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Emergency Medicine > Exam > Flashcards

Exam Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Diabetic Ketoacidosis

A

Profound deficiency of insulin results in hyperglycemia
Plenty of glucose…but can’t get it into the cells
Lack of insulin leads to breakdown of triglycerides/fatty acids for energy with production of ketones

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2
Q

**Often the initial clinical presentation of a patient with DM I

A

Diabetic Ketoacidosis

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3
Q

Anion Gap

A

Anion Gap = Serum NA+ – (Serum Cl- + HCO3-)

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4
Q

Cause of increased anion gap metabolic acidosis:

A

“MUDPILERS”

(Methanol, Uremia, Diabetic/alcoholic/starvation ketosis, Paraldehyde, Isoniazid/Iron, Lactic acidosis, Ethylene Glycol, Rhabdo, Salicylates)

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5
Q

Tx of DKA

A
  1. Fluid: normal saline
  2. Insulin: 1hr post IVF
  3. Electrolytes: K+ replacement
  4. Once the blood glucose is ~200-250 mg/dL, start D5 (5% dextrose) in 1/2NS.
  5. Slow IVF rate to 250cc/hr when dehydration is improved
  6. Keep blood glucose between 150-250
  7. Give SQ Insulin at least 1/2 hour before stopping the insulin drip
    if pH <6.9, consider giving bicarb
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6
Q

When do you give Insulin in Tx of DKA?

A

1hr post IVF

correct orthostatic hypotension from fluid loss first

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7
Q

What happens when you don’t gradually correct blood sugar and correct it too rapidly?*

A

Keep blood glucose between 150-250**

Too rapid of a correction can lead to sequelae such as cerebral edema**

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8
Q

Most common cause of HHNK*

A

Infection

look for infection in pts w/known DMII

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9
Q

Which population of pts more affected by DKA v HHS?

A

DKA: type I DM, usu <40yo
HHNK: type II DM, usu >60yo
but not exclusive!

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10
Q

HHS is characterized by

A

Severely elevated glucose levels often >600mg/dl**
Commonly >800 mg/dl
Adequate insulin activity, but ↓ cell response
Hence, absence of lipolysis and ketogenesis
significant dehydration*

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11
Q

Causes of HHS

A

Precipitating Event:
Infection – most common*
MI, CVA, trauma, drug effects (steroids) or interactions

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12
Q

What respiration is NOT present in HHS*

A

Usually Kussmaul Respirations are NOT present

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13
Q

Why do you need to be more judicious in treating pts with HHS than DKA?

A

HHS patients often have underlying CVD making rehydration more complicated…
admit to ICU

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14
Q

Pts in myxedema coma are very sensitive to

A

very sensitive to opiates and may die from average doses.

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15
Q

Right heart strain on EKG and what is it classically associated with

A

S1Q3T3 (presence of an S wave in lead I, a Q wave in lead III, and an inverted T wave in lead III)
PE

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16
Q

Exertional chest pain is what until proven otherwise

A

Exertional chest pain is angina (CAD) until proven otherwise!!!
exercise stress test unless unstable
if high probability of CAD, get cardiac cath

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17
Q

most common cause of non-cardiac chest pain

A

GERD

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18
Q

Redflags of HAs

A

Fixed neurological deficits
Extremely abrupt onset
Papilledema
New onset headache especially in patients over < 5 or >50 y/o
Signs of infection (constitutional symptoms, nuchal rigidity)
Altered level of consciousness
New HA in a cancer patient or immunocompromised patient

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19
Q

Test most helpful in identifying CNS infection

A

Lumbar puncture

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20
Q

Test most helpful in identifying intracranial lesion or bleed

A

CT no contrast (do before LP) or MRI

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21
Q

Migraines are NOT treated with

A

narcotics (percocet, dilaudid, demerol)

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22
Q

Very poor indicators of respiratory failure in pediatrics

A

bradypnea
bradycardia
(both late signs)

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23
Q

Difference between O2 consumption in adults v children

A

Adults: oxygen consumption= 4mL/kg/min
Children: O2 consumption= 8mL/kg/min (so develop hypoxia and hypoxemia more rapidly)

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24
Q

MOST COMMON cause of shock in children worldwide*

A

Hypovolemic shock (from diarrhea, hemorrhage)

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25
Q

most common distributive shock in children

A

septic shock

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26
Q

difference between vein and artery when palpating

A

arteries have bounding pulse and veins don’t

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27
Q

What is the smallest gauge needle you should use when putting in an IV? (adults)

A

20 gauge (18 even better)

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28
Q

Disadvantage of peripheral IV access

A

can only be in 72hrs (3 days)!* then have to change to different site
potential for phlebitis

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29
Q

What medications can’t you give through peripheral IV?*

A 
Can not give TPN - total parenteral nutrition via peripheral IV)
chemotherapy
Hypertonic solutions
Potassium
Amiodarone
Vasopressors (Epinephrine, dopamine)
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30
Q

When can you draw labs with peripheral IVs?

