General stuff Flashcards
1
Q
PERC
A
Age >= 50 HR >= 100 SaO2 < 95% Recent trauma/surgery Hemoptysis Unilateral LE edema Hx DVT/PE Hormone use (OCPs, estrogen replacement)
If the patient is at low risk for PE and none of the above are present, PE can be safely be excluded from the DDx
2
Q
Wells criteria for PE
A
S/Sx of DVT (+3)
PE #1 dx or equally likely (+3)
HR > 100 (+1.5)
Immobilization > 3d OR surgery in last 4w (+1.5)
Prior DVT/PE (+1.5)
Hemoptysis (+1)
Malignancy treated in last 6m or palliative (+1)
3
Q
Wells criteria for PE - risk stratification
A
High risk > 6, need CTA
Intermediate risk 2-6, may d-dimer or CTA
Low risk < 2, rule out with PERC or d-dimer
4
Q
HEART score calculation
A
History
0 - Slightly suspicious
1 - Moderately
2 - Highly
EKG
0 - Normal
1 - Repol changes, e.g. LBBB, LVH, or dig
2- Significant ST deviation
Age
0 - under 45y
1 - 45-64y
2 - at least 65y
Risk factors
0 - no CAD/CVA/PVD, HTN, HLD, DM, tobacco, obesity, FH
1 - 1-2 risks
2 - 3+ risks OR hx CAD/CVA/PVD
Troponin
0 - normal
1 - 1-3x upper limit of normal
2 - over 3x upper limit of normal
5
Q
HEART score interpretation
A
Predicts 6wk risk of major adverse cardiac event
Low score 0-3 - consider d/c
Int score 4-6 - consider obs admit for further CV w/u
High score 7+ - consider urgent coronary cath
For patients at least 21yo with symptoms suggestive of ACS. Do not use in STEMI on EKG or hypotension.
6
Q
Status epilepticus definition
A
SZ not resolving spontaneously within 5 minutes OR at least 2 SZ within 5 minutes without return to baseline mental status
7
Q
Status epilepticus treatment algorithm
A
DEFG- Don’t ever forget GLUCOSE
- Lorazepam (0.1mg/kg, max 4mg) OR diazepam (0.2mg/kg, max 10mg, can do IM), CAN REPEAT IV DOSES
- Fosphenytoin (20mg/kg, max 1500mg) OR levitiracetam (60mg/kg, max 4500mg)
- Phenobarbital (20mg/kg)
- Propofol (1-2mg/kg) to sedate, begin EEG monitoring if possible
8
Q
DKA treatment
A
Fluids- NS 30mL/kg, repeat if necessary
Insulin- 0.1U/kg/hr, halve dose once glucose under 250
Lytes- avoid starting insulin until K lvl known, start once under 5.0, replete others esp Mg as indicated
Treat underlying condition inciting DKA
9
Q
Wells criteria for DVT
A
Presence of the following (+1 each): Active cancer Prior DVT In bed last 3d OR surgery in last 4w Recent immobilization of LE Calf swelling at least 3cm more than opp leg 10cm below tibial tuberosity Collateral (nonvaricose) superficial veins present Entire leg swollen Localized TTP along deep venous system Pitting edema confined to affected leg
Alt dx at least as likely (-2)
10
Q
Flexor tenosynovitis s/sx
A
Kanavel signs
- Fusiform swelling
- Finger held in slight flexion
- Pain with passive extension
- Tenderness along flexor tendon sheath
11
Q
Sgarbossa criteria (modified)
A
Any of these individual criteria may identify MI in LBBB or ventricular-paced rhythms:
- Concordant ST elevation at least 1mm in a lead with +QRS
- Concordant ST depression at least 1mm in V1-V3
- Any lead with at least 1mm ST change which is greater than 25% the height of the preceding discordant S-wave (modified criterion awaiting confirmation for paced rhythms)
Remember NEW LBBB IS ALWAYS PATHOLOGICAL until proven otherwise
12
Q
Wells criteria for DVT interpretation
A
For use in OP or ED settings for patients at risk of DVT, not for IP management
0 - Low risk, can exclude DVT with negative d-dimer
1 - Moderate risk, if HIGH SENSITIVITY d-dimer negative can exclude w/o US
2+ - High risk, US needed. If negative US with positive d-dimer, consider repeating imaging within 1wk
Any positive d-dimer necessitates US
13
Q
CHA2DS2-VASc score
A
Age:
0 - 64y-
1 - 65-74y
2 - 75y+
Female sex +1
Prior CVA/TIA/TE +2
CVA risks (+1 each) Hx HTN Hx PVD Hx CHF Hx DM
14
Q
CHA2DS2-VASc score interpretation
A
CVA risk for patients with AFib
0 - Low risk, may not require AC
1 - Moderate risk, antiplatelet vs AC
2+ - Higher risk, needs AC
Consider balance of starting AC w/ HAS BLED bleeding risk
15
Q
PECARN under 2y
A
- AMS, GCS under 14, or palpable skull fx?
