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EM 101 > First Line Treatments - Pharm > Flashcards

First Line Treatments - Pharm Flashcards

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1
Q

Tx of Ischemic Priapism?

A

Terbutaline 5-10mg PO

or 0.25-0.5 SQ or pseudoephedrine 60mg PO

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2
Q

Tx of Epididymitis w/ STD suspected (<35 yrs old)?

A

Doxycycline 100mg PO BID x10-14 days
AND
AZITHROMYCIN

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3
Q

Tx of Epididymitis w/ STD suspected (but PCN allergy)?

A

Doxycycline 100mg PO BID x10-14 days
AND
Azithromycin 2gm x1

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4
Q

Tx of Epididymitis without suspicion for STD (>35 yrs old)?

A

Ciprofloxacin 500mg BID x10-14 days

OR Levofloxacin 750mg PO QD x10-14 days

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5
Q

Tx of Appendage Torsion?

A

NSAIDs, will self resolve in 1-2 weeks

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6
Q

Tx of Fournier’s Gangrene?

A

Ciprofloxacin 400mg IV
AND
Clindamycin 1.2gm IV
+/- Vancomycin 1gm IV

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7
Q

Tx of Orchitis?

A

NSAIDs, ice, scrotal support

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8
Q

Tx of Uncomplicated UTI?

A

Nitrofurantoin 100mg BID x5 days
(aka Macrobid)

**unless creatinine clearance <30 mL/min

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9
Q

Tx of Complicated UTI?

A

Ciprofloxacin 500mg BID x5-14 days
OR
Ceftriaxone 1gm IV daily

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10
Q

Tx of Complicated UTI and critically ill or septic?

A

Imipenem 500mg IV q6h
AND
Vancomycin 15-20 mg/kg q8-12 hours with or without loading dose

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11
Q

Tx of Vaginal bleeding in pregnant woman?

A

If Rh(-), RhoGAM 300mcg IM

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12
Q

What are the contraindications to administering Methotrexate in ectopic pregnancy?

A
  • unstable or ruptured
  • quant HCG >15,000 IU/L
  • fetal cardiac activity
  • free fluid on US
  • gestational sac >3.5 cm
  • liver or renal disease
  • patient is breastfeeding
  • patient with unreliable follow up
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13
Q

Seizure prevention in preeclampsia?

A

Mg 2-4g IV load over 30 minutes, then 1g/hr

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14
Q

Seizure abortive in eclampsia?

A

Mg 2-4g IV q5-10 min

Diazepam 5mg IV q 5 min OR Phenytoin 15-20mg/kg IV once

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15
Q

What medication should be used for BP control in preeclampsia/eclampsia

A

Labetalol 10-20mg IV once, then double dose q10 min up to 80 mg to max 200 mg

And Hydralazine 5-10mg IV q20min as needed

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16
Q

In preeclampsia/eclampsia, what is the goal BP?

A

Don’t drop BP more than 25% in first 30 min. Goal BP 140-155/90-105 within the first several hours

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17
Q

When giving magnesium, what do you need to be sure to monitor?

A

Magnesium toxicity:

  • diminished deep tendon reflexes
  • somnolence
  • dilated pupils
  • decreased respiratory drive
  • hypotension
  • bradycardia
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18
Q

In addition to hydration and correcting metabolic derangements, what is the treatment for hyperemesis gravidarumcausing hypovolemia?

A

Ondansetron (or metoclopramide)

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19
Q

What is the treatment for nausea and vomiting in pregnancy that is not causing hypovolemia?

A

Prophylaxis (at night):
Doxylamine Succinate 10mg
AND Pyridoxine(B6) 10mg
(separate or combo pill)

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20
Q

What is the tx for vaginitis caused by suspected herpes?

A

Acyclovir 400mg TID

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21
Q

What is the tx for suspected GCC or PID?

A

Ceftriaxone 250mg IM x1

AND Doxycycline 100mg BID

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22
Q

What is the tx for vaginitis caused by Trichomoniasis?

A

Metronidazole 500mg BID x7days

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23
Q

What is the tx for bacterial vaginosis?

A

Metronidazole 500mg BID x7-14 days, and partner should seek treatment

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24
Q

What is the treatment for uncomplicated vaginal candidiasis?

A

Fluconazole 150mg PO x1

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25
Q

What is the treatment for complicated vaginal Candidiasis (DM or recurrent infections)?

A

Fluconazole 150mg PO x2 (days 0 and 3)

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26
Q

What is the treatment for vaginal candidiasis in a pregnant patient?

A

topical cream i.e. miconazole x7days

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27
Q

What is the treatment for diverticulitis?

A

10-14 days PO abx:
- Cipro 500mg BID + Metro 500mg TID x 14 days
plus clear diet x2-3 days and slowly advance diet

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28
Q

What is the treatment for mild c. diff?

A

Metronidazole 500mg PO q8h x10 days

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29
Q

What is the treatment for severe c. diff?

A

Vanc 125-500mg PO q6h x10 days

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30
Q

What is the treatment for severe c. diff with complications?

A

Vanc 125-500 PO q6h x10 days
AND Metro 500mg IV q8h
plus surgical consultation

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31
Q

What is the treatment for abdominal pain plus nausea/vomiting?

A

Ondansetron 4 mg IV q8h

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32
Q

What is the 2nd line treatment for abd pain plus n/v?

A

Metoclopramide 10 mg PO/IV q6h
Prochlorperazine 10 mg PO/IV 6h/25 mg PR x1
Diphenhydramine 25-50 mg PO/IV q6h

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33
Q

What is the treatment for Appendicitis pain?

A

Morphine 0.05-0.1 mg/kg

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34
Q

What is the treatment for appendicitis nausea?

A

Ondansetron 4 mg IV

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35
Q

What is the treatment for uncomplicated (non-perforated) appendicitis undergoing surgery?

