Everything Flashcards
1
Q
What clinical scenario mirrors that of heat stroke?
A
Anticholinergic toxicity
2
Q
When is U/S a more appropriate imaging modality for diagnosing appendicitis?
A
If the patient is child, pregnant or you have a high suspicion for gynecologic disease, then ultrasound would be a more appropriate initial imaging modality.
3
Q
In what age groups is testicular torsion most common?
A
First year of life and puberty
4
Q
Asystole and PE require what immediate action to get blood flow to the brain?
A
CPR
5
Q
Ethylene glycol is metabolized to:
A
oxalate
6
Q
V-tach first treatment ACLS
A
Amiodarone
7
Q
What is a TOA?
A
Tuboovarian abscess is a walled-off abscess that originates in the infected fallopian tube and extends to involve the ovary. Women with TOA appear ill, and will often have severe unilateral adnexal tenderness and fullness on bimanual pelvic examination.
8
Q
What tx is administered for calcium blockade?
A
Glucagon
9
Q
Multiple organ dysfunction syndrome means:
A
2 or more organs failing due to sepsis
10
Q
Tx for sympathomimetic toxidrome
A
sedation
hydration
treatment of complications such as rhabdomyalysis and hyperthermia
11
Q
Timeframe for highest efficacy of activated charcoal ingestion:
A
1 hour from ingestion
12
Q
Pearl
A
Horner’s syndrome in vertebral dissection can be mistaken for a blown other pupil
13
Q
Pearl
A
Do not delay recompression therapy to obtain imaging
14
Q
Pearl
A
If a patient tells you they’re constipated, ask “What do you mean by that?”
15
Q
Six characteristics of sympathomimetic toxidrome:
A
Tachycardia Hypertension Mydriasis Diaphoresis Hyperthermia Agitation
16
Q
Ddx for ovarian torsion (6 things)
A
Ovarian torsion Ovarian cyst Tubo-ovarian abscess Ectopic pregnancy Appendicitis Kidney stone
17
Q
Where is isopropyl alcohol found?
A
Isopropyl alcohol is found in many solvents, mouthwashes, and rubbing alcohols.
18
Q
Serious 6 can’t miss for CP
A
- MI
- Aortic Dissection
- Pericarditis
- PE
- Pneumothorax
- Esophageal Rupture
19
Q
What is a reassuring fetal heart rate?
A
110-160
20
Q
What diagnostic signs of cholecystitis are seen on U/S?
A
The important ultrasonographic findings of acute cholecystitis include the presence of gallstones, GB wall thickening (5mm or greater), pericholecystic fluid, and/or a positive sonographic Murphy’s sign (maximum tenderness with pressure from the US transducer directly over the gallbladder)
21
Q
Class of antiarrhythmic: TCAs
A
Class Ia - prolonged QRS, lengthening of QT
Sodium channel blocker
22
Q
Gold standard for diagnosing mesenteric ischemia:
A
Angiography (or CTA)
Unlike angiography, CTA cannot provide therapy, but can help triage patients towards those who can undergo angiography and those who should go to the operating room immediately. Paparevine and thrombolytics…
23
Q
A continuous abdominal bruit and a palpable abdominal thrill are suggestive of:
A
Aortovenous fistula
24
Q
Sudden, worst HA, +/- syncope;
Dangerous Disease to r/o - Workup - Tx
A
Subarachnoid hemorrhage
CT first, LP later
BP control, consult neurosurgery
25
What does S in AEIOU TIPS stand for?
```
AMS
Seizure
Sepsis
Stroke
Shock
Sub-arachnoid hemorrhage
Space-occupying lesion
```
26
Permissive hypercapnia settings
RR 8
| TV 7cc/kg
27
Dose of ASA for CP
325mg (chew)
28
Absence of P waves and irregularly irregular rhythm;
| dx?
Atrial fibrillation
29
Scorpion Pearl
Evidence of a scorpion sting such as a puncture site is almost never seen.
30
If Nitro causes confusion and listlessness, what might have happened?
Right heart MI or valve dysfunction
| Use of Viagra (PDE5 inhibitor, cGMP specific)
31
Most common cause of CVA <45
Vertebral dissection
32
SBO Pearl
Abdominal radiographs may miss small bowel obstruction in up to 25% of cases and should be followed by CT if the diagnosis is not clear
33
What is U/S ruling out in hemodynamically unstable abdominal pain?
Hemoperitoneum
Ruptured AAA
Ruptured ectopic pregnancy
34
Most common location for mesenteric artery thrombus
Celiac trunk, then SMA
35
What should you always check in men complaining of abdominal pain where appendicitis is being considered?
The testicles. Do not miss torsion.
36
Negative deflection means
E impulse traveling away
37
ED goals in cases of pneumoperitoneum:
Rapid IV fluid resuscitation;
IV Abx
Surgical emergency
38
Physical Exam must-considerations for the evaluation of toxicity:
Vital Signs (there is a reason they are called “vital signs”)
Mental status (agitated, confused, somnolent?)
Pupils
Skin color
Track marks/skin poppers
Presence of sweat
Bladder size (urinary retention)
39
Interesting pearl about the urine in an antifreeze ingestion
If you apply a Wood's lamp, it may flouresce.
40
Symptoms of vertebral artery dissection
```
Wide based gait
Diminished heel to toe
Diminished finger to nose
Vertigo
HA/neck pain
```
41
Pathophysiology of ASA OD:
Uncoupling of oxidative phosphorylation leads to profound anion gap metabolic acidosis
42
Anion gap Equation:
[Na+] - ([Cl−] + [HCO− 3])
43
Toxicity Pearl
Always obtain an acetaminophen level (can miss lethal overdose if not checked)
44
Treatment goals in heat stroke:
Reduce body temp to <39.4C by promoting cooling through evaporation and conduction
45
Management of pit viper bite
FabAV antivenin +/- fasciotomy in OR
46
Pneumoperitoneum Pearl
10-14% of patients with pneumoperitoneum may have a non surgical cause of free air.