If any, HCT. If none, next questions: - Occipital/parietal/temporal hematoma, LOC over 5s, abnormal behavior, or severe mechanism?
(Severe mech- MVC w/ eject, death, rollover; peds/bike vs auto; fall at least 3ft; high-impact projectile)
If any, Obs vs HCT. If none, may d/c.
16
Q
PECARN over 2y
A
- AMS, GCS under 14, or palpable skull fx?
If any, HCT. If none, next questions: - LOC, vomiting, severe headache, or severe mechanism?
(Severe mech- MVC w/ eject, death, rollover; peds/bike vs auto; fall at least 5ft; high-impact projectile)
If any, Obs vs HCT. If none, may d/c.
17
Q
Sickle cell pain crisis treatment
A
Basic labs- Assess lytes, transfusion needs
CXR- r/o acute chest syndrome
Fluids
Pain control- IV opiates
Oxygen- even if not hypoxic to limit sickling
18
Q
Bradycardia ddx
A
Ischemia Hyperkalemia Arrhythmia Med OD- BBlockers, CCBs, Clonidine, Digoxin Myxedema coma Hypothermia Cushing's reflex from ICH
19
Q
Bradycardia treatment
A
Atropine up to 2mg total
Transcutaneous pacing
Epinephrine/Dopamine
Transvenous pacing
Treat underlying condition: Call cards for ischemia/arrhythmia Treat hyperkalemia- insulin, Ca, glucose TSH, consider giving T4 HCT in trauma
20
Q
Tachycardia MDM
A
ABCs, IV, O2, monitor, crash cart with airways Unstable? CARDIOVERT Sinus? Treat underlying condition Regular vs irregular? Wide vs narrow?
21
Q
Tachycardia- narrow regular ddx and rx
A
PSVT, AFlutter w/ consistent block (usually HR 120 +/- 20), orthodromic WPW
Block AV node- Adenosine, maybe diltiazem/verapamil
Cardioversion 100J
22
Q
Tachycardia- narrow and irregular ddx and rx
A
AFib, AFlutter w/ variable block, multifocal ATach
Block AV node- Diltiazem or shock, NOT adenosine
Treat underlying hypoxia/COPD in MAT
Cardioversion 200J
23
Q
Tachycardia- wide and regular ddx and rx
A
VT UNTIL PROVEN OTHERWISE- CARDIOVERT 100J+
Rarely SVT w/ BBB- adenosine
Antidromic WPW- adenosine
24
Q
Tachycardia- wide and irregular ddx and rx
A
AFib/AFlutter w/BBB- Block AV node w/ adenosine, rate/rhythm control
WPW w/AFib (prior hx, bizarre EKG w/ varying QRS widths)- cardiovert, AVOID AV BLOCKERS
TdP- cardiovert, Mg
DEFIBRILLATE
25
ACLS cardiac arrest algorithm
Start CPR, give NC/NRB O2, attach monitor/pads, IV/IO access, advanced airway w/ ETCO2 capnography
VT/VF? CPR x2 minutes, defibrillate biphasic 200J q2mins, epi q3-5mins, amio x2, treat reversible causes
PEA/asystole? CPR x2 minutes, no shocks, epi q3-5mins, treat reversible causes
26
ACLS cardiac arrest epinephrine dosing
1mg
1: 10,000 IV concentration
1: 1,000 IM concentration
27
ACLS cardiac arrest amiodarone dosing
300mg first dose
| 150mg second dose
28
Reversible causes of cardiac arrest, most common in peds?
