General EM Flashcards
what is the most common congenital heart abnormality associated with WPW
Ebstein anomaly
definition of status epilepticus
seizure lasting longer than 5 minutes OR 2 or more seizures without regaining consciousness between them
key historical features when assessing seizure in the ED
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.
common precipitating factors for seizures in epilepsy patients
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.
first line in status epilepticus
lorazepam 2mg IV
second line in status epilepticus
phenytoin loading dose 20mg/kg .. rate of 50mg/min
third line, refractory status epilepticus
propofol 1mg/kg IV
risk factors for aortic dissection
- chronic hypertension
- Marfan, Ehlers-Danlos, bicuspid aortic valve, famhx of dissection
- chronic cocaine or amphetamine use
- previous cardiac surgery
Stanford classification Type A aortic dissection means
any dissection involving ASCENDING aorta
Stanford classification Type B aortic dissection
dissection involving only the descending aorta
3 historical features most highly associated with aortic dissection
abrupt onset, pain described as ripping or tearing, severe in intensity
physical exam findings in aortic dissection
SBP or pulse deficit in extremities, new onset aortic insufficiency murmur, focal neuro deficit PLUS chest, abdo or back pain, and shock or hypotension
CXR findings in aortic dissection
widened mediastinum, abnormal aortic contour, displacement of aortic intimal calcification from previous CXR, pleural effusion, or deviation of trachea, bronchus, or esophagus
imaging study to diagnose aortic dissection
CT angiogram with contrast
goal blood pressure in aortic dissection
below 120mmHg systolic
agent of choice for bp lowering in aortic dissection
short-acting β-blockers such as propranolol, labetalol, or esmolol are preferred over long-acting β-blockers.
management of type A aortic dissection
surgery, endovascular repair
diagnosis of temporal arteritis
need 3 of 5;
- age > 50
- new headache
- temporal artery abnormality (tender, decreased pulsation)
- ESR > 50
- abnormal temporal artery biopsy
risk factors for subarachnoid hemorrhage
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
BP target in aortic dissection
below 120/80
BP target in ischemic stroke
receiving thrombolysis - below 185/110
no thrombolysis- treat if above 220/120 (lower by 15%)
BP target in intraparenchymal hemorrhage
SBP below 180 - INTERACT2 trial showed no benefit for below 140
risk factors for venous thromboembolism
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)
syndrome that occurs in patients with PE who have a PFO
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
ECG changes associated with PE
sinus tachycardia S1Q3invertedTin3 incomplete RBBB complete RBBB T wave inversion in leads V1-4
PERC criteria (9) use in low clinical probability <15%
- age under 50
- pulse below 100
- SpO2 greater than 94%
- no hemoptysis
- no previous DVT/PE
- no active cancer
- no recent surg/immob
- no estrogen
- no leg swelling
Wells for DVT
- 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
Wells for PE
- suspected DVT
- alt diagnosis less likely than PE
- active ca.
- hemoptysis
- pulse > 100
- prior VTE
- immob in past 4 weeks
potential for false positive D-dimer results in
age > 70 pregnancy active cancer or mets surgery in past week liver disease rheumatoid arthritis infections trauma
potential for false negative D-dimer
warfarin therapy symptoms lasting over 5 days presence of small clots isolated pulmonary infarction lipemia isolated calf vein thrombosis
treatment of PE
anticoagulants - DOACs - apixaban
preferred agent for VTE in malignancy
LMWH
preferred agent for VTE in renal failure or hemodynamic instability
UFH
treatment of DVT causing phlegmasia cerulea dolens
UFH, place limb neutral level, arrange for catheter directed thrombolysis (if cannot occur within 6 hours, consider systemic thrombolytics)
treatment of DVT in arm with PICC
remove PICC, anticoagulant as usual
treatment of superficial thrombophelbitis
NSAID, voltaren gel; anticoagulate IF extensive
treatment of isolated calf vein thrombosis
3 months anticoagulation OR reultrasound in 1 week to assess progression, if none do not treat
definition of massive PE
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
definition of submassive PE
normal BP but evidence of strain
less severe PE
normal BP, no strain
treatment of massive PE
thrombolysis
indication for hospital admission in DVT
- 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
who to treat with sub segmental PE ?
active cancer patients
most common cause of wheezing in infants
bronchiolitis
3 presentations consistent with unstable angina
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
TIMI score components
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.
if you have a patient with an inferior MI you should get ___
an ECG with right sided VR4 to look for RV infarct
Sgarbossa criteria
- concordant ST deviation >1mm
- ST-segment depression of 1 mm or more in leads V1, V2, or V3
- discordant ST deviation >5mm
deeply inverted T waves OR variant pattern of biphasic T waves in the V2, V3
Wellen’s syndrome - indicative of critical LAD stenosis; often present when pt pain free and resolve when pain ongoing
STEMI criteria
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
treatment of STEMI
aspirin 160mg chew, nitroglycerin spray 0.4mg q5min x 3, plavix 300mg po, unfractionated heparin IV, /fondaparinux SC, metoprolol 50mg po, PCI/fibrinolytics
contraindications to fibrinolytics in STEMI
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)
indications for beta blocker in acute MI
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)
complications of MI
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
indications for temporary transcutaneous pacing in AMI
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
indications for temporary transvenous pacing in AMI
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)
most sensitive finding for placental abruption after trauma in pregnancy
uterine irritability (more than three contractions per hour)
how to position pregnant trauma patient
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
checklist for trauma in pregnancy
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.
high risk features mandating Xray in C spine
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
any low risk factor in Cspine rules
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