A

only during initial insertion!

subsequent labs not reliable from medications given

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31
Q

contraindication for peripheral IVs

A 
If the medication can be given orally
Cellulitis 
Injury to the Extremity
Previous IV infiltration
Surgical Procedures:
Compromised Lymphatic: Lymph node dissection (breast cancer /radical mastectomy), Lymphedema
Burns
AV fistula
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32
Q

Extravasation

A

severe version of infiltration of fluid from IV into surrounding tissue; severe local tissue damage (tissue necrosis, disfigurement, loss of function)
avoid by not administering contraindicated medications(Chemotherapy, potassium, vancomycin, cefotaxime, Hypertonic solution, amiodarone, calcium chloride)

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33
Q

central venous catheters can be used to asses

A

assess right ventricular function and systemic fluid status.

goes right in SVC through subclavian vein

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34
Q

contraindications to central venous catheters

A

trauma
hemodialysis, pacemaker
mod to severe coagulopathy

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35
Q

PICC(Peripheral Inserted Central Catheter)

A

Inserted into cephalic, basilic, brachial vein into the distal Superior Vena Cava
Ultrasound guided, placed by an IV nurse, confirmation placement via CXR (can take over 1hr total for placement!)
15-30 days
can draw blood from it

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36
Q

Order of preference of veins for PICC

A

Basilic
Brachial
Cephalic
Median cubital vein

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37
Q

difference between PICC and central line

A

PICC typically few days to months, administer IV antibx. Central line CVP/PCWP monitoring, TPN, chemo, more long term treatment.

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38
Q

majority of central line associated bloodstream infections are from

A

Non-tunnel central venous cath (e.g Quinton)
short term use
(tunneled has cuff that prevents bacteria)

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39
Q

Locations to insert central venous catheter

A

internal jugular
subclavian: most preferred
femoral

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40
Q

What do you not give during spinal trauma?

A

steroids, no evidence

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41
Q

Nexus criteria for imaging

A

imaging isnotnecessary if patientsyounger than 60 yearssatisfyallfiveof the following low-risk criteria:

Absence of posterior midline cervical tenderness

Normal level of alertness
Altered mental status:
Glasgow Coma Scale (GCS) score below 15
Disorientation to person, place, time, or events
Inability to remember three objects at five minutes
Delayed or inappropriate response to external stimuli

No evidence of intoxication
No abnormal neurologic findings
No painful distracting injuries

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42
Q

Most injuries to the middle column are

A

unstable

composed of PLL, post vertebral body, post annulus fibrosis

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43
Q

Corticobulbar/Corticospinal tracts

A

Motor impulse originates in cerebral cortex
Crosses over at the medulla
Signal travels down the contralateral side via the corticospinal and corticobulbar tracts to target muscle

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44
Q

Corticobulbar/Corticospinal tracts

A

Motor impulse originates in cerebral cortex
Crosses over at the medulla
Signal travels down the contralateral side via the corticospinal and corticobulbar tracts to target muscle
Corticobulbar tract: connection to brainstem nuclei of cranial nerves
Corticospinal tract: connection to spinal nerves

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45
Q

Upper motor neuron lesions cause:

A 
Spasticity
Increased tone
Positive Babinski sign
Clonus
Possibly mild muscle atrophy
Hemiparesis/weakness
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46
Q

Lower motor neuron lesions cause:

A

Fibrillation’s (single fiber - invisible)
Fasciculation’s (motor unit - visible)
Paralysis/hypotonic
Flacid muscles with atrophy
Flexion contracture of tendons cause skeletal deformity

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47
Q

Spinothalamic Tract

A

Pain and temperature; crude touch
Crosses over shortly after sensory input enters spinal cord
Travels spinothalamic tract on the contralateral side to thalamus and then into cerebral cortex

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48
Q

Posterior (Dorsal) Column

A

Position and vibration; Fine touch
Travels up ipsilateral side of spine where signal entered
Crosses over at medulla then to thalamus and cerebrum

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49
Q

Which nerves supply the diaphragm?

A

C3-C5 Nerve roots innervate the phrenic nerve which supplies diaphragm
C5 injury or higher – intubation
Watch for Respiratory Failure

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50
Q

Hypotension is from what in trauma until proven otherwise?*

A

Hypotension is from blood loss UNTIL proven otherwise in the trauma setting!
SEARCH for the CAUSE

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51
Q

spinal cord injury causes loss of what in neurogenic shock?*

A

SCI causes loss of alpha adrenergic tone –> dilation of arteries/veins* to the areas that the cord innervates such as T1-4 (heart) –> Bradycardia**
The sudden loss of sympathetic nervous system signals to the smooth muscle in the vessel walls results in uncontrolled vasodilation**

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52
Q

Spinal Shock

A

Immediate transient loss of spinal cord function below level of injury
Areflexia- no reflexes
Hypotension
Flaccid Paralysis

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53
Q

Goal of mean arterial pressure

A

85-90 mmHg

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54
Q

Primary Assessment

A 
Airway
Breathing
Circulation
Disability
Exposure
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55
Q

Secondary Assessment - spine trauma

A 
Neuro Exam:
Mental Status Exam
Sensory Exam (dermatomes)
Motor (myotomes) 
Sweating and skin vasomotor tone are absent below the level of spinal cord lesion. 
DTRs
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56
Q

spinal compressions are common in

A

osteoporosis

can be treated w/balloon kyphoplasty if severe

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57
Q

Flexion Distraction vFlexion Dislocation

A 
flexion distraction (n seat belt injuries) affect posterior and middle columns, intact anterior prevents dislocation
flexion dislocation affects all 3 columns, most damaging
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58
Q

Jefferson fracture

A

Fracture of anterior and posterior arches of C1
“burst fracture of C1”
40% have associated Axis fractures (C2)
50% associated with vertebral artery injury

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59
Q

How to best see Jefferson Fractures

A

open-mouth odontoid view: shows overhang of Cl on C2 (THESE STILL ARE GOING TO GET CTs!!)