H's and T's
Hypoxia, hypovolemia, hypothermia, hypo-/hyperkalemia, hydrogen (acidosis)
Tension PTX, tamponade, thrombosis pulmonary/cardiac, toxins
Hypoxia most common for peds
29
ETT size, laryngoscope blade by age
ETT = Age/4 + 4
4 blade, 8 tube - Large adult
1 blade, 3 tube - Full-term neonate
30
PALS cardiac arrest algorithm
Start CPR, give NC/NRB O2, attach monitor/pads, IV/IO access, advanced airway w/ ETCO2 capnography
VT/VF? CPR x2 minutes, defibrillate biphasic 200J q2mins, epi q3-5mins, amio/lidocaine x2, treat reversible causes
PEA/asystole? CPR x2 minutes, no shocks, epi q3-5mins, treat reversible causes
31
PALS epinephrine dosing
0.01 mg/kg IO/IV q3-5mins
| If no access, may give 0.1 mg/kg via ETT
32
PALS shock dosing
2 J/kg, then 4 J/kg, then up to 10 J/kg (max adult dose 200 J)
33
PALS amiodarone dosing
5 mg/kg, may give twice
34
PALS lidocaine dosing
1 mg/kg loading dose
| Maintenance 20-50 mcg/kg/min
35
PALS bradycardia algorithm
ABCs, IV access, O2, monitor, crash cart with airways
If demonstrating shock after appropriate ventilation, epi q3-5mins
If not improved, give atropine
If not improved, consider external pacing
36
PALS atropine dosing
0.02 mg/kg, may repeat once
| Dose range 0.1 - 0.5 mg total
37
PALS tachycardia algorithm
ABCs, IV access, O2, monitor, crash cart with airways
Unstable? CARDIOVERT
Sinus? Treat underlying condition
Wide? ASSUME VT, CARDIOVERT
Narrow? Likely SVT, vagal maneuvers if stable, then adenosine
38
PALS SVT adenosine dosing
0.1 mg/kg push, then 0.2 mg/kg push
| Max is adult doses of 6 mg, 12 mg
39
GCS calculation
```
Eyes:
1 - No response
2 - Opens to pain
3 - Opens to voice
4 - Opens spontaneously
```
```
Verbal:
1 - No response
2 - Incomprehensible sounds
3 - Incoherent words
4 - Confusion
5 - Appropriately conversational
```
```
Motor:
1 - No response
2 - Abnormal extension (decerebrate)
3 - Abnormal flexion (decorticate)
4 - Withdraws from pain
5 - Localizes pain
6 - Follows commands
```
40
NRP algorithm
If baby is not full-term, crying, or does not have good tone: Warm, dry, stimulate, clear airway
If at 30s HR under 100, resp gasping/apneic: Apply PPV, SpO2 monitoring
If at 60s HR under 100, take ventilatory corrective steps
If HR drops under 60, start chest compressions, coordinate PPV with compressions, consider intubation
If HR still under 60, IV epi; consider hypovolemia/PTX
41
NRP ventilatory corrective steps
MR SOPA
```
MASK- Adjust PPV
REPOSITION head to open airway
SUCTION airway
OPEN mouth, jaw lift
PRESSURE- Increase on PPV to visualize chest rise
AIRWAY- ETT/LMA
```
42
NRP PTX diagnosis
Positive transillumination of thorax
43
NRP goal SpO2 by time
```
1min - 60-65%
2min - 65-70%
3min - 70-75%
4min - 75-80%
5min - 80-85%
```
10min - 85-95%
44
CVC placement prep
```
US site to assess
Cleanse skin
Open kit, open gloves
Add 3 caps, add US cover, ready saline for flushing, ready lidocaine prn
Mask, cap
Get sterile, gown, glove
Drape
Flush line, (clamp short ends)
(Prep lidocaine)
Prep US probe
Place needed items in field- lidocaine, cannulation needle, guidewire, scalpel, dilator, gauze, line, flush, biogel, plastic guard, suture+drivers
```
45
CVC placement steps
Identify site
Numb local skin for insertion and later sutures, deep tissue of tract
Cannulate vein with US guidance maintaining negative pressure
Once flash is noted, steady needle and remove syringe
Place guidewire, should advance easily
Remove needle
Curl wire into hand for enhanced control, always have 1 hand on wire
Assess wire placement with US
Nick skin with scalpel directed away from wireTr
Dilate, remove, hold pressure with gauze
Place line, advance to appropriate depth
Remove wire
Loosen clamps, draw then flush all lines, then cap
Place biogel
Attach plastic guards
Sew to secure
Place dressing
46
Class I STEMI equivalents
Ischemic sx concerning for ACS AND:
STE in contiguous leads
Posterior STEMI -- check posterior leads for septal ischemia vs posterior STEMI
Post-arrest STEMI
Non-STE-ACS who develops HD/electric instability (e.g. VT/VF), intractable ischemia, or acute decompensated HF
47
Peds chest tube sizing
ETT size x4
48
Class IIA STEMI equivalents
Ischemic sx concerning for ACS AND:
LBBB + Sgarbossa criteria
STE in aVR and diffuse ST depression
49
STE in aVR DDx
ACS:
Left main coronary occlusion
Triple vessel disease
Proximal LAD occlusion
```
Non-ACS:
Severe anemia, e.g. GIB
Type A dissection
Massive PE
Hyper-/hypokalemia
Na-channel blocker toxicity
```
50
Class IIB STEMI equivalents
Ischemic sx concerning for ACS AND:
Ventricular pacemaker + Sgarbossa criteria
de Winter T waves -- ST depression in mid-precordial leads (~V2-V4) with associated peaked T-waves (indicate unstable proximal LAD lesion, likely to evolve into STEMI within hours)
