FINAL Flashcards

Question

ASA overdose

Answer 1

-Aspirin, Oil of wintergreen, Bengay, Air fresheners, mouthwash -Toxic = 300mg/kg -!Acute toxicity: N/V, tachy, tachypnea!, fever -!Chronic toxicity: Tinnitus, GI irritation, AMS -Severe: Cerebral and pulmonary edema, hypoglycemia causing seizure -Labs: ABG/VBG!!!, ASA level, Acetaminophen level, BMP, LFTs -!!Primary resp alk + Anion gap metabolic acidosis -E.g. ↑ pH 7.44 | ↓ PCO2 26 | ↓ HCO3 18 -Salicylate level ≥ 30mg/dL -Cause of death: Cerebral edema (seizure), pulmonary edema (ARDS), metabolic acidosis / resp alk -Tx: -ABCs, IV, O2 PRN, monitor -glucose for CNS hypoglycemia -!Decon: Activated charcoal -!Urine alkalinization with !SODIUM BICARB! infusion (urine pH > 8) -check K -> correct hypokalemia prior to alkalinization (if there is any) -DONT do in CHF or renal failure pts bc of volume load -goal serum pH of 7.45-7.55 or a urine pH of 7.50-8.0 -Hemodialysis!: -!!pulmonary edema, cerebral edema (severe confusion/AMS, seizure, coma), renal failure, acidemia, level >100mg/dL (acute) or > 60mg/dL (chronic)

Answer 2

-beta blocker OD -> glucagon, insulin + dextrose, intralipid fat emulsion therapy if refractory -iron- GI upset, kids -> IV crystalloid, antiemetics, whole bowel irrigation, DEFEROXAMINE (severe) -rat poison = warfarin -> lavage, charcoal, vitamin K, FFP, PCC -benzo -> flumazenil -heparin -> protamine

Answer 3

-HEMORRHAGIC: -MCC death -tachy, hypotension -EFAST + -> morisons pouch, hemothorax -negative EFAST does not r/o bleed -CT abd/pelvis -Tx- pressure, MTP, surgery -TAMPONADE- -Becks- hypotension, muffled heart sounds, JVD -pulsus paradoxus -tachycardia -EFAST- RV collapse -Tx- pericardiocentesis -TENSION PNX- -hypotension -tachy -listen -Tx- needle decompression -> chest tube -NEURO- spinal cord injury (later) -TOXICOLOGIC: -brady if BB, CCB -tachy- sympathomimetic, toxidromes -AMS -Drug screen -CT head if AMS unexplained -antidotes

Answer 4

-MOA -> PRIMARY SURVEY (ABCDE, c-collar, monitor, xray, efast, labs) -> 2NDARY SURVEY (head to toe, AMPLE) -> IMAGING (once stable) -> DISPO -Airway: -GCS <8, stridor, drooling, burns, expanding hematoma -Breathing: -equal B/L breath sounds -trachea deviation -crepitus @ neck/chest -fail chest- >=2 consectuvie ribs in >= 2 places -> supportive tx -Circulation: -2 large bore IVs -pulses, BP -IVF, massive transfusion -GOAL MAP >=80 -tourniquet, pressure, pelvic binder -Disability & dextrose: -pupils -neuro- GCS -4 extremity movement -brain or spinal cord injury -hypoglycemia!!, ETOH, drugs -ICH -Exposure/environment: -naked!!! -warm blankets -burns, toxins, urethral meatus, finger in every orifice -log roll (4 people)- check the back, c collar

Answer 5

-use for explained hypotension in trauma -visualize 10 structures/spaces in 4 areas -RUQ- hepatorenal -1. morrisons pouch -2. hemothorax -3. liver tip -MC place for fluid -check this first -shark fin sign -+ spine sign is bad -LUQ- splenorenal -4. btwn kidney and spleen -5. btwn spleen and diaphragm -6. hemothorax -7. spleen tip -+ spine sign is bad -Subxiphoid- cardiac -8. pericardium -9. heart chambers (RV) -Suprapubic- -10. pouch of douglas (btwn uterus and rectum) / rectovesical pouch -+ anterior and lateral pleural spaces -> pneumothorax or pleural effusion -pelvic fx and retroperitoneal bleed require CTA for dx

Answer 6

TOP PIC: -Normal RUQ ultrasound -Spine should only extend up until the lung border -Lung should have mirror artifact -Air is mucking the view of the spine above the diaphragm -> spine sign -BOTTOM PIC: -Large pleural effusion in RUQ +Spine sign = can see the spine above the diaphragm due to pleural fluid allowing sound waves to penetrate -black between the lung and diaphragm = pleural effusion maybe

Answer 7

-TBI: hematoma, SAH, contusion, diffuse axonal injury -2ndary phase caused by impaired cerebral blood flow -> edema, bleed -GCS tx and severity is guided by GCS -GCS 3-8 -> severe, CT -GCS 9-12 -> moderate, head CT -GCS 13-15 -> mild TBI (canadian ct rules) -Neg CT - mild TBI, concussion -Positive CT- specific dx based on findings -Tx: -return to play -> cleared by neurologist -if worsening HA, vomiting, AMS, bruising around eyes/ears, seizures -> Return to ED

Answer 8

-image c-spine injury if neuro deficit / GCS depressed -> use NEXUS / canadian CT spine rules otherwise -you want alignment of anterior and posterior contour line and spinolaminar line -Pre-hospital c-collar does not mandate imaging -Canadian CT spine rules requires: -GCS=15 (intoxication is OK if alert and cooperative) -Vital signs are stable -Neuro exam is normal -No known c-spine disease or prior surgery -alert, stable -!!!CT non contrast is 1st line for moderate-high risk pts w/ cervical injury -if no sx / CT neg and high suspicion -> MRI -> good for soft tissue, cord, ligaments -IMAGING DOES NOT R/O SCI -no sx + neg CT -> cleared -> advise movement

Answer 9

-Sensory (ascending): -position, vibration, light touch- dorsal columns -pain (pinprick), temp- ventral columns, spinothalamic -Motor (descending): -corticospinal -S1-S2- buckle my shoe (achilles) -L3-L4- kick the door (patella) -C5-C6- pick up sticks (biceps) -C7-C8- lay them straight (triceps) -L1-L2- cremasteric -S3-S5- anal wink

Answer 10

-GCS 13-15 + at least 1 of following: -LOC -Amnesia to head injury event -Witnessed disorientation -Exclusion criteria: -Age <16yo -Blood thinners -Seizures after injury, or, anticoagulation use -PECARN: -<2yo and 2-16yo -CT if: -GCS<15 -AMS -Signs of skull fracture (basilar skull fx >2yo) -consider in kids with: -LOC from head trauma -Non-frontal hematoma or acting differently and <2 yo -Vomiting from head trauma -Severe headache -Severe mechanism: -MVC + [Ejection, rollover, vs. pedestrian, death at scene ] -High impact object -Fall >3ft (<2yo) or >5ft (>2yo)