47
A young college student is brought in by EMS. He is very agitated and altered and requires restraints. His vitals are as follows: pulse 138, respiratory rate 24, blood pressure 154/92, Temp 101.2, Sat 98% on room air. Physical Exam reveals mydriasis, flushed skin, sweating and agitation;
What toxidrome?
Sympathomimetic toxidrome
48
The earliest sign of an IUP by transvaginal ultrasound is:
The double decidual sac sign;
| 4.5-5 weeks after the last menstrual period (LMP)
49
CSF leak and battle's sign is commonly associated with what injury?
Basilar skull fracture
50
Absence of air in the colon or rectum suggests:
A complete bowel obstruction
51
Besides anticholinergic toxidrome, what lethal effects can a TCA OD have?
A direct alpha-adrenergic blockade, inhibition of norepinephrine and serotonin reuptake, and blockade of fast sodium channels in myocardial cells. This can lead to tachycardia, prolongation of the QRS complex, dysrhythmias, and cardiovascular collapse.
52
Symptoms of a severe reaction to a scorpion sting:
Roving eye movements
Jerking movements of limbs
Restlessness
Drooling
53
Do all patients with pneumoperitoneum show it on xray?
No. 50% of patients with perforated viscus during laparotomy may demonstrate no pneumoperitoneum on plain x-rays.
54
Signs that portend imminent respiratory arrest include:
●Depressed mental status
●Inability to maintain respiratory effort
●Cyanosis
55
What is the LD of acetaminophen?
150mg/kg
56
Symptoms of ASA OD:
```
ill appearing
breathing fast
vomiting
confused
sometimes febrile
```
57
Unilateral air trapping on CXR suggests what dx?
Foreign body
58
DKA, first step in management is to administer:
IV NS with K+
59
What tx is administered for beta blockage?
Glucagon
60
Risk Factors for Biliary Disease (8)
```
Female gender
Age > 40 years
Family history
Obesity
Multiparity
Rapid weight loss
Sickle Cell or other hemolytic disorders (pigmented stones)
Diabetes (increased risk of cholecystitis)
```
61
EKG
| Limb leads are
```
AVR, AVL, AVF, I, II, III
frontal plane (side to side)
```
62
What does O in AEIOU TIPS stand for?
AMS
Opiates
Oxygen
63
Ectopic Pearl
Paradoxic bradycardia can occur in ectopic pregnancy, thus vital signs should not be reassuring and all patients with ectopic pregnancy should be considered potentially unstable.
64
If there is rhythm on the monitor, how do you determine if it is PEA?
Check for carotid or femoral pulse
65
Questions to ask when decompression sickness is suspected?
```
How long?
How deep?
How cold?
How experienced?
Dive computer?
```
66
Lyme carditis includes:
AV block
| Carditis
67
Hematocrit may be elevated in:
severe dehydration
68
Syncope upon surfacing from a dive is what until proven otherwise?
Arterial gas embolism
69
Mgmt of ASA OD:
management of the airway
gastric decontamination
administration of sodium bicarbonate for widening of QRS
hemodialysis
70
Steps for treating migraine
| Step 1
Benadryl/toradol/compazine or metoclopramide (reglan)
71
If administering a depolarizing or nondepolarizing muscle paralytic, what three things must you consider?
1. Can I bag?
2. Can I tube?
3. Can I trach?
72
Cyanosis is uncommon in severe respiratory distress. Consider what diagnoses when present:
Severe hypoxia
| Methemoglobinemia
73
Where is methanol found?
Methanol is found in windshield wiper fluid.
74
Female
Abdominal pain
Free fluid in the pouch of Douglas on u/s
dx?
Ruptured ovarian cyst
75
Tests for potential CHF exacerbation
```
BNP
CXR
CBC
BMP
Put pt on O2, +/- bipap
trop
EKG
```
76
AAA rupture can be mistaken for:
Renal colic
77
In what patient population should you always consider a ruptured AAA?
A ruptured AAA should be in the differential diagnosis for any patient older than 50 years with abdominal, back, or flank pain.
78
What toxicities are activated charcoal not effective for?
Metals
Alcohols
Hydrocarbons
79
All women of childbearing age presenting to the ED with abdominal or pelvic pain should have:
Urine pregnancy test immediately
80
Class of antiarrhythmic: Amiodarone
Class III - C
Also Dofetilide
K channel blocker
Act to prolong QRS/QT
81
MUDPILES for metabolic acidosis
```
M = Methanol
U = Uremia
D = DKA or AKA (alchoholic ketoacidosis)
P = Paraldehyde
I = Iron, Isoniazid
L = Lactate (many causes including carbon monoxide, sepsis, blood loss?)
E = Ethylene Glycol
S = Salicylates
```
82
What is the Alvarado score?
A calculator to evaluate for appendicitis
83
What is an occult PTX?
Seen on CT but not CXR
84
Patients presenting with mesenteric artery ischemia can have their symptoms confused with:
PUD (ie postprandial abdominal pain)
85
Gallstone ileus causes what on CXR?
Multiple air-fluid levels
86
GCS score for eyes:
4 – Spontaneous
3 – Loud voice
2 – To Pain
1- None
87
All alchohols are metabolized by:
Alcohol dehydrogenase;
| Therefore, the initial treatment for methanol and ethylene glycol involves the blockade of ADH.
88
Initial treatment for hyperkalemia
Calcium gluconate
89
Tx for fast and wide QRS ACLS
Amiodarone
90
What might an abdominal xray show in AAA, if other diagnostic testing is limited?
A curvilinear calcification of the aortic wall or a paravertebral soft tissue mass can be found.
91
Torsion Pearl
Consider torsion in any patient with testicular trauma who still has pain 1-2 hours after an injury.
92
SBO Pearl
Strangulation is the most lethal complication of small bowel obstruction and can be present without peritoneal signs on examination.
93
What does A in AEIOU TIPS stand for?