51
Wellen's syndrome EKG, significance
Recent ischemic sx history PLUS:
Deeply inverted (75%)/biphasic pos-to-neg (25%) T-waves in V2-V3
Associated isoelectric ST/minimal STE
No precordial Q waves, good R progression
These EKG findings persist even once pain free
May have normal or mildly elevated troponin
Highly specific for critical proximal LAD lesion -- these patients need cath lab, do poorly medically
52
Stroke cortical localizing signs
Aphasia
Hemineglect
Gaze deviation/preference
Hemianopsia
53
Chest tube placement & depth
Incision in anterior axillary line at nipple level to avoid pectoralis, rotate tube laterally while inserting to maintain on posterior wall and drive towards apex
Depth should be about 1/2 size
54
How to differentiate types of regular wide-complex tachycardia
```
Considering VT (presume) vs SVT w/ aberrant conduction or AFlutter w/ aberrant conduction and consistent block
Look for atrial activity- VT IF AV-DISSOCIATION
```
Consider obtaining Lewis Lead EKG when uncertain atrial activity for increased sensitivity:
Place RA lead at manubrium -- highest yield
Place LA lead at R lower sternal border
Place LL lead at R lower costal margin
55
Checkmark sign
ST segment is straight line from J up to peak of T
| Concerning for ACS if symptomatic
56
S1Q3T3 significance
Classically taught sign of PE, but unreliable w/ low sensitivity & specificity
57
aVR ST elevation significance in rapid atrial tachycardias
Not indicative of CAD
| If resolves once in sinus rhythm, do not work up
58
Anaphylaxis dx
1. Sudden onset history of illness involving respiratory compromise and/or hypotension/end-organ dysfxn
2. At least 2 of: skin/mucosal sx, resp compromise, hypotension/end-organ dysfxn, and/or GI sx
3. Hypotension (in general at least 30% decline from baseline or less than 90 SBP) after exposure to known allergen
59
Adult anaphylaxis treatment, dosing
1st line is epinephrine:
0.3-0.5mg IM (1:1000) q5-10mins prn anterolateral thigh
```
2nd lines -- shouldn't precede epi:
Diphenhydramine 50mg po/IV
Ranitidine 50mg IV / 150mg po
Duoneb
Methylpred 125-250mg IV OR Prednisone 40-60mg po
```
Refractory hypotension:
IV epi gtt: 1-10mcg/min IV
Can make "dirty drip" w/ 1mg (1mL 1:1000) in 1L --> 1mcg/mL --> give at desired mL/min rate
Pts w/ beta-block: Glucagon 1-5mg IV over 5mins, then 5-15mcg/min continuous
60
Peds anaphylaxis treatment, dosing
1st line is epinephrine:
0.01mg/kg IM (1:1000) q5-10mins prn anterolateral thigh
```
2nd lines -- shouldn't precede epi:
Diphenhydramine 1mg/kg po/IV
Ranitidine 1mg/kg po/IV
Duoneb
Methylpred 1-2mg/kg IV OR Prednisone 1-2mg/kg po
```
Refractory hypotension:
IV epi gtt: 0.1-1.5mcg/kg/min IV
Can make "dirty drip" w/ 1mg (1mL 1:1000) in 1L --> 1mcg/mL --> give at desired mL/min rate
61
Sick infant ddx (mnemonic)
THE MISFITS
Trauma - consider birth and non-accidental
Heart disease/Hypovolemia
Endocrine - congenital adrenal hyperplasia, congenital hypo-/hyperthyroidism
Metabolic - consider DiGeorge syndrome w/ hypocalcemia, SZ
Inborn errors of metabolism - most commonly A UFO (amino acids, uric acids, fatty acid, organic acid)
Seizures - look for "boxing" or "bicycling"
Formula problems - consider hyponatremia from dilution or hypovolemia from concentration
Intestinal disasters - consider necrotizing enterocolitis w/ pneumatosis intestinalis, aganglionic colon/Hirschprung's, volvulus
Toxins - check glucose, UDS
Sepsis - most common, but make sure to consider other etiologies
62
Suspected congenital heart disease testing, concerns
In neonates (less than 1m), most important test is HYPEROXIA TEST:
Place on NRB O2, draw ABG in 5-10mins, IF PO2 LESS THAN 100 THIS IS HEMODYNAMICALLY SIGNIFICANT CONGENITAL HEART DISEASE UNTIL PROVEN OTHERWISE!
pO2 100-250 is less conclusive, err on side of caution
Be careful with O2 (increases pulmonary vasodilation) and fluids (start 10mL/kg) as they may worsen pulmonary edema
63
Congenital heart disease treatment, SE
PGE IV 0.05mcg/kg/min to maintain patent ductus arteriosus in ductal-dependent lesions
Side-effects include apnea, hypotension -- give fluids, be ready to intubate
CONSULT PEDS CARDS
64
Pediatric assessment triangle
Appearance + Breathing work + Circulation to skin
Combo of abnormalities in each determines presence of clinical Stability, Shock, Respiratory distress/failure, CNS/metabolic issue, Cardio-pulmonary failure
65
Capacity vs competence
Capacity - determined by care providers, may vary with time
| Competence - determined by courts
66
How to determine capacity
Can pt understand risks and benefits of treatment options, including refusing treatment?
