Gen ER Flashcards
What are three categories of stridor and at least three causes in each?
1) Supraglottic
(epiglottitis, peri/retro-pharyngeal abscess, adenotonsillar hypertrophy, craniofacial abN)
2) Glottic
(laryngomalacia, laryngospasm, VC paresis/paralysis/dysfunction, VC nodule/mass)
3) Subglottic
(laryngotracheobronchitis, anaphylaxis, bacterial tracheitis, subglottic stenosis, subglottic web, subglottic hemangioma, tracheomalacia)
What are the two categories of causes of epistaxis?
List five in each
LOCAL
- trauma
- inflammation (URTI, staph)
- congenital syphilis
- foreign body
- allergic rhinitis
- telangiectasia (Osler-W-R)
- juvenile angiofibroma
- nasopharyngeal lymphoepithelioma
- rhinitis sicca
SYSTEMIC
- hematologic (platelet or hemophilias ie ITP, leuk, aplastic anemia, vWD, DIC, vitK, ASA, VPA, NSAIDs)
- hypertension (arterial, superior vena cava syndrome, CF)
- vicarious menstruation
How to manage epistaxis?
- pressure, lean forward consider: - dental roll under front gums - gauze soaked with epi 1:1000 - nasal packing, tampons - cautery with silver nitrate stick
home therapies: humidifier petroleum jelly consider antibiotic ointment consider nasal decongestants
For nasal cauterization, name the indications, contraindications (2) and complications (3) of the procedure.
indications: failure to control bleed with pressure and topical vasoconstrictor
contraindications: bleeding diathesis (hemophilia, ITP) or previous cauterization within 6 weeks
complications: septal perforation, staining of the upper lip or nares, bacterial superinfection or the cauterized area
* refrain from cauterizing both sides of the nasal septum
For nasal packing, name indications and complications of the procedure.
indications: bleeding that cannot be controlled with pressure and topical vasoconstrictor, with a contraindication to or failure of cauterization
complications:
1) bacterial rhinosinusitis
2) toxic shock syndrome
3) nasal alar or columnar necrosis
4) septal ulceration or perforation
5) synechiae formation
6) hypoxemia or resp distress from nasal obstruction
Name the components of the GCS score
Eyes Verbal Motor
Eyes 4-open spontaneously 3-closed and open with voice 2-close and open with pain 1-closed
Verbal 5- coherent 4- confused 3- garbled 2- moans 1- nil
Motor 6- command 5- localizes 4- withdraws 3- decorticate 2- decerebrate 1- flaccid
Describe AVPU method of assessing level of consciousness
Alert
Voice
Painful
Unresponsive
Name the components of the pediatric trauma score and describe its relevance in practice
Size Airway Systolic blood pressure Central nervous system Skeletal Cutaneous
The PTS emphasizes the importance of patient size and ability to maintain the airway. Studies have confirmed its use as a predictor of outcome: 9% mortality for PTS >8, 100% mortality for PTS <0 and a directly linear correlation between 0-8.
Name physical exam findings that would suggest a difficult airway
- small mouth
- inability to open the mouth
- TMJ abnormalities
- narrow receding mandible
- protuberant maxillae
- large tongue
- distance <6cm between mandible and thyroid prominence
- inability to place in the sniffing position
- short, full or bull necks
- neck mass
- significant penetrating trauma to face or neck
Describe ECG changes seen with hypothermia with a core temperature <32C
- marked sinus bradycardia
- 1st degree AV block
- Osborn or J waves
- Ass’ w/ long QT
Describe changes seen in hypothermia with temperatures:
31-32C
28-31C
<28
31-32C: normal vitals, loss of shivering
28-31C: decreased HR and BP, afib, dilated pupils
<28C: absent pulse and BP, Vfic, coma, fixed pupils
Name 5 management pearls of hypothermia resuscitation
Warm fluids to 43C Correct hypoglycemia Watch for coagulopathy If VF defib no more than three times until temp >30C Drugs rarely effective until T>30C
What are the stages of frostbite
- initial stinging
- cold, pale, decreased sensation
- blotchy and painful areas
Describe features of heat stroke
core temp >41C dry, hot, ashen skin ARF rhabdo headache, disorientation -> coma, weakness, gait disturbance
Describe features of heat exhaustion (or water depletion)
T <40C lethargy nausea, vomiting heaadches BP, incr HR
Name good and poor prognostic features with regards to submersion injury prognosis
Good:
ROSC <10 minutes
Submersion <5 minutes
PERL, NSR at scene
Poor:
Delayed CPR
ROSC >25 minutes
Submersion >10 minutes
Describe features of high voltage injuries
tetany *can prevent grip release, arching
muscle damage -> compartment syndrome -> rhabdo
CNS injury
VF / cardiac arrest
Monitor heart, urinanalysis
What are the features of a brown recluse spider bite?
local pain -> central blister -> subcutaneous discoloration ->ulcer
systemic reactions develop in small children: fever, n&v, joint pain, hematuria
treat with analgesia and local care, excision and grafting if severe
What snakes do you have to worry about in Canada?