A 
Start within ONE HOUR of surgery
- Cefoxitin 2g IV QID
or 
- Ciprofloxacin 400 mg IV Q12h 
PLUS Metro 500 mg IV q6h
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36
Q

What is the treatment for perforated appendicitis undergoing surgery?

A 
Immediately start:
- Cefoxitin 2g IV QID
or 
- Ciprofloxacin 400 mg IV Q12h 
PLUS Metro 500 mg IV q6h
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37
Q

What is the treatment for perforated appendicitis undergoing surgery that is high risk?

A 
Cefepime 2 g IV q12h 
\+ Metro 500 mg IV q8h
OR
Pip/Tazo (Zosyn) 4.5 g IV QID
OR
Imipenem 500 mg q6h
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38
Q

What is the treatment for acute pancreatitis?

A

LR 250-500 mL/hr
or LR 5-10 mL/kg/hr
given over first 24 hours

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39
Q

What is the treatment for pancreatic necrosis?

A

Imipenem 500 mg IV q6h

b/c known to penetrate

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40
Q

What is the treatment for status epilepticus?

A

Benzos: Midazolam, Lorazepam, Diazepam

If refractory –> Fosphenytoin IV

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41
Q

What is the treatment for an agitated patient? (oral medication)

A

Haloperidol 5 mg PO, 0.5-1 mg PO if elderly

or Olanzanzapine 5-10 mg PO
or Lorazepam 1-2 mg PO

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42
Q

What is the treatment for an agitated patient? (injectable)

A

Benzos:
Lorazepam 1-2 mg IV/IM
Haloperidol 0.5-10 mg IV/IM
Ziprasidone 10-25 mg IM

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43
Q

What is the treatment for extrapyramidal symptoms?

A

Diphenhydramine 25-50 mg PO/IV/IM
or Benztropine 1 mg PO/IV/IM

Check EKG if on antipsychotics

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44
Q

What is the treatment for EtOH withdrawal with seizures?

A

Benzos:
Lorazepam - start with 2mg IV/PO q2h
up to 6-8mg IV q15-60min

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45
Q

What is the treatment for EtOH withdrawal hallucinations?

A

Haloperidol
or Ziprasidone
or Dexmedetomidate

Load 1mcg/kg IV over 10 min
then infusion 0.2-0.7 mcg/kg/hr

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46
Q

What is the treatment for Ibuprofen overdose (>/= 400 mg/kg)?

A

one dose activated charcoal

more doses would not help

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47
Q

What is the treatment for methanol & ethylene glycol overdose/poisoning?

A

Fomepizole 15 mg/kg IV load then 10 mg/kg q12h
plus thiamine 100 mg IV q6h x 2 days
plus pyridoxine 50 mg IV q6h x 2 days

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48
Q

What is the treatment for methanol & ethylene glycol overdose/poisoning is pH < 7.3?

A

sodium bicarb to promote urinary excretion

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49
Q

What is the treatment for isopropyl alcohol poisoning?

A

supportive

NO fomepizole

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50
Q

What is the treatment for peripheral vertigo?

A 
Meclizine 25 mg PO
or benadryl 25 mg PO or IV
or valium 5mg IV
or ondansetron 4 mg IV
PLUS IV fluids
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51
Q

What is the treatment for hepatic encephalopathy?

A

Lactulose 30-60 grams PO, NGT or 300 grams PR

second line: Rifamixin 400 mg TID

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52
Q

What is the treatment for hyperkalemia?

A

Calcium then Insulin 10 units + 1 amp D50

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53
Q

What is the treatment for Spontaneous Bacterial Peritonitis?

A

Third Gen Cephalosporin

  • Cefotaxime 2g IV q8h
  • Ceftriaxone 2g IV q24 h
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54
Q

What is the treatment for Spontaneous Bacterial Peritonitis if the patient has a penicillin allergy?

A

Levofloxacin 750 mg IV q24h
Ciprofloxacin 400mg IV BID
Pip/Tazo 4.5 g IV TID

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55
Q

What is the treatment for DKA and K+<3.3?

A

20-30 mEq/hr IV K+

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56
Q

What is the fluid treatment for DKA in adults?

A

1-2 L NS Bolus over 1-2 hours

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57
Q

What is the fluid treatment for DKA in pediatric patients?

A

20 mL/kg NS over first hour, then 250-500 mL/hr

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58
Q

What is the treatment for ongoing seizure?

A

Lorazepam (Ativan) 2-4 mg IV/IM, repeat PRN

max of 0.1 mg/kg

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59
Q

What is the treatment for ongoing seizure refractory to Lorazepam after 5 minutes?

A

Fosphenytoin 20-30 PE/kg at 150 PE/min IV
or
Levetiracetem 20 mg/kg IV to max 60 mg/kg
or
Valproic Acid 20-40 mg/kg @ 7.5 mg/min IV
or
Phenobarbital 20 mg/kg IV at 50-100 mg/min

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60
Q

What is the dosing of Lorazepam for acute seizure?

A

2-4 mg IV/IM, repeat PRN

max of 0.1 mg/kg

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61
Q

What is the dosing of Fosphenytoin for acute seizure?

A

20-30 PE/kg at 150 PE/min IV

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62
Q

What is the dosing of Leviteracetem for acute seizure?

A

20 mg/kg IV to max 60 mg/kg

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63
Q

What is the dosing of Valproic Acid for acute seizure?

A

20-40 mg/kg @ 7.5 mg/min IV

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64
Q

What is the dosing of Phenobarbital for acute seizure?

A

20 mg/kg IV at 50-100 mg/min

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65
Q

What is medication and dose for Nephrolithiasis pain control?

A

Morphine 0.1mg/kg or 4 mg IV

and Ketorolac 30 mg IV if no CKD

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66
Q

What is medication and dose for Nephrolithiasis nausea control?

