, vomiting, diarrhea, CKD, primary aldosteronism
S/s: paresthesias, muscle cramps, tetany
EKG: flat T waves, ST depression, U wave, atrial arrhythmias
Dx: Chemistries, urine, 24-hour urine
Tx: increase K+, check Ca, Mg
Hyperkalemia
Eti, S/s, workup, manage
Eti: Acute kidney failure, CKD, addison’s disease, EToH, Ace inhibitors, RBC destruction
S/s: paresthesias, muscle weakness, confusion, hyperactive DTRs, decreased strength
ECG: Peaked t-waves, PR prolongation, QRS widening, ventricular arrhythmias
Dx: Chem, urine, EKG, urinary output
Tx: Calcium gluconate/chloride for cardiac stability
possibly dialysis
Types of hyponatremia
Hypotonic: Low mOsm
Isotonic: Normal mOsm: pseudohyponatremia
Hypertonic: assess for hyperglycemia
Types of hypotonic hyponatremia
Hypovolemic: decreased water and sodium
Euvolemic: increased water, normal sodium
Hypervolemic: increased total body water
Causes of respiratory acidosis
S/s:
Dx:
Tx:
Abnormal hypoventilation: - COPD - Drugs - Pneumonia - Neuro disorders (guillain barre) - Respiratory disfunction S/s: somnolence, confusion, asterixis, myoclonus Dx: up pCO2, down pH, up HCO3 Tx: mechanical ventilation
Causes of respiratory alkalosis
S/s:
Dx:
Tx:
Hyperventilation: CO2 is blown of faster
Eti: PE, prego, sepsis, hypoxemia, mechanical vent, anxiety, stimulation of respiratory center
S/s:may have symptoms of low Ca (perioral numbness, tetany, paresthesias)
Dx: low pCO2, high pH, low HCO3
Tx: Treat disorder, mechanical vent
Causes of metabolic acidosis
S/s:
Dx:
Tx:
Body producing too much acid or not enough bicarb, increase lactic acid, ketoacids, or kidney failure.
S/s: Comp hyperventilation, kussmaul breathing
Dx: Low bicarb, low ph, low pCO2 (comp)
Tx: treat cause, buffer, hemodialysis
Mnemonic for metabolic acidosis
M: methanol U: Uremia (CKD) D: Diabetic ketoacidosis P: Propylene glycol I: infection, iron, isoniazid, inborn errors of metabolism L: Lactic acidosis E: Ethylene glycol S: salicylates
Causes of metabolic alkalosis
S/s:
Dx:
Tx:
Eti: requires both loss of H+ and maintance (impairment of renal HCO3 excretion, decreased GFR)
Vomiting: loss of acid, K+, Na+
S/s: no specific symptoms
Abdominal pain associated symptoms questions
N?V?D?C?CP?SOB?back pain?Urinary sx?
females: missed periods, vaginal bleeding or discharge
Abdominal pain questions
Po intake, anorexia, symptoms change with eating, is the pain constant or intermittent, what was the ride to ER like?
Medical history: GERD, history of ulcers
Surgical history: endoscopy, colonoscopy…
Abdominal pain physical exam
PE: mucous membranes, heart and lungs, CVA tenderness,
Lay down: Point where it hurts, check BS, rebound, guarding and peritoneal signs,
Check for testicular torsion
Abdominal pain ddx
appendicitis cholecystitis pancreatitis diverticulitis bowel obstruction mesenteric ischemia bowel perforation kidney stone gastritis gastroenteritis AAA
abdominal pain work up labs?
Abdominal lab set: pregnancy
UA: kidney
CBC: anemia, wbc for surgery prep
chem 10: hypokalemia = ileus, creatinine for CT prep
coags: pre-op lab, early sign of liver disease
lfts: cholecystitis workup
lipase: pancreatitis
vbg with lactate for older patients: screen for mesenteric ischemia
Pain control for abdominal pain
Morphine: frequent titrated doses
0.1mg/kg, 70kg male = 7-8mg
safer more conservative dose: 4mg IV, may repeat Q15minutes for 3 total doses PRN for pain
Hold for somnolence, hypoxia, or systolic blood pressure under 100
Zofran: 8mg IV with narcotics
Benedryl: for histamine response: 12.5-25mg IV for rash if needed
Abdominal pain imaging when required by quadrant?