Massasauga and Western rattlesnake
Name indications for admission in anorexia nervosa (8)
systolic <90 HR<45 bpm (some <40 bpm) orthostatic changes of 30 bpm systolic 20 mmHg temp <35.5C 75% of goal weight support and comorbidity failure of outpatient
What is the management of neonatal mastitis?
Treat as a potentially severe infection in infants <2 months of age with septic work-up (use low risk criteria to determine LP or not in >1 month), IV antibiotics and admit.
What inborn error of metabolism should you suspect if there is hypoglycemia, hyperammonemia and metabolic acidosis?
What if there are urine ketones as well?
Fatty acid oxidation disorder
Organic aciduria
What inborn error of metabolism should you suspect with neonatal hypoglycemia and lactic acidosis?
Glycogen storage disease
What inborn error of metabolism should you suspect with very high serum ammonia?
Urea cycle defect
What are BRUE low risk criteria?
- age >60 days
- born at >/= 32wks and CGA >/=45wks
- no CPR by trained medical professional
- event lasted <1 minute
- first event
What investigations may you consider in a low-risk BRUE patient?
ECG
pertussis
brief monitoring with continuous O2 and rechecks
What is an oral ranula and how do you treat?
A ranula is a mucus extravasation cyst involving a sublingual gland and is a type of mucocele found on the floor of the mouth.
Self resolve in 3-6 weeks
What are risk factors for SCFE?
obesity steroid use Down's syndrome endocrinopathy osteodystrophy
What are the P’s of compartment syndrome?
pain out of proportion to PE findings passive stretch exacerbation paresthesias point discrimination loss paresis pallor pulselessness
Name medications which may cause methhemoglobinemia?
dapsone benzocaine sodium nitrate sulfonamides quinones well water phenozopiridine
How does macrophage activation syndrome or reactive hemophagocytic lymphohistiocytosis present and who is at risk?
Presentation with fever, HSM, rash and liver dysfunction.
- cytopenias >2 cell lines
- hypertriglyceridemia
- hypofibrinogenemia
- elevated ferritin
Varios auto-immune disorders are at risk
What is the most specific test for SLE?
dsDNA
Which populations is ARF most common in?
Fiji, Tonga, India, Pakistan, Turkey, Mozambique
Dermatomyositis is complicated by what deficiencies?
complicated by velopalatine muscle weakness
- cough, nasal voice, difficulty handling secretions
- PTX, ILD, GI hemorrhage & perf, soft tissue calcinosis
How does juvenile dermatomyositis present?
5-10yoM with proximal muscle weakness
photosensitive rash involving nasolabial folds
Gottron papules
lab abnormalities (aldolase, AST, ALT, LDH, CPK)
What should you suspect with high fever, salmon rash, leukocytosis, anemia and thrombocytosis?
JIA
If a Kawasaki patient is on aspirin therapy and you suspect that they have the flu, what should you do?
Don’t stop treatment! Start tamiflu!
Name three possible treatments for hereditary angioedema? What to send to confirm?
icabitant
ecallantide
recombinant C-1 inhibitor
send serum complement factor 4
C1 inhibitor level
What to consider in a patient with fever, urticaria and arthritis?
Serum sickness!
1-2 weeks post offending agent
type III hypersensitivity reaction, immune-complex mediated
What is the classic presentation of DRESS?
2-6 weeks post medication (antiseizure)
morbilliform rash -> exfoliative -> fever, liver, LADN, edema, mucosal involvement in 50%
What is the mode of inheritance and classic presentation of Wiskott Aldrich?
What is most lethal?
eczema, thrombocytopenia, recurrent infections
x-linked
susceptibility to infxns with S. pneumo, N. meningitides, H. influenza
bleeding risk is deadly! ICH, massive GI
What is the risk of anaphylaxis with Ceftriaxone in a penicillin-allergic patient?
<1%
How can you manage an accidental epipen auto-injection?
- observation
- soaking in warm water
- topical nitroglycerin
- phentolamine injection (reversible alpha agonist)
What inborn error of metabolism presents with intermittent encephalopathy, ataxia, confusion, coma and hyperammonemia?
Ornithine transcarbamylase deficiency, a urea cycle defect
x-linked dominant
female heterozygotes have a milder episode presentation exacerbated by a high protein diet and stress
A failure to thrive baby with jaundice and an E. coli UTI should be suspected of what condition?
galactosemia!
lethargy, poor feeding, FTT, hypoglycemia, eventually direct hyperbilirubinemia
galactose deposition in liver = HSM, eyes = cataracts, heart = MR
An 18mo presents with hypoglycemia in the context of a gastrointestinal illness, no ketones are present in their urine. What diagnosis should you suspect? How to confirm?`
MCAD (AR)
order urine organic acids and acylcarnitine profile
What to suspect with lethargy, vomiting, seizures, acidosis, hyperammonemia and ketones?