Answer 11

-EPIDURAL: -progressive obtundation (N/V, HA, LOC) -unequal pupils (dilated on side of clot) -cushings -> HTN, brady, irregulat resp -hernaiation -MI -does not cross suture lines -heterogenous appearance -> active bleed -Tx- surgery -SUBDURAL: -btwn brain and dura -higher mortality than epidural -crosses suture lines, does NOT cross falx -elderly- personality changes, focal deficit -surgery -if small, subacute, neuro intact -> observe -SAH traumatic: -increase ICP either from hemorrhage or hydrocephalus from obstruction of ventricular system (3rd) -Dx- CT within 6 hrs -if CT neg and >6hrs -> LP or CTA -Tx: -R/O aneurysmal cause! -> require surgery -!Reverse coagulopathy -Warfarin reversal: PCC, FFP, Vit K -UFH, LMWH: Protamine sulfate -Thrombocytopenia: Platelets -BP systolic < 160mmHg -Reduce ICP - Hypertonic saline -Prevent cerebral vasospasm- Nimodipine -Dispo: Neuro ICU -Intraparenchymal -trauma or non-trauma (malignant HTN) -often evolve over hrs/days -mass effect common -small vessles -Tx: definitive airway, reverse anticoag, control BP (dont allow hypotension), control ICP

Answer 12

-classic presentation- ipsilateral fixed dilated pupil and contralateral hemiplegia -cushing reflex- HTN, brady, irregular respiration -if seziures -> benzo -reverse anticoagulation -keep SBP ~ 160 -raise HOB -mannitol -hypertonic saline -hyperventilation -ventriculostomy

Answer 13

- fx of Skull base -Serious and life-threatening complications -Hemotympanum – 1st sign -Raccoon eyes - delayed -Battle sign - delayed -“Halo” sign -Anosmia -EOM defects -Hearing loss -loss of balance -Carotid artery or vertebral artery injury -Cervical spine injury

Answer 14

-aka orbital blowout fx -may entrap !inferior rectus muscle! -> !vertical stabismus! (one eye deviated up) -numb on middle face (maxillary branch of trigeminal runs thru inferior orbital groove) -blunt or penetrating trauma -pain with eye movement -floor- diplopia! and/or nausea -roof- forehead numbness -proptosis or enophthalmos -widened intercanthal distance -bradycarida!- oculocardiac reflex causes dec HR when pressure apple to extraocular muscles -Dx: -!CT no contrast -CT indicated if bony tenderness, step off, crepitus, entrapment -PE- acuity, fields, IOP, slit lamp, EOM -ophthalmology consult for dec acuity, widen intracanthal space (fx), orbital comartment syndrome (rock hard eyelids), CSF, entrapment esp if causing oculocardiac reflex -r/o brain bleed, c-spine fx, CSF leak, entrapment syndrome, airway -Tx: -elevated HOB -ice pack for first 48hrs -nasal decongestants, corticosteroids -complications -> surgery -do NOT blow nose

Answer 15

-RF- sickle cell -> exchange transfusion -more blood can cause staining and increase IOP -Tx: -Place clear eye shield -Elevate head of bed -topical BB if IOP -tx bleeding disorders ->1/2 -> admit and ophtho -<1/2 -> expedited outpt ophtho eval

Answer 16

-CORNEAL ABRASION: -ask ab contacts -if central -> dec acuity -dx- fluorescein stain and woods lamp -eyelid EVERSION! -Tx- topical antibiotics (erythromycin, tobramycin, gentamycin) -cipro if contacts -tetracaine for pain in ED -24-48hr ophtho f/u -NO shields, steroids, contacts, tetracaine (at home) -CORNEAL LACERATION: -Full thickness laceration of the anterior chamber -MC sharp -teardrop pupil -flat anterior chamber -seidels sign- fluorescein swirls due to leaking aqueous humor -DO NOT TONO PEN (check IOP), DO NOT PATCH (do shield) -Tx- immediate consult -IV antibiotics, analgesia, anti-emetics, tetanus -GLOBE RUPTURE: -Full thickness laceration of the globe -MC blunt -teardrop pupil -flat anterior chamber -seidels sign- fluorescein swirls due to leaking aqueous humor -DO NOT TONO PEN (check IOP), DO NOT PATCH (do shield) -Tx- EMERGENT consult -IV antibiotics, analgesia, anti-emetics, tetanus, CT for globe

Answer 17

-Nasal Congestion: -Sinusitis: -purulent -facial pain ->10 days -Allergic rhinitis: -clear -itchy -pale, boggy mucosa -Nasal polyps: -chronic congestion -dec smell -mobile lesions -pale -aspirin exacerbated -often B/L -Septal hematoma: -blood btwn perichondrium and cartilage -worst morbidity of nose -bulding, bluish/red, soft -pain -complications: abscess, necrosis, saddle nose, perforation -Tx- I&D w/ b/l packing -augmentin, removal 2-3days

Answer 18

-MSK lowest priority in trauma -Neurovascular > Bone/Muscle -DIRECT PRESSURE -PROXIMAL PRESSURE -TOURNIQUETS -PRESSURE DRESSINGS -HEMOSTATIC DRESSINGS -“Hard signs” -surgical repair -no pulses, no cap refill, no senses -no bruit/thrill -active/pulsatile hemorrhage -limb ischemia signs -compartment syndrome -expanding hematoma -“Soft signs”- CTA or ABI (may still require OR) -ABI > 0.9 -> not arterial -ABI < 0.9 -> CTA -> OR if +

Answer 19

-acute breakdown and necrosis of MUSCLE -Causes: -TRAUMA/COMPRESSION -Prolonged immobilization -Seizures -Burns -Compartment syndrome -meds (STATINs MC), substance abuse (amphetamines), infections (influenza), metabolic or genetic factors -triad- muscle pain, weakness, dark urine -non-specific sx- fever, malaise, n/v, tachy, abd pain, oliguria -Dx: -LABS: -↑ CPK (>20,000) !!! -↑ LDH -!Hyperkalemia, phos -Hypocalcemia -+/- AKI -U/A: MYOGLOBINURIA !!!! -Red/Brown/Pink/Dark urine that is heme (+) but no RBCs on microscopy!!!!! -EKG: +/- hyperkalemia if severe -Tx: -IVF to flush out myoglobin -Treat any hyperkalemia!! -Severe -> dialysis -Complications: -ACUTE KIDNEY INJURY and ATN due to excess myoglobin

Answer 20

-CRITICAL reduction in blood flow to tissue -MC in lower limbs -MC long bone fx -> tibia -Circumferential thermal burns -Tight casts -RF: Bleeding disorders or anticoagulation -OPEN fx can get compartment syndrome -CAN occur in low-energy or atraumatic injuries (drug overdose) -Late or missed presentation: -Myonecrosis, Rhabdo, Contracture, Sensory loss, Infection, Non-union, Amputation, Death -Pain out of proportion -> 1st and most reliable finding -within hrs or within 48hrs of insult -Unrelieved with initial measures -!!Worse with passive stretching -Paresthesia's -!!Tense compartments -Not usually swollen -6 P’s as it progresses -Dx: -Perform and document serial exams (q 30 mins) -Absolute compartment pressure > 30 mmHg or -Delta pressure < 30 mm Hg (delta = diastolic BP – compartment pressure) -Tx: -Early recognition -!!Consult ortho, trauma, or acute care surgery for emergency surgical fasciotomy -Prior to surgery: -Remove all dressings / splints / casts -Keep limb at neutral level -High flow oxygen -Improve BP with IVF -Give opioid analgesics! -incisions left open to recheck in 24-48hrs -> assess need for debridement -Monitor for rhabdo and renal injury