A

Zofran 4 mg IV

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67
Q

What is the treatment for nephrolithiasis plus UTI?

A

Ciprofloxacin or 3rd gen cephalosporin

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68
Q

What is the antibiotic for epidural abscess with possible MRSA?

A

Vanc 15-30 mg/kg IV

PLUS Metronidazole 500 mg IV
PLUS Cefotaxime 2 g IV

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69
Q

What is the antibiotic for epidural abscess without concerns for MRSA?

A

Nafcillin 2 g IV
or
Oxacillin 2 g IV

PLUS Metronidazole 500 mg IV
PLUS Cefotaxime 2 g IV

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70
Q

What is the treatment for epistaxis refractory to pressure?

A

topical vasoconstrictor – oxymetazolone or phenylephrine
intranasal spray or cotton pledgets soaked in vasoconstrictor and anesthetic – viscous lidocaine 2% or lidocaine 4% topical solution with 0.5% phenylephrine
leave in place for five minutes

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71
Q

What is the treatment for ITP?

A

steroids, IVIG, or anti-D immunoglobulin

avoid NSAIDs

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72
Q

What is the treatment for TTP?

A

FFP and plasma exchange with stat hematology consult

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73
Q

What is the treatment for DIC?

A

if severe bleeding –> transfuse
if clotting –> heparin

FFP for prolonged coagulation and bleeding
Cryoprecipitate for fibrinogen <100 despite FFP
Platelets if <50k and bleeding
Platelets if <20k and no bleeding
pRBCs PRN for anemia

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74
Q

What is the treatment for HIT?

A

stop heparin

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75
Q

What is the treatment for GI bleeding if the patient has known ascites/liver failure?

A

Rocephin (Ceftriaxone) or Azithromycin

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76
Q

Activated charcoal does not absorb ..?

A
  1. acids or alkalis
  2. alcohols
  3. metals or ionic compounds (eg iron potassium lithium)
  4. hydrocarbons

*** must have normal GCS and maintaining own airway

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77
Q

What is the dose of activated charcoal?

A

1 g/kg

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78
Q

What are really the only toxicities that whole bowel irrigation is used for?

A

iron (>60 mg/kg elemental iron)
slow release calcium channel blockers
slow-release potassium chloride

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79
Q

What is the substance/dose used for whole bowel irrigation?

A

polyethylene glycol - 30 mL/kg/h

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80
Q

For which ingestions would you consider multi-dose activated charcoal administration and what is the dose?

A

carbamazepine
phenobaritone
quinine
theophylline

dose is 1 g/kg activated charcoal four hourly

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81
Q

For alkalinization of the urine during treatment of salicylate toxicity, what is the dose of sodium bicarb?

A

1-2 mmol/kg NaHCO3 stat

then you can infuse further doses over the next 1-2 hours, aiming for a urinary pH >7.5

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82
Q

What amount of iron would have to be ingested to be considered significant?

A

> 40 mg/kg

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83
Q

What is the treatment for iron overdose?

A

whole bowel irrigation if significant ingestion and confirmed with xray

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84
Q

When should deferoxamine be considered in iron overdose?

A

serum iron concentrations >90 micromol/L

or if 60-90, visible on xray, and patient is symptomatic

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85
Q

What is the dose of deferoxamine for acute iron ingestion?

A

15 mg/kg/hr IV, then reduce rate after 4-6 hours so that the total IV dose dose not exceed 80 mg/kg/24 hrs

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86
Q

When can you stop treatment for iron ingestion?

A

until the child is asymptomatic, the anion-gap acidosis is resolved, and the serum iron concentration is <60 micromol/L

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87
Q

What is the treatment for hypertension related to toxic injection?

A

calcium-channel blocking agents, phentolamine, labetalol, or nitroprusside

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88
Q

What is the first line treatment for patient with ventricular tachycardia in the context of intoxication, specifically drugs with drug with sodium-channel blocking properties (eg, tricyclic antidepressants, carbamazepine, cocaine)?

A

Sodium bicarb

Types IA (eg, procainamide), IC, and III antiarrhythmic agents are not recommended and are potentially dangerous since they may further impair cardiac conduction.

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89
Q

What anti-epileptic medication is contraindicated in treatment of seizures due to intoxication?

A

Phenytoin

also Keppra is unlikely to help –> use benzos instead

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90
Q

What is the treatment for hyperthermia related to drug toxicity?

A

possibly ice water immersion

do not use antipyretics like acetaminophen or ibuprofen

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91
Q

What is the antidote for Acetaminophen toxicity?

A

N-acetylcysteine (NAC) IV 150 mg/kg over 1 hr
then infuse 12.5 mg/kg/hr x 4 hrs
then 6.25 mg/kg/hr x 16 hrs

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92
Q

What is the antidote for anticholinergic toxicity?

A

Physostigmine

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93
Q

What is the antidote for arsenic toxicity?

A

dimercaprol/BAL

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94
Q

What is the antidote for beta blocker toxicity?

A

glucagon

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95
Q

What is the antidote for copper toxicity?

A

penicillamine

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96
Q

What is the antidote for cyanide toxicity?

A

thiosulfate, hydrocobalamine

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97
Q

What is the antidote for digoxin toxicity?

A

digoxin specific immune Fab fragments

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98
Q

What is the antidote for ethylene glycol toxicity?

A

Fomepizole

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99
Q

What is the antidote for glypizide toxicity?

A

glucose, octrotide

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100
Q

What is the antidote for heparin toxicity?

A

protamine

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101
Q

What is the antidote for hydrofluoric acid toxicity?

A

calcium

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102
Q

What is the antidote for isoniazid toxicity?

A

pyridoxime

103
Q

What is the antidote for lead toxicity?

