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Emergency Medicine > Exam 1 > Flashcards

Exam 1 Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

basic vital signs

A

blood pressure, pulse, respiratory rate, temperature, pulse oximetry (and now pain)

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2
Q

when normal signs do not = hemodynamically stable state

A

acute blood and fluid loss
serious illness in infants
meds blunt response (elderly)

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3
Q

normal (adult) vital signs

A

BP: 90-120 / 60-80
HR: 60-100bpm
RR: 12-20

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4
Q

classification of blood pressure

A

normal: <120 and <80
pre-HNT: 120-139 or 80-89
HNT, stage 1: 140-159 or 90-100
HNT, stage 2: >160 or >100

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5
Q

children vitals - trends

A

BP is lower (80-110 systolic)
HR (80-100) and RR (15-30) higher

Note: infants even more dramatic

  • BP: 70-90 systolic
  • HR: 100-150
  • RR: 25-50
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6
Q

causes of tachypnea

A 
Pneumonia
Asthma Exacerbation
Heart failure
Pulmonary embolism
Anxiety
Drug intoxication
Metabolic Acidosis
Lung Trauma, rib fx
Pain
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7
Q

causes of bradypnea

A

Alcohol or drug overdose
Sedative or hypnotic medications
Impending respiratory failure
OSA/ Sleep apnea

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8
Q

best way to measure HR

A

apical rate (bottom left of heart) for 60 seconds

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9
Q

causes of tachycardia

A 
Fluid or blood loss
Anxiety
Pain
Sepsis
Allergic Reaction
Fever
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10
Q

causes of bradycardia

A

Medications
Drugs
Brain injury
Heart blocks

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11
Q

temperature

A

most accurate = rectal

oral is 0.6 C (1 F) lower than rectal

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12
Q

fever

A

not an illness - a clinical response (that of uncompfortable)

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13
Q

temperature: C to F conversions

A

37 = 98.6 F
38 C = 100.4 F
39 C = 102.2 F
40 C = 104 F

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14
Q

pulse oximetry

A

measures arterial hemoglobin (hgb) saturation

limits:

  • hypoperfusion (below 80 mmHg systolic)
  • hypothermia
  • anemia: if Hct is
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15
Q

causes of low oxygenation

A

elevation
hypoventilation
probe not on correctly (see waveform)
V-Q mismatch: atelectasis, pneumonia, PE, ARDS, CHF

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16
Q

AHA BP technique

A

seated for 5 min w/ arm supported at heart level

appropriate cuff size (bladder nearly or completely encircle arm)

no smoking or caffeine for 30 min

two or more readings separated by 2 min should be average (more taken if differ by >5mmHg)

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17
Q

blood pressure cuff - repercussions of improper fit

A

too narrow: overestimates BP

too wide: underestimates BP

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18
Q

causes of hypotension

A 
Acute blood or fluid loss
Sepsis
Anaphylaxis
Medications, drug overdoses
Fit people
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19
Q

causes of hypertension

A 
Medication non-compliance
Pain, anxiety (white coat syndrome)
Poor cuff size
Medical History: HTN, CAD, DM, renal insufficiency, 
Drugs :  cocaine, meth, decongestant
MAOI use with tyramine containing food (old anti-depressent)
Pheochromocytoma (tumor)
Renal Stenosis
“Hypertensive Emergencies”
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20
Q

hypertensive urgency

A

symptomatic elevated BP without End Organ Damage

BP of >180/120 used to suggest treatment

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21
Q

hypertensive emergency

A

elevated BP with End Organ Damage, such as ARF, MI, CHF, SAH (subarachnoid hemorrhage), stroke, etc.

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22
Q

possible result of HTN emergency

A

Pulmonary Edema - crackles in lungs

Aortic dissection – ripping tearing CP to back

ACS (Acute Coronary Syndrome) – CP, EKG changes, elevated trop

Preeclampsia – protein in urine, HA, edema

Hypertensive Encephalopathy – mental status changes

Subarachnoid Hemorrhage – sudden, worst ever HA

Ischemic Stroke – neuro deficits

Renal Failure – decreased UOP, high creatinine

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23
Q

HTN emergency workup

A

guided by symptoms

EKG : ST segment changes, suggesting ischemia
UA : Hematuria, casts, proteinuria suggesting renal impairment
CXR : pulmonary edema c/w CHF;
Widened Mediastinum c/w Aortic dissection

Other studies:
Electrolytes: elevated Cr, hyperkalemia
Head CT:  if concerned for stroke
Upreg:  preeclampsia 
Utox
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24
Q

HTN emergency - management

A

Immediate but careful reduction in BP - lower slowly (except aortic dissection and ischemic stroke)

Reduce MAP by no more than 10-20% in 1st hour

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25
Q

calculation MAP

A

MAP = [(2 x diastolic) + systolic] / 3

Usual 70-110

MAP of about 60 is needed to perfuse the coronary arteries, brain, kidneys

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26
Q

hypertensive urgency - treatment

A

Labetolol 200 mg po
Captopril 25 mg po
Nitroglycerin tab or spray
Clonidine .1-.2 mg PO

Note: clonidine drops BP quickly but can can cause quick rebound to HNT - ask when not to use