Answer 21

-central retinal artery occlusion: -same stroke RF -amaurosis fugax -afferent pupillary defect (swinging light test) -fundoscopy- pale retina, cherry red spot, fixed, dilated -tx- ASAP optho consult (anterior chamber paracentesis), admit with stroke work up -gentle massage globe- dislodge emboli -dec IOP- acetazolamine, mannitol, timolol -inc CO2- hyperventilation -inc O2- 100% nonrebreather ->2hr -> vision loss -central retinal vein occlusion: -DVT of eye -fundoscopy(pic)- blood and thunder hemorrhage, cotton wool spots, macular/optic disc edema -check b/l dont miss papilledema -tx- ASA, lower IOP, steroids, urgent consult -retinal detachment: -flashers & floaters -lower curtain -ocular US -check visual fields -grey retina with folds, vitreous hemorrahge (cant r/o w/ fundoscopy) -tx- emergent ophtho consult -vitreous hemorrhage: -abn neovascularization -> bleed -red haze, cobwebs, shadows -worse in morning -check IOP, pupillary reflex -ocular US -tx- underlying cause -optic neuritis: -MS -afferent pupillary defect -painful EOM -optic disc swelling -MRI or CT head -loss of color / vision -ocular US -tx- IV steroids, neuro or ophtho consult

Answer 22

-glaucoma: -acute (painful), chronic (not painful) -IOP > 20 -tx- miotics, lower IOP -temporal arteritis: -3/5: >50yo, HA, temporal tenderness/dec pulse, ESR >50, bx + -polymyalgia rheumatica- proximal limb weakness -may have afferent pupillary defect -pale edematous optic disc -tx- No vision loss- high dose prednisone -Vision loss- solumedrol IV -iritis: -h/o autoimmune ds or trauma -slit lamp -tx- pain control, steroids

Answer 23

-RETINAL DETACHMENT: -Fundoscopy- pale, grey retina with folds, vitreous hemorrahge (cant r/o w/ fundoscopy) -US- hyperechoic membrane floating inside vitreous -> moves with eye movement -VITREOUS HEMORRHAGE: -Fundoscopy- neovascularization, red haze, cobwebs, shadows -US- snowstorm appearance- hyperechoic -CRAO: -fundoscopy- cherry red spot, pale retina -arteries are narrow -US- wnl -CRVO: -fundoscopy- blood and thunder -> diffuse retinal hemorrhage, dilated tortuous veins -flame hemorrhages -optic disc edema -US- wnl

Answer 24

-!Red/painful eye, vomiting, HA, AMS -!Precipitated by dark room, or using mydriatics -Canal of Schlemm is narrowed, cannot drain fluid -Vision threatening -Systemically unwell -Steamy hazy cornea -!Mid-dilated, non-reactive pupil -!Elevated IOP >40-70 (normal 10-21mmHg) -May have a rock hard globe -Tx: -Emergent ophthalmology consult -Pain control -↓ IOP: mnemonic STAMP -Supine- lower head of bed -Timolol: eye drops -Acetazolamide 500mg IV (carbonic anhydrase inhibitor) -Mannitol 1g/kg IV (osmotic decompression ) -Pilocarpine eyedrop

Answer 25

-PRESEPTAL: -Staph, group A strep, strep pneumo -injury (scratches, bug bites), URI, stye, blepharitis, conjunctivitis -Fever, erythema, lid edema -Young = do a septic workup -PO Augmentin, clinda -POST-SEPTAL: -2ndary spread (sinusitis, dental infections, dacryocystitis, orbital surgery, endogenous sources) -Staph, strep, pseudomonas, enterococcus, H. flu -Proptosis, Ptosis -Limited EOM (diplopia) -Chemosis -Suspect compression optic neuropathy if afferent pupillary defect, ↓ visual acuity, visual field deficit and ↑ IOP -Clinical dx -> confirm w/ CT -blood cultures -Tx: IV clinda or cefuroxime, admission, ophtho consult for possible debridement -Complications: Meningitis, abscesses, cavernous sinus thrombosis, CN deficits, orbital compartment syndrome -RETROBULBAR HEMATOMA(pic): -Blunt trauma -> hematoma behind eye -Proptopsis -Decrease visual acuity -Non-reactive pupil -IOP>40 -Tx- Lateral canthotomy, emergent

Answer 26

-conjunctivits: -spares the ring around the pupil -episcleritis: -self limited -blanches with phenylephrine -> dx and differentiates from scleritis -scleritis: -rare but emergent -> vision threat! -pain, blurry vision, photophobia -sclera edema, violet/blue globe -underlying autoimmune ds -does NOT blanch with phenylephrine -tx- oral steroids, NSAIDs, emergent ophtho -anterior uveitis/iritis: -inflammation of internal structures -Etiology: Infectious, post-traumatic, autoimmune (associated with HLA-B27)!! -sudden, unilateral deep pain -!direct and consensual photophobia -> painful constriction -miosis -ciliary flush!! -slit lamp - cell and flare (WBC in anterior chamber (hypopyon) -> foggy) -tx- topical cycloplegics (dilate pupil) and topical steroids -anesthetics dont work bc its deep -ophtho consult -keratitis: -inflammation of cornea -vision blurry, red -perilimbic flush - not as deep as ciliary flush -UV keratitis- welders, fluorescein shows superficial punctate! keratitis) -> tx- no ophtho consult -> patch, cycloplegics, topical, antibx -!!corneal ulcer- contact lens (pseudo) -> SOFT/HAZY white EDGES (unlike sharp abrasion) -> EMERGENCY / IV antibx -tx- prophylactic antibx -call ophtho -NO steroids for HSV

Answer 27

-!Hold pressure below nasal bridge -> ENTIRE fleshy part -Should be uncomfortable -Tongue depressor option -Lean head slightly forward -Ice on forehead or occiput -Wait 10-20 mins -Look in nose and throat -Tx options (dont need to know): -!Afrin spray (oxymetazoline) + pressure + time = manages majority of bleeds -Anterior bleed (MC)- Silver nitrate cautery (never on septum) -Anterior nasal packing: Surgicel/Surgiflo, Vaseline gauze, xeroform gauze, Merocel, Nasal tampon

Answer 28

-AOM: -hearing loss -impaired mobility of TM -buldging/red -if perf -> drainage / crust -bullous myringitis = blisters on TM (mycoplasma) -tx- analgesics, hydration, antibx, consider t-tube -complication- mastoiditis, meningitis, facial nerve paralysis, intracranial abscess -MASTOIDITIS: -abscess in mastoid bone -proptosis of ear -!thin-cut CT temporal bone -2wks antibx -possible surgical drainage -complications- meningitis, skill osteomyelitis, venous sinus thrombosis, brain abscess, facial nerve palsies

Answer 29

-Swimming, excessive ear cleaning, hearing aids, headphones -!Pseudomonas!, S. epidermis -Significant drainage, debris, granulation tissue in EAC -Must check TM, should be normal -Tx: -Debridement -Topical antibiotics: neomycin/hydrocortisone suspension, ciprodex -Consider ear wick (merocel) placement if very swollen -OTITIS EXTERNA (necrotizing) (malignant) -Osteomyelitis of temporal bone/skull, rapidly progressive -Pseudomonas aeruginosa -immunocompromised (DM) -!!Exquisite pain and discharge, out of proportion -radiate to jaw -Granulation tissue and bony-cartilaginous junction is pathognomonic -Possible CN7 palsy -CT and admission most often -4-6 wks of ORAL ciprofloxacin (topical not enough)