AMS
| A for alcohol
94
A 68 year old male presents to the emergency department with worsening shortness of breath for 3 days. This morning he woke up from sleep with shortness of breath. He has a past medical history of hypertension and coronary artery disease. He takes losarten, clonidine, metoprolol and aspirin daily. He has no medication allergies. Temperature is 37.5°C, blood pressure is 188/92, heart rate is 94 and respiratory rate is 22. Pulse oximetry on room air shows an oxygen saturation of 93%. The patient appears to be in moderate respiratory distress and is using accessory muscles to breath. His cardiac examination reveals an S3, pulmonary examination reveals bibasilar rales. Jugular venous distention is noted at 6cm. He has 1+ lower extremity edema. The remainder of the examination is unremarkable. Which of the following is the most appropriate next step in management?
Supplemental O2
95
the testicle is anchored within the scrotum by the:
tunica vaginalis
96
Common complications of heat stroke:
Seizures
Respiratory failure
Rhabdomyolysis
Multi-organ dysfunction syndrome
97
What is the appropriate treatment for mesenteric ischemia?
Aggressive fluid resuscitation
98
What are risk factors for mesenteric artery embolus?
Risk factors for mesenteric artery embolus include arrhythmias (atrial fibrillation being the most common), post-myocardial infarction with mural thrombi, valvular heart disease, and structural heart defects (such as right to left shunts).
99
Unilateral, sudden HA, orbital tenderness, tears, male, tobacco, 40s;
Most likely dx - workup - tx
Cluster HA
Dx is clinical;
O2
100
Four origins of mesenteric ischemia?
1. Mesenteric artery embolus (50%)
2. Mesenteric artery thrombus (20%) - highest mortality
3. Mesenteric vein thrombus (10%)
4. Nonocclusive ischemia (20%)
101
Tx for Acetaminophen OD:
In addition to decontamination with repeated doses of activated charcoal, the antidote N-acetylcysteine (Mucomyst) should be administered if indicated by the Rumak nomogram (toxic level measurer).
102
Carotid dissection symptoms
```
Severe onset
Painful with prostration
Sinus pain/ear pain
Loss of vision in 1 eye
Neurologic symptoms persist days after dissection
```
103
Methanol is metabolized to:
formaldehyde
104
Where is normal ventricular vector (axis) directed?
Toward the left hip
105
Pharyngitis that improves, followed by severe sepsis;
| diagnostic r/o
Lemierre's syndrome
106
What antibiotics are indicated for uncomplicated appendicitis?
ampicillin-sulbactam
cefoxtin
a combination of metronidazole and ciprofloxacin
107
Common causes of sympathomimetic toxidrome:
over-the-counter cold agents (containing ephedrine);
illegal street drugs (eg, cocaine, amphetamines, methamphetamine);
dietary supplements (ephedra);
illicit designer drugs (eg, 3,4-methylenedioxy methamphetamine (MDMA, “ecstasy”)
108
Overweight, young female, visual symptoms, HA;
| Most likely dx - workup - tx
Pseudotumor cerebri/Idiopathic Intracranial HTN;
CT/LP;
LP may be therapeutic;
+/- acetazolamide
109
Treatment for acute Raynaud's
Nitro paste or phentolamine
110
Female
Abdominal pain
absence of blood flow to one ovary on pelvic ultrasound with doppler;
dx?
Ovarian torsion
111
AMS and uncooperative;
| Next best step?
Calm, or sedate/restrain
112
If 2 mg lorazepam push x 3 doses fails to stop a seizure, what is the next step?
15 mg/kg Phenytoin (Dilantin) IV piggyback
113
Abdominal pain in conjunction with hemodynamic instability should alert the physician to the possibility of: (4 things)
Hemorrhage, sepsis, perforated viscus, necrotic bowel
114
How id choledocolithiasis treated?
surgical or endoscopic (ERCP) removal of the stone
115
Best mgmt for severe hypothermia with mental status changes and cardiac dysrhythmia:
Active core rewarming
116
Best study for diagnosing pneumoperitoneum
CT
117
Common cause of HHNK (Hyperglycemic hyperosmolar nonketotic coma)
T2DM with dehydration
118
A lucent period is commonly associated with what head injury?
Epidural hematoma
119
RUQ tenderness in the setting of PID suggests what syndrome?
Fitz-Hugh-Curtis syndrome where the infection extends to cause a perihepatitis with inflammation of the liver capsule and ‘violin string’ scar tissue formation;
Referred R shoulder pain also possible
120
Rare symptom of opiate OD:
Flash pulmonary edema
121
What is the tx for thyrotoxicosis?
IVFs, propranolol
122
Most common reaction to scorpion sting
Parasthesias and pain at site
123
Dose of morphine for CHF/MI
4 or 5mg
124
What is the pathophysiology of appendicitis?
Elevated appendiceal intraluminal pressure results initially from luminal obstruction and continued secretion from the luminal mucosa
125
Mortality in cases of pneumoperitoneum:
30-50%
126
What diagnosis should always be considered in an elderly patient presenting with abdominal pain?
Mesenteric ischemia
127
When is immediate surgical consult needed in the setting of abdominal pain?
Hemodynamic instability
| Rigid abdomen
128
Complications of severe hypothermia/reasons why we consider intubation:
Bronchorrhea
Ileus
Depressed protective airway reflexes
129
Common causes of vertebral dissection
```
Chiropractor
Yoga
MVA
Crossfit
Rollercoaster
Dance
```
130
ACLS
Patient found unresponsive and CPR performed until arrival to ED. EKG demonstrates wide-complex regular rhythm with no palpable carotid pulse, consistent with PEA (pulseless electrical activity) arrest. Next step in mgmt:
Epinephrine
131
What are risk factors for spontaneous secondary PTX (not due to Marfan/personal or FH, smoking)?
COPD,
cystic fibrosis,
tuberculosis,
AIDS patients with pneumocystis pneumonia
132
Unexplained hypotension in a childbearing female is what until proven otherwise?
Ectopic pregnancy
133
What kinds of organisms should be covered in an antibiotic regimen for a perforated viscus?
Gram neg, pos, anaerobes
| Some appropriate choices include ciprofloxacin and metronidazole, piperacillin/tazobactam, or imipenem.