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27
Q

medications for HNT - general word roots

A
  • olols: beta blockers (block receptors for epi / adrenaline so heart beats slower and less intensely, which vessels dilate)
  • prils: ACE inhibitors (ACE converts Ang I to Ang II, which constricts muscles around blood vessels)
  • zides: diuretics (inc. salt in urine which takes H20 with it, decreasing vol. of fluid in vessels)
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28
Q

severe HTN (asymptomatic)

A

Treat if BP>180-200/110-120

Diuretics: HCTZ, 25 mg PO qd
- uncomplicated HTN

B-blocker : metoprolol 50mg PO BID
- angina, Post MI, migraines, SVT (supraventricular tachycardia)

ACE Inhibitor: Lisinopril 10mg PO qd

  • if HF, renal disease, stroke, DM
  • starting medications
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29
Q

pain

A

an unpleasant sensory and emotional experience with actual or potential tissue damage or described in terms of such damage.

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30
Q

oligoanalgesia

A

inadequate pain control

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31
Q

clinical features of pain

A

physiologic: inc. BP, inc. HR, tachypnea, nausea, diaphoresis (sweating), and skin color changes (pale or flushed)
behavioral: crying, yelling, cursing, withdraw, posturing,

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32
Q

pain and vital signs

A

vital signs are no a reliable guide to pain relief

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33
Q

pain assessment - pneumonic

A 
O: onset
P: provoking factors (what makes worse or better)
Q: quality (sharp, dull, constant)
R: radiation (where it moves)
S: severity
T: time course
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34
Q

results of poor pain management

A 
Unnecessary suffering
Delayed healing
Altered immune response
Altered stress response
Development of chronic pain
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35
Q

non-pharmacologic treatment for pain

A

heat/cold
immobilization/elevation
explanation/reassurance
distraction

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36
Q

narcotics - proper use

A

treatment of moderate to severe pain

- best known narcotics are opiates (derived form opium)

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37
Q

narcotics - things to consider when selecting

A 
route of administration
 - surgery: NPO
suitable initial dose
frequency of administration
side effects
use in- vs. out-patient
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38
Q

routes for pain medications

A

IV: easy to titrate, rapid onset of action, no delayed respiratory depression

IM: intramuscular - not common in ER

SQ: subcutaneous

PO: oral - slow onset, NPO (?), N/V

IO: interosseous - into bone marrow (often tibia), fast onset, good option with collapsed peripheral veins or edema; can deliver all meds!

IN: intranasal -pain control, seizures, palliative care, opiate OD, good for kids, limited on dose (max 1 ml q nostril)

PR: per rectal

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39
Q

conversion: pounds to KGs

A

lbs/2.2 = kgs

lbs/2 - 10%(lbs/2) - kgs

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40
Q

conversion: KGs to pounds

A

kg x 2.2 = lbs

kgx2 + 10%(kgx2) = lbs

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41
Q

analgesic

A

pain killer

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42
Q

narcotics / opioids - administration route for specific meds

A

PO: oxycodone, hydrocodone, codeine, methadone, tramadol

Common IV: hydromorphone, fentanyl, morphine
- Note that most of these meds can be given IM and PO also

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43
Q

side effects of opioids

A 
Nausea and vomiting (25%)
Constipation
Urinary retention
Respiratory depression (more pronounced in IV)
Sedation
Miosis (pupil restriction)
Pruritis (itching)
Antitussive (rid cough), antidiarrheal
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44
Q

acute opiate withdrawal - symptoms

A

Mydriasis (pupil dilation), yawning, increased bowel sounds, piloerection (goose bumps), restlessness, plus flu like symptoms:

  • n/v/d, abdominal cramping
  • rhinorrhea, lacrimation (tears)
  • myalgias, arthralgies, piloerection
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45
Q

acute opiate withdrawal - treatment

A

symptom management

may offer Clonidine (1-3 mg TID prn)

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46
Q

Janka’s PO pain med regimen

A
  1. Motrin 600-800 TID and/or Tylenol 1 g TID-QID
    - can take OTC
  2. Norco 5/325 or Percocet 5/325 1 tab QID prn, w/ colace, prune juice, metamucil; driving precautions
  3. Rarely –Dilaudid 2 mg QID prn +/- NSAIDs
    - may be missing something if need to prescribe in ER
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47
Q

prescribed opiate abuse in CO

A

CO has 2nd highest rate of prescription painkiller abuse in nation

coloradopdmp.org - website that lists all controlled substances a person has been prescribed

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48
Q

drug seeking behavior - red flags

A
  • Out of town
  • Lost or stolen prescription
  • ED visits on weekends or night
  • Frequent ED visits (no follow up appointments)
  • Unusual knowledge of controlled substances
  • Request a specific drug
  • Long list of drugs they are allergic to
  • Do not permit a physical exam
  • Create a sense of urgency
  • Common complaints: dental pain, back pain
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49
Q

drug speaking behavior - management

A

Attempt to contact patient’s physician to confirm history

Confirm patient has provided a copy of a photo ID and SSN

Check the CO PDMP

Talk to the the patient about your concerns

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50
Q

procedural sedation

A

pharmacological state of profound sedation with maintenance of all protective reflexes, spontaneous ventilation is adequate and airway is maintained

