Exam 3 Flashcards
vaginal bleeding
MUST do a pregnancy test
Check hematocrit (determine significance of bleeding - stable v. unstable)
vaginal bleeding and abdominal pain - history ?’s in ED
Pain: OPQRST
When did bleeding start, quantity, clots, tissue, color, trauma
Gyn hx: LMP, G’s, P’s, Abortions, chance of pregnancy, last sexual encounter, protection used, dyspareunia (pain w/ sex), STD hx
dyspareunia
pain with sex
vaginal bleeding and abdominal pain - physical exam in ED
vitals, sick appearing (sweating, pale), tachycardia
abdominal exam: masses, inguinal nodes
pelvic exam: speculum, bimanual, external genitalia, cervical os
note: pain with abd palpation (appendix) v. pain with bimanual (adnexal - PID)
pelvic exam
Exam Set Up: cotton swabs, chux, speculum, wet prep, GC/Chlam
Inspect perineum, vulva, urethra, and peri-anal region
Cervix must be visualized to R/O polyps, ulcers, STD, mass
May require use of swabs and/or suction to visualize structures
vaginal bleeding - lab studies
pregnancy test
CBC, chem-7 for renal function
pregnant: type and screen, quantitative BhCG (how far along) and Rh (neg get Rhogam)
pregnant trauma: Kleihauer-Betke
standard pregnancy test (hCG) accuracy
Urine
95% sensitive/specific
+ 2 weeks after ovulation
May get false negative if dilute urine
Serum
+ 7-10 days after ovulation
Quantitative Beta-hCG -“beta quant”
normal pregnancy, BhCG doubles approximately 48 hours
Low HCG levels: suggest ectopic pregnency or “blighted ovum” (anembryonic pregnancy)
High BhCG suggest GTD (molar pregnancy or choriocarcinoma), multiple pregnancy
Always, miscalculation of dates may be considered
ultrasound in pregnancy - confirming IUP
determines if an IUP (intra-uterine pregnancy) is present; may miss heterotopic pregnancy
A living IUP may be definitively diagnosed when cardiac activity is seen in the uterine cavity (usually seen at 6-7 weeks)
Rh prophylaxis
Administer RhoGAM to the gravid patient who is Rh (-) and is vaginally bleeding
Exception: when father is known Rh–
When in doubt treat
types of spontaneous miscarriage
threatened inevitable incomplete complete septic
Note: 80% occur prior to 12 weeks.
Cardiac activity on US reduces
threatened miscarriage
vaginal bleeding with a closed cervical os and benign PEX
inevitable miscarriage
vaginal bleeding with cervical dilation; cervical os is open
incomplete miscarriage
passage of only parts of products of conception (POC), usually occurs at 6-14 weeks; cervical os is open
complete miscarriage
passage of all products of conception (POC) and fetal tissue prior to 20 weeks; Os is closed
septic miscarriage
evidence of infection during any stage of abortion - induced or spontaneous
yankower suction
used to visualize cervix if very bloody
septic miscarriage - treatment
OB consult for urgent D and C
Blood and cervical cultures and gram stains
Broad spectrum antibiotics: Unasyn or Clindamycin PLUS gentamycin
Pregnant trauma patient - causes
MVAs
domestic violence
minor blunt trauma
Pregnant trauma patient - injuries
Placental Abruption
Uterine rupture
Maternal fetal hemorrhage
Preterm labor
Pregnant trauma patient - evaluation
Keep pt in left lateral decubitus position (avoid compression of IVC - supine hypotension) OB and trauma consult Two large bore IV’s, supplemental O2 Rhogam Fetal heart tones
Kleihauer-Betke Assay Test
blood test performed on maternal blood to quantify fetal maternal blood mixing (if abdominal trauma)
Perform on all Rh negative women (followed by Rhogam)
But, if you suspect abdominal trauma, just give 300mcg Rhogam
pregnant trauma patient - treatment goals
Pelvic exam: look for trauma, vaginal bleeding, PROM (do not perform if blood on external inspection)
FHTs: minimum of 4-6 hrs of fetal monitoring on labor deck
If high acuity: pt transferred or trauma takes over
perimortem c-section