Answer 30

-Emergency! -> sepsis, airway compromise -Causes: dental infection/procedure , polymicrobial -Rapid cellulitis of floor of mouth -Pain, drooling, dysphonia, fever, trismus, hot potato voice, stridor (late sign) -!Cellulitis of redness, brawny neck edema -!Raised firm area under the tongue -> tongue protrusion or elevation (no tongue swelling) -!Neck/throat tenderness -!Submandibular “woody” induration, crepitus, tenderness -Often CT scan of neck, labs -Intubate early -broad spectrum IV antibiotics -PROMPT ENT / oral surgery consult for possible surgical I&D, ICU admission

Answer 31

-PERITONSILLAR ABSCESS: -20-40yo -Recent or current strep, acute tonsillitis -!Muffled “hot potato” voice -!Uvula deviation -!Trismus = cannot open jaw d/t pterygoid muscle irritation -!fluctuant, swollen, red, loss of landmarks -May be drooling, halitosis -Dx: Clinical! -> can get CT or U/S -Def tx = drainage!: Needle aspiration vs. I&D -Obtain wound culture -Complication: hitting the carotid -Send home with antibiotics !(clindamycin or ampicillin/sulbactam 10-14 days) -RETROPHARYNGEAL ABSCESS: -young <5yo -recent strep, OM, tonsillitis, Post op (dental, endoscopy), trauma (fish bone) -Sore throat, fever, neck pain, dysphagia, odynophagia, neck stiffness (meningitis mimic) -!Pain / limitation of neck extension/flexion -Unilateral posterior pharyngeal edema & erythema -Stridor, pooling secretions, sniffing position, voice change -> bad -Dx: Lateral neck XR or CT scan w/ contrast! -Tx: -IV Antibiotics (clindamycin) -ENT consult (surgical I&D) -Intubate if signs of impaired airway -Complication: Mediastinitis, Lemierre’s syndrome, Obstruction

Answer 32

-sore throat- Usually viral URI! -dysphagia, referred pain to ears, neck, jaw, fevers, chills, myalgias -tonsil enlargement, posterior pharynx injected/red, cervical lymphadenopathy -Dx: +/- throat cx, cbc, bmp, monospot, flu -Meds: OTC NSAIDs, salt-water gargles, lozenges, consider decadron 10mg IM for severe pain -Exudative tonsillitis: -Strep throat -Centor criteria (fever, exudates, no cough, anterior cervical LAD) -tx- Amoxicillin -Mono: -EBV; less common CMV, HIV, HBV, toxo -Fever, fatigue, tonsillar exudate, anterior or posterior! cervical LAD -Monospot (heterophile antibody test) -> low sensitivity and high specificity -Doesnt work in <5yo -> bc no antibodies -Refrain from sports 21 days

Answer 33

-EPIGLOTTITIS: -Etiologies: -HiB (Haemophilus influenzae B) * before vaccines -Strep or staph aureus -RAPID onset 12-24 hrs of: -Fever -Sore throat -Muffled voice -stridor -Anxious and ill-appearing -Dx: -before even examine -> CALL -Lateral neck XR: Thumbprint sign -Tx: -Early airway management -Emergent ENT consult -O2, nebulized meds -IV Ceftriaxone (3rd gen cephalosporin) -Admit if airway compromise -CROUP (laryngotracheitis): -barking -NO DROOL -low fever -worse at night -Dx- XR- steeple sign -Tx- humidified O2, nebulized racemic epi and albuterol!!!, observe 2 hrs -low O2 sat, young (<3mo)- nebs, steroids, admit -Other stridor in kids: -Anaphylaxis -Foreign body -Neck abscess -Congenital abnormalities compressing the airway -angioedema -> steroids, diphendydramine, famotidine, epinephrine IM if airway compromise

Answer 34

-vit K doesnt work fast -> use PCC or FFP + vit K -Indications for reversal: -Major bleeding in a critical site: -Intracranial bleed -Intraperitoneal bleed -Retroperitoneal bleed -tamponade (from bleed) -Hemothorax -GI bleeding -IM (compartment syndrome, limb loss) -Joint- Intraarticular -things you cant apply pressure to -Hemodynamic instability -SBP <90 mmHg or decrease >40mmHg -Syncope -Hgb drop of ≥ 2 g/dL from bleed -Requiring ≥2 U PRBCs -Likely okay to watch and wait: Menstrual bleed, Epistaxis, Mild GI bleeding, Cutaneous bleeding

Answer 35

-Rare condition -Fe2+ -> Fe3+, “functional anemia” -Methemoglobin cant bind O2 -Causes: Nitrites (food), Topical anesthetics, Pyridium, Dapsone, Reglan -Severity = Concentration of methemoglobin ->10% = cyanosis , dusky skin -20-50% = fatigue, tachycardia, dizziness, dyspnea, chest pain ->50% = AMS, seizures, fatality -Labs: -Methemolgobin on comprehensive blood gas -Often normal PaO2 -!!SpO2 ~85% unresponsive to supplement O2 -Tx: Methylene blue!!! + Stop offending agent -Methylene blue CI in G6PD deficiency -Methylene blue is a MAO-I and can cause serotonin syndrome in pts on SSRI or SNRIs

Answer 36

-Homozygous HgS = most serious form -Sxs dont appear until 4mo of age when HgF is replaced by the abnormal HbA -Short RBC half life = chronic anemia (normal = 12-18) -they live in chronic anemia -> hmg 6-8 -Recurrent splenic infarcts -> decline in spleen by 4-12mo -> susceptibility to encapsulated bacteria -Triggers: infection, dehydration, stress, extreme temperatures -ACUTE COMPLICATIONS: -Hypotension/tachycardia: -!!Sepsis -!!Splenic sequestration -!!Aplastic crisis -Severe pain: -!Acute chest syndrome -!Priapism -!!Vasoocclusive crisis (VOC) * dx of exclusion -Abdominal pain: -!Splenic sequestration -SOB: -!Acute chest syndrome -Acute anemia: -!Aplastic crisis -!Splenic or hepatic sequestration -!Acute chest syndrome -Fever: -!Acute chest syndrome -!Vasoocclusive crisis -!Infection / Sepsis (think encapsulated organisms) -Asplenic pts- Have No Spleen (Haemophilus, Neisseria, Streptococcus pneumoniae)

Answer 37

-Neutropenia = Low absolute neutrophil count (ANC) -!!!!ANC ≤ 500 cells/microL -Fever (IDSA definition)= -!>1hr of ≥100.4°F (38°C), OR -!Single elevated temp ≥101.0°F (38.3°C) -Common in CHEMOTHERAPY -MC infections: GI, blood, skin, lungs, Urinary tract -but Fever or malaise may be only presenting sx -ANC reaches a nadir (lowest point) 5-10 days after chemo -Hematologic cancers ↑ risk of neutropenic fever -!Dx: -Thorough PE: -check for mucositis -Defer rectal until after antibiotics (infection risk) -Look for local infection: -Labs -Blood cultures x 2 (before antibiotics if possible) -CXR / Sputum cultures -UA / Urine culture -Consider CT abd, pelvis, chest -Consider GI panel -Maintain isolation and barrier precautions -pts are immunocompromised! -> may be no S&S -Tx: -Resuscitate and tx as sepsis if necessary -Fever + Neutropenia is a med emergency -High risk pts or sick pts will require !broad spec IV antibx and admission! -stay until ANC resolves -> 2wks -Low risk pts that are well appearing can be considered for outpt antibx tx with !Augmentin and ciprofloxacin! after 4 hr observation period