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51
Q

procedural sedation - levels

A

Minimal: mild anxiolysis (antianxiety) or pain control
- ventilation, CV fx maintained; no cardiac monitoring needed

Moderate (“conscious sedation”): pt is sleepy but arousable to voice or light touch (eyes closed)
- GOAL FOR MOST ED procedural sedation

Deep: requires painful stimuli to evoke a purposeful response
- may require assistance to maintain airway, CV fx usually maintained

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52
Q

general anesthesia

A

Patients cannot maintain airway or airway reflexes

Requires support of airway, breathing and cardiovascular functions

NOT COMMON IN ER

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53
Q

procedural sedation - patient evaluation

A

History: last meal, allergies, substance use and abuse, major organ system abnormalities, previous anesthesia use and complications.

Physical Exam: airway, heart, lungs

Fasting preferred

Patients with severe cardiac or pulmonary problems are poor candidates

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54
Q

procedural sedation - monitoring

A

Hemodynamic: cardiac monitor, auto BP cuff ( q 5 min)

Respiratory/Airway: continuous pulse oximetry, suction equipment, supplemental O2, bag valve mask, end tidal CO2?

Level of consciousness

IV access, reversal agents, COR cart

Provider skill set: necessary if problems occur

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55
Q

predictors of difficult airway

A

Obesity with short neck
Reduced neck movement
Reduced TMJ movement
Receding mandible

Mallampati grading system scale: assess ease of intubation if needed

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56
Q

Mallampati grading system scale

A

Assess ease of intubation if needed:

  • class 1: soft pallet, uvula, pillars visible
  • class 2: soft palate and uvula visible
  • class 3: soft palate and base of uvula
  • class 4: only hard palate visible
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57
Q

NSAIDS - mechanism

A

Potent inflammatory action occurs through inhibition of prostaglandin synthesis at wound site by blocking COX enzymes (reducing inflammation, pain and fever)
- aka, inhibits COX-1 and COX-2

Note: also upsets GI (ulcers) and causes bleeding (anti-coag) since prostaglandins protect stomach and help with coagulation

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58
Q

discharge criteria (from ER)

A 
Stable vital signs 30 min)
No evidence of respiratory distress
Minimal nausea (tolerate PO fluids)
Ambulation equal to pre-procedure
Alert, oriented, and able to retain discharge instructions
Responsible person to watch patient
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59
Q

wound management - history questions

A 
mechanism of injury 
 - how happen (bite, blunt, penetrating)
 - potential for infection
 - how long ago
tetanus status, meds, allergies, co-morbidities
foreign body possibility
 - sensation of FB
if hand injury: dominant hand, type of work
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60
Q

wound management - physical exam

A

document neurovascular function (injury to tendons, nerves, joint capsule, blood vessels)
- BEFORE anesthesia!

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61
Q

wound closure and suturing

A

typically do not close >8 hrs after injury (primary intention)

face/scalp/neck: up to 24 hours

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62
Q

bite wounds - animal or person

A

typically do no close (unless gaping or for cosmetic)

ABX: Augmentin

must call animal control (ask about rabies)

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63
Q

wound management - anticipatory guidance

A

begin to wash wound 1-2 days (impervious t water after 24-48 hrs)

remodeling lasts for up to 6 months (cannot predict scar at time of sutureing)

sunscreen will help scarring

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64
Q

mechanism of injury - 3 types

A

shear: simple dividing of tissue (sharp glass, knife); low energy force
- heal with good result

Compression: crushes skin against bone (stellate laceration)
- baseball bat, windshield

Tension: flap type laceration
- high energy forces with surrounding tissue devitalized and prone to infection

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65
Q

tetanus prophylaxis

A

Update if last Tetanus was > 10 years ago

If very dirty or high risk, consider updating if last dose 5-10 years ago

Tdap if adult; DTaP if pediatric

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66
Q

infection prevention

A

irrigation: high volume good
debridement: cut out fatty tissue and irregular edges

blood supply: higher = less infection

prep: clean would

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67
Q

prophylactic antibiotics in wound management

A

healthy patient do not require

Use in specific situations:

  • wound in mouth, genitals, feet (w/ saliva, feces, vaginal secretions)
  • delayed presentation
  • immunosupressed pt (DM, steroids, renal insufficiency)
  • bites of any kind
  • cartilage (poor blood supply) or joints
  • valvular heart disease
  • contaminated woulds with soil and organic materials (wood)
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68
Q

rabies - most likely transmitters

A

wildlife (92% exposures): raccoons, skunks, bats, foxes)

domestic animals (8%): cats, dogs

internationally: stray dogs
never: small rodents (squirrels, chipmunks, rats, mice, etc.)