134
Xrays to get for suspected bowel obstruction:
An upright chest film (looking for free air/perforation),
an upright abdominal film (looking for air fluid levels),
and a supine abdominal film (looking for distended loops of bowel)
135
What are the pieces of cholinergic toxidrome?
```
SLUDGE:
Salivation
Lacrimation
Urination
Diaphoresis and defecation
Gastrointestinal upset
Excessive bradycardia or tachycardia (muscarinic or nicotinic)
```
136
What does P in AEIOU TIPS stand for?
AMS
Psychiatric
Poisons
137
Most common location for mesenteric artery embolus
SMA
138
Acalculous cholecystitis is common in what patient populations?
Acalculous cholecystitis is more often in patients who are elderly, post-operative, or critically ill from other causes.
139
What does E in AEIOU TIPS stand for?
AMS
Electrolytes
Encephalopathy
Epilepsy
140
Pathophysiology of acetaminophen OD:
In an acute overdose, APAP is metabolized to NAPQI which combines with glutathione and is excreted. When the majority of the glutathione is used, NAPQI causes hepatic toxicity.
141
What is the P wave?
Depolarization of right then left atria through Bachmann's bundle
142
AMS and petechiae suggest what dx?
Meningiococcemia (Neisseria sepsis)
143
Inspiratory wheezes tend to be what part of the airway
Inspiratory stridor suggests obstruction above the vocal cords (eg, foreign body, epiglottitis, angioedema)
why? Bernouli's principle - airflow
144
Risk factors for mesenteric ischemia due to mesenteric vein thrombus:
MVT risk factors include hypercoagulable states (Factor V Ledien, protein C deficiency, etc.), recent surgery, malignancy, and cirrhosis.
145
Risk factors for non-occlusive mesenteric ischemia:
```
Cardiogenic shock
Congestive heart failure
Arrhythmias
Sepsis
Hypotensive states
Drugs causing mesenteric vasoconstriction
```
146
Supraventricular rhythms have what kind of QRS complexes?
Narrow QRS
147
What are the pieces of the anticholinergic toxidrome (5 things)?
```
Mad as a hatter (Altered mental status)
Blind as a bat (mydriasis)
Hot as Hades
Red as a beat
Dry as a bone
```
148
SAMPLE
```
get useful information quickly
S - c/c
A - Allergies
M - Meds
P - PMH/PSH
L - Last meal
E - Events/HPI
```
149
A patient presents with severe abdominal pain radiating to the back. Xray shows intra abdominal air above the liver. What is the next best step?
Surgical consultation
150
Ddx for testicular torsion (11 things):
```
Testicular torsion
Torsion of the appendix testis
Epididymitis
Orchitis
Renal colic
Varicocele
Kidney stone
Appendicitis
Hernia
Hydrocele
Testicular trauma
```
151
Mainstay of treatment of patients with frostbite
Immediate warm water immersion
| Tetanus prophylaxis and debridement occur later
152
Two common associations with Afib:
Ischemic heart disease
| Thyrotoxicosis
153
Immediate antagonism of K+ at the cardiac membrane is achieved with:
IV administration of calcium chloride or gluconate
154
What does the PR interval represent?
Atrial depolarization plus travel to AV node while ventricles fill
155
Sources of angioedema
```
NSAIDs
ACEi
ARBs
C1 esterase inhibitor deficiency
Patients who receive intravenous (tPA) for acute ischemic stroke are also at risk for developing angioedema, which tends to be hemi-lingual and contralateral to the ischemic hemisphere
```
156
What is a HIDS scan?
A HIDA scan is a nuclear imaging procedure that utilizes a radioactive tracer, technetium-99m, to evaluate GB function. The tracer is injected intravascularly, circulates to the liver, and is excreted into the biliary system
157
The most important laboratory test to order before surgery is:
type and screen/cross
158
Isoelectric means
E impulse traveling perpendicular
159
EKG
| 1s =
5 big boxes
160
Contraindications to the use of IV contrast:
Renal failure
| Allergy
161
Body temp in heat stroke:
>40.5C
162
Who should receive a transvaginal u/s when considering ectopic pregnancy?
a transvaginal ultrasound should be performed on all patients in whom the diagnosis of ectopic pregnancy is considered despite the β-hCG level, as both IUP’s and ruptured ectopics have been diagnosed at very low levels
163
Hyperkalemia values:
Hyperkalaemia is defined as a potassium level > 5.5 mEq/L;
Moderate hyperkalaemia is a serum potassium > 6.0 mEq/L;
Severe hyperkalaemia is a serum potassium > 7.0 mE/L
164
What does I in AEIOU TIPS stand for?
AMS
| Insulin
165
What is the inpatient tx for PID?
Cephalosporins and doxy
166
When is IV administration of calcium chloride or gluconate indicated for hyperkalemia?
Hypotension
| Unstable dysrhythmia
167
Obligatory test for any patient who has syncope
EKG
168
What is Morrison's Pouch?
The hepatorenal recess (subhepatic recess, pouch of Morison or Morison's pouch) is the space that separates the liver from the right kidney. As a potential space, the recess is not filled with fluid under normal conditions.
169
Symptoms of moderate hypothermia:
AMS
Absence of shivering
Bradycardia
Bradypnea
170
Most common causes of pneumoperitoneum
Perforated abdominal viscous (peptic ulcer rupture);
Tumor
Trauma
171
Unilateral adnexal tenderness or fullness may suggest the presence of:
Tubulo-ovarian abscess
172
An S3 suggests:
An S3 heart sound suggests left ventricular systolic dysfunction, especially in the setting of ADHF
173
Naloxone Pearl
The Naloxone will wear off before the opiate so the patient can NOT be discharged without a period of observation. Administration of Naloxone may cause the patient to go into opiate withdrawal, so be prepared for a very violent and combative response and use only the dose necessary to return a normal respiratory rate.
174
Why get a UA when considering appendicitis?
Pyuria without bacteria present can be cause by inflamed appendix in close proximity to the ureter or bladder.
175
Dose of nitro for CP
0.4mg
176
Where do most esophageal tears occur?
Distal esophagus
177
Tx for isopropanol ingestion
Isopropanol is usually not life threatening and can be managed by supportive care. In rare instances hemodialysis may be required.