Perform within 5 minutes of maternal cardiac arrest
Continue ongoing maternal resuscitation
Viable gestational age approx 24 weeks (+) FHT
trauma stats
#1 cause of death ages 1-46 #3 cause of death overall
Injury causes: #1 MVC (blunt trauma) #2 Suicide #3 Falls (blunt trauma)
35% ED visits
distribution of trauma-related deaths
immediate deaths (seconds to minute): usually untreatable/nonsurvivable (severe CNS injury, hemorrhage)
early deaths (minutes to hours): the "golden hour"; potentially preventable (hemorrhage, severe TBI) - FOCUS IN TRAUMA
late deaths (days to weeks): ICU deaths (sepsis, multi organ failure - MOF)
the golden hour
the period of time (within the first hour or two after injury) that most potentially preventable deaths from trauma occur (early deaths - hemorrhage or severe TBI)
NEXUS Criteria for determining c-spine immobilization
No midline tenderness No focal neurological deficit Normal alertness No intoxication No painful distracting injury
Note: also used to determine imaging
shock - definition
2 leading cause of death in trauma
state of severe systemic reduction in tissue perfusion characterized by decreased cellular oxygen delivery and utilization, as well as decreased removal of waste byproducts
most common shock in trauma
ALWAYS hemorrhagic
lethal triad
coagulopathy, hypothermia, acidosis
occurs with hemorrhage (leads to distributive shock)
shock: initial management
IV access
- 2 peripheral large-bore IV’s
- Central line
Fluid resuscitation
- 2L IVF warmed LR (lactate ringers) or NS (nasal saline)
- Blood products
acute mountain sickness - prophylaxis
gradual acent: 1st night at 1500m prior to ascending additional 1000m (sleeping elevation key)
Acetazolamide (Diamox) 125 mg BID: start one day prior to travel and continued for 2 days after reaching max altitude
- makes you a bit acidic
Avoid alcohol or dehydration
Eat high carb diet (40 min prior to arrival) and use of NSAIDS
concentration of O2 in air vs. PO2
Concentration of oxygen present in air is 21% both at sea level and high altitude
Inspired PO2 drops as barometric pressure decreases (both with higher altitude and farther from equator)
CO poisoning - challenges to diagnosis
Normal pulse ox reading.
Half- life is 4-6 hrs in room air and 40-60 minutes with 100% O2
Mismatch of C0Hb levels to presenting SXS
Identifying low-level chronic CO exposure in smokers/COPD pts
Identifying pt who SXS are intermittent/resolve when leave environ
Rule of Nines
used to estimate percentage of body burned when reporting to burn center / trauma unit
- arms and head are 9%
- front, back, each leg is 18%
- palm of hand is 1%
- only applicable for 2nd and 3rd degree burns
burns - when to refer to burn center
Second degree partial-thickness burn > 10 % TBSA (total body SA)
Burn to face, hands, feet , perineum, major joints
Full-thickness
Electrical, inhalation or chemical burn
Pediatric burn in hospital w/o meds burn staff
Associated trauma or major pre-existing medical conditions
Associated emotional or mental health condition
Cognitive impairment
rhabdomyolysis
serious syndrome due to a direct or indirect muscle injury; results from death of muscle fibers and release of their contents into the bloodstream
- must monitor in electrical injuries
Lichtenberg ferning pattern
characteristic marking on skin following a lighting strike (looks like a red/streaky fern)
life threatening conditions that may present as behavioral change
CNS infection CNS trauma Intoxication Etoh/drug withdrawal Hypoglycemia Hypoxia ICH (intra-cranial hemorrhage) Poisoning Seizure disorder Acute organ system failure
barriers to a complete psych evaluation in the ED
Provider discomfort or bias Other patients are sicker Patient takes too much time Patients may mistrust the medical staff Patients may have a cognitive impairment/hallucinations interfering with evaluation