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69
Q

principles of wound care

A

inspect and examine

prep (baby soap and H2O) and anesthesia

wash/irrigate/debride
- note: clip, do not shave hair

hemostasis (stop blood)
- if pulsing, explore arterial injury (if close, hematoma will occur)

exploration - explore through full ROM in bloodless field (use instruments)

closure (type, material used)
dressing
care instructions

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70
Q

local anesthesia for wound care

A

Drug classes: amides
- most common class: lidocaine (1-2 hrs), bupivicaine (4-6 hrs)

Drug class: esters
- cocaine, procaine, tetracaine (eye drops)

Epinephrine: often added to local anesthetic

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71
Q

epinephrine - why added to local anesthetics

A

provides hemostasis

longer duration of action

slows systemic absorption thus decreasing potential toxicity

can use “more” (but may not need to)

Note: never use on fingers, toes, penis, nose, or ears (extremities)

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72
Q

epinephrine - where not to use

A

fingers, toes, penis, nose, or ears (extremities)

- can block only circulation and cut off blood

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73
Q

ways to limit pain on injection of local anesthetic

A

Anesthetic is acidic (low pH) = burns!

Sodium bicarbonate 1:10 (shelf life 1 week)
Warming the solution
Size of the needle (smaller)
Injecting slowly
Use of a topical anesthetic
Ice on wound (especially helpful in kids)

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74
Q

wound irrigation

A

volume is key: more is better (min: 250cc, ave: 1 liter, 100cc/cm of wound length)

moderate pressure (except loose tissue = low pressure) - 18 gauge IV cath w/ 30-60 cc syringe
 - can use pulse evac if dirty

Do not irrigate puncture wounds - SOAK

use isotonic solution (saline) or tap water

75
Q

types of wound closure

A

primary intention
secondary intention
tertiary intention

76
Q

primary intention

A

surgical repair with initial reapproximation of tissue layers

typically do not close >8 hrs after injury

face/scalp/neck: up to 24 hours

77
Q

secondary intention

A

epithelialization and growth from base

used in ulcerations, abscess cavities, avulsions, punctures, bite wounds

also used in wounds >8 hrs since injury

78
Q

tertiary intention

A

delayed primary closure - surgical closure in 3-5 days after injury (only if no signs of infection)

used of high velocity wounds, contaminated wounds, old wounds, stab wounds

will lessen scarring and heal faster

79
Q

terms for describing layers of skin - how deep wound is

A 
epidermis - outermost
dermis
subcutaneous tissue (hypodermis)
superficial fascia
muscle layer
deep fascia
80
Q

prepping wound - hair removal / debridement

A

after cleaning (baby soap and H20)

  • clip, do not shave, hair
  • never clip eye lashes or brows

Debridement (all devitalized or necrotic tissue should be removed)

  • improves vascularity
  • reduces infection
81
Q

sutures - types, size, needle

A

absorbable: vicryl, chromic, gut
non-absorbable: ethilon, prolene, silk

size: inverse relationship (6.0 smaller than 2.0)

needle: reverse cutting needed used in ER (allows smooth, atraumatic penetration of touch skin and fascia)
- tapered needles used on soft tissue (or when smallest hole is needed)

82
Q

absorbable sutures - tensile strength and time to dissolve

A

Vicryl: has 2-4 weeks of tensile strength, can take 2+ months to dissolve

Plain Gut: 7-10 days of tensile strength; up to 90 d. to absorb

Fast Absorbing Gut: 5-7 days of strength, absorbs in 3-4 weeks

83
Q

suture sizes for different areas of body

A

face: 6-0
trunk: 3-0, 4-0
extremities: 4-0
- 5-0 on hands, toes
scalp: 4-0 (or staples)

84
Q

alternatives to sutures

A

staples: good for scalp

steri strips: older people with fragile skin, kids, used to anchor would on fragile skin

dermabond: glue (needleless wound repair)
- do not use deep
- best used on low tension wounds (avoid hands, feet, joints)
- do not use on places requiring frequent washing
- DO NOT USE topical antibiotics after closure

85
Q

goals of suturing

A

minimize tension, evert edges, symmetrical alignment, good wound prep, homeostasis to allow full visualization of injury

86
Q

wound care - what to tell patients

A

apply topical ABX ointment after lac repair and BID for 3-5 days (except Durabond)

dressing left on for 24 hours; after that removed and left open to air

clean wound: 50-50% H20 and water around wound edges or baby soap and H20

no soaking (swimming or hot tub)

timing of suture removal (if applicable)

signs of infection

avoid sun exposure (sunscreen for 6 mo)

87
Q

wound care - special concerns

A 
Lip: vermillion border
Oral: thru and thru
Hand lacerations: FB, joint/tendon
Eyelid lacerations: lacrimal system
Nose: septal hematoma
Ear: dressing is key
Puncture wounds: pseudomonas
Hand lacs: fight bite
Cheek lacs: facial nerve
88
Q

puncture wounds

A

do not close: heal to secondary intention

plantar wounds (bottom of foot): tx with Cipro to cover for pseudomonas (esp if went through shoe)

remove FB

soak - do not aggressively irrigate

89
Q

hand lacerations - special considerations

A

examine in position of injury and through full ROM (in bloodless field)

consider flight bite

x-ray for foreign body

PE: motor and sensory distally, perfusion/cap refill
- tendon involvement = referral

90
Q

ear lacerations - special considerations

A

use small (6-0) non absorbable sutures to close skin

cartilage only approximated

dressing is key: form into ear crevasses so no blood accumulation and distortion

91
Q

lip lacerations - special considerations

A

look for intraoral / thru and thru

look for dental injury

throw 1st stitch to approximate vermillion border (if involved)

if not, begin on mucosal aspect then repair orbicularis oris

ABX: PCN or clindamycin

92
Q

eyelid lacerations - special considerations

A

when to refer:

  • inner surface of lid
  • lid margins
  • lacrimal duct involvement (plastics referral)
  • ptosis involvement (eyelid)
  • tarsal plate involvement (on each lid - muscle attachment)
93
Q

nasal laceration

A

look for (and drain) septal hematoma - bloody pouch

align skin surrounding nasal canals

mucosal involvement: close with absorbable

94
Q

facial lacerations

A

parotid gland: must ensure duct potency into oropharynx

facial nerve: motor control of most of muscles of facial expression; taste to anterior 2/3 of tongue

95
Q

suture removal recommendations

A 
Face: 3-5 days
Scalp: 7-10 days
Hands: 7-10 days
Feet: 7-10 days
Extremities: 7-14 days (joints) 
Trunk: 7-10 days

note: leaving sutures in too long = scar

96
Q

lacerations - when to refer

A 
Patient request
Foreign bodies
Deep Structure involvement
Time constraints
Eye lid considerations
Level of comfort
97
Q

foreign bodies

A

x-ray finds glass, metal, gravel >2mm

if pt feels FB sensation, take good look

organic material (soil, wood, clay) more likely to become infected

98
Q

regional blocks: advantages over infiltration

A 
No tissue distortion
Avoids infiltrating highly sensitive areas (palm)
Longer duration of anesthesia
Smaller amount of anesthetic needed
Abrasion cleaning
Fracture analgesia
99
Q

regional blocks (or any anesthesia) - precautions

A

use sterile technique

  • alcohol swab anesthetic you are using (if already opened)
  • prep area before injecting
100
Q

regional blocks for facial anesthesia

A

supraorbital nerve: whole forehead

supratrochlear nerve (side of nose)

infraorbital nerve: under eye to top of lip

mental nerve: bottom lip and chin

Note: all line up with pupil
Note: rub tissue following injection to spread anesthesia

101
Q

supraorbital nerve block

A

blocks forehead

Procedure: inject into SQ space just superior to eyebrow in line with pupil to medial brow

102
Q

infraorbital nerve block

A

blocks lower eye lid, medial check, side of nose, upper lip

Procedure: inject mucosa above first maxillary pre-molar (tooth behind canine); angle up towards infraorbital notch under eye

103
Q

mental nerve block

A

blocks labial mucosa, gingiva, and lower lip down chin

Procedure: inject into mucosal fold at canine/first premolar

104
Q

abscesses

A

difficult to get good anesthesia

use hemostat and Q-tios to get pus out

use packing to keep wound open for drainage (remove in 48 hours)

105
Q

suturing - general tips

A

facial sutures: 2-3mm from wound edge, 3-5 mm apart

Other body parts: 3-4 mm form wound edge, 5-10 mm apart

Note: always begin suturing distal to you and suture towards you

106
Q

simple interrupted stitch

A

technique: gather more tissue at base than at surface; eversion key; enter at 90 degree angle
- # of ties = size of material

when used: standard wound closure (low tension and not too deep)

107
Q

subcutaneous / buried stitch

A

technique: enter at mid dermis and exit at dermal/epidermal junction; then enter dermal/epidermal junction and exit mid dermis
- avoid placing in adipose tissue
- know it deep (bottom of stitch)

when used: gaping wounds

108
Q

running suture

A

technique: simple interrupted at one end and tie knot (only cut short end), continue stitching along wound.
- to tie off: leave loop of suture and tie as if tying with two ends (pull loop through)

when used: in hurry with long, strait wound

109
Q

horizontal mattress

A

technique: take big bite (1 cm from edge) and out other side. On same size, go down 1 cm and re-enter, taking another big bite (tie off on original entering side)
- add simple interrupted stitches and, when done, pull out horizontal mattress

when used: temporary placement w/ high tension repair to approximate edges; wounds with increased tension (fascia and over joints)

110
Q

vertical mattress

A

technique: take big bite (1 cm from wound edge); reverse needle and go back through 1-2 mm from wound edge) - tie off on original side
- typically continue with these same sutures along wound (may add few simple interrupted)
- risk: too much tension = strangulation, maceration, infection

when used: excess, lax skin (all in one - avoid a layered closure)

111
Q

chest pain differential - cardiac

A

angina/MI
aortic dissection (ripping pain through back)
pericarditis/tamponade

112
Q

chest pain differential - pulmonary

A

pneumonia/bronchitis
pulmonary embolism
pleurisy (inflammation of pleura - membranes of pleural cavity)
pneumothorax/pneumomediastinum

113
Q

chest pain differential - neuro/psych

A

Thoracic outlet syndrome (compression of nerves, arteries, or veins form lower neck to armpit)
Herpes Zoster (shingles)
Anxiety
Radiculopathy (pinched or compressed nerves)