178
What testicle is more frequently affected in torsion?
Left
179
Where is ethylene glycol found?
Antifreeze
180
Medication and dose to administer during cardiac arrest
Epinephrine 1mg
181
EKG
| Chest or precordial leads are
```
V1-V6
horizontal plane (front to back)
```
182
CXR in ADHF findings include:
cardiomegaly, cephalization of blood vessels, interstitial edema (eg, "Kerley B" lines, peribronchial cuffing), and vascular congestion. Pleural effusions may be present.
183
Contraindications for methotrexate administration in the medical mgmt of ectopic pregnancy
hemodynamic instability, inability to return for follow-up, breastfeeding, immunodeficiency, renal, liver or pulmonary disease, peptic ulcer disease, and blood dyscrasias
184
What is cholangitis?
Cholangitis is inflammation of the bile ducts and is most often caused by a polymicrobial bacterial infection. Biliary obstruction – such as from a stone or neoplasm – serves as a major factor in its pathogenesis. The condition is less common than cholecystitis, but has significantly higher mortality (40% vs 15%).
185
Test to r/o Lemierre's syndrome
Contrast CT of neck
186
Scorpion species in the US responsible for serious toxicity
Centruroides exilicauda
187
Asthma meds
Albuterol 2.5mg/3ml neb
Ipratroprium
Salumedrol
Mg --> antiinflammatory and bronchodilator
188
Neurological deficits, dBP>120, AMS
| Dangerous Disease to r/o - Workup - Tx
Encephalopathy
| Bring MAP down to less than or equal to 25%
189
Test to r/o ovarian torsion
Transvaginal U/S w/ Doppler to confirm blood flow
190
Suspicion for Perforated viscous includes what in the workup?
Upright abdominal CXR
Amylase/lipase (consider pancreatitis)
IVF
191
What does U in AEIOU TIPS stand for?
AMS
| Uremia
192
ADH blockers:
Fomepizole;
| Ethanol
193
Major disease complication of synthetic MJ use
CVA
194
Most common cause of Afib
HTN
195
MI Pearl
Clinicians are more likely to miss an MI in the patient whose chief complaint is dyspnea, rather than chest pain.
196
Sepsis criteria include
```
2 or more:
Temp >38°C (100.4°F) or < 36°C (96.8°F);
HR > 90;
RR>20 or PaCO2>32;
WBC > 12,000, < 4,000 or >10% bands
```
197
In the evaluation of ectopic pregnancy, if the patient is ill appearing, has severe pain, or any abnormal vital signs, they should receive:
Immediate bolus NS
198
Bilateral HA, tightness;
| Most likely dx - workup - tx
Tension HA
Dx of exclusion
Tx is pain control
199
Three common causes of anticholinergic toxidrome:
TCA’s Tricyclic antidepressants
Antihistamines
Overactive bladder medication
200
A migrant worker is found wandering on a deserted road. He is confused, sweating and wheezing. You notice that he has been incontinent. His vitals are as follows: Pulse 36, respiratory rate 24, Blood pressure 100/68, Temp 98F, Sat 96% on room air;
What toxidrome?
Cholinergic toxidrome
201
Heme-positive or grossly bloody stools can be indicative of:
Aortoenteric fistula
202
If an IUP is visualized, a concurrent ectopic pregnancy (heterotopic pregnancy) is statistically unlikely unless:
the patient has received fertility treatments
203
V-tach second treatment or unstable ACLS
Cardiovert
204
Rapid ascent can precipitate what decompression illness?
Arterial gas embolism
205
What size ET tube should you use in massive hemoptysis?
8, to facilitate bronchoscopy
206
Mainstay of treatment for a scorpion sting
Analgesia
207
Subtle signs of mesenteric ischemia picked up on CT:
circumferential thinking of the bowel wall
bowel dilatation
bowel wall attenuation
mesenteric edema (which may not be seen on angiography)
208
Biliary disease Pearl
Normal labs should not preclude the use of diagnostic imaging when there is a strong clinical suspicion for acute cholecystitis
209
How long does it take for xanthochromia to show up on LP?
>2 hours since start of bleed
| note there will be increased opening pressure
210
MONA BASH stands for
```
Morphine
O2
Nitrates
ASA
Beta blocker
ACEi
Statin
Heparin
```
211
When is antivenom indicated for scorpion stings?
Severe reactions and anaphylaxis only
212
7 steps for immediate AMS management
1. Assessment of the ABC’s
2. Cardiac monitoring and pulse oximetry
3. Supplemental oxygen if hyperemic
4. Bedside glucose testing
5. Intravenous access
6. Evaluation for signs of trauma and consider c-spine stabilization
7. Consider naloxone administration if narcotic overdose is suspected
213
hot, dry skin;
>40.5C;
CNS abnormalities ie delirium, convulsions, coma;
dx?
Heat stroke
214
Steps for treating migraine
| Step 4
Call Neurology
215
ADHF Pearl
The radiograph may lag behind the clinical picture and approximately 20 percent of patients admitted with ADHF have a nondiagnostic CXR. Lung ultrasound is more sensitive than CXR in diagnosing ADHF and should be used if available.
216
What is Todd's paralysis
Focal weakness after a seizure
217
Patient presentation of ovarian torsion
sudden onset of unilateral pelvic pain, sometimes radiating to the groin, often associated with nausea and vomiting. Look for corroborating evidence on pelvic exam: adnexal tenderness on the same side as the pain and less commonly an adnexal mass
218
Body temp associated with moderate hypothermia:
28-32C
219
Mixed inspiratory and expiratory stridor suggests:
Expiratory stridor or mixed inspiratory and expiratory stridor suggests obstruction below the vocal cords (eg, croup, bacterial tracheitis, foreign body).
220
Which is the greatest risk for suicide?
Panic disorder
Female Gender
Panic disorder
221
If the BP is low, what pain medication may considered in the setting of abdominal pain?
Fentanyl
222
What does I in AEIOU TIPS stand for?