delirium
global impairment in cognitive functioning that is sudden in onset and presents with diminished level of consciousness, inattention, visual hallucinations
- usually reversible
dementia
pervasive disturbance primarily in memory, generally gradual in onset
psychosis
“impaired contact with reality”, characterized by symptoms, such as:
- hallucinations, delusions, impulsive, a range of emotions from apathy to fear and rage (pos. or neg. sxs)
indications for definitive airway
Need for airway protection:
- maxillofacial fx
- risk of abstraction (hematoma, URT injury)
- risk for aspiration (bleeding, vomit)
- unconscious, GCS<8, combative
Need for ventilation or oxygenation:
- inadequate resp effort
- massive blood loss (need for vol resuscitation)
- severe closed head injury
- apnea, unconscious
Note: chemical paralysis before insertion (do neuro exam first)
Jefferson fracture (burst fx)
occurs to C1: anterior and posterior arches break
- transverse ligg interrupted
Odontoid fracture
occurs to C2 (w/ dens): occurs w/ flexion, extension and rotational injuries
- types 1 and 2 involve Dens only (surgery needed)
- type 3 lower on vertebrae and heals better
Hangman fracture
occurs to C2: bilateral pedicle fx
- most common c-spine fx
- hyperextension and axial load
c-spine fracture above C4 - what am I worried about
paralysis of muscles of respiration (C3-5 innervates diaphragm)
criteria for 72 hour mental health hold (M-1 hold)
- who can initiate
- who can lift / discontinue
gravely disabled
imminently dangerous to self
imminently dangerous to others
who can initiate:
- physician
- officer
- licensed mental health therapist, social workers, nurse (NOT a PA)
who can discontinue:
- physician
- psychologist
components of medical clearance exam
First: scene safety and stabilization
exclude organic/medical causes of a psychiatric problem
ABCs
Treat any acute medical problems (hypoglycemia? hypoxia?)
Laboratory testing (CBC, BMP, TSH), toxicology screens (urine drug screen, breathalyzer)
Determine the disposition (M1 hold requiring psych eval or not)
medical (organic) disease characteristics for altered mental status
Age <12 years >40 years old - elderly or multiple meds Sudden onset / fluctuating course Disoriented Visual hallucinations Emotional liability Abnormal PE Hx of substance abuse or toxins (this includes EtOH and drugs) No previous psychiatric history
psychiatric (functional) disease characteristics for altered mental status
Age 13 to 40 years Gradual onset / continuous course Scattered thoughts Awake and alert Auditory hallucinations Flat affect Psychiatric history Normal PE
psych eval in ED: history questions
Gather hx from friends, family, EMS
Always ask, “why now”? Why today? Acute or choleric situation?
What are the pt’s current and historical stressors?
Resources (i.e. therapist)
Previous psychiatric illness
3 questions to ask:
- Auditory / visual hallucinations
- Drug / alcohol abuse and patterns
- Suicidal/ homicidal intentions
Any deterioration in physical, mental or emotional functioning
psych eval in ED: physical exam
Vital signs Appearance: dress, groomed, etc. Speech pattern: slurred, rapid pressured HEENT: pupils, EOM’s (extra-ocular mov’t), nystagmus (uncontrolled mov’t), proptosis (pop out), goiter? Skin: diaphoretic, flushed, dehydrated? Neurological exam: - focal neuro deficits (NOT psych) - cranial nerves - mental status exam (MMSE)
psych eval in ED: labs
No routine tests: urine tox, breathalyzer is often minimum
- Serum tox: OTC drugs
- Urine tox: drug of abuse
Check current medication levels: lithium, Valproic Acid, etc.
Check glucose (esp. w/ DM, drug overdoses, elderly)
Explore relevant medical considerations (thyroid, DM)
what blood test should you always get with altered mental status
finger stick glucose!!