114
Q

chest pain differential - MSK

A

costochondritis
rib trauma
rib Strain/ coughing
- nonspecific

115
Q

chest pain differential - GI

A 
PUD (peptic ulcer disease)/gastritis
 cholecystitis (gallbladder)
 pancreatitis (radiates to back / alcoholic)
 peritonitis
 GERD/spasm
 esophageal rupture
116
Q

chest pain differential - life-threatening conditions

A 
Ischemia/ MI
Aortic Dissection
Pericardial Tamponade
Pulmonary Embolism
Esophageal Rupture
117
Q

Chest pain - history / initial evaluation

A

ABC’s (airway, breathing, circulation)

History: associated sxs, medications, tx w/ meds, similar or previous episodes, recent trauma

Pain characteristics (OPQRST)

118
Q

Chest pain - physical exam

A

Pulmonary:

  • chest wall tenderness (MI, MSK)
  • rales (LV dysfunction, pneumothorax)

Cardiac:

  • new murmur
  • Hamman’s crunch

Vascular:

  • carotid or femoral bruits
  • equal pulses

Abdominal:
- tenderness (cholecystitis, pancreatitis, etc.)

Neuro:

  • AMS (altered mental status)
  • focal defects

Derm:
- vesicular rash (herpes zoster)

119
Q

MI - characteristics on physical exam

A

chest pain to palpation (15%)

120
Q

Hammans Crunch

A

heard on cardiac exam (w/ stethoscope) - crunching, rasping sound, synchronous with the heartbeat; heard over the precordium; produced by the heart beating against air-filled tissues.

occurs with: pneumediastinum/pneumopericardium or esophageal rupture

121
Q

cardiac risk factors - non modifiable

A

family hx
gender (male)
age (>45 male, >55 female)

Note: be sure to ask about in hx, but although predictive of CAD in asymptomatic pts, poor predictor of AMI in ED

122
Q

cardiac risk factors - modifiable (7 major)

A 
HTN
Smoking
Hyperlipidemia
Diabetes
Obesity
(cocaine)

Note: be sure to ask about in hx, but although predictive of CAD in asymptomatic pts, poor predictor of AMI in ED

123
Q

Acute Coronary Syndrome (ACS)

A

Ranges from angina to MI

  • Occluded vessels can cause anginal pain with exertion (relieve with rest or NTG - nitroglycerin)
  • Plaque rupture can lead to total vessel occlusion/ Acute Myocardial Infarction
  • spectrum of clinical presentations

Range: Stable Angina, Unstable Angina, NSTEMI, STEMI

124
Q

vessel changes with coronary syndrome

A

plaque grown into vessel walls (not build up on inside of lumen)
- so, plaque rupture is more likely to cause MI than stenosis

125
Q

classical MI symptoms

A 
substernal chest pain/pressure
 diaphoresis (sweating)
 nausea
 dyspnea (SOB)
 radiation to arm/jaw
 exertional

Lasting <2min or >24 hours is less likely to be ischemic

126
Q

atypical MI symptoms

A 
palpitations
nausea
SOB
epigastric pain
weakness
fatigue

more common in women and diabetics; up to 50% of people with unstable angina may have atypical sxs and no chest pain

127
Q

ACS - 4 sxs that are specific

A

Diaphoresis
Vomiting (not nausea)
Exertional chest pain
Radiating pain to the back or right arm

Note: just good to know this (possibly not tested)

128
Q

stable angina

A

predictable pattern of chest pain/pressure/squeezing that occurs with exertion and relieved with rest or Nitroglycerin

  • lasts 5-15 min
  • occurs in known CAD
  • normal condition (stable)

Note: PE, labs, CXR, EKG all normal in stable angina

129
Q

unstable angina

A

new onset, change in severity, duration, frequency of the normal angina

Note: PE, labs, CXR, EKG all normal in unstable angina

130
Q

NSTEMI (non-ST elevation MI)

A

worsening or changing symptoms, with myocardial damage

- see troponin elevation

131
Q

STEMI (ST elevation MI)

A

worsening or changing symptoms, with myocardial damage

- see troponin elevation and EKG changes

132
Q

chest pain: diagnostic tests

A

EKG: perform w/in 10 min of arrival (normal does not guarantee no MI)

CXR: heart size, pneumomediastinum, pulm. congestion, free air)

Labs: troponin, LFTs/lipase, D dimer, CBC, BMP

Additional studies:

  • chest CT or V/Q scan: r/o PE
  • abd CT: r/o aortic dissection
  • cardiac US/echo: heart failure
133
Q

EKG changes indicative of MI

A

T wave inversion
ST elevation
Significant Q waves

134
Q

risks for cholecystitis - 4 Fs

A

forty
fat
female
fertile

135
Q

D dimer

A

a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis (fibrin degradation product)
- helps to dx or rule out thrombosis (blood clot) or dx DIC (disseminated intravascular coagulation)

136
Q

cardiac markers

A

troponin: rises w/in 1.5-3 hrs of injury (for acute MI)
- 3 hour repeat troponin to r/o acute MI or risk stratify

CK-MB, myoglobin: not relevant in ED

137
Q

troponin v. stress test

A

troponin are for acute MI

stress tests are for CAD

138
Q

present to ED w/ chest pain - initial treatment and medications

Note: there are algorithms for this (UTD)

A

IV, pulse ox, monito, EKG (in 10 min)
- Oxygen is sat < 90%

Aspirin (160-325mg, po/pr)