LUQ: rigid abdomen or suspected obstruction
EpiG: rarely needs imagine: US RUQ to look for stones
RUQ: cholecystitis: US for stones or sludge
RLQ: appendicitis: usually iv contrast CT of abdomen and pelvis
suprapubic: UTI
LLQ: diverticulitis: CT with IV contrast
Flank pain: colic pain: kidney stones: CT abdomen/pelvis w/o contrast
If you have an elderly patient with HTN or afib that complains of intense abdominal pain but not a lot of tenderness, that get worse every time they eat: check?
VBG with lactate to screen for mesenteric ischemia
and get surgeons involved early
If the person has had multiple abdominal surgeries and vomiting with diffuse tenderness think?
Bowel obstruction: and CT with PO contrast if they can tolerate their kidneys can tolerate the contrast.
Elderly patient with HTN that present with back pain, abdominal pain, syncope or hematuria think what?
AAA
Have a low threshold to ultrasound patients
Aorta >2cm and symptomatic for AAA = OR immediately
Between 2-5cm and asymptomatic = need follow up
>5cm = surgical consult
OPQRST
Onset Provocation Quality Radiation Severity Time
Female specific qualities of abdominal pain
Additional questions to ask
Vaginal bleeding, or discharge Missed periods Urinary symptoms Fevers, chills Nausea, vomiting, diarrhea, back pain Pregnancy history Sexual history
Sexual history
Ever had sex
Last time
How many partners
Get parents out of room
DDx female specific abdominal pain
Ectopic pregnancy Threatened abortion Normal pregnancy STDs: gonorrhea, chlamydia, trichomoniasis PID Tubo-ovarian abscess Ovarian torsion Ovarian cyst Bacterial vaginosis, candidiasis
Female patient with:
- Sudden onset of lower abdominal or pelvic pain with nausea or vomiting
What should be suspected
Ovarian torsion
There is such a thing as intermittent torsion
- Negative US does not rule out ovarian or testicular torsion.
- Torsion is a clinical diagnosis, US can be helpful
What is the treatment for gonorrhea and chlamydia?
Standard for of care is to treat for both even if only treat positive for one.
Cervicitis:
- Ceftriaxone 125mg IM, 1g Azithromycin PO 1 dose
- Zofran can be given with for nausea
PID: (cervical motion tenderness)
- Ceftriaxone 250mg IM, Doxycyclin 100mg BID 14days
Shouldn’t have sex for 7 days, and partners should be tested and treated.
Tubo-ovarian abscess
S/s
Eti: usually a severe PID that has gone untreated and formed an abscess
S/s: low abd pain, vag discharge
In cases where suspicious of ovarian torsion, should be suspicious of tubo-ovarian abscess as well.
Tx: usually admitted and given IV abx, obgyn consult
trichomoniasis
Eti: motile organism on wet prep
s/s: itching, discharge, dysuria, dyspareunia, abd pain rare symptom
Tx: Flagyl, 2g 1 time dose, 500mg BID x 7days
- Don’t drink EtoH while on Flagyl
bacterial vaginosis
Overgrowth of gardnerella vaginalis, replaces normal flora of lactobacilius
S/s: usually presents as malodors discharge
Dx: wet prep: clue cells
Tx: Flagyl, 2 g 1 time dose, 500mg BID x 7days
candidiasis
yeast infection, common after abx use
s/s: itching or discharge
dx: KOH; fungal elements
tx: 1 dose fluconizole 150mg PO, or topical treatment 7 days
Chest pain questions
OPQRST, what where you doing when the pain started
Associated symp: n/v/sweat/abd/back pain/syncope
Have you had this pain before
Past hx: htn, hyperL, MI, CHF,
Recent ECG, echo, stress test, catheterization
Medications:
DDX of chest pain: 6 most deadly
Pulmonary embolism Esophageal rupture Tension pnuemo MI Aortic dissection Cardiac tamponade
Physical exam for chest pain
What is there volume status: heart and lung sounds, murmurs, JVD Press on chest wall Abdominal exam (AAA) Back exam Legs: edema or swelling (pitting) Pulses: aortic dissection
Work up for chest pain
ECG and chest x-ray (esophageal rupture, pneumo)
Esophageal rupture (boerhaave’s syndrome)
Xray: free air under diaphragm, peritonitis on abdominal exam, history of recent forceful vomiting, alcoholics, recent endo
Aortic dissection
Risk
S/s
Dx
Risk: HTN, pregnancy, marfans, ellohrs danlos
S/s: ripping or tearing pain the radiates to the back
Difference of BP between L and R arms greater than 20mmHg.
