ER deck 2 Flashcards
When not to use succinylcholine for int
ubation
Succinylcholine raises potassium. Do not use it in a crush injury or burns or in patients with massive muscle denervation due to spinal injury as hyper Kalemia may be severe and cause ischemia and or myocardial infarction. Immobilization may also cause hyperkalemia so no succinylcholine for people with casts.
Also don’t use it in lithium, lithium increases onset time and duration of sedation with succinylcholine
Rocuronium dose
0.8 to 1.2 µg per kilogram. Usually 100 µg for the average adult. rocuronium comes in 50 µg ampules. If you’re intubating, make sure you have 220 gauge IV s in the antecubital and flush after the Rocuronium
Average dose of morphine and Zofran?
4 mg of each you can repeated every 15 minutes until you reach the max for morphine
PVC vs PAC
PVCs have WIDE QRSs. PVCs themselves have no P waves.
-BiGeminy - every other normal
QRS there is a PVC
- Trigeminy: Every 2nd normal
QRS there is a PVC
- Check K+, Ca++ and Mg++
and correct any derangements
PACs are narrow but just out of order. It may just look like an irregular sinus rhythm. There will be P waves for each QRS
HypoKalemia
below 3.5 [3.5 - 5 is normal]
presents usually as weakness, fatigue and exercise intolerance
give a bolus to restore but you’ll need to give Mg++ also as they run together and its hard to raise K+ if Mg++ is low. Go ahead and check Ca++ too.
Hypomagnesemia
Weakness
Tetany
Fatigue
Wide QRS to Torsades
Give MgSO4 and K+
Altered Mental Status DDX?
Alcohol/Drugs
Hypoglycemia
UTI (elderly)
Hypoxia
Hyponatremia
Head Trauma
Postictal period
Sepsis (usually other signs more
impressive than AMS)Vistaril
Hydroxyzine
Antihistamine for Anxiety and insomnia
H1 blocker
very old school but it works
Budesonide
Inhaled Steroid
Straight up it is PULMICORT
if mixed with Formoterol, a Long Acting Beta Agonist (LABA) it is SYMBICORT.
Ipatropium Bromide
Inhaled Anticholinergic
It decreases contractility of smooth muscle in the bronchioles by inhibiting ACh at muscarinic receptors. This prevents them from constricting in an asthma attack.
MDI or Nebulized
Straight up it is ATROVENT
Together with Albuterol in a NEBULIZATION it is DUONEB
Together with Salumetrol in an MDI it is COMBIVENT
It is more effective than albuterol alone
Liquid PREDNISONE dose in Asthma
0.5mg - 1mg / Kg in a divided dose
Treat early but in short bursts
I’ve read 3pm - 5 pm may be the best time of day to give the 2nd dose as it gives time for the steroid to calm the inflammation before bed.
DuoNeb
Ipatropium Bromide: Reduces
bronchial smooth
muscle contractility
anticholinergic
\+
Albuterol: Short Beta 2 Agonist
Only by nebulizer. The combo is more effective than either alone.
Combivent
Ipatropium Bromide: Reduces
bronchial smooth muscle
contractility
+
Salumetrol: Long Acting Beta 2
Agonist
Only by MDI.
Mainly for COPD
Asthmatics usually use DUONEB for severe rescue - that’s where they usually encounter Ipatropium. Its in the ED and on the Rigs.
Otherwise they use SYMBICORT for maintenance: a steroid + a LA Beta Agonist instead of COMBIVENT because the don’t usually need the Ipatropium.
Monteleukast
Singulair 10 mg/day
For allergic Asthma
Don’t Use Nitrofurantoin in…
past the 38th week of pregnancy and up to 1 Month Infancy. Causes Hemolysis.
in G6PD Deficiency (also don’t use Bactrim or Cipro in G6PD). Causes Hemolysis.
The Elderly in general. BEERS says no d/t:
It also causes Pulmonary Fibrosis and Inflammation at high levels so you don’t want to give it to folks with poor kidney function as high levels will result since it is renally cleared.
In the elderly, use Cefalexin (Keflex), also a good choice in G6PD, pregnancy and infancy
UTI Rx:
Nitrofurantoin 100mg BID X 7 days for Adults with good kidney function and no hemolysis risk (neonate, late pregnancy and G6PD). Risk of pulmonary fibrosis/inflammation in which case you STOP and SWITCH
Keflex (Cephalexin) 1st gen cephalosporin still kills e.coli
Use it when you can’t use Nitrofurantoin. Use it in elderly people.