A

dimercaprol

104
Q

What is the antidote for lidocaine toxicity?

A

lipid emulsion (aka intralipid) and sodium bicarb)

105
Q

What is the antidote for magnesium toxicity?

A

calcium

106
Q

What is the antidote for MAOI or SSRI toxicity?

A

cyproheptadine or benzos for serotonin syndrome

107
Q

What is the antidote for methemoglobinemia?

A

methylene blue

108
Q

What is the antidote for methotrexate toxicity?

A

folic acid, leucovorin

109
Q

What is the antidote for mercury toxicity?

A

dimercaprol (BAL), EDTA or DMSA

110
Q

What is the antidote for opioid toxicity?

A

naloxone

111
Q

What is the treatment for warfarin overdose?

A

vitamin K

112
Q

What is the treatment for salicylate toxicity?

A

alkalinization of the blood to 7.5 or higher with:
1 AMPS/100 mEq NaHCO3

followed by D5W with 150 mEq NaHCO3/L at 200-250 mL/hr

+/- hemodialysis
+ IV potassium repletion

ADMIT

113
Q

What is the treatment for acute digoxin toxicity?

A

10 vials Digoxin immune Fab
(effects within 30-120 min)

Atropine for bradydysrhythmias
Magnesium for VT/VF

114
Q

What is the treatment for opioid overdose?

A

0.4 mg Naloxone IV in adults

If no effect, increase dose q2-3 min
2mg –> 4 mg –> 10mg –>15mg

(0.1 mg/kg in kids – max2mg)

Monitor for 4-6 hrs back to baseline
If require 2 or more doses of Naloxone –> admit

115
Q

What is the treatment for opioid withdrawal?

A

Clonidine 0.1mg PO
- can repeat dose every 30-60 min
Monitor BP closely!

116
Q

What is the method for decontamination/elimination in TCA overdose?

A 
IV intralipid (central administration preferred)
1 ml/kg to 1.5 ml/kg bolus q3-5 min to a total of 3 ml/kg
IV drip started at 0.25 mL/kg/min-0.5ml/kg/min for 1 hr or until max dose of 8 ml/kg delivered
117
Q

What is the tx for arrhythmia due to TCA overdose?

A

Sodium Bicarb
Bolus 100mEq for QRS>100, repeat q5min until QRS narrows
QRS<100, start drip (150mEq/1L of D5W, infusing at 150/hr) until goal pH 7.45-7.55 on ABG

118
Q

What is the preferred method for BP support in TCA overdose?

A

Start with IV fluids – fill the tank
- consider hypertonic saline (3%) to saturate Na channels
May need to add pressors –> neosynephrine or norepi preferred to overcome alpha blockade

119
Q

What labs and imaging should be ordered for suspected hyperthermia/heat stroke?

A
  1. EKG
  2. CXR (pulm edema common in heat stroke)
  3. Labs: CBC and coags, BMP, Mg/Phos/Ca, and CPK (acute renal failure, rhabdomyolysis), liver enzymes (acute liver failure), +/- tox screen
120
Q

What empiric abx should be given to infants 0-28 days with fever?

A 
Ampicillin 100mg/kg/24 hrs divided q6h
PLUS either
Gentamicin 5 mg/kg/24hrs divided q8h
or
Cefotaxime 150 mg/kg/24 hrs divided q8h

(avoid ceftriaxone in infants <28 days due to possibly inducing acute bilirubin encephalopathy)

121
Q

If pressor is required during sepsis, what is first line and its dose?

A

Norepinephrine:

  • initial starting dose: 8-12mcg/min
  • Weight based dosing: 0.01-3mcg/kg/min

(Increases BP and HR)

122
Q

What are two second line pressors for sepsis and their associated dose?

A

Epinephrine & Vasopressin

Epinephrine:
- Initial starting dose: 5-35 mcg/min
- weight based dosing: 0.1-0.5 mcg/kg/min
(increases BP and HR)

Vasopressin:
- fixed dosing at 0.04 units/min

123
Q

If patient is septic and only have peripheral IV access, what pressor can be used (although not first line)?

A

Phenylephrine
- initial starting dose: 25-180 mcg/min
- weight based dosing: 0.5mcg/kg/min
(can cause reflex bradycardia)

124
Q

What abx are used for outpatient tx of community acquired pneumonia in previously healthy people?

A

Azithromycin 500 mg PO x1 and 250mg PO QD x4days
OR
Doxycycline 100 mg PO BID x7 days

125
Q

What abx are used for outpatient tx of community acquired pneumonia in patients with co-morbidities or recent abx?

A

Levofloxacin 750 mg PO QD x5days
OR
Cefpodoxine 200mg PO BID + Azithromycin 500 mg PO QD x7days

126
Q

For outpatient tx of CAP, if aspiration is suspected, which abx should be added?

A

Clindamycin or Metronidazole

127
Q

What is inpatient abx tx for CAP?

A

Levofloxacin 750mg PO/IV
OR
Ceftriaxone 1 g IV q12h PLUS Azithromycin 500 mg PO/IV

128
Q

What additional abx should be added for inpatient abx tx of CAP if patient requiring ICU?

A

Vancomycin

129
Q

What is inpatient abx tx for HCAP, HAP, or VAP?

A 
Cefepime 2g IV q12h
\+
Levofloxacin 750 mg IV qd
\+
Vancomycin 1g IV q12h
130
Q

What is abx tx for presumed PCP pneumonia?

A

Trimethoprim/Sulfamethoxazole 240/1200mg IV q6h

consider steroids

131
Q

In patients with pneumonia, what 2 risk stratification tools help determine need for admission?

A

CURB-65

Pneumonia Severity Index

132
Q

What absolute neutrophil count defines neutropenia?

A

ANC < 500 cells/microL

ANC = WBC x (%neutrophils+%bands)

133
Q

What are the empiric abx for suspected meningitis in pediatrics <1 month old?

