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AA-EM MDM > General stuff > Flashcards

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

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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)

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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

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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

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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.

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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

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7
Q

Status epilepticus treatment algorithm

A

DEFG- Don’t ever forget GLUCOSE

  1. Lorazepam (0.1mg/kg, max 4mg) OR diazepam (0.2mg/kg, max 10mg, can do IM), CAN REPEAT IV DOSES
  2. Fosphenytoin (20mg/kg, max 1500mg) OR levitiracetam (60mg/kg, max 4500mg)
  3. Phenobarbital (20mg/kg)
  4. Propofol (1-2mg/kg) to sedate, begin EEG monitoring if possible
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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

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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)

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10
Q

Flexor tenosynovitis s/sx

A

Kanavel signs

  1. Fusiform swelling
  2. Finger held in slight flexion
  3. Pain with passive extension
  4. Tenderness along flexor tendon sheath
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11
Q

Sgarbossa criteria (modified)

A

Any of these individual criteria may identify MI in LBBB or ventricular-paced rhythms:

  1. Concordant ST elevation at least 1mm in a lead with +QRS
  2. Concordant ST depression at least 1mm in V1-V3
  3. 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

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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

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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
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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

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15
Q

PECARN under 2y

A
  1. AMS, GCS under 14, or palpable skull fx?
    If any, HCT. If none, next questions:
  2. 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.
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16
Q

PECARN over 2y

A
  1. AMS, GCS under 14, or palpable skull fx?
    If any, HCT. If none, next questions:
  2. 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.
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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

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18
Q

Bradycardia ddx

A 
Ischemia
Hyperkalemia
Arrhythmia
Med OD- BBlockers, CCBs, Clonidine, Digoxin
Myxedema coma
Hypothermia
Cushing's reflex from ICH
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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
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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?
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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

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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

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23
Q

Tachycardia- wide and regular ddx and rx

A

VT UNTIL PROVEN OTHERWISE- CARDIOVERT 100J+
Rarely SVT w/ BBB- adenosine
Antidromic WPW- adenosine

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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

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25
Q

ACLS cardiac arrest algorithm

A

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

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26
Q

ACLS cardiac arrest epinephrine dosing

A

1mg

1: 10,000 IV concentration
1: 1,000 IM concentration

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27
Q

ACLS cardiac arrest amiodarone dosing

A

300mg first dose

150mg second dose

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28
Q

Reversible causes of cardiac arrest, most common in peds?

A

H’s and T’s
Hypoxia, hypovolemia, hypothermia, hypo-/hyperkalemia, hydrogen (acidosis)
Tension PTX, tamponade, thrombosis pulmonary/cardiac, toxins

Hypoxia most common for peds

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29
Q

ETT size, laryngoscope blade by age

A

ETT = Age/4 + 4
4 blade, 8 tube - Large adult
1 blade, 3 tube - Full-term neonate

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30
Q

PALS cardiac arrest algorithm

A

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

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31
Q

PALS epinephrine dosing

A

0.01 mg/kg IO/IV q3-5mins

If no access, may give 0.1 mg/kg via ETT

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32
Q

PALS shock dosing

A

2 J/kg, then 4 J/kg, then up to 10 J/kg (max adult dose 200 J)

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33
Q

PALS amiodarone dosing

A

5 mg/kg, may give twice

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34
Q

PALS lidocaine dosing

A

1 mg/kg loading dose

Maintenance 20-50 mcg/kg/min

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35
Q

PALS bradycardia algorithm

A

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

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36
Q

PALS atropine dosing

A

0.02 mg/kg, may repeat once

Dose range 0.1 - 0.5 mg total

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37
Q

PALS tachycardia algorithm

A

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

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38
Q

PALS SVT adenosine dosing

A

0.1 mg/kg push, then 0.2 mg/kg push

Max is adult doses of 6 mg, 12 mg

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39
Q

GCS calculation

A 
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
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40
Q

NRP algorithm

A

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

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41
Q

NRP ventilatory corrective steps

A

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
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42
Q

NRP PTX diagnosis

A

Positive transillumination of thorax

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43
Q

NRP goal SpO2 by time

A 
1min - 60-65%
2min - 65-70%
3min - 70-75%
4min - 75-80%
5min - 80-85%

10min - 85-95%

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44
Q

CVC placement prep

A 
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
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45
Q