Chest pain plus motor neuro deficit else wear in the body
Dx: CT chest with IV contrast
Cardiac tampanode
S/s
Becks triad: muffled heart sounds, jvd, hypotension (late finding)
Narrow pulse pressure
MI
S/s
Work up
Pressure, made worse by exersion, left side of body, diaphroesis, pain that radiates to the shoulder
Work up: ECG, chest xray, CBC, chem 10, coags, cardiac enzymes (troponins, ckmb
Initial treatment of suspected MI
325 aspirin past 24 hours
Nitroglycerin 0.4mg q5mintues x 3 doses (no ED meds)
morphin + zophran
Pulmonary embolism
s/s
risk
sx: pluritic chest pain all over the chest, tachycardia, tachypnea, SOB, hypoxia
risk: pregnancy, OCP’s, trauma, recent surgery, malegnancy
Pulmonary embolism
w/u
EKG
chest xray
cbc, chem 10, coags
PE rule out criteria: PERC rule
Breaths: can be used if low risk blood in sputum room air sat less than 95% estrogen use age greater than 50yo thrombosis in the past, PE or DVT heart rate greater than 100 surgery in last 4 weeks
Perc pos: d-dimer
PE treatment
submassive: lovonox or heparin drip,
cardiac enzymes plus BNP
hemodynamicly unstable and PE: thrombolytics
GI bleed ddx: upper gi
Esophageal varices
Mallory-weiss tear
peptic ulcer diease
Dieulafoy lesion
Lower GI bleeding ddx
Arteriovenous malformation
Diverticulosis
Colon cancer
Hemorrhoids
GI bleed PE
VS: blood pressure, pulse, mental status Nose and throat Abdomen; peritoneal signs Rectal exam and FOBT Extremities: looking for signs of shock (cool clammy extremities)
What should be done to a patient with suspected GIB?
- 2 large bore IVs to establish access
- Oxygen
- Labs: for baseline: crossmatch, CBC, chem, coag,
- ECG: in patients with CAD for signs of ischemia in GOB
demarkation point between Upper GIB and Lower?
Ligament of treitz
Acute mesenteric ischemia
Etiology and pathogenesis
Eti: Blood supply to bowel is insufficient to meet the metabolic demands.
MC: is embolism to the superior mesenteric artery from the intracardiac thrombus from afib.
Path: necrosis of mucosa, later muscular and serosal layer, no longer effective barrier to intraluminal bacteria = generalized peritonitis.
Acute mesenteric ischemia history and PE
Hist: Acute onset of vague diffuse abdominal pain in an elderly patient with a history of CAD or afib.
Pain: classically described as being out of proportion to findings.
PE: Virtually normal except, vague mid to lower abdominal pain without peritoneal signs.
DDX for acute mesenteric ischemia
AMI Peptic ulcer disease pancreatitis small bowel obstruction volvulus diverticulitis cholecystitis nephrolithiasis ruptured AAA
Diagnostics for AMI?
Lab features.., Gold standard?
Tx:
Labs: leukocytosis, metabolic acidosis, lactate levels up
Gold standard: angiography!
Tx: O2, cardiac monitor, IV access, fluids, abx’s, nasogastric tube (gastric decompression)
Laparotomy and surgical embolectomy followed by resection of necrotic bowel.
Angiography
IV contrast plus xray or flouroscopy.
The word itself comes from the Greek words ἀνγεῖον angeion, “vessel”, and γράφειν graphein, “to write” or “record”
Epidemiology for cholecystitis
4 F’s: fat, female, fertile, forty
What is a life threatening complication of cholecystitis?
Ascending cholangitis: obstruction of the common bile duct and infection of the duct
Back pain physical exam?
PE: HEENT, h&L Point where it hurts, middle or paraspinal muscles, CVA Abdominal exam Males: testicular exam, sensory exam of groin pubic, RE.. Motor and Sensory exam: Strength: Hip flexor, and LE strength Sensory: legs and feet Straight leg raise test
DDx back pain
Start with assumption of serious cause work backward. Abdominal aortic aneurysm Aortic dissection Renal colic Cauda equina Epidural abscess Tumor or mass Fracture Pylo or UTI Abdominal Zoster Muscular skeletal
Abdominal aortic aneurysm
Epi and classic symptoms
Epi: older adult with HTN
Low threshold for US
2-5cm who are symptomatic or >5cm urgent referral
Aortic dissection
Epi and classic symptoms
Usually presents with chest pain, but can present with back pain, think with both.
s/s: think in patients with pulse or motor defects
Renal colic
Epi and classic symptoms
Usually younger patients
Usually sudden onset of back or flank pain, CVA tender
Microscopic hematuria 70-80%
They look like they can’t get comfortable, writhing
Cauda equina
Sudden onset of ripping or tearing back pain that has loss of bowel or bladder control, saddle anesthesia. Sudden loss of motor function.