AMS
| Infection
223
Tx for fast and narrow QRS ACLS
Adenosine
224
Afib increases the risk of:
Thrombus formation and arterial embolization
225
What are Class II antiarrhythmics?
Beta blockers
226
T/F: HTN causes HA
False. HTN rarely causes HA.
227
AMS Pearl
Decreased level of consciousness with cranial nerve findings is a brainstem lesion until proven otherwise.
228
If a COPD exacerbation does not improve with standard tx, suspect what?
Pulmonary emboli may be responsible for up to 25 percent of apparent "COPD exacerbations" and should be suspected when the patient fails to improve with standard COPD treatment measures.
229
Recommended bedside diagnostic maneuver for suspected aortic dissection
Bilateral blood pressures in arms
230
9 Risk Factors for Ectopic Pregnancy
```
Pelvic Inflammatory Disease
Previous ectopic pregnancy
Tubal surgery including BTL
Previous pelvic or abdominal surgery
Tubal Pathology
In utero diethylstilbestrol (DES) exposure
Intrauterine device use
Smoking
Infertility and infertility treatments
```
231
Patient presentation of gallstone ileus
Like a SBO
232
Common BP medications for HTN encephalopathy
Nitroprusside
Labetalol
Fenoldepam
233
Tx for Lemierre's syndrome
Ampicillin-sulbactam or a carbapenem;
| Dispo: Admit
234
Class of antiarrhythmic: Beta blocker
Class II - B
| Block AV node, decrease sympathetic activity on heart
235
EKG
| 1 big box =
0.2s (200 ms)
| 5 small boxes
236
Biliary disease Pearl
RUQ pain lasting more than 6 hours should NOT be attributed to benign biliary colic regardless of the presence or absence of significant laboratory or imaging abnormalities. Persistent pain should prompt admission and further evaluation.
237
Unilateral HA, N/A, photophobia;
| Most likely dx - workup - tx
Migraine
Dx is clinical
Metoclopramide, ketorolac, tromethamine, IVFs
238
When are bloody stools seen in mesenteric ischemia?
Bloody diarrhea and heme-positive stools are a late finding after bowel has infarcted.
239
What is phentolamine? Drug class and uses
Phentolamine (Regitine) is a reversible nonselective α-adrenergic antagonist.
Lowers BP
Use in cocaine OD
Can prevent sin injury after norepi injection
Use in acute Raynaud's
240
Diagnostic imaging choice for suspected DVT
U/S of affected extremity
241
Tx for hypoglycemia causing AMS
Dextrose
242
People with polycystic kidneys also have what in their brains?
Berry aneurysms
243
Two easily reversible causes of AMS to consider:
Hypoglycemia, Narcotic OD
244
Causes of bowel obstruction
tumors and hernias, strictures, intussuseption, volvulus, Chrohn’s disease, and gallstones
245
Suppurative thrombosis of internal jugular vein;
F. necrophorum implicated;
Unilateral neck swelling, tenderness, induration
dx?
Lemierre's syndrome
246
What is papaverine?
Vasodilator
It can treat angina, heart problems, and blood vessel problems by relaxing muscles and blood vessels. It can also relax muscles in the digestive system and other parts of the body.
247
Class of antiarrhythmic: CCBs
Class IV
| Reduce conduction on AV node, reduce contractility of heart
248
What toxicity can present totally asymptomatically and can be missed if not screened for?
Acetaminophen OD
249
```
Labored breathing
Good inspiratory effort, lungs clear
Heart sounds distant
Cancer patient
No peripheral edema;
Dx and next step?
```
Dx - Malignant pericardial effusion
| Next step - bedside cardiac u/s
250
97% of ectopic pregnancies occur in the:
Fallopian tube
251
In a COPD exacerbation, when is noninvasive positive pressure ventilation used?
Hypoxia that is refractory to initial management
252
What hematologic cancer carries an increased risk of bowel obstruction?
Non-Hodgkin's lymphoma
253
Where is Hartmann's pouch?
pouch at the junction of the neck of the gallbladder and the cystic duct
254
What are some valvular dysfunctions that can present with dyspnea?
Aortic stenosis, mitral regurgitation, or ruptured chordae tendinae
255
What is the classic triad of a AAA?
The classic triad of ruptured AAA is:
pain
hypotension
pulsatile abdominal mass
256
The most common vital sign abnormality in PE
Tachypnea
257
What is the appropriate management for a patient with testicular torsion when who can't get to the OR immediately?
Manual detorsion
258
When is MRI indicated in the diagnosis of appendicitis?
MRI is typically reserved for pregnant patients with a nondiagnositic ultrasound.
259
The three toxic alcohols to remember for toxicity:
isopropanol
methanol
ethylene glycol
It is important to obtain a metabolic panel on these patients.
260
FAST exam - where
Focused Assessment with Sonography for Trauma
(FAST) should include views of (1) the hepatorenal recess (Morison pouch), (2) the perisplenic view, (3) the subxiphoid pericardial window, and (4) the suprapubic window (Douglas pouch).
If an extended FAST (E-FAST) examination is performed, views of (1) the bilateral hemithoraces and (2) the upper anterior chest wall should also be obtained.
261
Unilateral HA, neck pain, +/- trauma
| Dangerous Disease to r/o - Workup - Tx
Carotid artery dissection
CTA/MRA, u/s
Anticoagulate
262
Preferred antibiotic to send home with for PID
Doxy
263
What treatment for hyperkalemia works through the stabilization of cardiac membranes?
Calcium
264
Abx for dental infection
Augmentin
265
Causes of high output heart failure
severe anemia,
pregnancy,
Beriberi (thiamine deficiency),
thyrotoxicosis
266
What bedside diagnostic and therapeutic procedure should be taken with testicular torsion?
Rotate the affected testicle in a medial to lateral position (540 degrees)
267
What does T in AEIOU TIPS stand for?
```
AMS
Trauma
Temperature
Toxins
Tumor
Thyrotoxicosis
```
268
When is HIDA indicated in the diagnosis of cholecystitis?
HIDA scan is indicated if US is equivocal or negative for cholecystitis in the presence of a high clinical suspicion.