B-52
medication regime for chemical restraint in violent pts - pt sleeps for 10 hrs
- Benadryl (50mg IM), Haldol (5mg IM), Ativan (2mg IM)
violent patient: chemical restraint options
Benzodiazepines: Ativan 1-2mg PO/IV/IM (short-term); Valium 5-10mg PO/IV/IM (lasts a bit longer)
Traditional Antipsychotics: Haldol 5-10mg PO/IM/IV (also great for puking)
Atypical Antipsychotics: Zyprexa (olanzapine) 5-10mg po/IM (less sedating than traditional antipsychotics)
B-52: Benadryl (50mg IM), Haldol (5mg IM), Ativan (2mg IM) → sleep for 10 hrs
major depression - criteria for dx
Sxs at least daily for two wks
Depressed Mood OR Loss of interest or pleasure in activities (anhedonia) PLUS Five or more SIGECAPS: • S sleep • I Interest • G Guilt • E Energy • C concentration • A appetite • P psychomotor changes • S suicidal feelings
bipolar - criterial for dx
Depression with a manic component Manic episode: at least 1 week marked by abnormally elevated or irritable mood PLUS 3+ of following sxs: o D: distractibility o I: indiscretion/Impulsivity: o G: grandiosity o F: flight of ideas o A: activity – high energy o S: sleep – decreased need o T: talkativeness
Note: people DO kill themselves (suicide 25-50% attempt)
borderline personality disorder
mood instability, aggression (intense anger), impulsivity, frequent self-injury, needy
Fourth greatest risk factor for suicide (after depression, schizophrenia, and addiction)
- more likely to attempt than complete suicide
panic attack
episode of intense fear or discomfort in which 4 of the following symptoms develop abruptly and peak with in 10 minutes; resolution of sxs in 30 min; may be unexpected or situational / explained or unexplained
• Sxs: SOB, palpitations, sweating, nausea, hot flashes, fear of going crazy, dizziness, trembling, choking, chest pain, paresthesias (burning or prickling), fear of dying
Dx of exclusion: R/O MI, PE, pneumothorax, dehydration, hypoxia
Tx: relaxation, pysch eval, benzos
suicide
Common
Most common methods: firearms, hanging (men), poisoning (women)
Assess lethality: specific plan, previous attempt, impulsive / poor tolerance of frustration
Tx: treat anxiety, agitation, psychosis or pain, offer to contact support (family, therapist); consult psychiatric services; ADMIT if concerned for pt safety / safety of others (1:1 security watch if any doubts about pt safety)
medications with behavioral manifestations
Steroids TCAs (tricyclic anti-depressants) Anticonvulsants Benzodiazepines Amphetamines/related drugs (CNS stimulant; used to tx ADHD) Narcotics Street drugs (alcohol, cocaine, meth)
pitfalls in assessing psych / AMS patient in the ED
Inadequate evaluation
Failure to recognize acute worsening of a chronic condition that may be organic
Failure to treat the treatable
Failure to look at the medication list
alcohol metabolism and rate of elimination
metabolized by alcohol dehydrogenase in liver
Steady state of elimination 15-40 mg/hour
- Improved elimination in practiced consumers (alcoholics metabolize faster)
acute intoxication (low levels): signs and sxs
clouded judgment, ataxia, nystagmus, altered personality, slurred speech, hypotension, tachycardia
acute intoxication (high levels; severe): signs and sxs
obtundation (low alertness), hypoventilation, hyporeflexia, hypothermia, severe hypotension
severe EtOH intoxication - treatment
May need physical restraints
Screen for life threatening problems (don’t believe the history)
Observe until clinically sober
No practical therapies to reverse alcohol (alcohol IS dialyzable)
- tx dehydration with IV fluids
- hypoglycemia is common; screen for electrolyte abnormalities (esp. Mg)
- “Banana bag” for chronic alcoholics (key if person is not eating)
banana bag
given to chronic alcoholics who are not eating (in ED): • D5 NS or D5 1/2NS • 2 gm Mag sulfate • multi-vitamin with folate • 100mg thiamine
- *rMg/Folate/Thiamine: can be done PO
severe alcohol consumption: two syndromes / complication
Wernicke’s encephalopathy: acute and reversible
- Sxs: nystagmus, ataxia, confusion
Korsakoff’s encephalopathy: persistent and irreversible
- Sxs: persistent learning and memory deficits
Note: both caused by SEVERE thiamine deficiency
Alcohol intoxication: discharge from ED
Chronic alcoholics: EtOH blood level doesn’t dictate discharge, may be “clinically sober”
Road test: watch pt walk
Minors only get released to parents / guardians
Adults get discharged to a sober adult or go to detox
Alcohol withdrawal: characteristics
caused when a patient who is chronically habituated stops drinking