CVC placement steps

A

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

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46
Q

Class I STEMI equivalents

A

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

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47
Q

Peds chest tube sizing

A

ETT size x4

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48
Q

Class IIA STEMI equivalents

A

Ischemic sx concerning for ACS AND:

LBBB + Sgarbossa criteria
STE in aVR and diffuse ST depression

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49
Q

STE in aVR DDx

A

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
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50
Q

Class IIB STEMI equivalents

A

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)

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51
Q

Wellen’s syndrome EKG, significance

A

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

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52
Q

Stroke cortical localizing signs

A

Aphasia
Hemineglect
Gaze deviation/preference
Hemianopsia

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53
Q

Chest tube placement & depth

A

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

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54
Q

How to differentiate types of regular wide-complex tachycardia

A 
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

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55
Q

Checkmark sign

A

ST segment is straight line from J up to peak of T

Concerning for ACS if symptomatic

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56
Q

S1Q3T3 significance

A

Classically taught sign of PE, but unreliable w/ low sensitivity & specificity

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57
Q

aVR ST elevation significance in rapid atrial tachycardias

A

Not indicative of CAD

If resolves once in sinus rhythm, do not work up

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58
Q

Anaphylaxis dx

A
  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
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59
Q

Adult anaphylaxis treatment, dosing

A

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

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60
Q

Peds anaphylaxis treatment, dosing

A

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

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61
Q

Sick infant ddx (mnemonic)

A

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

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62
Q

Suspected congenital heart disease testing, concerns

A

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

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63
Q

Congenital heart disease treatment, SE

A

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
Q

Pediatric assessment triangle

A

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
Q

Capacity vs competence

A

Capacity - determined by care providers, may vary with time

Competence - determined by courts

66
Q

How to determine capacity

A

Can pt understand risks and benefits of treatment options, including refusing treatment?

67
Q

Brugada syndrome etiology and associations, meds to avoid

A

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
Q

Brugada syndrome diagnostic criteria

A

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
Q

Brugada syndrome EKG findings

A

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
Q

NSVT treatment

A

Find and treat underlying cause

71
Q

Hypokalemia EKG findings

A 
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
Q

Suture needle type to avoid further tissue damage

A

Taper

Good for bleeding AV fistulas

73
Q

Pericardial effusion EKG findings, immediate management

A

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
Q

EKG low voltage definitions

A

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
Q

Hypothermia EKG findings

A

J-waves (Osborn waves) after QRS
Prolonged intervals
Bradycardia
Slow AFib

76
Q

Normal PR interval

A

120-200ms

77
Q

DDx short PR interval

A

Junctional rhythm
OR
Pre-excitation – i.e. WPW, check for delta-waves

78
Q

T-wave larger than QRS – dx?

A

ACS

79
Q

Massive PE EKG findings

A

R-axis deviation AND tachycardia

Concerning history

80
Q

Syncope EKG ddx

A 
ACS
Dysrhythmia
Long QT
WPW
HOCM
Brugada
ARVD
ASD
81
Q

Arrhythmogenic RV dysplasia findings

A 
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
Q

V1 tall R-wave ddx

A

HOCM, RVH, R-heart strain
WPW, Brugada
Hyperkalemia, Na channel blocker toxicity
Dextrocardia, misplaced leads

83
Q

LAFB EKG findings

A 
L-axis deviation
Lat leads (I, aVL): small Q, large R (qR)
Inf leads (II, III, aVF): small R, large S (rS)
84
Q

Polymorphic VT ddx, etiologies

A

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
Q

Normal EKG precordial progressions of QRS, T-waves

A

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
Q

VT types, Rx

A

Monomorphic VT - shock, procainamide > amiodarone, BBs
Polymorphic VT (generic) - shock, amiodarone, BBs
TdP - shock, Mg, treat underlying condition

87
Q

Hyperacute T-waves definitions, concern, management

A

(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
Q

Vision loss ddx

A

Painful:
Giant cell arteritis
Optic neuritis
Acute angle closure glaucoma

Painless:
Retinal detachment
Vitreous detachment/hemorrhage
CRAO
CRVO
CVA syndromes
89
Q

Pneumonia ddx

A

COPD, asthma
Bronchiectasis, lung CA - esp in recurrent cases
PE
CHF, MI

90
Q

Pneumonia Rx

A

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
Q

Pneumonia dispo

A

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
Q

HOCM ECG findings

A

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
Q

Ovarian torsion diagnosis, pearls

A

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
Q

Hyperkalemia ECG findings

A 
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
Q

Hyperkalemia Rx

A

ACLS (atropine, pacing, pressors) usually doesn’t work
Bicarb, calcium – consider giving empirically to aid in diagnosis, rarely contraindicated
Glucose, insulin
Eventual HD