67
Brugada syndrome etiology and associations, meds to avoid
Due to cardiac sodium channelopathy, ergo may worsen w/ sodium channel blockers (lidocaine, procainamide)
VF/VT may be induced in setting of fever, hyperkalemia
68
Brugada syndrome diagnostic criteria
Consider in any patient presenting with syncope
Requires typical EKG abnormality (coved- or saddle-type) AND any of the following:
```
Hx VT/VF
FHx SCD
FHx coved-type EKG
VT/VF inducible during EP study
(Agonal respirations during sleep)
```
69
Brugada syndrome EKG findings
RBBB/IRBBB AND:
STE in V1-V2 with COVED appearance (STE followed by inverted T) OR SADDLE appearance (STE w/ positive T, ST segment still positive but forms saddle shape)
May be more obvious if leads moved up 1 interspace
70
NSVT treatment
Find and treat underlying cause
71
Hypokalemia EKG findings
```
U-waves ("Camel hump" T-waves)
Prolonged QT (due to T-U fusion)
Pseudo-ischemic patterns -- ST depression, inverted Ts, aVR STE
Inverted Wellen's waves in precordium
PVCs, ventricular dysrhythmias
```
72
Suture needle type to avoid further tissue damage
Taper
| Good for bleeding AV fistulas
73
Pericardial effusion EKG findings, immediate management
Tachycardia
Low voltage QRS, ESP IF NEW FINDING
Electrical alternans -- classic, but only <30% of cases
Avoid antiplatelets/anticoagulants/thrombolytics until ruling out effusion w/ bedside US
74
EKG low voltage definitions
Sensitive:
QRS of I + II + III < 15
OR
QRS of V1 + V2 + V3 < 30
Specific:
All limb lead QRS < 5mm
OR
All chest lead QRS < 10mm
75
Hypothermia EKG findings
J-waves (Osborn waves) after QRS
Prolonged intervals
Bradycardia
Slow AFib
76
Normal PR interval
120-200ms
77
DDx short PR interval
Junctional rhythm
OR
Pre-excitation -- i.e. WPW, check for delta-waves
78
T-wave larger than QRS -- dx?
ACS
79
Massive PE EKG findings
R-axis deviation AND tachycardia
| Concerning history
80
Syncope EKG ddx
```
ACS
Dysrhythmia
Long QT
WPW
HOCM
Brugada
ARVD
ASD
```
81
Arrhythmogenic RV dysplasia findings
```
Findings esp in V1-V3
T-wave inversions
Prolonged S-wave upstroke at end of QRS
Epsilon wave at end of QRS
VT paroxysms w/ LBBB morphology
```
82
V1 tall R-wave ddx
HOCM, RVH, R-heart strain
WPW, Brugada
Hyperkalemia, Na channel blocker toxicity
Dextrocardia, misplaced leads
83
LAFB EKG findings
```
L-axis deviation
Lat leads (I, aVL): small Q, large R (qR)
Inf leads (II, III, aVF): small R, large S (rS)
```
84
Polymorphic VT ddx, etiologies
RULE OUT ARTIFACT (pseudo-PVT) -- Make sure there are no regular narrow, regular QRS complexes overlying tracing
PVT -- often related to myocardial ischemia or drug (esp digoxin) toxicity, normal QT
TdP -- PVT in the setting of long-QT
85
Normal EKG precordial progressions of QRS, T-waves
R-wave progression -- QRS complexes should become more positive in amplitude from anterior to lateral
T-waves in V6 should be larger than V1 if both are upright. Loss of precordial T-wave balance (i.e. To-tall-T-wave in V1) in setting of CP is concerning for early ischemia -- exceptions for LBBB or LVH
86
VT types, Rx
Monomorphic VT - shock, procainamide > amiodarone, BBs
Polymorphic VT (generic) - shock, amiodarone, BBs
TdP - shock, Mg, treat underlying condition
87
Hyperacute T-waves definitions, concern, management
(Usually in precordial leads)
1- T-waves larger than entire QRS complex
2- Straight ST segment into T-wave ("checkmark")
Concerning for ischemia until proven otherwise, regardless of patient demographics. Get repeat ECGs, esp w/ sx changes
88
Vision loss ddx
Painful:
Giant cell arteritis
Optic neuritis
Acute angle closure glaucoma
```
Painless:
Retinal detachment
Vitreous detachment/hemorrhage
CRAO
CRVO
CVA syndromes
```
89
Pneumonia ddx
COPD, asthma
Bronchiectasis, lung CA - esp in recurrent cases
PE
CHF, MI
90
Pneumonia Rx
OP w/o complications- Macrolide (AZITHRO/clarithro/erythro) OR doxycycline
OP w/ IC/comorbidities- Macrolide/doxy AND beta-lactam/3rd gen cephalosporin OR fluoroquinolone monotherapy
IP- Macrolide AND 3rd gen ceph
Consider adding vancomycin and using zosyn to cover Pseudomonas in place of ceftriaxone for severe cases/HAP
91
Pneumonia dispo
Hypoxic patients must be admitted. Consider admission for pts w/ poor follow-up/low reliability.