Real life symptoms early: urinary retention followed by overflow incontinence.
Epidural abscess
Pt. Fever back pain in an IV drug user
Tumor or mass with back pain
Epi, s/s
Epi; Red flags (weight loss, night sweats, back pain at night, hx cancer), current history of active cancer.
S/s: motor deficits
Back pain and fracture: who and when
Epi: trauma, older patient pointing to middle of back
Pyelonephritis: basic symptoms
Back pain and fever, with or without urinary symptoms
mnemonic for serious back pain etiology
CRAFTI: Cauda equina Renal Abdominal Aortic Aneurysm or Aortic dissection Fracture Tumor or mass Infection
Workup for back pain
UA, CBC, Chem 10 (really depends on clinical picture)
Imaging: Ultrasound, CT of aorta, plain films
Definition of dizziness
Patient has sensation of room is spinning around them.
Dizziness questions
when it started how suddenly constant or comes and goes had before neuro symptoms tinnitus, loss of hearing = central vs peripheral vertigo
Peripheral vertigo vs central
Peripheral: dysfunction in patients ear: BPPV
Central: central nervous system: tumor, stroke, intracrania bleeding
Peripheral (not as serious): central (more serious)
Peripheral: suggested by acute onset, feeling really bad, episodic
Central: continuous, gradual in onset
Components of peripheral vertigo
Sudden Severe Seconds to minutes Horizontal nystagmus Worsened by certain head positions No neuro findings Auditory: may have tinnitus or decreased hearing
Components of central vertigo
Gradual onset Mild intensity Duration weeks to months Nystagmus: horiz, vert, or rotary No relation to head position Usually neuro findings Auditory: usually none
Dizziness PE
Don’t forget the ears
Neuro exam:
(focus points: finger to nose, rapid alternating movements, pronator drift, walking the patient) = posterior stroke worry.
Testing of EOM: look for nystagmus. BPPV = horizontal only.
(Induction of dizziness with EOM and resolution with visual fixation)
Ddx of dizziness serious central etiologies?
Central etiologies: Tumor/mass/intracranial bleeding Carotid or vertebral artery dissection Cerebellar stroke Infection
DDx of dizziness peripheral etiologies
Benign paroxysmysal positional vertigo (BPPV)
Acute otitis media (ear pain and bulging TM)
Labrynithitis (usually have preceding URI sympt) dizziness with hearing loss
Perilymphatic fistula (hearing loss, worse with valsalva)
Meniere’s: Triad: dizziness, fluctuating hearing loss, tinnitus, waxing and wanes over years.
Ear canal foreign body: anything that irritates TM
Dizziness workup
Labs: usually low yield
Imaging: central? CT non-con head CT,
MRI for cerebellar or posterior stroke.
Treatments used to treat dizziness
Meclizine (Antivert): antihistamine with anti-emetic properties 25mg PO BID Diazepam (valium): 5mg PO TID Ondansetron (Zofran): 4 to 8mg PO Q6hr Epley maneurver: hand out
Syncope definition
Rapid loss of consciousness followed by rapid return to baseline
Syncope hx:
Differentiate between dizziness, lightheaded, or syncope
Pt. describe in their own words what happened
Stressors: emotion, hydration, food
Associated symptoms
Duration of being out, seizures?
Postictal state?
Syncope w/ HA or with neuro symptoms, with CP, BP complete ROS
Past med hx: seizures, DM, stroke/tia, MI, known AAA, family hx of heart disease (sudden cardiac death).
PE for patient with syncope
check head for trauma
neuro exam
heart for murmurs (and while bearing down and squatting)
head to toe exam (checking for back and abd tenderness)
Ddx syncope
Seizure SubA/intracranial hemorrhage Ruptured AAA Aortic dissection Stroke/TIA GI bleed MI Aortic stenosis Pulmonary embolism Arrhythmia Carotid sinus sensitivity Hypoglycemia Sepsis Toxicologic Orthostatic hypotension
Syncope workup
pay special attention to cardiac etiology
Every patient need at least: ECG, and bHCG(if women)
Tests to add to older patients:
CBG, CBC, Chem 10, UA, non-con head CT
ECG of patient with syncope: 4 things to look for?