Answer 38

-ABCDE -Maintain O2 >95% -Early and aggressive pain control -Utilize incentive spirometer -> encourges deep breath despite pain -> prevents acute chest syndrome -Lab tests: -CBC w/ diff -BMP w/ LFTs -!!RETICULOCYTE count- would be higher in these pts normally -> if aplastic crisis it will be lower -LDH- if its high it can mean hemolysis -Consider: CXR (fever, respiratory symptoms, chest pain), Viral swab, blood cx (if fever), UA, Urine cx, CSF analysis or synovial fluid analysis in the setting of fever -ALWAYS EVALUATE: -Cardiopulmonary symptoms -Hemoglobin level -Reticulocyte count -All dx tools (such as elevated reticulocyte count) are unreliable pain indicators

Answer 39

-MC manifestation of SCD -vitals can be normal even in pain -Can occur in any system: -pulmonary arterial tree (CP, SOB) -Coronary arteries (STEMI) -CNS (HA, strokes) -MSK (dactylitis, bone pain, VTE) -Kidneys (CKD/ESRD, Hematuria etc) -mild !fever and leukocytosis! -!bony infarctions! -Fat embolism -> ARD, petechia, AMS, renal/liver failure -Vasoocclusive Pain crisis- MC pain @: long bones, lower back -Stroke -Acute chest syndrome -Papillary necrosis -Avascular necrosis -Ulcers -Dactylitis: -Painful and swollen hands/feet - < 2yo -Usually 1st presentation -Tx: -Analgesia -Re-eval q15-30 mins -Consider PCA pump -Add Benadryl q4-6 hrs for itching -Gentle hydration to euvolemia: -D5 ½NS @ 1.0-1.5x maintenance (hypotonic) -Do NOT IV bolus -> avoid overhydration -> pulmonary edema -SPO2 at least 95% -Dispo: -Admit if required ≥2 doses of narcotics -Discharge if pain controlled, with PO meds

Answer 40

-Splenic vasoocclusion traps large amount of RBCs in spleen -> splenomegaly -LUQ pain, splenomegaly, hypotension/shock -acute anemia -Children! < 5yo mostly -Fever -Shock: HR, RR, BP, poor perfusion -Supportive findings: -!Acute anemia (drop HGB of ≥2g/dL from baseline) -!!Normal or ↑ reticulocytosis -!Thrombocytopenia (d/t trapping) -range from minor to major -> progress to shock and death within hrs -Supportive tx: Fluid resus, cautious pRBC transfusion, elective splenectomy -Admit

Answer 41

-fever, low Hgb, reticulocyte <1 -Severe and sudden drop in hgb AND reticulocytes -Assoc with parvo b19 -Fever, pallor, fatigue, lethargy, shock dyspnea -Labs: Pancytopenia -Anemia with HGB ~3-6 g/dL (normal 12-16g/dL) -!!Reticulocytopenia (as low as 0%) (normal 0.5-2.5%) -most important aspect of tx: simple RBC transfusion!! -Dispo: Admit! until bone marrow production is resumed

Answer 42

-aplastic crisis -splenic sequestration -acute chest syndrome -dactylitis -transfusion -salmonella

Answer 43

-Can occur anytime after VOC -Treat before occurs -> Incentive spirometry, Analgesia -!!MCC of morbidity and mortality in SCD (10%) -!!!!Fever, cough!, chest pain!, dyspnea, hypoxia!, wheeze, rib/sternum pain -Tachypneic, rales, wheezing, effusion, low O2 -CXR: !New pulmonary opacity! -multilobar infiltrates -Tx: -!Antibiotics - make sure ischemic tissue isnt getting infected -Pain control -Supplemental O2 >95% -Incentive spirometry -Consider transfusion guided by hematologist -!Admit due to high chance of respiratory failure -Transfusion indications: -mild- 1-2 units PRBC simple transfusion -Severe- exchange transfusion: -Pts with hx of severe acute chest syndrome requiring exchange -diffuse acute chest X-ray finding -Oxygenation continues to worsen despite simple transfusion -Hypoxemia is particularly severe (ex. < 85%) -Evidence of other organ systems being involved, especially multiorgan failure

Answer 44

-0 mins= arrive -<10mins= ABCs and POC glucose, last well known, exam -supplement O2 if <94% -NIH stroke scale -<15mins= notify stroke team -<25mins= Head CT or MRI -tells us if hemorrhagic or ischemic -> helps guide BP management -get CTA immediately if ischemic -MRI for posterior -<45mins- Interpretation of scan, decide tPA -<60mins- IV alteplase within 3-4.5hrs from sx onset -Labs: Coagulation, CBC, BMP, lipids, A1C, T&S -ECG- afib, large strokes you can see deep TWI and prolonged QT (ICP)

Answer 45

-tPA: - !< 3hrs since onset of sx (<4.5 in select individuals) -!≥ 18yo -if tPA head bleed complication -> 10u cryo + 6U platelets -Dual anti-platelet therapy: -Minor strokes (NIHSS ≤5) do not always receive tPA -Initiate DAPT within 24hrs of sx onset -ASA + clopidrogel/ticagrelor -Endovascular therapy (EVT)/ Intra-arterial thrombectomy -Embolectomy or angioplasty with catheters -Indicated in LARGE VESSEL OCCLUSIONS! (LVO) in the ANTERIOR CIRCULATION! -done up to 24 hours! after sx onset -even if patient received tPA -Indications: -<6hrs from sx onset (but up to 24 hrs) -High baseline function prior to sx onset -Minimal tissue damage on CT -NIHSS score > 6 -tPA CI: -Absolute: -!ICH on CT -Presentation- sus of SAH -!Neurosurgery, head trauma, or stroke in previous 3mo -Uncontrolled HTN (>185/>110)! -!Hx of ICH -Known intracranial arteriovenous malformation, neoplasm, or intracranial aneurysm -!Active internal bleeding -Suspected or confirmed endocarditis -Known bleeding diathesis with platelet count < 100,000/μL -Elevated PTT with heparin administered in last 48hrs or oral anticoagulants -Glucose < 50 mg/dL or >400mg/dL -Relative CI: -Recent GI or urinary tract bleeding (past 21 days) -Minor or rapidly improving stroke sx -Major surgery or serious nonhead trauma in past 14 days -Seizure at stroke onset -Recent arterial puncture at a noncompressible site -Recent LP -Post-MI pericarditis -Pregnancy

Answer 46

-Anterior cerebral artery (ACA)- contralateral WEAKNESS IN LEG > arm/face -Middle cerebral artery (MCA)- contralateral WEAKNESS IN ARM/FACE > legs -dominant side (MC left) = aphasia -non-dominant side (MC right) = hemineglect -Posterior circulation stroke- -posterior cerebral, basilar, vertebral arteries -dizzy/vertigo, ataxia, nausea, diplopia, dysarthria -contralateral homonymous hemianopsia (loss of half of visual field on same side)