Consider CURB-65 for dispo in non-hypoxic patients (predicts 30d mortality):
Confusion
Uremia (BUN > 19)
RR > 30
BP low (SBP < 90, DBP < 60)
Age >= 65
1 pt per category, consider OP mgmt for 0-1.
92
HOCM ECG findings
Lateral Q waves (I, aVL, V5-6) -- most specific
LVH
Precordial ST and T changes
May have large R in V1-2 and inferior Q waves
93
Ovarian torsion diagnosis, pearls
Ultrasound is best test, but not very sensitive--ovary may demonstrate doppler flow during period of detorsion
Suspect when symptomatic with ovary larger than 5cm, has mass, or is midline
94
Hyperkalemia ECG findings
```
BIZARRE wide (usually) complex QRS
Severe bradycardia
Does not improve with atropine (not vagally induced HR)
Pacing does not capture mechanically
Abrupt rate and rhythm changes
```
95
Hyperkalemia Rx
ACLS (atropine, pacing, pressors) usually doesn't work
Bicarb, calcium -- consider giving empirically to aid in diagnosis, rarely contraindicated
Glucose, insulin
Eventual HD
96
Local anesthetics causing allergy, alternative
CAN'T TREAT PAIN with ESTERS
Cocaine
Tetracaine
Procaine/chloroProcaine
Use amides, esp BUPIVACAINE instead
97
Flank pain ddx
```
Consider retroperitoneal etiology:
AAA -- ALWAYS CONSIDER, esp if older w/o prior stone hx
Renal colic
Pyelonephritis
?pancreatitis
```
98
Epistaxis management
Apply pressure for 30 minutes
--If active bleeding during this interval, skip straight to nasal tampon, then posterior pack and admit
Expel clot with forceful noseblow
Visualize septum, cautery with AgNO3 if possible
Otherwise place cotton w/ viscous lidocaine and afrin for 5 mins, then cotton w/ TXA 500mg for 20 mins
If still bleeding, place anterior nasal tampon soaked in sterile water, observe at least 15 mins for cessation, then d/c w/ Keflex and ENT f/u in 3 days
99
Thyroid storm s/sx/dx
```
Tachycardia
Fever
AMS
N/V/abd pain
Moist skin
Hyperthyroid on testing--Undetectable TSH, high T4 and T3
```
100
Thyroid storm treatment, mechs
B-blocker -- propranolol preferred (60-80mg q6)
Thionamide -- blocks T4 synthesis, PTU preferred initially over methimazole, esp in pregnancy
Iodine -- START 1H AFTER THIONAMIDE, blocks release of T4, use Lugol's or SSKI
Glucocorticoids -- reduce conversion of T4 to T3, dampen autoimmunity, stabilize vessel tone, hydrocortisone 100mg q8
101
Stridor ddx
Croup
Epiglottitis--esp in adults or unimmunized
Bacterial tracheitis--usually more toxic than croup with recent URI suggesting secondary infxn
102
Salter-Harris fracture classification
```
I - Straight across
II - Above
III - Lower
IV - Through Everything
V - cRush
```
103
Air gas embolism dx, Rx
Suspect in those surfacing with AMS, hard neuro abnormalities, and unstable vitals within 10 minutes
Place supine, 100% O2, hyperbaric treatment
104
Vertigo ddx, testing
Posterior CVA
Labyrinthitis
BPPV
HINTS test - FOR PATIENTS WITH ACTIVE/CONSTANT VERTIGO as good or better than MRI
Head Impulse -- Is VOR intact? If NEGATIVE--concerning for CVA
Nystagmus -- Unidirectional? If not, i.e. vertical/multidirectional--concerning for CVA
Test of Skew -- No diplopia w/ rapid alt eye covering? If present--concerning for CVA
105
Respiratory decompensation on vent causes
```
DOPES
Dislodgement of tube
Obstruction, e.g. mucus plugging
PTX
Equipment failure
Stacking of breaths, esp for asthmatics
```
106
Regular really wide complex tachycardia ddx, rx
If QRS width greater than 200ms and regular, etiology is tox/metabolic UPO, e.g. hyperkalemia
```
Give Ca, BICARB -- QRS should narrow with meds
ACLS antiarrhythmics (Na-channel blockers) may worsen d/t Na-channel toxicity
```
107
Neck zones
I - sternal notch to cricoid cartilage
II - cricoid cartilage to angle of mandible
III - angle of mandible to inferior auricle
108
Neck zone trauma management
Surgery warranted for:
Airway compromise - Expanding hematoma, airway obstruction
Hemorrhagic shock - Severe active bleeding, Refractory shock, Diminished peripheral pulses, Bruit/thrill, Cerebral ischemia
Consider early intubation if concerned for deterioration, airway compromise
Consider CTA neck, observation if stable vs surgery consult for exploration
109
TCA OD pathophys, ECG
TCA OD causes Na-channelopathy in cardiac tissue