  • only thing shown to reduce mortality!
  • contraindications: bleeding ulcer, anaphylaxis

Pain control: morphine or fentanyl

Nitrates (NTG)

  • sublingual q 5 min x 3
  • if pain relieved, nitropaste to chest
  • if no pain relief or labile BP, start drip
  • contraindicated: hypotensive (BP<90 systolic, HR<50) or RV infarct
139
Q

nitroglycerin (NTG) treatment - chest pain or suspicion of MI

A

sublingual q 5 min x 3

  • if pain relieved, nitropaste to chest
  • if no pain relief or labile BP (fluctuates from normal to high); start drip

Contraindicated: hypotensive (BP<90 systolic, HR<50) or RV infarct

140
Q

If patient is have an (N)STEMI (based on EKG, troponin levels, etc.) - additional treatment

A

percutaneous coronary interventions (PCI) - stent
- door to “balloon time” is 90/120 min of ED arrival (120 min if not PCI capable facility and transport needed)

thrombolysis (“-ases”) w/in 30 minutes if not PCI center (can’t balloon)

141
Q

thrombolytics for acute MI

A

clotbusters (“-ases”)
- tPA, Streptokinase (SK) , tenecteplase(TNKase), reteplase (rPA)

successful reperfusion rates between 60-80%

main complication is bleeding (rare but often fatal b/c intercerebrayl hemorrhage = ICH)

142
Q

PCI (Percutaneous Coronary Intervention)

A

gold standard for acute MI (NSTEMI or STEMI)

  • preferred to thrombolytics if available
  • door-to-balloon time is ideally within 90 minutes

aka: balloon angioplasty, stenting

143
Q

chest pain presents to ER - where patient should go from there

A

telemetry (admit and watch): concerning hx. w/ no ST elevation, pain free, normal troponin

Cardiac ICU: actue MI, ongoing pain, elevated troponin, NTG drip

home (low risks patients):

  • low HEART score (0-3)
  • two negative troponin, 3 hrs apart
  • single lab troponin negative 6 hrs from onset of sx w/ constant pain
144
Q

once you send for a troponin in ER > opened door to potential cardiac disease - what’s appropriate follow-up

A

must initiate provocative testing within 72 hours (in outpatient setting)
- stress tests

145
Q

various stress tests

A

performed in outpatient setting to assess myocardial health

Treadmill: least expensive, most available, but lowest sensitivity (68%)

Stress echo: no radiation, better sensitivity (80%)

Nuclear Stress Testing: (myocardial perfusion imaging) highly accurate, but radiation, takes longer

146
Q

chest pain presents to ER (diagnostic tests performed) - risks scores that help to decide next steps

A

HEART: more appropriate for ED patients (low risk = discharge home = score 0-3)

TIMI: simple but poor predictive value for ED (low risk = score of 0-1)
- used by PCP and cardiac docs

Both: mdcalc.com

147
Q

HEART score

A

risk score used to determine if patient should be sent home, admit for clinical observation, or early invasive strategies performed following presentation to ER with chest pain

  • 0-3: d/c home for out patient f/u
  • 4-6: consider admit
  • 7-10: admit and diagnostics

Takes into account:

  • History
  • EKG
  • Age
  • Cardiac Risk Factors
  • Troponin

Allows for clinical gestalt (judgement)

148
Q

GI cocktail

A

mix of medications that can be given to receive chest pain possibly due to indigestion
- caution: can make an MI feel better, so caution if think pt should be admitted (possibly do not want to take away sxs)

149
Q

cocaine chest pain - basics and what to avoid

A

stimulatory: leads to vasoconstriction, inc. platelet aggregation, atherosclerosis
- MI occurs in 6% of abusers w/ chest pain

Tx: benzodiazepine (combat agitation, HNT, tachycardia)

AVOID beta blockers > leads to unopposed alpha agonist effect and worsening vasoconstriction

150
Q

cardiogenic shock

A

insufficient cardiac output to meet metabolic demands of the tissues

Hypoperfusion = hypotension, tachy or brady-cardia, cool mottled skin, altered mental status, oliguria (dec. urine output)

Emergency!!

151
Q

left-sided heart failure - sxs

A

pulmonary edema, frothy sputum, orthopnea (SOB when flat), dyspnea on exertion

systolic dysfunction: EF<40%

152
Q

right-sided heart failure - sxs

A

dependent edema, hepatic enlargement, JVD

usually result of left-sided failure

153
Q

heart failure - CXR findings and labs

A

cephalization: dilated upper lung vessels

Kerley B lines: horizontal lines of congestion at bases of lungs

overall: pulmonary congestion

Labs: BNP (brain natriuretic peptide)

154
Q

heart failure - ER treatment

A

sit up, give O2, nitroglycerin

small amounts of fluid, treat dysrhythmias or electrolyte balance

send for Eco / ADMIT

155
Q

pulmonary embolism - classic triad of sxs

A

chest pain, dyspnea, hemoptysis (coughing up blood)