Prolonged QT: higher chance of PVC falling on T wave
(Long QT: males: longer than 440ms, females: 460ms)
10-11 small squares on paper
(T wave within first 1/2 between R-R interval)
Look for Wolf parkinson white (delta wave before QRS)
Brugada syndrome: young otherwise healthy individual without heart disease with episode of syncope
EKG: (RBBB pattern and ST elev V1-V3)
HCOM: Young and healthy athlete
ECG: Large R waves in V4-V6 or AVL, deep q waves in lateral leads
Disposition patients with syncope
Patients over 50 should probably be admitted, definitely over 65
San Francisco Syncope Rule
CHESS CHF Hematocrit <30 EKG abnormalities SOB Systolic BP
Rehydration in the ED
Clinical signs of dehydration:
most sensitive sign: tachycardia
Acetaminophen overdose
S/s
W/u:
Tx:
Delayed hepatic injury 24-72 hrs later
S/s: may be asx, anorexia, n/v, RUQ pain, hepatic necrosis (jaundice, LFTs)
W/u: LFTs (AST>ALT), serum acetaminophen level, 4 hr post ingestion level, use nomogram to predict severity
Tx: if 4hr > 150, start N-acetylcysteine (12-16 hrs of ingestion)
Aphetamines/stimulates overdose:
S/s:
W/u:
Tx:
Sympathomimetic (like cocaine)
s/s: psychomotor agitation, euphoria, mydriasis, diaphoresis, tachycardia, HTN, hyperthermia, possible seizures
W/u: serum drug level not helpful. ECG, cardiac enzymes, check urine for myoglobin
Tx: Supportive (cooling, sedation w/benzos, hydration), no specific antidote. Propranolol if v-tach.
Sedative overdose (benzos) Tx:
Flumazepil
Carbon monoxide
S/s
W/u
Tx:
Hx: multiple individuals same location
S/s: tachypnea, flu like sxs, CNS symp, vomiting, (cherry red oral mucosa)
W/u: VBG, chem, trops, CK, ECG, ct
Tx: 100% O2 by nrb, hyperbaric therapy
Salicylates overdose
S/s
W/u
Tx
ASA, oil of wintergreen, pepto
Toxicity >150mg/kg
S/s: n/v, tinnitus, tachyC, hyperthermia, hyperventilation, respiratory alkalosis (turning into metabolic acidosis
W/u: serum salicylate
Tx: ABCs, treat electrolyte inbalances, activated charcoal
Severe tx: hemodialysis
Opiates overdose
s/s
w/u
tx
consider in ams patient with pinpoint pupils
S/s: CNS depression, miosis, respiratory depression, hypothermia, hypoT, bradyC
W/u: blood/urine levels
Tx: ventilation and/or naloxone
Tricyclic antidepressants overdose
3 C’s: Cardiac abnormalities, convulsions, coma
Tx: supportive, cardiac monitoring, sodium bicarb if arrhythmias
Alcohol overdose
CNS depressant
S/s: ataxia, dysarthria…
W/u: serum ethanol, osmolar/anion gap metabolic acidosis, hypoglycemia
Tx: Supportive, thiamine (wernickes aphasia), IV glucose (if hypoglycemic)
cocaine overdose
Sympathomimetic
Tx: cooling, sedation w/ benzos, hydration
cyanide overdose
S/sx: CNS, CV, respiratory, n/v,
w/u: lactate, VBG, ABG
Tx: Hydroxocobalamin, sodium thiosulfate, sodium nitrate
organophosphates
Tx: airway, pralidoxime, atropine
poisonous mushrooms
s/s: GI, CNS,
Tx: activated charcoal, benzo, atropine
Heavy metal overdose
Tx: chelation therapy w/ deferoxamine
sympathomimetic syndrome
Too many adrenergic signals
Adrenergic signs: mydriasis (dialation of pupil), diaphoresis, psychosis, paranoia, bruxism (grinding of teeth), CV, HA, arrhythmias
sympatholytic syndrome
blocks anything to do with epi
S/s: orthostatic hypoT, fatigue, sedation, respiratory dep
serotonin syndrome
increased serotonergic activity in CNS
S/s: mental status changes, diaphoresis, tachyC, hyperthermia, HTN, v/d, mydriasis, dry MM, flushed skin, myoclonus, hyperreflexia
When to use activated charcoal
<60 mins after ingestion
- salicylates, poisonous mushrooms…
What does decorticate represent on GCS
Definition: To remove the cortex
In GCS: abnormal flexion of the arms, scoring 3 on motor response
What does decerebrate represent on GCS
Definition: to remove the brain or to cut the spinal cord.
In GCS: arms extended to sides, scoring 2 on motor response