```
ECG shows:
Tachycardia, often wide
R-axis
Tall R in V1 w/ pseudo-Brugada pattern
Tall R in aVR w/ STE
Large S in lateral leads
Possible long QT when normal rate
```
110
TCA OD Rx
ABCs, Monitor
Give fluids for hypotension
Bicarb for VT/VF or QRS over 100ms -- dose until improvement/QRS narrows
DO NOT GIVE ACLS ANTIARRHYTHMICS (amiodarone, lidocaine, procainamide) -- worsen Na-channelopathy
111
Ulnar/radial fracture/dislocations, Rx
Monteggia - proximal Ulna fracture and radial head dislocation
Galeazzi - distal Radius fracture and ulnocarpal dislocation
Both require emergent ortho for ORIF
Can remember which bone is fractured by MUGR mnemonic
112
AOM candidates for delayed antibiotics
```
Previously healthy
At least 2yo
Symptoms less than 48h
Unilateral AOM
Temp under 39C
```
--Start abx in 2-3 days if not better
113
Digoxin toxicity, Rx
May cause any non-atrial arrhythmia
Bidirectional VT is specific
May give empiric DigiFab if any arrhythmia present
114
Estimation of appropriate respiratory compensation for metabolic acidosis
Decimal value of ABG pH should be approximately serum CO2
| I.e. pH 7.23, CO2 23 is appropriately compensated
115
Full acid base evaluation process
1. Labs - A/VBG, lactate, albumin, chemistry, acetone
2. pH - Above 7.45 = primary alkalosis; Below 7.35 = primary acidosis
3. BG CO2 - If over 45 = resp acidosis; If under 35 = resp alkalosis
4. Strong Ion Difference (SID) = Na - Cl; If Low (under 38) = met acidosis; If High (over 38) = met alkalosis
5. Lactate - Elevated if over 2 = Consider infection, shock, SZ, hepatic failure, malignancy, dead gut, tox
6. Strong Ion Gap (SIG) = Base deficit + (SID - 38) + 2.5 (4.2 - Alb) - Lactate;
This is corrected base deficit. If over 2, there is an unmeasured anion causing acidosis -- GET OSMs FOR THESE
7. Consider compensations
116
Osmolar gap calculation
Osm Gap = Measured Osm - (2*Na + Gluc/18 + BUN/2.8 + EtOH/3.7)
If Osm Gap over 10, consider toxic alcohols, Li
Toxic alcohols highly suspected if over 50
117
When to avoid activated charcoal as treatment for ingestions?
Avoid for ingestions of metals, alcohols, or corrosives
118
Fluid resuscitation for burn victims
Parkland formula:
Total LR = 4mL/kg * %SA burned
Give first half in first 8h, second half in following 16h
119
Pediatric maintenance fluids
4-2-1 rule:
4 mL/kg/hr for first 10kg
2 mL/kg/hr for 10-20kg
1 mL/kg/hr for 20+kg
E.g. 30kg kid needs 70mL/hr maintenance
120
Differentiating long QT
```
Wide T waves:
HypoMg
HypoK
Na channel blocking drugs
Increased ICP
Congenital
```
Wide ST segment:
HypoCa
Hypothermia
121
Spectrum of sepsis
SIRS, sepsis, severe sepsis, septic shock
122
SIRS definition
```
At least 2 of:
Hyper-/hypothermia (outside 36-38C)
HR over 90
RR over 20 or PaCO2 under 32
WBC over 12k, under 4k, or over 10% bands
```
--Note BP is not in these criteria
123
Sepsis definition
SIRS and suspected/confirmed infection source
124
Severe sepsis definition
Sepsis and any of these:
Lactic acidosis (over 2)
SBP under 90
SBP drop at least 40 from normal
125
Septic shock definition
Severe sepsis with persistent hypotension despite adequate fluid resuscitation--require pressors
126
ECG signs of RV infarction
1/3 of inferior STEMIs
Esp if there are reciprocal changes in V2 with isoelectric/elevated V1
ALWAYS GET R-SIDED LEADS
127
RV STEMI treatment
Patients are very preload dependent:
As long as lungs are clear, give ASA + massive amounts of fluids, activate cath
AVOID NITRATES AND PRESSORS
128
Causes of intractable seizures, Rx
```
If status epilepticus isn't responding to standard Rx, consider:
Hypoglycemia- glucose
Hyponatremia- 3%NS
INH toxicity- pyridoxine
Cyanide toxicity- hydroxocobalamin
```
129
Short QT ddx
Hypercalcemia (No ST segment)
Digoxin toxicity (2/2 intracellular hyperCa)
Short QT syndrome (peds, very rare)
130
STE ddx
```
Myocardial injury- trauma, ACS
Global ischemia- dissection, massive GI bleed, PE
Early repolarization
Myo-/pericarditis
Vasospasm
Ventricular aneurysm
LBBB/PPM
High voltage (LVH, WPW, athlete)
Na+ channelopathy- TCA, hyperK+, Brugada
Hypothermia
Takotsubo
Intracranial abnormalities
HyperCa++
```
131
What's confused for Mobitz?