A 
Ampicillin 50 mg/kg QID
\+
Gentamicin 2.5mg/kg IV TID
\+
Cefotaxime 50mg/kg IV QID
134
Q

What are the empiric abx for suspected meningitis in pediatrics >1 month old?

A

Ampicillin 50 mg/kg QID
+
Cefotaxime 100mg/kg IV TID

OR

Ceftriaxone 50mg/kg IV BID
+
Vancomycin 15 mg/kg IV QID

135
Q

What are the empiric abx for suspected meningitis in adults?

A 
Ceftriaxone 2g IV BID
OR
Cefotaxime 2g q4h
\+
Vancomycin 15-20 mg/kg IV BID
\+
If >50y/o: Ampicillin 2q q4h (covers Listeria)
136
Q

What are the empiric abx for suspected healthcare-associated meningitis?

A 
Vancomycin 15-20mg/kg IV BID
\+
Cefepime 2g IV TID
OR
Merepenem 2g IV TID
137
Q

What is the empiric tx for suspected HSV meningitis?

A

Acyclovir 10mg/kg IV TID

138
Q

What is the empiric tx for suspected cryptococcal meningitis?

A

Amphotericin B 0.7-1mg/kg IV QD
AND
Flucytosine 25 mg/kg PO QID

139
Q

What is the empiric tx for suspected TB meningitis?

A

Isoniazid 300 mg PO QD,
Rifampin 600mg QD,
Pyrazinamide 2g PO QD,
Ethambutol 1.6g PO QD

140
Q

What is the acronym for the quick differential for headaches?

A

BITE ME

Bleed, Infection, Thrombosis, Eye, Mass, Environmental

141
Q

What is normal opening pressure during LP?

A

9-18 cm H2O

142
Q

What is the first line treatment for a low-risk, mild headache?

A

Ibuprofen 800mg
Acetaminophen 1000mg
and/or
Caffeine 200mg

(all PO)

143
Q

What is first line for a low-risk, moderate-severe headache?

A

Ketorolac 30 mg IV (unless Ibuprofen already given)
+
Prochlorperazine 10mg IV (or Metoclopramide 10mg IV)
+
IV fluids

144
Q

What is the treatment for a cluster headache?
(unilateral, assoc with scleral injection, lacrimation, congestion, rhinorrhea, facial sweating, miosis, ptosis, or eyelid edema)

A

Oxygen 6-10L and sumatriptan 6mg SQ

145
Q

What are contraindications to triptan administration?

A

HTN, CAD, peripheral vascular disease, arrhythmias, recent MAOi, SSRI, or triptan use (serotonin syndrome)

146
Q

What are potential side effects of prochlorperazine?

A 
dystonic reaction (treat with benadryl)
QTc prolongation
147
Q

How is warfarin reversed?

A

Vitamin K 5-10mg IV over 10 minutes (INR corrected in 6-24 hrs)
PLUS either:
FFP or PCC

FFP (3-6 hrs to infuse, INR corrected in ~12 hrs)
PCC (INR corrected 15 min after 1 hr infusion, dosing is weight-based)

148
Q

How is aspirin reversed?

A

Platelet transfusion

149
Q

How is Heparin reversed?

A

Protamine Sulfate – call pharmacy for dosing, bc dependent on dose of heparin, route given, and time of last dose

150
Q

How is Dabigatran reversed?

A

No antidote. Half-life is 12 hours in patients with normal renal function.
One third is protein bound with 60% removed after 2-3 hrs of hemodialysis.

151
Q

What is the BP goal in patients with hemorrhagic stroke?

A

If presents with SBP 150-200, goal is <140

Otherwise aim for 25% reduction

152
Q

For BP control in intracranial hemorrhage patients, what is the first line medication and dose?

A

Nicardipine
- initial rate of 5 mg/hr IV
(can increase by 2.5 mg q15min until desired BP or max rate of 15 mg/hr.)
Once goal BP achieved titrate down to 3 mg/hr

  • use cautiously in patients with heart failure who are already taking beta blockers
153
Q

For BP control in ICH, what is the dose of labetalol?

A

10-20mgIV q10min (max dose 80mg/dose)

154
Q

When is labetalol contraindicated?

A

Bradycardia, heart failure, severe COPD

155
Q

For BP control in ICH, what is the dosing for Hydralazine?

A

10-20 mg IV q4-6h
(max dose 40mg/dose)

BP response may be delayed and unpredictable. Typically only for patients with contraindication to labetalol

156
Q

If patient begins to show signs of herniation in ICH, what is the treatment? (discuss with neurosurg)

A

Mannitol 1g/kg IV infusion with goal of serum osmolality of 300-310
- side effects include hypovolemia from diuresis

Hypertonic Saline dose is typically 30 mL of 23.4% saline over 20 mins
- requires infusion through a central line (3% saline does not)

157
Q

What is the goal cerebral perfusion pressure (CPP) in ICH?

A

Goal CPP is 50-70 mm Hg

CPP = MAP-ICP

158
Q

What is the goal BP in SAH?

A

<140 mmHg
(use nicardipine, labetalol, or hydralazine)

  • prevents delayed vasospasm that leads to secondary ischemia
159
Q

What labs are diagnostic of temporal arteritis?

A

ESR>50, elevated CRP, and CBC, which may show normochromic anemia

160
Q

What medication should be given as soon as temporal arteritis is suspected?

A

60mg of Prednisone PO daily for 2 weeks

start immediately; will not affect biopsy results in the first 48 hrs

161
Q

If temporal arteritis patient has vision loss, what is the medication that should be given & dose?