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60
Q

How to manage jefferson fractures

A

Most will be managed with skeletal traction/immobilization (halo) - 6-12 weeks
Unstable: Will need ORIF

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61
Q

Hangman’s fracture

A

Traumatic spondylolisthesis
Bilateral fracture of pars interarticularis
Anterior displacement of vertebra in relation to vertebrae below
Usually the result of hyperextension + axial compression.

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62
Q

Flexion Teardrop Fracture

A

Considered MOST UNSTABLE and dangerous C-spine injury: force great enough to displace anterior-inferior edge of vertebral body usually causes comminution of vertebral body and displacement of fragments into spinal cord.
lateral C spine to Dx
usu causes acute anterior cervical cord syndrome
usu C5-6 (greatest flexion/extension points)

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63
Q

Clay Shoveler’s

A

Usually an avulsion of spinous process of C7 or T1, due to heavy lifting (or shoveling clay) or direct trauma
stable - flexion force of neck
Tx: soft collar, activity modification

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64
Q

where does the spinal cord end?

A

L1

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65
Q

where in thoracic and lumbar spine most at risk of injury

A

T11-L2 transition zone between fixed T spine and mobile L spine most at risk for traumatic injury due to stress during motion

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66
Q

What should you image with calcaneal fractures?*

A

T/L Spine!

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67
Q

Central Cord Syndrome

A

Most common Cord syndrome 9%
Injury to corticospinal tract
Greater loss of motor (more weakness) UE>LE
Corticospinal tract for UE more centrally located
Hyperextension injury with cervical stenosis
Vascular compromise of anterior spinal artery
can have permanent hand disability
loss of bladder control

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68
Q

anterior spinal cord syndrome

A

Injury to ventral 2/3s of cord, sparing posterior column
Paraplegia (loss of motor function - corticospinal tract) + disassociated sensory loss with loss of pain/temperature (Spinothalamic tract)
Dorsal intact: Position sense, vibration, deep pressure
Infarction of the cord in the territory of anterior spinal artery
Poorest prognosis

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69
Q

Brown-Sequard Syndrome

A

Hemi-dissection of the cord typical with penetrating trauma
Rare 1-4%
Ipsilateral motor loss (pyramidal deficit) + ipsilateral loss of position, tactile discrimination, and vibratory sensation (Dorsal column) + contralateral loss of pain and temperature (Spinothalamic tract) 1-2 levels (dermatomes) below injury
Some recovery seen

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70
Q

Conus Medullaris

A

transition of spinal cord from CNS to PNS
Located between T12 and L2
LE weakness- symmetrical motor impairment
Absent lower-limb reflexes
Saddle anesthesia
Areflexic bowel and bladder

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71
Q

Cauda Equina Syndrome

A

Lumbar, Sacral, Coccygeal nerve roots (vertebral column injury distal to L2)
Peripheral Nerve injury rather than SCI
Lower motor neuron only (absent DTR, permanent areflexic bladder, absent bulbocavernosus reflex)
Motor/Sensory Loss in LE (Asymmetrical motor impairment)
Sciatica
Bowel/Bladder Dysfunction
Saddle Anesthesia

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72
Q

Lethal Six

A 
airway obstruction
tension pneumothorax
open pneumothorax
massive hemothorax
flail chest
Cardiac tamponade 
(burns too)
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73
Q

Hidden Six

A 
thoracic aortic disruption
tracheobronchial disruption
myocardial contusion
traumatic diaphragmatic tear
esophageal disruption
pulmonary contusion
Rib Fractures ****
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74
Q

Becks Triad

A

JVD
Muffled Heart Tones
Hypotension
cardiac tamponade

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75
Q

what should prompt concern for an intraperitoneal injury

A

Any wound from the nipple line to the groin anteriorly or scapular tip to the infragluteal fold posteriorly

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76
Q

Tx of neurogenic shock

A

Hypotension + Bradycardia (IVF)
Consider Dopamine, Phenylephrine, Levophed if not responding
MAP goal

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77
Q

Tx of hypovolemia

A

Hypotension + Tachycardia (give the, what they need –> 1:1:1)
Consider Dopamine, Phenylephrine, Levophed if not responding
MAP goal

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78
Q

What should you do ASAP in spinal trauma?