PACs-- P-P interval must be constant prior to diagnosing Mobitz
132
RBBB typical appearance
No STE allowed, V1-V2 may have mild STD or be isoelectric. Often missed by computer.
Any STE is concerning for MI
133
Differentiating benign early repolarization from STEMI
BER-- Diffuse J point elevation without reciprocal STD, concave up ST segments from J point, STE in II greater than III, no ST changes with repeat EKGs or compared to priors.
Also MUST HAVE J-WAVE (positive deflection) or S-WAVE (deflection below PR baseline) IN V2 AND V3.
Note STEMI may have any/all of above findings, but is more likely to show changes compared to prior or acutely
134
Bradycardias unresponsive to ACLS
Massive MI
Tox--BB or CCB OD
Hyperkalemia
Hypothermia
135
Meningitis treatment
Steroids before antimicrobials
Ceftriaxone 2g (covers Neisseria, Strep, H flu)
Vancomycin (covers resistant strains)
+/- Ampicillin (Listeria)
Acyclovir
LP should not delay empiric treatment if suspected
136
Intra-abdominal infection treatment
```
Zosyn (GNR + anaerobic coverage)
OR
Levo-/Ciprofloxacin AND metronidazole
OR
Augmentin AND metronidazole
```
137
Cystitis treatment
Bactrim
Nitrofurantoin
Cephalexin
Augmentin
138
Undifferentiated sepsis treatment
Vancomycin (MRSA) AND Zosyn (GNR, Pseudomonas, anaerobes)
OR
Meropenem +/- vancomycin
139
ESBL treatment
Carbapenems
| Fosfomycin
140
VRE treatment
Nitrofurantoin (if isolated cystitis)
Daptomycin
Linezolid
141
Ears/sinus/pharynx infection treatment
AOM--Amoxicillin
```
Other infections--
Augmentin
Cefdinir
Bactrim
Doxycycline
Azithromycin
*Steroids for symptom relief*
```
142
Mouth infection treatment
```
Augmentin
Pen VK
Clindamycin
Cefdinir
*Control source if abscess formed*
```
143
Poor R-wave progression criteria
R-wave less than 3mm in V3
144
Poor R-wave progression ddx
```
8 L's
LBBB
LAFB
LVH
LV dysfxn
LAD (prior AS MI)
Long life (elderly)
Lungs (COPD)
Lead misplacement
```
145
Hemodialyzable toxins
```
MELS
Methanol
Ethylene glycol
Lithium
Salicylates
```
146
ECMO tox indications
Reversible conditions refractory to antidotes, classically:
bBlockers
CCBs
Digoxin
147
Diffuse STE ddx
```
Large STEMI +/- reciprocal STD
Pericarditis
Vasospasm +evolving changes with treatment
Ventricular aneurysm +Q waves
BER
```
148
POCUS for aortic dissection echo findings
```
5 E's
Ejection fraction
Equality between left and right
Effusion
Entrance
Exit--greater than 4cm is bad, also consider with AR
```
149
Pediatric laryngoscope blade by age
Size 00 premature
Size 0 neonate
Size 2 at age 2
Size 3 at 3rd grade (age 8)
150
How to setup needle cric
Large angiocath--CVC kit, 14G, or 16G
Attach plungerless 3mL syringe
Attach ADAPTER from size 7.5ETT to allow bagging
151
Refractory VF treatment
Double sequential defibrillation, i.e. 200J x2 simultaneously
152
ECMO types and uses
In general for insults causing cardiac/pulmonary failure refractory to maximal medical therapy which are reversible
VA ECMO- for any cause which includes cardiac failure as a component
VV ECMO- for purely pulmonary etiologies
153
ECMO indication examples
```
ACS
Arrhythmias
Drug toxicity
Cardiomyopathy
PE, sepsis with cardiac depression
ARDS
Status asthmaticus
Congenital diaphragmatic hernia
Meconium aspiration
Massive hemoptysis
```
154
Digoxin toxicity ECG
Slow regularized AFib - not necessarily toxic
Slow atrial flutter w/ variable conduction
Dali mustache T-waves
155
Oral boards diagnostics not to forget
Accuchek
UPreg
EKG
CXR
156
Oral boards history
SAMPLE
```
Signs/Symptoms
Allergies
Meds
Pertinent PMH
Last PO intake
Events preceding
```
157
STEMI with R axis DDX
Massive PE
Hyperkalemia
TCA overdose
Septal STEMI - less likely