96
Q

Local anesthetics causing allergy, alternative

A

CAN’T TREAT PAIN with ESTERS
Cocaine
Tetracaine
Procaine/chloroProcaine

Use amides, esp BUPIVACAINE instead

97
Q

Flank pain ddx

A 
Consider retroperitoneal etiology:
AAA -- ALWAYS CONSIDER, esp if older w/o prior stone hx
Renal colic
Pyelonephritis
?pancreatitis
98
Q

Epistaxis management

A

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
Q

Thyroid storm s/sx/dx

A 
Tachycardia
Fever
AMS
N/V/abd pain
Moist skin
Hyperthyroid on testing--Undetectable TSH, high T4 and T3
100
Q

Thyroid storm treatment, mechs

A

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
Q

Stridor ddx

A

Croup
Epiglottitis–esp in adults or unimmunized
Bacterial tracheitis–usually more toxic than croup with recent URI suggesting secondary infxn

102
Q

Salter-Harris fracture classification

A 
I - Straight across
II - Above
III - Lower
IV - Through Everything
V - cRush
103
Q

Air gas embolism dx, Rx

A

Suspect in those surfacing with AMS, hard neuro abnormalities, and unstable vitals within 10 minutes
Place supine, 100% O2, hyperbaric treatment

104
Q

Vertigo ddx, testing

A

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
Q

Respiratory decompensation on vent causes

A 
DOPES
Dislodgement of tube
Obstruction, e.g. mucus plugging
PTX
Equipment failure
Stacking of breaths, esp for asthmatics
106
Q

Regular really wide complex tachycardia ddx, rx

A

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
Q

Neck zones

A

I - sternal notch to cricoid cartilage
II - cricoid cartilage to angle of mandible
III - angle of mandible to inferior auricle

108
Q

Neck zone trauma management

A

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
Q

TCA OD pathophys, ECG

A

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
Q

TCA OD Rx

A

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
Q

Ulnar/radial fracture/dislocations, Rx

A

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
Q

AOM candidates for delayed antibiotics

A 
Previously healthy
At least 2yo
Symptoms less than 48h
Unilateral AOM
Temp under 39C

–Start abx in 2-3 days if not better

113
Q

Digoxin toxicity, Rx

A

May cause any non-atrial arrhythmia
Bidirectional VT is specific
May give empiric DigiFab if any arrhythmia present

114
Q

Estimation of appropriate respiratory compensation for metabolic acidosis

A

Decimal value of ABG pH should be approximately serum CO2

I.e. pH 7.23, CO2 23 is appropriately compensated

115
Q

Full acid base evaluation process

A
  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
Q

Osmolar gap calculation

A

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
Q

When to avoid activated charcoal as treatment for ingestions?

A

Avoid for ingestions of metals, alcohols, or corrosives

118
Q

Fluid resuscitation for burn victims

A

Parkland formula:

Total LR = 4mL/kg * %SA burned
Give first half in first 8h, second half in following 16h

119
Q

Pediatric maintenance fluids

A

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
Q

Differentiating long QT

A 
Wide T waves:
HypoMg
HypoK
Na channel blocking drugs
Increased ICP
Congenital

Wide ST segment:
HypoCa
Hypothermia

121
Q

Spectrum of sepsis

A

SIRS, sepsis, severe sepsis, septic shock

122
Q

SIRS definition

A 
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
Q

Sepsis definition

A

SIRS and suspected/confirmed infection source

124
Q

Severe sepsis definition

A

Sepsis and any of these:
Lactic acidosis (over 2)
SBP under 90
SBP drop at least 40 from normal

125
Q

Septic shock definition

A

Severe sepsis with persistent hypotension despite adequate fluid resuscitation–require pressors

126
Q

ECG signs of RV infarction

A

1/3 of inferior STEMIs
Esp if there are reciprocal changes in V2 with isoelectric/elevated V1
ALWAYS GET R-SIDED LEADS

127
Q

RV STEMI treatment

A

Patients are very preload dependent:
As long as lungs are clear, give ASA + massive amounts of fluids, activate cath
AVOID NITRATES AND PRESSORS

128
Q

Causes of intractable seizures, Rx

A 
If status epilepticus isn't responding to standard Rx, consider:
Hypoglycemia- glucose
Hyponatremia- 3%NS
INH toxicity- pyridoxine
Cyanide toxicity- hydroxocobalamin
129
Q

Short QT ddx

A

Hypercalcemia (No ST segment)
Digoxin toxicity (2/2 intracellular hyperCa)
Short QT syndrome (peds, very rare)

130
Q

STE ddx

A 
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
Q

What’s confused for Mobitz?