A

CLEAR CERVICAL COLLAR AND OFF BACK BOARD ASAP

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79
Q

Bulbocavernosus reflex

A

squeeze the penis to determine if the anal sphincter simultaneously contracts Indicative of S2-S4

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80
Q

Cremasteric reflex

A

running a pin or blunt instrument up medial aspect of thigh– if scrotum rises SPINAL Cord is intact

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81
Q

Rectal tone indicates in spinal trauma

A

Cauda equina syndrome, cord transection

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82
Q

Priapism indicates in spinal trauma

A

complete spinal cord injury

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83
Q

SIRS Criteria***

A 
Temp > 38 or <36
HR > 90
 RR > 20 or PaCO2 < 32
 WBC 
> 12,000
< 4,000
> 10% immature forms (bands)
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84
Q

Sepsis tx

A 
Goal directed therapy:
Central venous O2 saturation >= 70
CVP >= 8 to 12
MAP >= 65
Urine output >= 0.5 cc/kg/hr
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85
Q

Sepsis immediate measures within 1st hour

A

Blood cultures

Administer broad spectrum antibiotics:
Piperacillin/tazobactam, unasyn (amp/sulbactam), if PCN allergy 3rd gen cephalosporin and add metronidazole/Flagyl (to cover anaerobes)
Perforated appendicitis: use cipro and Flagyl for anaerobes, treat like diverticulitis

Measure lactic acid
Administer crystalloids (30 cc/kg)
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86
Q

Sepsis Tx within 6hrs

A

Repeat lactic acid
Assess for perfusion improvement
Initiate pressors as indicated

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87
Q

What is neurogenic shock secondary to?**

A

cord issue, NOT HEAD TRAUMA

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88
Q

Neurogenicshock Treatment

A

Trendelenburg position
IV fluids: Increase intravascular volume
Pressors: It’s a vasodilation problem due to loss of tone so tone them up sympathetically! Pressors!
Must balance fluids and pressors

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89
Q

primary goal in Tx of head trauma

A

prevent secondary brain injury

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90
Q

MOST COMMON INJURED MENINGEAL Vessel

A

middle meningeal artery, can cause epidural hematoma

pterion injury

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91
Q

Which meninges are vascular and which ar avascular

A

dura is vascular

arachnoid is avascular

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92
Q

subarachnoid space contains

A

CSF and veins/arteries

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5
Perfectly
93
Q

Normal intracranial pressure

A 
10mmHg = normal
>20mmHg = abnormal
>40mmHg = severe
94
Q

Interventricular measurement of ICP can

A

Ability to measure ICP AND DRAIN CSF**

95
Q

CPP (Cerebral Perfusion Pressure)

A

difference between your mean arterial pressure and intracranial pressure (MAP-ICP)
net pressure gradient that drives oxygen delivery to brain tissue, but NOT actually CEREBRAL BLOOD FLOW
normally 50-150mmHg

96
Q

Systolic shouldn’t go below what*

A

90mmHg

97
Q

Primary survey of head traumas

A

Mechanism– Direct/Indirect/Penetrating. This is your brief history.
ABCDE’s
Immobilize C-spine: suspect until proven otherwise\
IV access/labs at the end

98
Q

What should you get before intubating a head trauma?

A

get Glasgow coma scale - get baseline neuro

“less than 8 intubate” (Referring to GCS) - Loss of gag/inability to clear secretions

99
Q

Cushings Reflex

A

Bradycardia, Respiratory depression—INCREASED ICP

100
Q

intracranial bleeds do not cause

A

hypotension

101
Q

Crystalloid of choice in hypotension

A

normal saline

102
Q

H’s of secondary brain injury

A 
Hypotension
Hypoxia
Hypoglycemia
Hyperthermia
Hypocapnia - dec cerebral blood flow
103
Q

Disability survey in ABCDEs

A

glasgow coma scale: doc before meds
pupillary response
rule out other causes

104
Q

what vaccine should you inquire about in secondary survey?

A

tetanus status

105
Q

What labs should you draw during head trauma

A 
CBC
CMP
Type/Cross 
ABG
Tox Screen/ETOH
Coags***
Lactate esp if bleeding/ongoing Hypotension
Pregnancy
106
Q

Where should the head of bed be with TBIs?

A

30degrees

107
Q

Most common vessel affected in epidural hematoma*

A

middle meningeal arteries (arterial bleed)

108
Q

Sx of epidural hematoma

A

Initial, brief LOC—lucid interval—rapid neuro deterioration

Fixed dilated pupil on the unilateral side as herniation (swelling impinges CNIII)

109
Q

Subdural Hematoma

A 
30% of TBIs, more common than epidural
Shearing force on venous bridging veins between dura and arachnoid
expands more slowly
more severe bc damage parenchyma
may be relatively non-Sx - nonfocal***
110
Q

what type of hematoma is subdural?*

A

concave hematoma, follow contour of cortex

111
Q

who are most commonly affected by subdural hematoma?

A

elderly and alcoholics

112
Q

If isolated Subarachnoid hemorrhage– Consider*

A

aneurysm

113
Q

subarachnoid hemorrhage

A

non-space occupying
venous bleed
may inc ICP if blocks CSF outflow
if asymp and stable serial CT and normal exam can discharge

114
Q

Most common type of skull fracture!