Answer 47

-Vertebral artery supplies brain stem and cerebellum -Branches of vertebral artery: AICA, Basilar artery, PCA, PICA -Crossed-findings are classic = Ipsilateral CN palsy + contralateral hemiplegia -!5 D’s: dizziness (vertigo), dysarthria, dystaxia, diplopia, dysphagia -!LOC, N/V, ataxia, nystagmus -Require MRI for dx!!!! -“Locked in syndrome” -Basilar artery infarction -Quadriplegia, can’t speak or swallow. Eyes are spared, and patients are awake and cognitively ware. -Posterior inferior cerebellar artery (PICA) = Wallenberg’s syndrome -Dysphagia, dysphonia -hiccups -Ipsilateral CN deficits with contralateral pain/temp loss -ipsilateral Horner syndrome -ipsilateral gait Ataxia with a tendency to fall to affected side, nystagmus, vertigo -dysmetria- failure of finger to nose

Answer 48

-MCC of stroke in <50yo -RF- trauma, chiropracter, connective tissue disorder, migraines, infection, OCP, smoking, post partum -!can cause intramural hematomas and emboli -> TIA/CVA sx -sudden -!Head/face/jaw pain (74%) -!HA and/or neck pain (57-90%) -Horner’s syndrome (25%) (just miosis/ptosis) -CN palsy (8-16%) (mostly CN 12,9)- rare -Sx of ischemic stroke (weakness, numbness, vision changes) -Pulsatile tinnitus (16-27%) -Carotid artery dissection vs vertebral artery dissection: -Carotid: -Anterolateral aspect of neck -Radiates to jaw/face/head -Neuro sx- often contralateral -Partial Horner’s syndrome -CN deficit 9 +12 (contralateral) -MCA/ACA stroke sx -Transient monocular blindness (amaurosis fugax) -Retinal artery occlusion -Vertebral: -Unilateral, posterolateral neck and occiput -Neuro sx- contralateral or b/l -Posterior circulation stroke sxs -Vertigo, diplopia, visual field deficits -Wallenberg syndrome- Dysmetria, ataxia, ipsilateral hemiplegia, contralateral loss of pain and temp sensation

Answer 49

-Gold standard for imaging = digital subtraction angiography (rarely used) -!!Bc tend to present as stroke: -!non contrast CT head 1st -!then -> CTA neck ± MRA neck to determine involved vessel -Tx of extracranial cervical artery dissections: -Antiplatelet (ASA) or anticoagulation (LMWH) -Consider endovascular stenting -Intra-cranial do NOT get anticoagulated (no heparin/warfarin) due to risk of SAH, can still get anti-platelets

Answer 50

-migraines: -F-10-30yo, family hx -Unilateral throbbing pain with photo/phono-phobia, n/v -Triptans, NSAIDs are first line -cluster: -Unilateral lasting 30-90mins -Multiple HA daily over several weeks (clustered) -No prodrome or aura, no N/V, no photo/phono-phobia -Signs: Ptosis, miosis, ipsilateral conjunctival injection, lacrimation, rhinorrhea -Tx: 100% O2 NRB 15 mins and triptans -Tension: -B/l vice-like pain -No n/v, photo/phono-phobia -Analgesics like Tylenol or NSAIDs -Other common causes: -Fever associated HA -Sinusitis -TMJ disease -Trigeminal neuralgia -Tx: -1st line: IV antidopaminergics! as monotherapy -!Metoclopramide IV up to 3 doses -!Prochlorperazine IV -!Droperidol IV -MC SE: Akathisia! (restless), administer diphenhydramine if occurs -Acetaminophen IV or PO, 325-1000 mg -Ketorolac IV or IM -Triptans: outpatient, less effective than IV antidoaminergics -Sumatriptan 6mg SQ once -CI- CV ds, uncontrolled HTN, pregnancy -Consider dexamethasone! IV single dose to prevent recurrence 48-72 hrs post-ED discharge, if hx of recurrent headache -Consider greater occipital nerve blocks

Answer 51

-Meningitis: -CSF -cerebral venous thrombosis (CVT): -DVT of brain -F>M, 39yo -RF- hypercoag, infection -gradual, progressive HA -focal neuro deficits, seizures, dec LOC -Dx- -CT head- 1st test, 30% WNL, small hemorhagic lesions, vasogenic edema, venous infarction -> dense triangle sign, empty delta sign, cord sign -!!!!MRI with MRVenography (or CT venography) -Tx- heparin (LMWH) -Cervical artery dissection (carotid, vertebral)- horners (miosis+ptosis) -CO poisoning: -carboxyhemoglobin level -Giant cell arteritis: -ESR >50 -gradual onset (weeks/months) -low grade fever -polymyalgia rheumatica- symmetric aching and stiffness of shoulders, hip, neck, torse, worse in AM -Tx- steroids -> dont wait for Bx -Idiopathic intracranial HTN: -young, obese, female, irregular menses -!vitamin A toxicity, steroids, tetracycline! -diffuse HA over days/week -worse lying supine, walking in morning, valsalva -N/V, visual dx, pulsatile tinnitus -cushing reflex- HTN, brady, respiratory effort dec -B/L papilledema!!! -Dx- LP high opening pressure >250!!! -CT- slight like ventricles! -Tx- wt loss, acetazolamide, diuretics, therapeutic LP, corticosteroids, shunt, neuro -can cause blindness -Normal pressure hydrocephalus: -dementia, ataxia, urinary incontinence -> wet, wacky, wobbly -Dx- CT- enlarged ventricles -MRI -!!!LP is definitive- normal pressure!!! -Tx- shunt -Trigeminal neuralgia: -spontaneous remission -R>L, M>F, 50-60yo -Tx- carbamazepine!!, baclofen, surgical decompression, neuro referral for MRI -VP shunt HA: -kinking, obstruction, disconnection, infection -Dx- xray to look for kinking -shunt tap to look for infection/obstruction -Dx- -CT head if worst HA, different HA, meingeal sx, intractable vomiting, new onset >50yo, HIV, neuro sx -MRI if CT neg and red flags

Answer 52

-NON-TRAUMATIC: -MCC- aneurysm, AVM, neoplasm -posterior communicating artery -> CN3 palsy (dilated, down, out pupil) -!Sentinel warning bleed! that precedes the rupture -> severe HA, thunderclap, n/v -Rupture -> thunderclap, vomiting, seizure, dec LOC, neck pain, low grade fever, AMS, HTN -!pain can resolve with meds -!pain can resolve by the time you see them -Dx: -CT head within 6 hrs of sx -if neg and need further testing -> CTA/MRA to detect >3mm aneurysms or LP -LP: -↑ opening pressure -↑ RBC -xanthochromia (pink/yellow): -blood in CSF at least 2hrs -100% have xanthochromia by 12hr -RBCs should NOT diminish from tubes 1->4 -> declining RBC with successive tubes suggests traumatic lumbar tap -Tx: -ABCs -SBP <160 with labetalol, nicardipine, clevidipine -reverse coagulopathy (warfarin -> PCC + K or FFP) -if thrombocytopenic (<100k) -> platelet transfusion -nimodipine to prevent cerebral vasospasm