A

PACs– P-P interval must be constant prior to diagnosing Mobitz

132
Q

RBBB typical appearance

A

No STE allowed, V1-V2 may have mild STD or be isoelectric. Often missed by computer.

Any STE is concerning for MI

133
Q

Differentiating benign early repolarization from STEMI

A

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
Q

Bradycardias unresponsive to ACLS

A

Massive MI
Tox–BB or CCB OD
Hyperkalemia
Hypothermia

135
Q

Meningitis treatment

A

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
Q

Intra-abdominal infection treatment

A 
Zosyn (GNR + anaerobic coverage)
OR
Levo-/Ciprofloxacin AND metronidazole
OR
Augmentin AND metronidazole
137
Q

Cystitis treatment

A

Bactrim
Nitrofurantoin
Cephalexin
Augmentin

138
Q

Undifferentiated sepsis treatment

A

Vancomycin (MRSA) AND Zosyn (GNR, Pseudomonas, anaerobes)
OR
Meropenem +/- vancomycin

139
Q

ESBL treatment

A

Carbapenems

Fosfomycin

140
Q

VRE treatment

A

Nitrofurantoin (if isolated cystitis)
Daptomycin
Linezolid

141
Q

Ears/sinus/pharynx infection treatment

A

AOM–Amoxicillin

Other infections--
Augmentin
Cefdinir
Bactrim
Doxycycline
Azithromycin
*Steroids for symptom relief*
142
Q

Mouth infection treatment

A 
Augmentin
Pen VK
Clindamycin
Cefdinir
*Control source if abscess formed*
143
Q

Poor R-wave progression criteria

A

R-wave less than 3mm in V3

144
Q

Poor R-wave progression ddx

A 
8 L's
LBBB
LAFB
LVH
LV dysfxn
LAD (prior AS MI)
Long life (elderly)
Lungs (COPD)
Lead misplacement
145
Q

Hemodialyzable toxins

A 
MELS
Methanol
Ethylene glycol
Lithium
Salicylates
146
Q

ECMO tox indications

A

Reversible conditions refractory to antidotes, classically:
bBlockers
CCBs
Digoxin

147
Q

Diffuse STE ddx

A 
Large STEMI +/- reciprocal STD
Pericarditis
Vasospasm +evolving changes with treatment
Ventricular aneurysm +Q waves
BER
148
Q

POCUS for aortic dissection echo findings

A 
5 E's
Ejection fraction
Equality between left and right
Effusion
Entrance
Exit--greater than 4cm is bad, also consider with AR
149
Q

Pediatric laryngoscope blade by age

A

Size 00 premature
Size 0 neonate
Size 2 at age 2
Size 3 at 3rd grade (age 8)

150
Q

How to setup needle cric

A

Large angiocath–CVC kit, 14G, or 16G
Attach plungerless 3mL syringe
Attach ADAPTER from size 7.5ETT to allow bagging

151
Q

Refractory VF treatment

A

Double sequential defibrillation, i.e. 200J x2 simultaneously

152
Q

ECMO types and uses

A

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
Q

ECMO indication examples

A 
ACS
Arrhythmias
Drug toxicity
Cardiomyopathy
PE, sepsis with cardiac depression
ARDS
Status asthmaticus
Congenital diaphragmatic hernia
Meconium aspiration
Massive hemoptysis
154
Q

Digoxin toxicity ECG

A

Slow regularized AFib - not necessarily toxic
Slow atrial flutter w/ variable conduction
Dali mustache T-waves

155
Q

Oral boards diagnostics not to forget

A

Accuchek
UPreg
EKG
CXR

156
Q

Oral boards history

A

SAMPLE

Signs/Symptoms
Allergies
Meds
Pertinent PMH
Last PO intake
Events preceding
157
Q

STEMI with R axis DDX

A

Massive PE
Hyperkalemia
TCA overdose
Septal STEMI - less likely

AA-EM MDM (1 decks)

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