A

linear skull fractures

usu minimal clinical signif, unless affect middle meningeal artery and vein

115
Q

If the skin is violated (open fracture) in a depressed skull fracture, DON’T

A

DON’T probe wound

116
Q

Basilar Skull Fractures

A

Petrous portion of temporal bone 75%
+/- CSF LEAK
Increased risk of developing meningitis
Sx: Hemotympanum, CSF otorrhea/rhinorrhea, Raccoon Eyes, Battle Sign (bruising over mastoid process)

117
Q

Penetrating Brain Injury (PBI) need early

A

IV antibiotics

118
Q

What is a pertinent Hx question in brain/spinal trauma?*

A

anticoagulants!

119
Q

Heat exhaustion*

A

INTACT MENTAL STATUS*

Early identification critical to prevent progression to heat stroke

120
Q

Heat stroke*

A

LIFE THREATENING CONDITION
High core body temperature causes proteins to denature which leads to multi-system organ damage
Body can’t regulate core temp

121
Q

Forms of heat stroke

A

Exertional heat stroke – young people w/ who engage in prolonged strenuous physical activity, more rapid onset
Classic non-exertional heat stroke – think elderly, debilitated patients –> gradual environmental exposure

122
Q

human bite with highest risk of infection

A

clenched-fist wound

123
Q

Human oral flora*

A

Eikenella, group A Strep

124
Q

Human skin flora*

A

staphylococci and streptococci

125
Q

Most significant oral animal flora bacteria*

A

Pasteurella spp. – 50% dogs wounds, 75% cat wounds

126
Q

organism in cat scratch fever

A

Bartonella henselae

127
Q

infections are more common with what animal bite?*

A

cat bites

128
Q

Superficial signs of infection*

A

tenderness, erythema, swelling, warmth, purulence, lymphangitis, fluctuance (abscess)

129
Q

Deep signs of infection*

A

above PLUS persistent pain, pain with passive ROM, pain out of proportion, crepitus, joint swelling, systemic illness (fever, hemodynamic instability), persistent signs of infections despite intervention

130
Q

Most bite wounds should be left to heal by *

A

secondary intention (a.k.a. left open) due to high risk of infection (exception may be made for facial wounds)

131
Q

Schedule for rabies post-exposure prophylaxis***

A

Vaccine: 1 mL IM (deltoid) given on days 0, 3, 7, 14, 28*

*add day 28 If immunosuppressed

132
Q

Anti-venoms*

A

FabAV (CroFab) or Fab2AV (Anavip)

Reserved for those with bites to face or neck, or those with progressing symptoms (mod-severe)

133
Q

Coral Snake Bites

A

“Red on yellow kill a fellow, red on black venom lack”

134
Q

What is important to do first w/inset bites?*

A

Remove stinger right away! Longer sitting in there, longer they deposit venom

135
Q

Insect Sting anaphylaxis tx

A

ABCs!

IM Epinephrine into anterolateral thigh

136
Q

pathognomonic rash for fire ant bites

A

sterile pustules

137
Q

Clinical manifestation of black widow spider bites*

A 
neurologic overstimulation (e.g. muscles aches, spasm, rigidity)
tx w/diazepam and ca gluconate
138
Q

Clinical manifestation of brown recluse spider*

A

infarct of skin –> rapid blood coagulation within vessels
Single grey “sinking” macule, eroded in center, halo of hemorrhage; dec in 5-10 days
most concerning spider bite
debridement not proven beneficial

139
Q

when glucose is 30-50mg/dL

A

Catecholamine release:
Irritability, hunger (“hangry”), trembling
Diaphoresis
Tachycardia

140
Q

when glucose is <30mg/dL

A

Neuroglycopenic effects:
Focal neurologic deficits, headaches, dizziness
Confusion, bizarre behavior, visual disturbances
Hypothermia
Seizure or seizure-like activity

141
Q

Most common life-threatening complication of diabetes

A

diabetic ketoacidosis

more common in type 1

142
Q

Kussmaul respiration

A

Deep, rapid, sighing; aka air hunger

143
Q

Tx of alcoholic ketoacidosis

A

Administration of IV fluids containing dextrose can correct the acidosis
Thiamine 100mg IV or IM: malnutrition

144
Q

Thiamine deficiency can lead to

A

Wernicke’s syndrome (ataxia, muscle paralysis, confusion) or Korsakoff’s syndrome (memory)

145
Q

lactic acidosis - serum lactate level

A

Serum lactate is at least 4-5 mmol/L but may be as high as 10-30 mmol/L
Reference range ~1-2 mmol/L

146
Q

Clinical features of myxedema coma

A

Hypothermia
Hypoventilation leading to hypoxia and hypercapnia
Hyponatremia
Hypotension
Seizures and abnormal CNS signs may occur including altered mental status.