Answer 53

-Elderly, immobilized, psychiatric, dementia, homeless, certain meds -> neuroleptics, anticholinergics, diuretics, antihypertensives ->104 °F (40 °C) AND CNS dysfunction -exertional heat stroke- sweaty, any temp outside, young, rhabdo (CK), DIC and coagulopathies -!delirium, coma, seizures, HA -tachy, hypotension, tachyarrhythmia, tachypnea, alkalosis, hypoxia -transaminitis (splanchnic hypoperfusion) -ARDS, shock -vasodilation -> hypoperfusion -> organ failure -Dx: -coagulopathy -ABSENT SWEATING! -Dry! -AKI, hypernatremia, hyperkalemia, hypophosphatemia, hypocalcemia -hard to differentiate from shock -TLDR: -AMS -organ damage -anhidrosis (not universal) -Tx: -Large bore IV access x 2 -Cardiac monitor -Early airway -Core temp measurement -POC glucose -Bladder/Rectal probe continuous temp monitoring -Rapidly lower body temp to 102.2F (39C) -Tepid water mist and fans (evaporative) -Ice packs to groin, axilla, neck (conductive) -> large arteries -!!Cold water immersion (CWI) is standard of care -Volume resuscitation 1-2L -Avoid vasoconstrictors -!!!Antipyretics -> not indicated and may be harmful -Dispo: admit to critical care unit for monitoring of rebound hyperthermia, electrolyte abnormalities, and multi-organ system dysfunction

Answer 54

-causes- adrenal insufficiency, hypothyroid, hypoglycemia, DKA, burn -bradycardia!! -!!conduction disturbance - afib, increase intervals, AV block -Osbourn / J waves -peripheral vasoconstriction -cold diuresis -> central hypovolemia -hypotension -respiratory depression, hypercarbia, -mild- 90-95 -> !max shivering -> once you become apathetic its bad -moderate (80s), severe (70s), profound (<70) -Dx: -<95F (35C) -> rectal at least 15cm -Tx: -!goal = Rewarm -Stiff, blue, apneic, pulseless CAN come back to life -Hypothermia is neuroprotective -Rewarm @ torso before limbs -passive external: -remove wet clothes, + warm blankets -active external: -heated blankets and pads, forced air systems (bair hugger), radiant heat lamps, arctic sun (temp management system w/ water pads) -active core: -humidified warm O2, warmed IV fluids, lavage (bladder, gastric, peritoneal, thoracic), extracorporeal blood warming -Cardiac arrest in hypothermia: -Which came first -> arrest or hypothermia? -60s for pulse check -Dopplers or US for heart beats -ABGs -If temp >89.6F (32C) and still asystole, likely irreversible cardiac arrest, terminate CPR -Criteria for death: -Core temp >32C (89.6F) -Central venous serum K >12mmol/L -Obvious non-survivable trauma

Answer 55

-Only include 2nd and 3rd degree burns -Open hand = 1% T BSA -fluid indications: -adults >15% TBSA -children >10% TBSA -Parkland -4mL x TBSA % x kg -Rule of 9s for adults -Lund and Browder chart for pediatrics

Answer 56

-!!red flags -> carbonaceous sputum, intraoral burns, stridor, singed nasal/facial hair, enclosed space, red posterior pharynx ->15% TBSA -> high risk circulatory shock -> fluid resuscitation -compartment syndrome -hypovolemia -> internal injury (EFAST, CT), neurogenic shock from SCI, burns, -Dx: -TBSA ->20% TBSA, inhalation injury, abn vital signs -> get labs -CMP, CBC -CK- muscle damage -> hyperkalemia -blood gas with carboxyhemoglobin testing -lactate- anaerobic metabolism -cyanide -T&S -Tx: -ABCDE -intubation if upper airway edema -CO- 100% O2 non-rebreather -Cyanide (CN)- hydroxocobalamin -circumferential chest burn- escharotomy -TBSA>15% -> fluid resuscitation and labs -full exposure -> keep warm -clean burns with normal saline -follley for urine outpt -CO and CN poisoning can occur in fires -> Suspect CN if sudden collapse, if metabolic acidosis, serum lactate >8, or carbonaceous material in oropharynx -> both cause hypotension

Answer 57

-MCC of death after fire -Incomplete combustion of fuel (charcoal, kerosene, wood, gas, open stoves, car, basements, hooka) with poor ventilation -RF: Smoke inhalation, poorly functioning heating systems, no smoke alarms -HA!!!, nausea, dizziness, confusion, lethargy etc. -“Flu like” illness w/o fever, pets are sick too -Rare- classic “cherry red” lips or skin -Severe toxicity: AMS, chest pain, ECG changes, cardiogenic shock -MCC of death -> MI -!!Pulse ox and PaO2 - NORMAL -Dx: -ABG/VBG -> lactate causes -> metabolic acidosis -CMP -!!!!Carboxyhemoglobin (COHb) level- elevated -ECG- ST depressions- ischemia -> hyperbaric chamber!!! -Tx: -!100% O2 on non-rebreather -!Hyperbaric oxygen therapy (HBO) is indicated in the following: -Loss of consciousness, coma, seizures -CO levels >25% regardless of sx -Pregnancy -Myocardial ischemia or life-threatening dysrhythmias (ST depression)* -Evidence of end organ damage -Persistent sx even with high flow O2

Answer 58

-anaerobic metabolism triggered -> lactic metabolic acidosis -burning plastic in fire, jewelers, chemical labs -if inhaled -> SUDDEN collapse! -ingested/dermal - delayed sx -> Abd, nausea, coma, bradycardia, AMS, sudden CV collapse, death -Dx: -Normal PaO2 and O2 sat -severe lactic acidosis!!!!! -lactic acidosis w/ anion gap (don’t need cyanide lab test) -Tx: -intubate early 100% O2 -Hydroxocobalamin!!! (cyanokit) is a b12 precursor combines with cyanide to form B12 which is cleared renally

Answer 59

-tight throat, swollen lips, swollen tongue, stomach pain, syncope, hives -Dx: -(1) mucocutaneous involvement -(2) respiratory compromise -(3) reduced BP -(4) persistent GI sx -ABCs: -Check oropharynx for swelling of lips, tongue, mucous membranes -Assess for difficulty swallowing / throat tightness / listen for stridor -EPINEPHRINE -> No improvement -> definitive airway -> ET tube or crich -Check for wheezing from bronchoconstriction -Assess for respiratory distress (tripoding, abdominal breathing, tracheal tug, intercostal retractions) -Bronchoconstriction present: -Bronchodilators!!! (albuterol 2.5-5mg nebulizer, in addition to the epinephrine) -O2 if hypoxic -Check for tachy and hypotension -Syncope is common 2ndary to hypotension -Tx: -EPINEPHRINE -Adult: 0.3-0.5mg!! of 1mg/mL IM q5-10 min x 3 -Peds: 0.01mg/kg IM q5-10 min, max dose 0.5mg per dose -thigh > deltoid -1st line tx (even in mild) -No absolute CI! -blue to sky, orange to thigh -Other adjuncts: -!Antihistamine (Diphenhydramine) -!H2 blocker (Famotidine) -!Corticosteroids: Prednisone or methylprednisolone - block rebound -IV fluids – improves hypotension -Glucagon – to pts on BB, because BB prevents epinephrine effectiveness -Cardiac monitor, IV access, ECG -recumbent position with legs elevated if no edematous upper airway -Circulatory compromise: -!!!1-2L of IV fluids for distributive shock -No improvement --> vasopressor such as epinephrine 0.5-1cc 1:10,000 epinephrine IV infusion over 10-15 minutes