269
Why get an EKG for suspected mesenteric ischemia?
atrial fibrillation can put pts at risk for an embolic cause of mesenteric ischemia
270
What is Charcot's triad, and what diagnosis does it suggest?
RUQ pain, fever, and jaundice
| Cholangitis
271
Sepsis workup includes?
CXR (pneumonia)
Blood and cultures
UA
+/- LP
272
Tx for cholinergic toxidrome:
Atropine, pralidoxime, decontaminate
273
What is Prehn's sign?
Prehn's sign describes the (relief of pain with elevation of the testicle and) was once to be touted as a method to distinguish epididyydimitis from torsion since the pain associated with torsion is usually not relieved with elevation of the testicle (ie, positive Prehn's epidiydyimitis).
274
The T wave represents
Ventricular repolarization
275
large elevations in bilirubin and alkaline phosphatase should alert the physician to the possibility of:
Bile duct obstruction
276
What diagnostic test confirms the diagnosis of Fitz-Hughes-Curtis syndrome?
Elevated LFTs
277
What is the window for administering thrombolytics for an ischemic stroke?
3 hours
278
What is the coma cocktail for patients who have lost consciousness due to suspected toxicity?
1. Hypoxia: Place on 100% O2 nonrebreather (also useful prior to intubation)
2. Hypoglycemia: obtain a point of care fingerstick blood glucose
3. Opioids: administer Narcan 0.4 to 2mg IV to reverse opiates
4. With an unresponsive patient, if these measures do not reverse the patient’s symptoms, then intubation should be performed.
279
In cholangitis, in what order to lab abnormalities develop?
AST/ALT go up first
| Then bili
280
Appendicitis Pearl
Urinalysis with pyuria or hematuria can be appendicitis due to an inflamed appendix next to the bladder.
281
Fever, stiff neck, photophobia;
| Dangerous Disease to r/o - Workup - Tx
Meningitis
| Abx before LP, CT later, isolation bed, +/- steroids
282
What beta hcg levels are expected in ectopic pregnancy?
The discriminatory zone of β-HCG (ie, the level above which an imaging scan should reliably visualize a gestational sac within the uterus in a normal intrauterine pregnancy) is as follows:
1500-1800 mIU/mL with transvaginal ultrasonography, but up to 2300 mIU/mL with multiple gestates
6000-6500 mIU/mL with abdominal ultrasonography
Absence of an intrauterine pregnancy on a scan when the β-HCG level is above the discriminatory zone represents an ectopic pregnancy or a recent abortion.
283
If the diagnosis of testicular torsion is unclear, what diagnostic test should be obtained?
Order an ultrasound to assess for the presence or absence of vascular flow if the diagnosis is unclear.
284
Without antivenom, how long do symptoms of a scorpion sting last?
1-2 days
285
Patient presentation in acute decompensated HF
Common findings include tachypnea, pulmonary crackles, jugular venous distension, S3 gallop, and peripheral edema. ADHF is among the most common causes of acute respiratory failure among patients over 65 years.
286
Pathophysiology of salicylate poisoning
Salicylate overdose leads to stimulation of the medullary respiratory center, initially causing hyperventilation and respiratory alkalosis, followed by metabolic acidosis. In some cases, pulmonary edema may occur with severe poisoning. Prominent extrapulmonary signs include fever, tinnitus, vertigo, vomiting, diarrhea, and in more severe cases mental status changes.
287
2 diseases associated with mesenteric ischemia:
Atherosclerosis
Embolic disease
(Afib)
288
Nonbiliary differential for RUQ pain:
hepatitis, right lower lobe pneumonia, kidney stone/infection, and acute coronary syndrome with atypical presentation
289
How to assess for pulsus paradoxus
In order to determine if a pulsus paradoxus is present, measure the patient's systolic blood pressure after a normal exhalation. Then have the patient inhale normally and determine systolic pressure when the lungs are expanded. Pulsus paradoxus exists if the difference in systolic pressures is greater than 10 mmHg. Keep in mind that the absence of pulsus paradoxus does not rule out any disease.
290
Clinical signs of DVT
Leg swelling, edema, erythema, warmth, tenderness to palpation, dilation of superficial collateral veins, palpable venous cord
291
T/F: In a drowning scenario, hypoxia is based on the volume of water aspirated, not the content.
True
292
Three broad categories of AMS:
Delirium
Dementia
Psychosis
293
EKG
| 1 small box =
0.04s (40 ms)
294
SBO symptoms include
abdominal pain, abdominal distension, vomiting, and inability to pass flatus
295
Steps for treating migraine
| Step 3
1 mg depakote
296
findings consistent with tension PTX include:
hypotension, elevated neck veins, unilateral diminished or absent breath sounds
297
Why are first rib fractures concerning?
1. hard to get to - indicates trauma was severe
| 2. if broken --> PTX or can push on great vessels
298
Best test to diagnose cardiac tamponade/pericardial effusion
Cardiac u/s
299
Where do patients localize their pain in cases of mesenteric ischemia?
The abdominal pain will initially be severe and diffuse without any localization. One of the distinctive findings in mesenteric ischemia is that of abdominal pain that is out of proportion to examination. The patient may be screaming in pain, but their abdomen is soft with no guarding or rebound.
300
URI, HA, sinus tenderness, opacified;
| Most likely dx - workup - tx
Sinusitis
Dx is clinical +/- CT;
Nasap spray/pseudoephedrine
+/- Abx
301
Upright deflection means
E impulse traveling toward
302
Most common cause of SBO
adhesions
303
What are signs of severe disease in an asthma exacerbation?
```
use of accessory muscles
brief fragmented speech
profound diaphoresis
agitation
failure to respond to aggressive treatment
```
304
In papillary muscle rupture, which valve's regurgitation is responsible for shortness of breath?
Mitral valve
305
What inflammatory marker can be measured along with CBC when considering appendicitis?
C-reactive protein
306
AAA Pearl
When a patient has a known or suspected ruptured AAA, the patient should be considered unstable, regardless of initial vital signs or hemoglobin.