147
Q

how is Dx of adrenal insufficiency confirmed?*

A

confirmed by the synthetic ACTH (cosyntropin) stimulation test

148
Q

Tx of Adrenal insufficiency

A

Acute: Hydrocortisone 100mg IV q8h or Dexamethasone 0.1mg/kg q8h. Saline infusion. Thereafter, continue hydrocortisone 50-100 mg q 6-8 hours
Convalescent: Hydrocortisone (AM 10-20 mg; PM 5-10 mg) and Fludrocortisone acetate (.05-.2 mg); both glucocorticoid and mineralocorticoid

149
Q

Chvostek sign

A

sign of hypocalcemia
Tap over the facial nerve about 2 cm anterior to the tragus of the ear. Depending on the calcium level, a graded response will occur: twitching first at the angle of the mouth, then by the nose, the eye, and the facial muscles

150
Q

Trousseau sign

A

sign of hypocalcemia
Inflation of a blood pressure cuff above the systolic pressure causes localized ulnar and median nerve ischemia, resulting in carpal spasm

151
Q

Dx of hypercalcemia

A

Calcium >12 mg/dl

EKG – Prolonged PR interval, shortened QT interval & flattened T waves

152
Q

Dx of hypocalcemia

A

Calcium <2 mg/dl
ABG
Respiratory or metabolic alkalosis
Hypercapnia secondary to severe hypocalcemia

EKG – prolongation of the QT interval

153
Q

Dx of adrenal insufficiency

A

Low cortisol level
Eosinophil count is high
Electrolyte abnormalities
Blood, urine or sputum culture may be positive if bacterial infection is the cause of the crisis

154
Q

How do you differentiate between sympathomimetic and anticholinergic toxidromes*

A

sweating

155
Q

Antidote for Acetaminophen

A

N-acetylcysteine***

156
Q

Antidote for Anticholinergic agents*

A

Physostigmine*

157
Q

Antidote for Benzodiazepines*

A

Flumazenil*

158
Q

Antidote for Cocaine (or other sympathomimetics)

A

Benzodiazepine

159
Q

Antidote for Ethylene glycol

A

Fomepizole, ethanol, hemodialysis

160
Q

Antidote for Hydrofluoric acid

A

Calcium gluconate

Used in carpet cleaners, consumes Ca like nothing and continue through body and bone, life threatening

161
Q

most common cause of cardiac tamponade

A

pericarditis

162
Q

RF for aortic dissection

A

Marfan syndrome or hypertension

163
Q

Imaging for aortic dissection

A

Ct w/contrast or transesophageal echo

164
Q

up to 30% of PE can have elevation of what

A

elevated troponin

165
Q

What is test is 90% sensitive to PE?

A

D Dimer

166
Q

difference between STEMI and NSTEMI physiologically

A

STEMI: Full wall thickness infarction
NSTEMI: Subendocardial damage so no ST elevation

167
Q

MC cause of pericarditis

A

viral

168
Q

Dressler’s syndrome

A

pericarditis - post MI/tissue death immune response

169
Q

what position are Sx of pericarditis aggravated by

A

supine

better sitting up

170
Q

What should you rule out w/HA

A

Meningitis and Subdural Bleed

171
Q

classic triad of meningitis

A

Fever – 95% of patients
Nuchal Rigidity – 88% present with it, may last 7 days
Altered Mental Status – 78% confused or lethargic, 22% only responsive to pain, 6 percent unresponsive to all stimuli

172
Q

meningitis can be

A

bacteria (can kill you) or viral (wish it can kill you; Sx tx)

173
Q

Diagnostic testing for subarachnoid hemorrhage

A

CT no contrast

mandatory LP

174
Q

LP findings in subarachnoid hemorrhage

A

elevated opening pressure and an elevated red blood cell count that does not diminish from CSF tube one to tube four

175
Q

gold standard test for intracranial aneurysms after Dx of SAH made

A

digital subtraction angiography (images are produced using a contrast, and then a pre-contrast images is ”subtracted”)

176
Q

Subdural Hematoma is usu caused by

A

from tearing of the bridging veins, most commonly from head trauma*
(Arterial rupture accounts for 20-20% of cases)

177
Q

50% of subarachnoid hemorrhage presents as

A

coma
(up to 38 percent of patients have a transient “lucid interval” that is followed by a progressive neurologic decline to coma)

178
Q

Migraine cocktail

A

Reglan + Toradol +Benadryl + IV fluids

179
Q

What medication reduce the risk of early recurrence of headache

A

single dose of Dexamethasone, 10-25 mg

180
Q

In contrast to adults, cardiac arrest in infants and children in usually NOT from*

A

not from a cardiac cause

usually the result of Progressive respiratory failure Or SHOCK or both

181
Q

Respiratory Distress

A

increased respiratory rate and effort. Adequate ventilation is still maintained
still maintain adequate gas exchange

182
Q

how does respiratory failure develop from respiratory distress

A

As the child tires and/or function deteriorates

183
Q

Respiratory Failure

A

inadequate oxygenation, ventilation or both
REQUIRES intervention to prevent respiratory arrest-cardiac arrest
confirmation through ABG

184
Q

Head position during infant ventilation

A

Keep infants head in neutral position during breaths, because extending the head can block the airway.

185
Q

Quick Systolic Blood Pressure formula for children 1 year and older

A

Median: 90mmHg + (2 X age in years)
Minimum: 70mmHg + (2 X age in years)

186
Q

what voltage of defibrillator should you not exceed in infants/children

A

10J/kg
use 2-4J/kg, then 4 J/kg
child pads

187
Q

Choking-INFANTS

A

Alternating Back slaps (5) and Chest thrusts (5)
Repeat until the object is removed or the infant becomes unresponsive (then CPR, but looking for the object every time you open the airway. If you can see it, grab it!)