A

1000mg methylprednisone IV daily for 3 days, then maintenance dose
+
ASA 81 mg/daily – reduce risk of visual loss, TIA, or stroke

Add PPI while on steroids to reduce risk of peptic ulcer

162
Q

What labs and imaging should be ordered if venous sinus thrombosis is suspected?

A

Labs: CBC, BMP, Coags, HCG

Imaging: CT-venography or MRI/MR venography

163
Q

What is the treatment of venous sinus thrombosis?

A

Anticoagulation with heparin or LMWH, even in the presence of hemorrhagic infarction

164
Q

How is hypertensive emergency defined?

A

Hypertension that causes acute end organ damage (ie, CHF or increased Creatinine)

generally BP >180/120 (though rate is more important)

165
Q

How is hypertensive urgency defined?

A

Hypertension without the associated end organ damage

166
Q

What labs are important to obtain when evaluating hypertensive urgency/emergency?

A

Labs: CBC, BMP, UA, troponin, BNP;

and EKG – assess for LV hypertrophy or acute ST or T wave changes

167
Q

What is the goal BP reduction timeline in hypertensive emergencies?

A

1-2 hrs: max reduction in MAP 20-25%

2-6 hrs: Goal BP 160/100

168
Q

What are potential antihypertensive medications to be used in hypertensive emergencies?

A
  1. Nitroglycerin 5-100 ug/min
  2. Labetalol 20-80mg IV bolus then 0.5-2 mg/min (Caution in bradycardia)
  3. Nicardipine 5-15mg/hr
  4. Hydralazine 5-20 mg q20-30min

In a true hypertensive emergency, use short-acting, titratable medications and place an A line to monitor BP closely

169
Q

For hypertensive urgency, rapid administration of antihypertensive therapy is unwarranted, what is the tx instead?

A

If patient has missed home med, start there.

Otherwise, initiate a maintenance dose of an oral medication before discharge in patients with SBP ?/= 200mg, or DBP >/=120 mm Hg;
this is optional in patients with lower BP

Asymptomatic patients may be discharged home.

170
Q

What is the treatment for carotid/vertebral dissection – extracranial dissection WITH ischemic neurologic symptoms?

A

Anticoagulation w/ unfractionated heparin (goal of PTT 45-60 sec) or LMWH (enoxaparin 1mg/kg BID or Dalteparin 100 U/kg BID)

  • this will usually either be followed by either warfarin or antiplatelet therapy (consult or inpatient team will decide this) bridge to outpatient therapy.
171
Q

What is the treatment for carotid/vertebral dissection – extracranial dissection WITHOUT ischemic neurologic symptoms?

A

antiplatelet therapy, NO anticoagulation

172
Q

What labs should be ordered if carbon monoxide poisoning is suspected?

A
  1. Carboxyhemoglobin level
    - baseline COHb in nonsmokers 3%, smokers 10-15%
  2. ABG (to evaluate acid-base status)
  3. Cardiac biomarkers if cardiac sx or risk factors
  4. CN (cyanide) level in patients with smoke inhalation injury

and EKG!

173
Q

What is the tx for CO poisioning?

A

100% O2 on nonrebreather for 90 min?

174
Q

If CN toxicity suspected/smoke inhalation injury, what is the tx?

A 
Sodium thiosulfate (25%) 1.65 mL/kg IV (max dose 12.5 g)
or 
Hydroxycobalamin 70mg/kg IV (5g is the standard adult dose)
175
Q

What labs should EVERY joint pain patient get?

A

UA
ESR/CRP
CBC
BMP

176
Q

What antibiotics should be ordered for open fractures?

A

Cephalexin +/- Gentamicin if contaminated

177
Q

What is a normal compartment pressure? What is abnormal and what indicates need for emergent fasciotomy?

A

Normal <12 mmHg
Elevated >20 mmHg
Need for Fasciotomy >30 mmHg

Can also use PULSE pressure (= diastolic pressure - compartment pressure) where <30mmHg indicates inadequate perfusion

178
Q

What labs should be sent on arthrocentesis fluid?

A 
Gram stain and culture
fluid cell count
crystals
synovial lactate
(glucose and protein are rarely helpful but can be sent)

Serum:
Consider serum lyme titer if suspicious
ESR and CRP will often be requested by consult services. CBC, BMP

179
Q

What should be on the differential for a painful joint?

A 
Septic arthritis
Gout
Pseudogout
Lyme Disease
Rheumatoid Arthritis
Cellulitis
Septic bursitis
osteoarthritis
180
Q

What is the treatment for septic joint with Gonococcus/Gram negative bacteria on gram stain?

A

Ceftriaxone 1g IV daily
+
OR washout

181
Q

What is the treatment for septic joint with Gam positives on gram stain, and not immunocompromised?

A

Vancomycin by total body weight
+
OR washout

182
Q

What is the treatment for septic joint with Gam positives on gram stain, and immunocompromised or IV drug user?

A

Vancomycin + Cefepime 2g QD
+
OR washout

183
Q

What is the treatment for septic joint with human or animal bite inoculation of wound?

A

Ampicillin + Sulbactam
+
OR washout

184
Q

How do you diagnose acute limb ischemia?

A

Doppler pulses –
normal if 1-1.4
borderline if 0.91-0.99
abnormal if <0.9

then arteriography, CT angiography, or MR angiography per hospital protocol or consultant preference.

185
Q

How do you manage acute limb ischemia?

A

Immediate IV heparin and aspirin followed by continuous heparin infusion
Vasc surg consult for revascularization +/-embolectomy, bypass graft

186
Q

How do you treat gout?

A

NSAIDs (Naproxen 500mg BID, Indomethacin 50mg TID, ibuprofen 800mg QID) –> high initial dose, then taper

  • If contraindication to NSAIDs (bleed, renal failure), then consider steroids

Colchicine: low dose course of 1.2 mg followed 1 hr later by 0.6 mg for 1.8mg total dose.
- warn pts of GI upset side effects

DONT use allopurinol or probenacid during acute exacerbations.