- onset 6-96 hrs after last drink
hyperadrenergic state: HTN, tachycardia, diaphoresis, agitation, tremor, mild fever, hallucinations (visual), seizures
Alcohol withdrawal: 4 categories and tx
Minor withdrawal: withdrawal tremulousness (give Ativan)
- onset 6-24 hours after drinking; duration < 48 hours
- anxiety, N/V, tremor, clear sensorium
- tx: Benzo (Ativan)
Major withdrawal: alcohol hallucinosis
- onset 10-72 hours after drinking; up to 5 days
- whole body tremor, vomiting, HTN, hallucinations, diaphoresis, fever
- tx: ADMIT (can die)
Withdrawal seizures
- occur 6-48 hr after last drink; generalized and brief; 30-40% go on to DTs
- tx: ADMIT (can die)
Delirium tremens (DTs) most severe form of ethanol withdrawal - tx: ADMIT (can die)
delirium tremors (DTs): characteristics and treatment
most severe form of ethanol withdrawal
AMS (global confusion) and sympathetic overdrive (autonomic hyperactivity) –> can progress to cardiovascular collapse
life threatening (15% mortality); occurs >3 days after last drink
Profound global confusion (hallmark of dx), tremor, fever, incontinence, autonomic hyperactivity, hallucinations
Treatment:
- R/O infection or other neurological abnormalities (head CT, LP, CXR)
- Hemodynamic support
- Thiamine/glucose/electrolytes; possible benzos, beta-blockers, haldol
Alcohol withdrawal: general treatment
Evaluate for co-morbidities
Correct fluid and electrolyte imbalances
Meds: BENZODIAZEPINES (may require large doses)
- Ativan 1-4 mg IV q hour to effect
- Tranxene 15-30 mg PO Q 6-8 hours for discharge
- May require Beta-blockers or Clonidine to blunt adrenergic effects
- Haldol to help with hallucinations, prn (and nausea/puking)
alcoholic ketoacidosis (AKA): sxs, how different from DKA, and treatment
sxs: binge drinking followed by days of starvation, vomiting, SOB/ Kussmaul respirations, N/V/abdominal pain, gastritis, pancreatitis
PE: tachycardia, tachypnea, abdominal tenderness
Labs:
- ABG/VBG: acidotic (inc anion gap)
- glucose: normal of low (unlike DKA)
- EtOH: zero or low
- urine dipstick: may or may NOT show ketones
Tx: corrects in 12-16 hrs
- IV fluids w/ glucose to clear the ketones
- No insulin; bicarbonate rarely needed
- Antiemetics to control vomiting; benzos for withdrawal
isopropyl alcohol: sxs, lab findings, tx
rubbing EtOH, mouthwash
- pt is drunk, but EtOH is zero
sxs: similar to EtOH, but longer duration and CNS effects profound (“twice as intoxicating”)
- fruity odor of ketones
lab findings: EtOh zero, anion gap normal, larger osmolal gap
tx: supportive (fluids and observe)
methanol: sxs, lab findings, tx
windshield wiper fluid, antifreeze
- pt is drunk, but EtOH is zero
- metabolized to formaldehyde (toxic!)
sxs: 12-24 hrs after ingestion (delayed), accumulates in retina (“visual snowstorm”), CNS changes, GI irritant
Labs: high anion gap metabolic acidosis, elevated osmolal gap
tx: 4-MOP fomepizole; dialysis if late
ethylene glycol: sxs, lab findings, tx
antifreeze, detergents
- pt is drunk, but EtOH is zero
sxs: 12-24 hrs after ingestion (delayed), renal failure
labs: high anion gap metabolic acidosis, elevated osmolal gap
- calcium oxalate crystals in urine
tx: 4-MOP fomepizole; dialysis if late
seizures: two classifications
generalized: diffuse brain involvement
- always with LOC
- tonic-clonic / grand mal
Focal: occurs w/ or w/o LOC
- may be sign of more complications
tonic-clonic / grand mal seizure: 3 stages
Tonic (rigid) phase: LOC, resp. arrest, fall, lasts < 1min
Clonic phase: rhythmic jerking of extremities (1-3 min), +/- incontinence, tongue biting, aspiration
Post-ictal phase: fatigue, H/A, N/V, myalgias (5-60min), confusion for several hours
seizures: common secondary causes
Trauma, intracranial (mass, aneurysm, bleed), ecclampsia, HTN encephalopathy, infection (meningitis, abscess), drugs (cocaine, MJ, EtOH, w/drawal, etc.), metabolic (hyponatremia, hypoglycemia, hypocalcemia), uremia, hepatic failure
seizure work-up: first time seizure
first time: more detailed W/U
• Head CT
• EKG
• Labs: CBC, chem 7 (Na and Glucose specifically), Ca/Mg, pregnancy (HCG); Urine tox
• Lumbar puncture: if febrile (R/O meningitis), immune-compromised, or possible SAH (sub-arachnoid hemorrhage)
Tx:
- Send home if normal W/U and return to baseline
- Outpatient neurology F/U: EEG
- no driving X 3 months (or until cleared by neurology)
seizure work-up: history of seizures
if known seizure disorder and normal pattern
- check glucose and anticonvulsant levels
- ask about: triggers, pattern (same, different), recent med changes, illnesses, etc.