Bactrim: 20% of e.Coli strains are resistant. Don’t use Bactrim or Cipro empirically
Ceftriaxone empirically if you can’t use Nitrofurantoin or Keflex. Then be sure to do a culture and switch if necessary.
G6PD Deficiency: Hemolysis. Heinz Bodies on a RBC Smear. Coombs test negative.
Don’t use Nitrofurantioin, Bactrim, Cipro
Mediterranean, African, Middle Eastern
Dk Urine (positive for RBCs or Hemoglobin) SOB, TACHY - because RBCs are stressed by hemolysis
Doesn’t present until a stressor (medication usually: Bactrim, Cipro, Nitrofur, Primiquine…)
Gastric vs Duodenal Ulcer sxs
DUODENAL: MOST COMMON ULCER
-Wakes Patient
-Pain relieved by food and comes back
after food has passed the duodenum in 1-2 hrs after eating
- H. Pylori
GASTRIC ULCERs: 2nd most common cause of GI Bleed
- Pain immediately on eating
- Early Satiety (weight loss...)
- NSAIDS
BOTH mainly caused by H. Pylori 70+ %
So… get a urea breath test before starting PPIs… otherwise you have to wait 14 days to get a reliable urea breath test result for PUD
Hydrogen breath test is for lactose intolerance.
Atrovent
Ipatropium, straight up
mix it with Salumetrol (a LABA) in MDI & you have COMBIVENT
mix it with albuterol in a neb & you have DUONEB
Bend, Lift, Twist….. (what gets hurt?)
DISC!!!
This is classic MOI for the slipped disc. CT the guy and send him off to PCP with a few days of valium. PCP can make the switch to Flexoril and send him to PT, order an MRI if he feels its necessary.
Ortho doesn’t do spines- Neurology does - let the PCP decide who to send him to. He’s going to need a work note.
Narcotics really won’t help. Heat and valium.
Document these parameters of intoxication always:
slurred speech,
nystagmus,
ataxia, and
somnolence
(+) slurred speech, (+) ataxia and (+) somnolence/stupor(-) nystagmus Put the negative last in your note
Establish the NEED for a drug/alcohol/tox screen in your note
Also go ahead and document :
Agitation
Aggression
Poor Insight
If you are ETOH, DRUG or TOX screening a competent not intoxicated patient, obtain verbal and, where possible, written consent.
The BIG CLUE in Salicylate Toxicity?
TINNITUS
Tinnitus with a significant anion gap acidosis is classic. Aspirin is, after all, an acid.
Agitated Delerium, Tachycardia Tachynea and Elevated temp as well but Tinnitus is the red flag.
Salicylate screening is part of the required MH Tox screen at CMC but not necessarily part of the alcohol screening
Add “Any recent ringing in your ears” to your ROS for altered mental status or just plain sick people.
Max time to administer Mucomyst orally in suspected Acetaminofen toxicity
8 - 10 hrs.
You draw the blood for testing at 4 hrs, if you know when it was ingested. Then you give the rescue loading dose, which is weight based.
If you don’t know the time of ingestion or it is beyond 8 hrs. take the blood then Just give the loading dose, adjust it when the levels come back
First dose is meant to be oral. Activated charcoal the pt if ingestion is within 1 hr of arriving at ED. Gastric Lavage as well. If Over two hrs, you may be out of luck for physically removing the acetaminophen.
n-acetylcystine
Mucomyst
Tylenol overdose
What to give in Salicylate Toxicity?
Bicarb Bolus and Glucose… And monitor ABCs..
Aspirin is an ACID…. Reverse Acidosis by ALKALINIZING the blood with BICARB (1mEq/Kg in a bolus) then 132mEq Bicarb to 1L of D5W (that is 2 44mEq ampules of BiCarb to 1 1L bag of D5W)
We want Urine pH over 7.5. This prevents reabsorption of aspirin from the filtrate in the kidney and alkalinizing the blood draws aspirin out of the brain.
Continue alkilinization until serum levels are less than 30mg/dL
Acidosis will likely be underway - reverse it.
Hyperventillation will likely occur as the body tries to rid itself of CO2,
“Give glucose to aspirin” the acid impairs glucose utilization so even when BGs are normal - Just give glucose. It may rapidly improve the cognition of your patient so you can question them.