187
Q

What type of splint should be applied for a scaphoid/lunate fracture?

A

thumb spica

188
Q

What type of splint should be applied for a First Metacarpal fx?

A

thumb spica

189
Q

What type of splint should be applied for De Quervain’s tenosynovitis?

A

thumb spica

190
Q

What type of splint should be applied for a ulnar styloid fracture?

A

ulnar gutter

191
Q

What type of splint should be applied for a 4th and 5th metacarpal fx?

A

ulnar gutter

192
Q

What type of splint should be applied for a 4th and 5th phalanges fx?

A

ulnar gutter

193
Q

What type of splint should be applied for a Distal Radius fx?

A

Sugar tong

194
Q

What type of splint should be applied for a Distal Ulnar fx?

A

Sugar tong

195
Q

What type of splint should be applied for wrist sprains?

A

Volar splint

196
Q

What type of splint should be applied for a metacarpal fx?

A

Volar splint

197
Q

What type of splint should be applied for distal humerus fx?

A

Posterior long arm

198
Q

What type of splint should be applied for a proximal humerus fx?

A

posterior long arm

199
Q

What type of splint should be applied for a radial head or neck fx?

A

posterior long arm

200
Q

What type of splint should be applied for olecranon fx?

A

posterior long arm

201
Q

What type of splint should be applied for severe ligamentous injuries of the elbow?

A

posterior long arm

202
Q

What type of splint should be applied for unstable ankle fractures?

A

Posterior leg/ Posterior Sugar tong

203
Q

What type of splint should be applied for a distal tib/fib fx?

A

Posterior leg/ Posterior Sugar tong

204
Q

What type of splint should be applied for midfoot fx (metatarsal/tarsal)?

A

Posterior leg/ Posterior Sugar tong

205
Q

What type of splint should be applied for proximal tib/fib fx?

A

long leg posterior

206
Q

What type of splint should be applied for unstable knee fx?

A

long leg posterior

207
Q

What type of splint should be applied for femur fx?

A

long leg posterior

208
Q

What is the treatment for status asthmaticus?

A

albuterol and ipratropium nebs and steroids

If in extremis, consider magnesium and IV epinephrine

209
Q

What size ET tube will work for most adults?

A

7.5

210
Q

What agents and doses should be used for the average expected uncomplicated intubation? (according to EMRA book)

A

20mg etomidate

120mg succinylcholine

211
Q

What are two pre-treatment agents that can be used in intubation and their doses?

A

Lidocaine 1.5 mg/kg (100mg)

Fentanyl 3mcg/kg (200mcg)

212
Q

Which two induction agents have little to no effect on BP?

A

Etomidate

Ketamine

213
Q

What is the dose for Etomidate when used as an induction agent?

A

0.3 mg/kg (20mg)

214
Q

What is the dose for Versed (Midazolam) + Fentanyl when used as an induction agent?

A

0.3 mg/kg (20mg)

3mcg/k (200mg)

215
Q

What is the dose for Propofol when used as an induction agent?

A

1.5 mg/kg (100 mg)

216
Q

What is the dose for Ketamine when used as an induction agent?

A

1.5 mg/kg (120mg adult)

217
Q

What is the dose for Succinylcholine when used as a paralytic agent? Onset/Duration?

A

1.5 mg/kg (120 mg)

Onset <1 min, Short duration (4-6 min)

218
Q

What is the dose for Rocuronium when used as a paralytic agent? Onset/Duration?

A

1 mg/kg (80 mg) of IDEAL BODY WEIGHT

Onset <2 min, Medium duration (30-60 min)

219
Q

What is the dose for Vecuronium when used as a paralytic agent? Onset/Duration?

A

0.08-0.1 mg/kg (10 mg)

Onset 2-3 min, Medium duration (25-40 min)

220
Q

What is the dose for Pancuronium when used as a paralytic agent? Onset/Duration?

A

0.1 mg/kg

Onset 2-3 min, Long duration (60-100 min)

221
Q

What are absolute contraindications to the use of succinylcholine?

A
  1. History of malignant hyperthermia
  2. Burns >5 days old until they are healed
  3. Spinal cord injury
  4. Stroke that occurred between 5 days and 6 months
  5. Neuromuscular disease
222
Q

What is the albuterol/ipatropium dose for acute asthma exacerbation?

A

Albuterol 4-8 puffs or 2.5-5mg q15-30min x1hr then q30min

Ipatroprium Bromide MDI 2 puffs or Neb: 0.5 mL of 0.02% onset 30+min, lasts up to 6 hrs

223
Q

In a patient with severe acute asthma exacerbation, what steroid/dose should be administered? what other med can be given?

A

PO: Prednisone 40-60mg
IV: Methylprednisolone 125mg IV

Magnesium 2-4g IV over 10-15 min

224
Q

What peak flow (FEV1) may be indicative of exacerbation?

A

FEV1 >70% : mild exacerbation
FEV1 >/=40%: mild-mod severity
FEV1 <40% or unable to obtain d/t clinical status: severe

225
Q

If patient with acute asthma exacerbation cannot tolerate inhaled therapy, what medication can be given?

A 
Terbutaline 0.25-0.5mg SQ q30min to max dose of 5mg over 4 hrs 
or
Epinephrine (1:1000) 0.2-0.5 mL SC Q20-30 min x3 doses
226
Q

If patients receive steroids in ED for acute asthma exacerbation, discharge on burst PO regiment, which is what?

A

Prednisone 40-60mg PO daily x3-7 days

If concern for poor compliance, alternative: Solumedrol 160mg IM x1 dose

227
Q

What antibiotic should be prescribed in UNCOMPLICATED moderate to severe COPD exacerbations?