307
Pulse 122, Respiratory rate 18, Blood Pressure 120/80, Temp 100.8F, Sat 98% on room air. She is mumbling and picking at her clothes. On exam, her pupils are 8mm and her skin is flushed but she is not sweating and her bladder is full;
What toxidrome?
Anticholinergic toxidrome
308
Unilateral HA, >55yo, tender temporal artery
| Dangerous Disease to r/o - Workup - Tx
Temporal arteritis/giant cell arteritis;
ESR +/- biopsy
Steroids, f/u with ophthalmology/rheumatology
309
What is whole bowel irrigation and when is it used?
Whole bowel irrigation involves the administration of an osmotically balanced polyethylene glycol electrolyte solution (like Go Lytely) to flush the bowel to prevent the absorption of ingested toxins. It is used in:
cases where charcoal is not effective;
with certain sustained release products;
in cases of illicit drug packet ingestions (body packers).
310
GCS for motor:
```
6 – Obeys commands
5 – Localizes to pain
4 – Withdraws to pain
3 – Abnormal flexion/posturing
2 – Abnormal extension/posturing
1 – None
```
311
What is choledocolithiasis?
Choledocholithiasis refers to the presence of gallstones within the common bile duct.
312
Class of antiarrhythmic: Dofetilide
Class III - C
Also amiodarone
K channel blocker
313
Why should doxy be given orally whenever possible?
Doxycycline should always be given orally when possible, because it is caustic to vessels.
314
Unilateral HA, blurry, fixed pupil;
| Dangerous Disease to r/o - Workup - Tx
Acute glaucoma
tonometry (measure IOP)
acetazolamide, beta blocker, consult ophthalmology
315
When does shivering cease?
32C
316
Fever, AMS;
| Dangerous Disease to r/o - Workup - Tx
Encephalitis
| LP first, CT later, IV Abx/antiviral, iso bed
317
Toxicity Pearl
Some lay people call any over-the-counter pain reliever by a single name regardless of actual name and drug class.
318
Steps for treating migraine
| Step 2
Mg
319
Differential for syncope + CP
MI
PE
Pericardial effusion
Thoracic aortic dissection
320
Side effects of antivenom
Serum sickness
| immediate and delayed hypersensitivity
321
Two common sources of cholinergic toxidrome:
```
organophosphate poisoning (pesticides)
nerve agents
```
322
Risk factors for ovarian torsion
prior ovarian cyst or mass, prior ovarian torsion, or current pregnancy (ie, corpus luteum cyst)
323
Tx for anticholinergic toxidrome
Mostly supportive (+/- specifics for TCA ingestion)
324
PE risk factors:
history of deep venous thrombosis or pulmonary embolism
prolonged immobilization
recent trauma or surgery (particularly orthopedic)
pregnancy
malignancy
stroke or paresis
oral contraceptive or other estrogen use
smoking
a personal or family history of hypercoagulability
325
What bHCG level would indicate IUP?
>1500
326
Suspect a larynx fracture in patients complaining of dyspnea in the setting of:
severe neck pain and dysphonia following blunt trauma
327
What is the normal size of an appendix?
A normal appendix on ultrasound is typically less than 6 mm and compressible. An appendix greater than 6-7 mm in diameter and noncompressible is indicative of appendicitis.
328
Afib treatment options include:
```
CCB
BB
quinidine
amiodarone
cardioversion
```
329
A patient was pulled from a frozen lake and is unresponsive;
Cardiac monitor shows v-tach;
Defibrillation attempt shows no change;
Next step?
Continue CPR only until warmed to 30C
330
Where can pain from a ruptured AAA radiate?
The pain can radiate to the chest, thigh, inguinal region, or scrotum.
331
What is bronchorrhea?
Bronchorrhea is the production of more than 100 mL per day of watery sputum. Chronic bronchitis is a common cause, but it may also be caused by asthma, pulmonary contusion, bronchiectasis, tuberculosis, cancer, scorpion stings, severe hypothermia and poisoning by organophosphates and other poisons.
332
GCS for verbal:
```
5 – Oriented
4 – Confused
3 – Inapprop words
2 – Incomprehensible sounds
1 – No Sounds
```
333
Two most common causes of PEA
Hypoxia
| Hypovolemia
334
Treatment for non-occlusive mesenteric ischemia
Correct underlying problem
335
10 No Miss Diagnoses in Abdominal Pain Differential:
```
Ectopic Pregnancy
Appendicitis
Abdominal Aortic Aneurysm (AAA)
Pelvic Inflammatory Disease (PID)/Tuboovarian Abscess (TOA)
Biliary Disease
Bowel Obstruction
Perforated Viscus
Mesenteric Ischemia
Testicular or Ovarian Torsion
Also...ACS
```
336
Reversal for dabigatran
Idarucizumab
337
```
CHF
Hypoalbuminemia
Cirrhosis
Nephrotic Syndrome
Causes of:
```
Transudative effusion
338
Infection, PNA, TB, Neoplasm, Uremia, Pancreatitis, Esophageal Rupture
Causes of:
Exudative Effusion
339
EKG PE
S1Q3T3
| ST Changes
340
Pertussis tx
Erithromycin or 1 m Azithromycin
341
RSI in asthmatics
Ketamine
342
Well's Criteria
```
HR > 100 1.5
Less likely alternative dx 3
Malignancy 1
Clinical sxs DVT 3
Hemoptysis 1
Immobilization 3 days/Surgery 4 weeks 1.5
Previous PE/DVT 1.5
```
343
What improves mortality in PJP PNA?
Steroids
344
Tx PJP PNA
Bactrim
345
Tx Croup (laryngotracheitis)
Dexamethasone
| Racemic epi if stridor at rest
346
Sever disease
Apophysitis of calcaneus
347
Tetanus tx
Metronidazole 10-14 days
348
Inaccurate Labs from IO
WBC, K, Ca, AST/ALT, blood O2
349
glucose dose neonates
10% 5 mL/kg (rule of 50s)
350
Reduces both preload and afterload
Nitro
351
Antibiotic coverage for suspected SBP
Fluoroquinolones
| TMPSMX