156
Q

virchows triad

A

factors thought to contribute to thrombosis

hypercoagulable state
venous stasis (or turbulence)
endothelial injury: from HNT, etc.
157
Q

pulmonary embolism - CXR findings

A

hampton’s hump: wedge shaped opacification suggesting infarct distal to emboli

westermark’s sign: dilation of pulmonary vessels proximal to embolism

158
Q

hampton’s hump

A

CXR finding: wedge shaped opacification suggesting infarct distal to emboli

  • pulmonary embolism
159
Q

Westermark’s sign

A

CXR finding: dilation of pulmonary vessels proximal to embolism w/ collapse of distal vessels

  • pulmonary embolism
160
Q

Homan’s sign

A

pain w/ squeeze of calf - positive result significant for DVT

161
Q

phlegmasi cerculea dolens

A

cyanotic limb due to swelling - positive result significant for DVT

162
Q

Stanford Type A

A

classification for aortic dissection: involves ascending aorta (even if also involves descending)

163
Q

Stanford Type B

A

classification for aortic dissection: dissection beyond brachiocephalic trunk

164
Q

cardiac tamponade

A

blood or fluid in pericardium prevents heart ventricles from expanding fully; excess pressure province heart from working properly

  • Beck’s triad: distant heart sounds, hypotension, JVD
  • pulsus paradoxus: on exam, detect beats on cardiac auscultation during inspiration that cannot be palpated on radial pulse
  • electrical alterans: on EKG - alternating QRS axis
165
Q

Beck’s triad

A

distant heart sounds, hypotension, JVD

significant for cardiac tamponade

166
Q

pulsus paradoxus

A

on exam, detect beats on cardiac auscultation during inspiration that cannot be palpated on radial pulse

significant for cardiac tamponade

167
Q

electrical alterans

A

on EKG - alternating QRS axis

significant for cardiac tamponade

168
Q

Dresslers Syndrome

A

pericarditis following MI, surgery or trauma

immune system response after damage to heart muscle (occurs within 1st week after surgery)

169
Q

Boorhave’s Syndrome

A

esophageal rupture

  • air where it should not be (Hamman’s crunch)
  • retching (dry-heaving), vomiting (blood)
  • ETOH abuse or ulcer
170
Q

Hamman’s crunch

A

crackles that correlate with heart beat (heard on auscultation); heart beating against air-filled tissues (air where it should not be)

happens with:

  • esophageal rupture
  • pneumomediastinum
  • pneumopericardium
171
Q

acetaminophen

A

tylenol, non-narcotic, mild or moderate pain
peds 15mg/kg (max adult 4g/day)
analgesia only (no anti-inflammatory or anti platelet)

can use in children <6mo

172
Q

NSAIDS - Ibuprofen (mortrin, advil) and naproxen (aleve)

A

non-narcotic, mild or moderate pain, anti-inflammatory, anti-pyretic
peds 10mg/kg (max adult 2400mg/day)

inhibit COX-1 and COX-2 (prostaglandin) synthesis

avoid: kids <6mo, 3rd trimester preg

173
Q

Ketorolac / Toradol

A

non-narcotic, IV version of highly effective NSAID

good for renal colic (abd pain caused by kidney stones), migraines

174
Q

aspirin

A

use: dec risk of non-fatal MIs, cancer

avoid in children and adolescents (Reyes - brain and liver swelling) and 3rd trimester preg

175
Q

hydrocodone

A

oral, narcotic, mild to moderate pain
used in conbo w/ tylenol (Norco, vicodin) or Ibuprofen (vicoprofen)

less potents than oxycodone

fewer side effects than codeine

176
Q

codeine

A

oral, narcotic

usually combined w/ aspirin or tylenol

metabolism issues: rapid and poor

great anti-tussive

177
Q

tramadol

A

oral, narcotic

good for chronic pain (fibromyalgia)

178
Q

morphine sulfate

A

narcotic by which all others compared, IV
3rd fastest of morphine, hydromorphone, and fentanyl
- onset: 5-10min; duration 2-6 hrs

hypotension and pruritis

179
Q

hydromorphone (Dilaudid)

A

opioid (narcotic), stronger than morphine sulfate w/ less pruritis, nausea, hypotension
2nd fastest of morphine, hydromorphone, and fentanyl
- onset 3-5 min IV; duration 2-4 hrs

note: great bioavailability when given orally

180
Q

fentanyl

A

opioid (synthetic narcotic), 100x more potent than morphine

Fastest of morphine, hydromorphone, and fentanyl (fentanyl = FAST)
- onset 1 min, duration 30-min

Often combined with Versed for “conscious sedation”

comes in many forms: lolli-pop, transdermal patch, IN

Caution: glottic wall rigidity

Reversal agent: Naloxone

181
Q

conscious sedation

A

fentanyl with versed

182
Q

narcotic reversal agents

A

methadone: used for managing opioid addiction (fatal arrhythmias, QT prolongation)

Suboxone: contains buprenorphine and naloxone; used for managing opioid addiction (ST and LT replacement therapy

Naloxone: opioid antagonist that “kills high” + rapid withdrawal sxs if misuse

183
Q

Clonidine

A

can be used for acute opiate withdraw (mainly do sxs managment)

184
Q

Versed

A

benzodiazepine

respiratory and CV depression

onset 1 min, lasts 1 hour

Emergency Medicine (3 decks)

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