Answer 60

-Observe for at least 6-8 hours from time of IMPROVEMENT -Biphasic reactions occur in 5% of cases -RX: EPI pen, 3 days of antihistamines and steroids -CLEAR instructions on epi pen use -CLEAR return precautions

Answer 61

-Hypothermia- cold blood -transfusion related acute lung injury (TRALI)- dyspnea, hypotension, fever! -> non-cardiogenic pulmonary edema -STOP ASAP -> O2 -Transfusion associated circulatory overload (TACO)- too much too fast -> pulmonary edema, HTN, respiratory distress -> diuresis them -STOP ASAP -> O2, diuretics -Coagulopathy (dilutional) - give cryoprecipitate -!!Hypocalcemia- calcium gluconate -Hyperkalemia- lysing of cells after some time -Metabolic abnormalities- bicarbonate

Answer 62

-Consider new hemophilia in unprovoked soft tissue bleeding or hematoma, hematuria, hemarthrosis -Hemophilia A: Inherited or acquired deficiency of factor 8 -Hemophilia B: Inherited or acquired deficiency of factor 9 -Do not be falsely reassured by minor MOI and normal exam -> especially in head trauma -Suspected bleeding, or trauma, with known hemophilia -> Factor repletion BEFORE CT scan -Hemophilia A: -!!Factor 8: 25U/kg for moderate, 50U/kg for severe/CNS bleeding -Cryo if no factor immediately available (has factor 8) -Hemophilia B: -!!Factor IX : 100U/kg for severe bleeding -FFP if no factor is immediately available -Hemophilia A -> high risk for DELAYED bleeds. If MVA with head injury, give Factor 8 even wtih neg CT scan -ex. 27yo male with hx of hemophilia A complaining of HA and nausea after bumping his head against an open cabinet door

Answer 63

-LE: -Always suspect calcaneus fx -> look for !concomitant fx of ankle and vertebrae! -calcaneal fx -> NWB on discharge -compartment syndrome of foot -> 10% -> significant morbidity -HEAD: -something drops directly on head -> fx and dislocations of vertebrae, spinal cord damage (cord syndromes), and even death -UE: -rare -consider damage done much further up and away from point of contact -Neurogenic shock: -injury above T6 -r/o obstructive and hypovolemic shock first -weak grip strength -loss of sensation B/L -hypotension refractory to IVF -bradycardia -hypothermia -Dx: -clinical -CT -Tx: -IVF -norepinephrine -> MAP 85-90 -consider atropine for brady -closed reduction

Answer 64

-Irreversible local tissue freezing -MC- periphery: Fingers, toe, nose, ear, penis -RF: -Low temp, high wind, water or snow -Impaired judgement (ETOH, drugs, fear/panic) -Occupational exposures (air conditioners) -Dx: clinical -r/o frostnip- paresthesia's resolve with rewarming -> REVERSIBLE -1st degree: numb, erythema/hyperemia!, edema. No blisters or infarction -2nd degree: Erythema, edema, CLEAR BLISTERS! -3rd degree: HEMORHAGIC blisters!, skin necrosis -4th degree: Tissue NECROSIS, gangrene. Will appear hard, cold, white, w/o sensation -Tx: -Remove wet clothes -Warm water (98.6-102.2°F) (37-39° C) bath for ~30 min -Refreezing causes more damage than waiting for definitive tx -> Dont rewarm unless you can maintain -Complete when tissue is red/purple and soft -Pain meds: -Tetanus prophylaxis -Wound care- Dry, bulky dressings and elevate body parts -Consider early consult with burn team -> assess tPA for microthrombi of deep frostbite -Surgical: -Delay until demarcation occurs -patience

Answer 65

-Remove loose clothes and jewelry -Irrigate with cool sterile water or normal saline -Eyes irrigated at least 15 mins w/ warm water -cover -TDAP, analgesics -Systemic antibiotics are not indicated -devitalized tissue should be debrided -1st degree: keep clean and dry, no special dressing bc dermis intact -> NSAIDs and topical aloe -2nd degree- partial thickness: topical ointment covered by a non-adherent dressing -3rd degree: Surgical excision by a burn surgeon -circumferential- escharotomy -Refer to burn center: -full thickness of any size -partial thickness >10% TBSA -face, hands, feet, genitalia, major joints, genitals -inhalation injury -small burns with high risk comorbid or extreme of age

Answer 66

-breakthrough- infection, drugs, noncompliance, ALCOHOL, trauma -MC trigger- subtherapeutic drug level of ASM -INH seizure -> tx vit B6 (pyridoxine) -Status epilepticus!- Unremitting convulsive seizure >20 mins, OR -!!!Back-to-back seizures w/o regaining full consciousness in btwn, OR -!!generalized convulsive seizure lasting ≥ 5 mins!!!!!!!! -Dx: -POC glucose -electrolyte, CBC -HCG -!if 1st seizure -> CT/MRI -!If not 1st seizure -> check ASM drug levels -> assess triggers- lack of sleep, change in meds, vomiting -Tx: -Consider loading dose in pts that are subtherapeutic (not actively seizing) -if first seizure -> not started on meds unless structural brain lesion, high risk of ocurrence (EEG), pt pref -Active Seizure tx: -POC glucose -0-10mins -> !1st line- Benzos- IV Lorazepam 4mg IV push over 2mins -> REPEAT! in 5-10mins if needed -alt- diazepam, midazolam -10-15mins -> !2nd line- Phenytoin load 20mg/kg IV over 20mins -RSI -15-20mins -> !3rd line- Propofol -EEG

Answer 67

-MCC of compression- cancer -PE: -Red flags: fever (abscess), LE/UE weakness (especially B/L), saddle anesthesia, diminished/absent reflex, + babinski, post void residual >100ml, midline tenderness!, CVAT, guarding/rigid, >50yo! -unilateral numbness/tingling along single dermatome (ex. L5 radiculopathy) -> NO MRI -ESR/CRP to see if early infection -Retroperitoneal bleed- +psoas, cullen/turner sign -IMAGING: -<6wks, atraumatic, no red flags -> NO IMAGE, supportive -X-ray- extremes of age, cancer, osteoporosis, new back pain in elderly, trauma -MRI- focal or progressive neuro deficit, cord compression, cancer, infection, fever, ESR >20 in IVDU, ABSCESS -Singular radiculopathy can have outpt MRI -Cauda equina- STAT MRI -CT scan- bleeds -Tx: -Cauda equina- STAT consult, steroids (dexa) if metastatic cause -> decompress within 24hrs -Abscess- do not delay antibiotics -> drain/decompress -Simple- NSAIDs, acetaminophen, heat, massage, PT, muscle relaxer

Answer 68

-can be no pain -vascular shearing, hollow viscus, solid organ injury -PE: -selt belt sign -handlebar sign -grey turner/cullen sign -> retroperitoneal -rebound tenderness, distention, guarding -SBP <90 -femur fx -tachy, pelvic pain, scrotal bruising -blood @ rectum -> pelvic fx -blood @ urethral meatus -> retrograde urethrogram -Dx: -EFAST -CT abd/pelvis w/ contrast! -Tx: -surgical consultation for exploratory laparotomy -pelvic fx -> resuscitate, pelvic biner, CTA, IR or surgical consult

FINAL Flashcards

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