188
Q

choking pregnant women or people obese

A

perform chest thrusts instead of abdominal thrusts.

189
Q

Choking in children>1 and adults

A

Stand or kneel behind victim
Make a fist with one hand
Place thumb side against the victim’s abdomen, in midline, slightly above the navel and below the breastbone
Press fist into the abdomen with a quick forceful upward thrust
Repeat thrusts until the object is expelled or the victim becomes unresponsive (Again, if unresponsive, start CPR looking for the object)

190
Q

Secondary Assessment history

A 
S: signs and symptoms
A: allergies
M: medications
P: PMH
L: last meal
E: Events leading to current illness
191
Q

Most common cause of bronchiolitis in children

A

RSV

192
Q

Disordered Control of Breathing are mostly what causes

A

neurologic: Seizures, CNS infections, head injury, brain tumor, hydrocephalus, neuromuscular disease

193
Q

oropharyngeal airway (OPA) or a nasopharyngeal airway (NPA) is contraindicated in

A

OPAs are contraindicated in responsive patients with a gag reflex because of the risk of vomiting and aspiration

194
Q

NPAs are contraindicated in

A

patients with basilar skull fractures because of the concern about the airway device entering the cranial vault through a thin disrupted cribriform plate.

195
Q

BAG MASK VENTILATION contraindication

A

severe facial trauma

196
Q

Good indicators of circulatory volume (indicating moderate dehydration) when used together

A

Capillary refill time > 2 seconds, decreased urine output, absent tears, dry mucous membranes, generally ill appearance.

197
Q

septic shock

A

Abnormal reduction in systemic vascular resistance, vasodilation, venodilation=pooling of blood in venous capacitance system and relative hypovolemia

198
Q

Anaphylactic Shock

A

Venodilation, systemic vasodilation and increased capillary permeability

199
Q

Neurogenic Shock

A

head injury, spinal injury, generalized loss of vascular tone.

200
Q

presentation of distributive shock in children

A

warm or cold shock
HYPOTENSION with a wide pulse pressure (warm shock) or a narrow pulse pressure (cold shock)
Bounding peripheral pulses
Brisk or delayed capillary refill
Warm flushed skin (extremities) or pale skin with vasoconstriction
Tachypnea
Tachycardia
Changes in mental status
Oliguria
Petechial or purpuric rash (septic shock)

201
Q

Signs of congestive heart failure

A

JVD, hepatomegaly, pulmonary edema
can result in increased respiratory effort
cardiogenic shock

202
Q

Obstructive Shock

A

Cardiac tamponade
Tension pneumothorax
PE
congenital heart lesions

203
Q

fluid resuscitation in shock*

A

isotonic crystalloid-NS or LR- in a 20mL/kg bolus over 5-20 minutes repeated to restore BP

204
Q

possible causes of delirium

A 
Hypoglycemia (or hyper)
Wernicke’s Encephalopathy (thiamine deficiency)
Hypertensive Encephalopathy
Delirium Tremens or other withdrawal states
Sepsis or Shock
Hypoxia or Hypercapnia	
Hypothyroidism or Hyperthyroidism
Hypercalcemia (as in metastatic breast cancer)
Uremia
Severe hyponatremia
NCS (non- convulsive status epilepticus)
Simple UTI in Nursing Home Patients
205
Q

201 psychiatric admission

A

Voluntary
Adult or emancipated minor
Understands legal aspects and signs form

206
Q

302 psychiatric admission

A

Involuntary Commitment
Requires a petitioner and a physician, and involvement of County Crisis Team
Must offer voluntary option
In PA, lose right to buy a gun

207
Q

Medical psychiatric clearance minimum testing

A 
Electrolytes, BUN, Creatinine
CBC
LFT’s
O2 Sat. by pulse oximeter or ABG’s if COPD
EKG over 40
CT if recent head trauma
208
Q

If there is decreased breath sounds and hypotension, you should suspect

A

ptx

209
Q

crystalloids in traumas have what kind of outcome

A 
bad outcomes (NS/LR)
best is blood transfusion for hypotension/hypovolemia
210
Q

heat rash

A

Skin irritation due blocked sweat ducts trapping sweat beneath the skin
Typically found on the neck, chest, groin, in skin folds
Rash may be papular, pustular or vesicular
May sting or be pruritic
Typically self-limiting

211
Q

SxS of heat stroke

A

Elevated core temp (typically >40.5°C)
Hot, dry skin (although some patients are diaphoretic)
Vague prodrome – HA, N/V, weakness
CNS symptoms – confusion, slurred speech, hallucinations, ataxia, seizures, syncope, delirium, coma
Hyperdynamic CV response – high CVP, low SVR, tachycardia
Elevated hepatic transaminases
Coagulopathy
Rhabdomyolysis and renal failure

212
Q

Heat Stroke – Work-up

A

CT head – r/o cerebral edema
CXR – heat stroke can be complicated by ARDS
Labs – CBC, CMP, VBG, PT/PTT, CPK
EKG – may develop myocardial ischemia
Urinalysis – look for myoglobinuria (seen w/ rhabdo)

213
Q

Rapid cooling measures in heat stroke

A

Evaporative cooling – fans, misting
Ice water immersion (most effective) – avoid prolonged cooling once to target temperature
Cool saline bags to neck, groin and axilla
Antipyretics are ineffective and may be harmful!