Pulmonary edema is a big risk. Intubate and use BiPap
congenital absence of nerve bodies for parts of the colon and rectum
Hirshsprung’s Disease (not really a disease, rather a condition)
These are the kids that don’t poop within 24-48 hrs of birth, have green brown vomit, distended bellies and/or explosive diarrhea on insertion of a pinky into the anus.
RX is mainly the pull through surgery where the un-ennervated portion of the colon is detached and “pulled through the rectum until an enervated portion is directly attached to the rectum. The un-ennervated portion is then dissected off.
Beta 2 Receptor Endogenous Agonist is
Epinephrine / Adrenaline
Both Beta Receptors (B1 and B2) are activated in Fight/Flight so their Distribution makes logical sense really.
Beta 1 is more central, it is the main cardiac receptor, increasing ventricular rate and contractility. Beta 2 is found in the sinoatrial node and the atria, so it does have some cardiac impact (noted when you take albuterol and your heart races…) but mainly Beta 2 acts more peripherally, to support the increased cardiac demand generated by Beta 1 activation.
When Epi Activates B2 receptors, Calcium Ion Channels open. THIS is why Calcium Channel Blockers are effective in SLOWING the heart down - they counteract both B1 and B2 activation by Epi. It’s also why the antidote to CCB toxicity (extreme CCB bradycardia) is Epi. They’re opposites in the heart. Well.., you’d also give Ca++ in the form of Calcium Gluconate, just to flood the system with Ca++. And you’d give insulin and glucagon to ensure sugar was available and being taken up. CCB toxicity Rx is rather like HyperK Rx with the addition of epi, which is also sometimes used in Hyper K.
Bronchioles:
Activation of Smooth muscle B2 receptors on the bronchioles relaxes and dilates the bronchioles - allowing greater effectiveness of respiration. This is needed because both Beta 1 and 2 receptors are activated in Fight or Flight situations and both B1 and B2 activation by Epi increase heart rate and contractility, placing increased demand on the lungs.
Bladder:
B2 receptors are also located on the Bladder, smoothing and relaxing the detrusor muscle so that you don’t have to pee when the tiger is chasing you. We opt more for anticholingergics for incontinence and overactive bladder but B2 agonists may also be of use.
Uterus:
B2 receptors on the uterus prevent you going into labor while also running from the tiger. Hopefully. We use a B2 Agonist (Terbutaline) to relax the uterus and prevent labor.
Liver:
B2 activation increases gluconeogenesis and glycogenolysis, liberating glucose into the blood to feed skeletal muscle and your brain while you flee the tiger.
Pancreas:
B2 receptors increase insulin secretion, enhancing glucose uptake by the skeletal muscles to help you run
Sphincters and GI:
Interestingly, B2 receptors in the GI have different effects. In the actual gut, smooth muscle relaxes and motility slows, shunting energy to the legs for running. In the sphincters though, B2 activation causes constriction - because you don’t want to poop or vomit while you’re running from the tiger. THIS is ALSO why patients on Beta Blockers and/or CCBs almost always have GERD and are FARTY - nothing is tightening their lower esophageal sphincters or their Anal Sphincters allowing acid reflux into the esophagus and making control of flatulance difficult.
Kidney:
B2 activation increases renin secretion which in-turn activates RAAS, keeping your blood pressure up while you flee! NOTE, this is one of the ways Beta Blockers and CCBs reduce blood pressure.
Brain:
Receptors for B2 are also found in the cortex and cerebellum. Apparently you need to think and keep your balance when the tiger chases you…
Organic Psychosis vs Psychiatric?
Older
VITALS UNSTABLE
Acute Onset
Disorientation/Memory Loss
FEMALE ATHLETE TRIAD?
Eating Disorder, Amenorrhea, Osteoporosis
Eating Disorder prompts excessive exercise and caloric reduction which decreases body fat which impairs estrogen synthesis which impedes menstruation. Insufficient estrogen/fat also interferes with RANK suppression in the bones, allowing osteoclast formation as in menopause and leading to early onset osteoporosis.
Try to nip this in the bud before the eating disorder sets all the dominos in motion. But… if eating disorder intervention isn’t working, consider estrogen therapy to at least protect her bones!!! Of Course, we’ll be looking to use transdermal BioIdenticals and not orals or injectables.
