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