ADMIT pts

214
Q

Complications of heat stroke

A

Disseminated Intravascular Coagulation (DIC)
Acute Kidney Injury
Rhabdomyolysis
Adult Respiratory Distress Syndrome (ARDS)
GI bleed
Hepatocellular Necrosis (Shock Liver) - iver susceptible to heat illness
Mortality <10% if treated appropriately but can have permanent neurologic injury in up to 20% of cases

215
Q

frostnip

A

Mildest form of peripheral cold injury
Superficial nonfreezing cold injury secondary to vasoconstriction
Pale skin +/- associated numbness and paresthesia
Skin is still pliable (different than frostbite)

216
Q

Chilblains (Perniones)

A

More severe than frostnip
Caused by exposure to nonfreezing temps and damp air
Onset within 1-5 hrs of cold exposure
Develops over hrs to days but subsides slowly over weeks
Develop red to violet raised lesions (papules or nodules)
Inflammatory lesions that may itch, burn or be painful
See on unprotected extremities – hands, feet
May progress to blisters, erosions or ulcers
Seen more in young and middle-aged women

217
Q

Frostbite pathophysiology

A

Decreasing temperature results in decreased tissue perfusion – eventually temp low enough to form intra and extracellular water crystals that disrupt cell membranes and protein structures
Ultimately leads to cell death w/ tissue ischemia and necrosis

218
Q

Frostbite – Four Degrees of Severity

A

First degree – hyperemia and edema
Second degree – hyperemia and edema AND large clear blisters
Third degree – hyperemia and edema and vesicles w/ hemorrhagic fluid (typically smaller than second degree)
Hemorrhagic fluid indicates deeper tissue injury
Fourth degree – most severe, complete necrosis with gangrene (typically dry)
Simpler classification (preferred by many clinicians) – superficial (1st & 2nd degree) vs deep (3rd & 4th degree)

219
Q

What sign is concerning in frostbites

A

loss of pain

220
Q

Frostbite Tx

A

Initial treatment of choice = rapid rewarming in a water bath at a temperature of 39-42°C (102.2-107.6°F)
Continue until extremity has a flushed appearance (typically 30-45 min)
Monitor temperature of water bath closely
Process is painful!!
tetanus prophylaxis if hemorrhagic blisters (deeper)

221
Q

Hunter’s Response

A

Initial vasoconstriction followed by a paradoxical and cyclical vasodilatation in response to cold that often occurs in the fingers, toes, and face.
cold induced vasodilation

222
Q

Temp of mild v moderrate hypothermia

A

Mild hypothermia (32-35°C) – vigorous shivering, hyperventilation, tachypnea, tachycardia, and cold diuresis as renal concentrating ability is compromised.

Moderate hypothermia (28-32°C) – further CNS depression, hypoventilation, hyporeflexia, decreased renal flow, and paradoxical undressing may be noted. Higher risk of arrhythmias, presence of J-wave on EKG
Pupils become dilated and minimally responsive
223
Q

severe hypothermia

A 
Severe hypothermia (<28°C) – marked susceptibility to v-fib, pulmonary edema, oliguria, coma, hypotension, rigidity, apnea, pulselessness, areflexia, unresponsiveness, fixed pupils, and decreased or absent activity on EEG
Metabolic acidosis, rhabdomyolysis
“They’re not dead till they’re warm and dead.”
224
Q

Who gets antibiotic prophylaxis in bites?

A

pretty much everyone!

if no infection, 3-5days; if infection, 5-14days

225
Q

Incubation time for rabies

A

2wks to 40-45days

226
Q

exception to tetanus prophylaxis in bites

A

insects

227
Q

Coma cocktail

A

for patient with altered consciousness
Dextrose to treat hypoglycemia: If rapid bedside glucose monitoring (1st) is not available or reveals low/near-low levels
Thiamine to prevent Wernicke’s encephalopathy
Nalaxone for suspected opioid intoxication

228
Q

common anticholinergic agents

A 
Antihistamines: Diphenhydramine (Benadryl, common people take for sleeping), hydroxyzine, meclizine (motion sickness)
Antispasmotics:Dicyclomine, oxybutynin
Atropine
TCA’s: Amitriptyline
Sleep aids (RX and OTC)
Jimson Weed
229
Q

cholinergics produce the same effects as what system

A

parasympathetic system

230
Q

Heparin antidote

A

protamine sulfate

231
Q

CO toxicity presents as

A

cherry red face

232
Q

fomepizole and ethanol MOA as antidotes for toxic alcohols

A

fomepizole inhibits alcohol dehydrogenase which metabolizes the toxic alcohols
ethanol is competitive inhibitor of ADH

Emergency Medicine (1 decks)

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