seizure work-up: status epilepticus treatment
epileptic seizure of greater than five minutes or more than one seizure within a five-minute period without return to normal in between
ABC’s, IV, O2, monitor, labs, Utox, temp
Benzo: Ativan (Lorazepam) 2- 4 mg IV repeat in 10 min
pediatric febrile seizures: simple v. complex
simple:
- generalized tonic-clonic
- lasts <15 min
- temp >38C/100.4F
- 6mo-5yrs
- only 1 seizure in 24 hrs
complex (further W/U):
- w/ focality
- lasts >15min
- post-ictal period
- outside 6mo-5yr
- multiple seizures
pediatric simple febrile seizures: management
Look for infection (identify and tx source)
Antipyretics (rectal Tylenol 15mg/kg, Advil 10 mg/kg),
Lorazepam/Ativan (benzo) (0.05-0.1 mg/kg) if seizing during visit
Make sure return to baseline
pediatric simple febrile seizures: general info for family
Usually occur on first day of illness
May be related to rate of rise of fever
Reassure family: very good prognosis, 1% risk of developing epilepsy (almost general public risk
Recurrence – between 15-70% likely
most common cause of electrolyte disturbance
lab error
anion gap: equation and normal range
sum of cations minus anions
anion gap = (Na+ + K+) - (Cl- + HCO3-)
normal: 8-16
- worry about high value (not low)
- calculated as part of CMP
arterial blood gases (ABG): what are they + normal range
pH: 7.35-7.45
PCO2: 35-45 (respiratory)
HCO3: 22-26 (metabolic)
ISBM: key values
- pH: 7.40
- HCO3: 24 mEq/L
- PCO2: 40 mmHg
metabolic acidosis: general causes
pH is < 7.4, HCO3 < 24 mEq/L
Loss of Bicarbonate: diarrhea, ileus, fistula, high-output ileostomy
Increase in acids: lactic acidosis, ketoacidosis, renal failure, necrotic tissue
metabolic acidosis (elevated anion gap): causes
MUDPILERS
• M: methanol
• U: uremia
• D: diabetic ketoacidosis
• P: paracetamol / acetaminophen, phenformin, paraldehyde
• I: iron, isoniazid (due to seizures), inborn errors of metabolism
• L: lactic acid
• E: ethanol (due to lactic acidosis), ethylene glycol
• R: rhabdomyolysis
• S: salicylates/ASA/Aspirin
metabolic acidosis (normal anion gap): causes
HARDUPS • H: hyperalimentation (TPN) • A: acetazolamide • R: Renal Tubular Acidosis • D: diarrhea • U: uretero-enteric fistula • P: pancreatoduodenal fistula • S: spironolactone
metabolic alkalosis: general causes
pH is > 7.4, HCO3 > 24 mEq/L
Volume loss with chloride depletion: vomiting, diarrhea, NG suctioning (getting rids of acid)
respiratory acidosis: general causes
pH < 7.4, PCO2 > 40 mmHg
Drug intoxication, cardiac arrest, COPD, hypoventilation, pneumothorax, pleural effusion
- retaining too much acid (CO2)
respiratory alkalosis: general causes
pH > 7.4, PCO2 < 40 mmHg
Hyperventilation (anxiety, pain, fever, wrong ventilator settings), acute asthma exacerbation, PE, high altitude, Aspirin OD
- breathing off acid (CO2)
complication that can occur if correct hypernatremia too quickely
seizures
complication that can occur if correct hyponatremia too quickly
central pontine myelinolysis