Maple syrup urine disease
aka methylmalonic acidemia = organic aciduria
What is the best way to confirm the appropriate location of an IUD?
pelvic ultrasound
then AXR
then CT / MRI
What is the presentation of a septic abortion?
How to manage?
abdominal pain
foul-smelling discharge
chills or fever
(can be seen post-misoprostol)
Rx Genta & Clinda, U/S +/- D&C
If a subdermal implant is suspected to have been broken, what is the best way to evaluate it?
Ultrasound
If a young girl presents with painful vaginal ulcers in the context of diarrhea, what should you suspect?
shigella vaginitis
culture to rule-out sexual abuse
treat with azithro
How do you treat phimosis? labial adhesion?
phimosis: reassurance mostly, topical steroids
labial adhesions: topical estrogen
What testing should you consider for abnormal uterine bleeding?
Management?
CBC & iron studies STI testing pregnancy trauma TSH, testo, LH, FSH vWF head imaging if neuro findings, galactorrhea
Consider TXA, monophasic combined OCP BID x 7 days
How do you manage a urethral prolapse?
confirm with catheter if doubt
surgery if necrosed
otherwise topical estrogen cream and sitz baths
What are the diagnostic criteria for bacterial vaginosis and treatment options?
3/4 of
1) homogeneous, thin, grayish-white discharge adherent to vaginal walls
2) vaginal pH >4.5
3) positive whiff test after KOH prep
4) >20% clue cells on wet prep
treat with Metronidazole or Clinda
What is a grape-like mass near the vaginal introitus?
rule-out sarcoma botryoides
Name causes of vaginal bleeding in a premenarchal girl
- nonhormonal: trauma, tumour, urethral prolapse, infectious vaginitis, intravaginal foreign body, genital warts
- hormonal: neonatal bleeding, exogenous estrogen, precocious puberty
Name causes of vaginal bleeding in a post-menarchal girl
menses hormonal contraception endometritis dysfunctional uterine bleeding bleeding diathesis complications of pregnancy
With a chemical injury to the eye, when do you stop irrigating?
stop irrigating when the pH of the affected eye is comparable to the unaffected eye (a little while after finishing, normal is 6.5-7.5, otherwise pH 5.5 = NS)
20 minutes minimum or 2L of fluid
sedate if they won’t cooperate!
What is Brown-Sequard syndrome?
a hemisection of the spinal cord:
ipsilateral loss of motor, proprioception, vibratory sensation
contralateral loss of pain and temperature
What is central cord syndrome?
bilateral motor paresis, upper > lower, distal > proximal
What is anterior cord syndrome?
paralysis below the level with loss of pain and temp
What is posterior cord syndrome?
loss of proprioception and vibration
What are the four types of hypersensitivity reactions and how are they mediated?
1: anaphylaxis, IgE
2: cytotoxic, IgG/IgM binds to host cell
3: immune complex, IgG with soluble antigen
4: cell mediated, T-cells
What elements of the CATCH CT head rule suggest a CT scan is indicated?
GCS <15 2hrs after injury
Suspected open or depressed skull fracture
Worsening headache
Irritability
Basal skull fracture
Boggy scalp hematoma
Dangerous mechanism (>3ft, MVC, bike without helmet)
What are the PECARN indications to absolutely do a non-contrast head CT?
GCS =14
Altered mental status
Palpable skull fracture <2
Signs of basilar skull fracture >2
What are the PECARN indications to consider doing a head CT vs observation?
<2: Non-frontal scalp hematoma LOC ≥ 5 seconds Severe injury mechanism head struck by high-impact object Abnormal activity per parents
>2-18: History of vomiting^ LOC Severe injury mechanism Head struck by high-impact object Severe headache
For air transport considerations, what two laws do you need to take into account and what do they imply clinically?
Boyle’s law: as pressure decreases, volume increases
significant considerations for pneumothoraces
Dalton’s law: at higher altitudes, the concentration of gas decreases
hypoxia increases at higher altitudes
With the following WBC counts following knee aspiration, what is your suspected diagnosis?
<2000
2-50,000
>50,000
<2,000 non-inflammatory (PMN <25%)
2-50,000 inflammatory (PMN 50%)
>50,000 infectious (PMN >75%)
What are the 5 layers of the scalp?
SCALP Skin Dense Connective Tissue Epicranial Aponeurosis Loose Areolar Connective Tissue Periosteum
What are the three reportable STIs in Canada?
chlamydia
gonorrhea
syphilis