Suspect Elder Abuse but Pt does not want DSS involved, you should…
Notify Adult Protective Anyway - According to ROSH Review. HOWEVER, in NY, there is no mandated reporting law so you need to negotiate this carefully with your patient. It isn’t clear if you face breach of HIPPA for reporting anyway in NY.
There is movement in NY for a permissive reporting statute which would confer liability immunity on the reporting professional -already well underway for banks visa vie financial exploitation of elders (think Cynthia T…) but it isn’t so far along for medical reporters as of 2016
Alcoholic Sxs of impending Delirium Tremens?
Fever, Tachycardia, Hypertension, Irritibility…
Next comes lowered seizure threshold and BAM! You have the DTs.
Admit this patient! Give them Benzos and a Banana Bag or two.
Chalazion vs Hordoleum
Chalazion is chronic, Hodoleum usually acute
Chalzion is Meiobian blockage, Hordoleium is more eyelash follicle
Chalazion isn’t yet infected. hordoleum IS infected. Hordoleum can result when a Chalazion gets infected.
Chalazion doesn’t hurt - Hordoleum does
Warm compresses for chalazion but compresses, expression and antibiotic drops for Hordoleum
HOLLIDAY-SEGAR REHYDRATION CALCULATION
47.9 ml/hr is calculated utilizing the Holliday-Segar method of 100 ml/kg/day for the first 10 kg, 50 ml/kg/day for the next 10 kg and 20 ml/kg/day for each additional kilogram. This total is then divided by 24 hours.
(100 ml/kg/day x 10 kg) + (50 ml/kg/day x 3kg) = 1150 ml/kg/day/24hr = 47.9ml/hr
This method is sometimes shortened to the 4-2-1 method of 4 ml/kg/hr for the first 10 kg, 2 ml/kg/hr for the next 10 kg and 1 ml/kg/hr for each additional kilogram.
(4 ml/hr x 10 kg) + (2 ml/hr x 3 kg) = 46 ml/hr
MALIGNANCY isn’t just bad, its an independent risk for
Clotting
Malignancy is a hyper coagulable state. Leg pain - think DVT. SOB - think PE. Get a doppler of the leg. Get a CTZ with contrast of the Chest for the SOB
Sunburst Pattern on X-Ray at the distal ends of long bones…
Osteosarcoma
MOST common tumor of children: femur, tibia, humerus
Painful swelling mass at tumor site in children (though not exclusively in childhood)
Elevated ALK Phos, ESR and LDL
Ionizing Radiation for Rx of childhood malignancy in increases risk.
Fifth’s Disease, Sxs & cause
Slapped Cheeks, Fever
Parovirus B19
In Sicke Cell Aplastic Anemia is a potential complication
Sort Internal Hemorroidal Bleeding from External?
No pain. Internals are located far enough inside that there are not pain receptors. Thus they can become infected and necrotic without warning.
Bright red blood on poop is hemorrhoid sign but externals hurt.
If fiber and increased water and NSAIDS don’t do it… refer to the general surgeon for rubber band therapy or hemorrhoidectomy.
Anion Gap Formula
Sodium - (Chloride + Bicarb) > 10
Anion Gap Metabolic Acidosis = Gap over 10 and pH less than 7.35
think DKA, especially in the setting of NVD in a diabetic
Sort Herpes ulcers from Syphillis Ulcers from Chancroid…
Herpes ulcers hurt and Syphillis chancres don’t. Chancroid ulcers do hurt but are more bulbous than pit like.
Herpes ulcers can appear quickly, within 3 days of exposure. Chancres take longer.
Diffuse ST elevation with PR depression?
Pericarditis
Best test IS the ECG
Pain relieved by sitting forward
Pericardial Friction Rub audible on auscultation
Rx: NSAIDS, its usually idiopathic
Roloux Formation suggests…
Multiple Myeloma
check urine for Bentz Jones proteins
Most anal fissures form on the … Midline or lateral?
Midline.
It’s weaker as the muscle cells come together there
Lateral anal fissures and ulcers are suggestive of Crohns fistulas to come, even Leukemia, HIV and Syphillis
Rx pain with LIDOCAINE GEL
Rx Nifedipine Gel and or Botox to relax the sphincter
Rx stool softeners in general and Sitz baths.
Flu Tell Tale Sign?
Comes on FAST
Muscle Aches
Fever
Rx Pregnant and Immunocompromised patients with Oseltamivir aka TAMIFLU but only w/in 3 days of onset
