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Emergency > General EM > Flashcards

General EM Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

what is the most common congenital heart abnormality associated with WPW

A

Ebstein anomaly

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2
Q

definition of status epilepticus

A

seizure lasting longer than 5 minutes OR 2 or more seizures without regaining consciousness between them

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3
Q

key historical features when assessing seizure in the ED

A

presence of a preceding aura, abrupt or gradual onset, progression of motor activity, loss of bowel or bladder control, presence of oral injury, and whether the activity was localized or generalized and symmetric or unilateral, duration of the episode and determine the presence of postictal confusion or lethargy.

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4
Q

common precipitating factors for seizures in epilepsy patients

A

missed doses of antiepileptic medications; recent alterations in medication, including dosage change or conversion from brand name; sleep deprivation; increased strenuous activity; infection; electrolyte disturbances; and alcohol or substance use or withdrawal.

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5
Q

first line in status epilepticus

A

lorazepam 2mg IV

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6
Q

second line in status epilepticus

A

phenytoin loading dose 20mg/kg .. rate of 50mg/min

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7
Q

third line, refractory status epilepticus

A

propofol 1mg/kg IV

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8
Q

risk factors for aortic dissection

A
  • chronic hypertension
  • Marfan, Ehlers-Danlos, bicuspid aortic valve, famhx of dissection
  • chronic cocaine or amphetamine use
  • previous cardiac surgery
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9
Q

Stanford classification Type A aortic dissection means

A

any dissection involving ASCENDING aorta

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10
Q

Stanford classification Type B aortic dissection

A

dissection involving only the descending aorta

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11
Q

3 historical features most highly associated with aortic dissection

A

abrupt onset, pain described as ripping or tearing, severe in intensity

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12
Q

physical exam findings in aortic dissection

A

SBP or pulse deficit in extremities, new onset aortic insufficiency murmur, focal neuro deficit PLUS chest, abdo or back pain, and shock or hypotension

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13
Q

CXR findings in aortic dissection

A

widened mediastinum, abnormal aortic contour, displacement of aortic intimal calcification from previous CXR, pleural effusion, or deviation of trachea, bronchus, or esophagus

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14
Q

imaging study to diagnose aortic dissection

A

CT angiogram with contrast

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15
Q

goal blood pressure in aortic dissection

A

below 120mmHg systolic

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16
Q

agent of choice for bp lowering in aortic dissection

A

short-acting β-blockers such as propranolol, labetalol, or esmolol are preferred over long-acting β-blockers.

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17
Q

management of type A aortic dissection

A

surgery, endovascular repair

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18
Q

diagnosis of temporal arteritis

A

need 3 of 5;

  1. age > 50
  2. new headache
  3. temporal artery abnormality (tender, decreased pulsation)
  4. ESR > 50
  5. abnormal temporal artery biopsy
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19
Q

risk factors for subarachnoid hemorrhage

A 
Hypertension
Smoking
Excessive alcohol consumption
Polycystic kidney disease
Family history of subarachnoid hemorrhage
Coarctation of the aorta
Marfan's syndrome
Ehlers-Danlos syndrome type IV
α1-Antitrypsin deficiency
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20
Q

BP target in aortic dissection

A

below 120/80

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21
Q

BP target in ischemic stroke

A

receiving thrombolysis - below 185/110

no thrombolysis- treat if above 220/120 (lower by 15%)

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22
Q

BP target in intraparenchymal hemorrhage

A

SBP below 180 - INTERACT2 trial showed no benefit for below 140

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23
Q

risk factors for venous thromboembolism

A

age > 50
obesity, BMI >35 increases risk
pregnancy/postpartum state
prior VTE (highest recurrence for unprovoked)
solid cancers (adenocarcinomas and metastatic disease highest risk)
hematologic (acute leukemias and myeloma have highest risk)
thrombophilias (non O blood type, Factor V Leiden, lupus AC, protein C/S deficiency, shortened aPTT)
recent surgery (endotracheal intubation or epidural anesthesia within past 4 weeks)
immobility (2 contiguous joints highest risk, ie. long arm cast)
bed rest (becomes risk at 72 hours)
indwelling catheters (ie. PICC)
travel (flights >6 hours)
CHF (related to systolic function)
stroke (greatest in 1st month after)
estrogen (highest in first few months of use)
non-infectious inflammatory conditions (IBD, lupus, nephrotic syndrome)

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24
Q

syndrome that occurs in patients with PE who have a PFO

A

paradoxical embolism syndrome - due to shower of emboli through R–>L shunt due to increased right sided pressure due to PE, causes stroke like symptoms