Uncomplicated:

  • Age <65
  • no comorbidities
  • FEV1>50
  • <3exacerbations per year
A 
Azithromycin (Z pack)
or
Cefpodoxime 
or
Doxy
or
Bactrim 
for 5 days
228
Q

What is the dose of epinephrine in anaphylaxis?

A 
IM epi (1:1000): 0.3-0.5mL q5min PRN, titrate to effect
(EpiPen=0.3mL)
Inject into anterolateral thigh
229
Q

What 3 medications can/should be given for patients with angioedema?

A
  1. Steroid: methylprednisolone 125mg IV or dexamethasone 10mg IV
  2. H1 blocker: Diphenhydramine 50mg IV
  3. H2 blocker: Famotidine 40mg IV or Ranitidine 50 mg IV
230
Q

What NT-proBNP and BNP levels are indicative of ADHF?

A

NT-proBNP >1000
BNP>400

(but these vary with age)
if age>75, cutoff of BNP>800pg/mL

231
Q

What are the signs/sx of flash pulmonary edema?

A

Rales, crackles
SBP >180 mmHg
Tachycardia

Usually history of poorly controlled hypertension

232
Q

What are the two initial mainstays of treatment for flash pulmonary edema?

A

BiPAP with a PEEP of 5-8 and titrate up

Nitroglycerin drip– start BIG >25mcg/min and titrate up

233
Q

If patient is in ADHF and bradycardic, what med?

A

Atropine or external pacing

234
Q

If patient is in ADHF and is hypotensive, what med should be administered?

A

Norepinephrine

If norepi unavailable, can give dopamine

235
Q

What 2 medications can be given in ADHF to increase inotropy?

A

Milrinone, Dobutamine

236
Q

If ADHF is refractory to medical treatment, consult cardiology for what intervention?

A

Placement of an intraaortic balloon pump (IABP)

237
Q

If patient is in ADHF and is fluid overloaded, what medication should be ordered?

A

Furosemide for diuresis

Give total daily home PO dose as IV dose
Ex: 40 mg PO –> 40 mg IV

Furosemide IV to PO conversion is 1:2
20mg IV = 40mg PO

238
Q

What is the dose of nitroglycerin in flash pulmonary edema/acute heart failure?

A

0.4mg of sublingual spray or tab for immediate relief
Start 0.3-0.5 mcg/kg/min (typical starting dose is 25 mcg/min) Titrate up q3min

If no IV access, can place 0.5 to 1 inch of nitro paste

239
Q

What is a side effect of Nitroglycerin administration?

A

decrease in BP, so very efficacious in HTN

However, do not use if BP <95-100

240
Q

What 3 patient populations should not receive nitroglycerin?

A
  1. taking phosphodiesterase inhibitors
  2. with severe aortic stenosis
  3. with right sided MI
241
Q

What are side effects of Lasix/Furosemide?

A

Can cause electrolyte abnormalities (hypokalemia, hypocalcemia, hypochloremia)
Peak diuresis 30 min

242
Q

What is the Furosemide (Lasix), Torsemide, Bumex conversion?

A

furosemide 40 mg = Torsemide 20mg = Bumex 1mg

243
Q

What is the dose for milrinone?

A

Bolus 50mcg/kg IV over 10 min then start 0.375 mcg/kg/min IV and titrate up

244
Q

What are possible side effects of milrinone?

A

can cause hypotension and cardiac arrhythmias.

Obtain cardiology consult

245
Q

What DDimer is generally considered abnormal?

A

> 500 ng/mL

246
Q

What things can artificially elevate ddimer?

A 
advanced age (beginning age 40)
active malignancy
pregnancy
recent operation
rheumatologic disease
sickle cell disease
247
Q

In the case of pulmonary embolism, what is the dosing of unfractionated heparin?

A

80 units/kg IV bolus
followed by
18 units/kg/hr IV infusion (goal PTT 60-85 sec)

If no weight available, 5000u bolus, 1000u/hr drip in average sized patient.

248
Q

In the case of pulmonary embolism, what is the dosing of fractionated heparin (LMWH)?

A

Enoxaparin: 1mg/kg SC q12h
Dalteparin: 100 units/kg SC q12h or 150 units/kg SC q24 hrs

249
Q

What are contraindications to fractionated heparin (LMWH)

A

renal insufficiency (CrCl <30), HIT, weight <50 kg or >100kg, recent or planned procedure

250
Q

In the case of pulmonary embolism, what is the dosing of Fondaparinux (Factor Xa inhibitor)?

A

5-10 mg SQ injection (dose depends on body mass), safe in patients with HIT

251
Q

In the case of pulmonary embolism, what is the dosing of Rivaroxaban Factor Xa inhibitor?

A

15 mg PO BID

252
Q

In the case of pulmonary embolism, what is the dosing of Argatroban (Direct thombin inhibitor)?

A

2mcg/kg/min IV –> If hepatic dysfunction 0.5 mcg/kg/min

CALL HEMATOLOGY before administering given dosing variability. Effects are NONREVERSIBLE.

253
Q

In the case of pulmonary embolism, what is the dosing of Warfarin (Vit K antagonist)?

A

Do not start warfarin prior to starting short-term anticoagulation given increased risk of recurrent DVT/PE

Should be overlapped with short-term anticoagulation for a minimum of 5 days AND until INR is therapeutic (INR 2-3) for 24 hrs

Typical initial dose is 5mg PO for the first 2 days then adjusted according to INR.

MANY meds interact with warfarin. be sure to review med list.

254
Q

In massive PE, what is thrombolytic dosing?

A

Alteplase (tPA): 15 mg IV bolus followed by 2 hr infusion of 100 mg.
Discontinue heparin during infusion.

If pulseless 50 mg IV bolus over 2-3 min, additional 50 mg IV bolus can be given 30 min later.

EM 101 (3 decks)

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