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25
Q

ECG changes associated with PE

A 
sinus tachycardia
S1Q3invertedTin3
incomplete RBBB
complete RBBB
T wave inversion in leads V1-4
26
Q

PERC criteria (9) use in low clinical probability <15%

A
  1. age under 50
  2. pulse below 100
  3. SpO2 greater than 94%
  4. no hemoptysis
  5. no previous DVT/PE
  6. no active cancer
  7. no recent surg/immob
  8. no estrogen
  9. no leg swelling
27
Q

Wells for DVT

A
  • active cancer
  • paralysis, paresis or immob of lower extremity
  • bedridden for >3 days because of surg
  • localized tenderness along deep venous system
  • swelling >3cm difference between calves
  • entire leg swollen
  • unilateral pitting edema
  • collateral superficial veins
  • alternative diagnosis as or more likely
  • prior history of DVT/PE
28
Q

Wells for PE

A
  • suspected DVT
  • alt diagnosis less likely than PE
  • active ca.
  • hemoptysis
  • pulse > 100
  • prior VTE
  • immob in past 4 weeks
29
Q

potential for false positive D-dimer results in

A 
age > 70
pregnancy
active cancer or mets
surgery in past week
liver disease
rheumatoid arthritis
infections
trauma
30
Q

potential for false negative D-dimer

A 
warfarin therapy
symptoms lasting over 5 days
presence of small clots
isolated pulmonary infarction
lipemia
isolated calf vein thrombosis
31
Q

treatment of PE

A

anticoagulants - DOACs - apixaban

32
Q

preferred agent for VTE in malignancy

A

LMWH

33
Q

preferred agent for VTE in renal failure or hemodynamic instability

A

UFH

34
Q

treatment of DVT causing phlegmasia cerulea dolens

A

UFH, place limb neutral level, arrange for catheter directed thrombolysis (if cannot occur within 6 hours, consider systemic thrombolytics)

35
Q

treatment of DVT in arm with PICC

A

remove PICC, anticoagulant as usual

36
Q

treatment of superficial thrombophelbitis

A

NSAID, voltaren gel; anticoagulate IF extensive

37
Q

treatment of isolated calf vein thrombosis

A

3 months anticoagulation OR reultrasound in 1 week to assess progression, if none do not treat

38
Q

definition of massive PE

A

systolic blood pressure of <90 mm Hg for >15 minutes, a systolic blood pressure of <100 mm Hg with a history of hypertension, or a >40% reduction in baseline systolic blood pressure

39
Q

definition of submassive PE

A

normal BP but evidence of strain

40
Q

less severe PE

A

normal BP, no strain

41
Q

treatment of massive PE

A

thrombolysis

42
Q

indication for hospital admission in DVT

A
  • extensive iliofemoral DVT with circulatory compromise
  • increased risk of bleeding (coagulopathy, PUD, liver disease)
  • limited CV reserve, need to monitor for hypoxemia
  • risk of poor compliance
  • contraindication to LMWH or DOAC, requiring UFH
  • known or suspected coexistent PE
  • high suspicion of HITT
  • renal insufficiency
43
Q

who to treat with sub segmental PE ?

A

active cancer patients

44
Q

most common cause of wheezing in infants

A

bronchiolitis

45
Q

3 presentations consistent with unstable angina

A

1) angina occurring at rest that is prolonged typically >20 mins
2) new onset angina that limits physical activity (ie. walking 1-2 blocks or climbing a flight of stairs)
3) angina that is occurring more frequently, with less activity and lasts longer

46
Q

TIMI score components

A

Age 65 y or older
3 or more traditional risk factors for coronary artery disease
Prior coronary stenosis of 50% or more
ST-segment deviation on presenting electrocardiogram
2 or more anginal events in prior 24 h
Aspirin use within the 7 d prior to presentation
Elevated cardiac markers
The presence of each of the above is assigned 1 point. The maximum possible score is 7.

47
Q

if you have a patient with an inferior MI you should get ___

A

an ECG with right sided VR4 to look for RV infarct

48
Q

Sgarbossa criteria

A
  1. concordant ST deviation >1mm
  2. ST-segment depression of 1 mm or more in leads V1, V2, or V3
  3. discordant ST deviation >5mm
49
Q

deeply inverted T waves OR variant pattern of biphasic T waves in the V2, V3

A

Wellen’s syndrome - indicative of critical LAD stenosis; often present when pt pain free and resolve when pain ongoing

50
Q

STEMI criteria

A

1mm of elevation in 2 contiguous leads, in any leads except V2-V3
need 2mm of V2-V3 in men over 40, 1.5mm in women 2.5mm in men under 40

51
Q

treatment of STEMI

A

aspirin 160mg chew, nitroglycerin spray 0.4mg q5min x 3, plavix 300mg po, unfractionated heparin IV, /fondaparinux SC, metoprolol 50mg po, PCI/fibrinolytics

52
Q

contraindications to fibrinolytics in STEMI

A

Absolute contraindications
Any prior intracranial hemorrhage
Known structural cerebral vascular lesion (e.g., arteriovenous malformation)
Known intracranial neoplasm
Ischemic stroke within 3 mo
Active internal bleeding (excluding menses)
Suspected aortic dissection or pericarditis

Relative contraindications
Severe uncontrolled blood pressure (>180/100 mm Hg)
History of chronic, severe, poorly controlled hypertension
History of prior ischemic stroke >3 mo or known intracranial pathology not covered in contraindications
Current use of anticoagulants with known INR >2–3
Known bleeding diathesis
Recent trauma (past 2 wk)
Prolonged CPR (>10 min)
Major surgery (<3 wk)
Noncompressible vascular punctures (including subclavian and internal jugular central lines)
Recent internal bleeding (within 2–4 wk)
Patients treated previously with streptokinase should not receive streptokinase a second time
Pregnancy
Active peptic ulcer disease
Other medical conditions likely to increase risk of bleeding (e.g., diabetic retinopathy)

53
Q

indications for beta blocker in acute MI

A

can give within first 24 hours to see benefit if there are no: (1) signs of heart failure, (2) evidence of a low cardiac output state, (3) increased risk for cardiogenic shock (cumulatively: age >70 years old, systolic blood pressure <120 mm Hg, sinus tachycardia >110 beats/min or bradycardia <60 beats/min, and longer duration of STEMI symptoms before diagnosis and treatment), or (4) standard relative contraindications to β-blockade (PR interval >0.24 seconds, second- or third-degree heart block, active asthma, or reactive airway disease)

54
Q

complications of MI

A

dysrhythmias
heart failure
cardiogenic shock
ventricular free wall rupture can cause tamponade
interventricular septal rupture can cause new murmur
papillary muscle rupture (inferior MI) new murmur –> surgical mgmt
pericarditis
RV infarct

55
Q

indications for temporary transcutaneous pacing in AMI

A 
Unresponsive symptomatic bradycardia
Mobitz II or higher AV blocks
New LBBB and bifascicular blocks
RBBB or LBBB with first-degree block
Some cases with stable bradycardia and new or indeterminate-age RBBB
56
Q

indications for temporary transvenous pacing in AMI

A

Asystole
Unresponsive symptomatic bradycardia
Mobitz II or higher AV blocks
New or indeterminate-age LBBB
Alternating bundle-branch block
RBBB or LBBB with first-degree block
Consider in RBBB with left anterior or posterior hemiblocks
Overdrive pacing in unresponsive ventricular tachycardia
Unresponsive recurrent sinus pauses (>3 s)

57
Q

most sensitive finding for placental abruption after trauma in pregnancy

A

uterine irritability (more than three contractions per hour)

58
Q

how to position pregnant trauma patient

A

wedge under the right hip area, tilting the patient approximately 30 degrees to the left, to prevent hypotension from inferior vena cava compression by the gravid uterus

59
Q

checklist for trauma in pregnancy

A

Before arrival: Assemble ED, obstetrics, and trauma team, as appropriate for >20 wk gestation
Attend to maternal airway, breathing, and circulation as a priority for both mother and fetus. Increase volume resuscitation 50% above that given to nonpregnant patients.
Maintain patient in the semi-left lateral decubitus position, or manually deflect the uterus to the left.
Bedside US: FAST for intraperitoneal fluid and to determine fetal heart rate and estimate fetal age to determine viability.
Initiate fetal cardiotocographic monitoring as soon as possible and continue for at least 4–6 h even if the patient is apparently uninjured and > 20 weeks gestation.
Perform needed imaging.
Include blood typing and Rh status in laboratory studies.
Administer Rho(D) immunoglobulin to Rh-negative mothers. Give tetanus as indicated.
Screen for potential intimate partner violence.

60
Q

high risk features mandating Xray in C spine

A

age over 65
dangerous mechanism (fall from elevation >3feet/5 stairs, axial load to head (ie. diving), MVC > 100km/h, rollover or ejection, motorized recreational vehicle, bicycle struck or collision)
paresthesias in extremities

OR
no presence of low risk features = imaging

61
Q

any low risk factor in Cspine rules

A 
simple rearend (excludes - pushed into oncoming traffic, hit by bus/large truck, rollover, hit by high speed vehicle)
sitting position in ED
ambulatory at any time
delayed onset of pain
absence of midline tenderness

Emergency (3 decks)

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