HIGHYIELD/REDFLAG Flashcards
DSM 5 criteria
(schizophrenia)
Disturbance of at least 6mos
1mo of active phase symptoms (2 or more, 1 has to be positive) [7]
- positive symptoms (1 of)
* Hallucination OR
* Delusions
- disorganized speech
- disorganized / catatonic behavior
- negative symptoms
* Social withdrawal
* Blunt effect
* Poor rapport w ppl
* Difficulty with abstract thinking
* Loss of spontaneous conversation
- impact on level of function
- not due to substance
- no mood symptoms
DSM5 criteria
(MDD)
> 2WEEKS
5 SYMPTOMS (SIGECAPS)
at least 1: 1) depressed mood OR 2) loss of interest
* Sleep
* Interests - decrease
* Guilt / worthlessness
* Energy - low
* Concentration
* Appetite change (incr / decr) / weight change
* Psychomotor agitation / retardation
* SI / plan / thoughts consumed with death
DSM5 criteria
(BIPOLAR D/O)
BIPOLAR 1
* 1 manic episode
* (MDE not needed)
BIPOLAR 2
* Hypomanic episode
* at least 1 MDE
DSM5
(MANIA)
1-2-3
1 WEEK daily symptoms
2 symptoms of mania: incr energy + mood
at least 3 of DIGFAST
* Disorganized
* Increased pleasure / risk taking
* Grandiose
* Flight of ideas
* Activity incr / goal directed
* Sleep (decreased)
* Talkative (pressured)
decline in function (needs hospitalization)
not due to drugs / organic reason (i.e. trauma)
DSM5
(panic attack)
Acute sense of fear reaches peak within minutes PLUS 4
palpitations
sweating
trembling
SOB / smothered feeling
choking feeling
chest pain / discomfort
nausea / abdominal distress
dizzy / light headed
chills / heat sensation
paresthesias
derealization
fear of losing control / going crazy
fear of dying
DX CRITERIA
(somatic symptom d/o)
more than 1 somatic symptom
- disrupting daily life
<6mos
more than 1 of:
1. disproportionate +persistent thoughts about seriousness of symptoms
2. high level of anxiety about health /symptoms
3. excessive time + energy devoted to theses symptoms / health concerns
DX CRITERIA
(functional d/o)
Factitious d/o - Primary gain
* Falsify psychological / physical signs
* present themselves (a child) as ill
* deceptive behavior apparent
* not explained by another psych dx
Malingering d/o - Secondary gain
* Medicolegal context of presentation
* discrepancy btwn person’s stress+ objective sx
* poor cooperation to evaluation
* hx of antisocial evaluation
List risk factors for suicide
SADPERSONS
Sex
Age (<19 / >45)
Depression / hopelessness
Previous attempts / psychiatric care
Excessive ETOH/drug use
Rational thinking loss
Separated, divorced, widowed
Organized / serious attempt
No social supports
Stated future death intent
<5 - outpt vs PLN
>6 - psych consult
Indications for MAID
> 18yrs
Valid health card /ID
Voluntary
informed consent
suffer from grievous + irremediable medical conditions
Define consent
VICS
Voluntary
Informed
Capable person (patient / SDM) - patient has capacity
Specific (procedure specific risks)
Define capacity
KAC
Knowledge of options
Awareness of consequences + personal cost benefit
Consistency of choice / values in relation to previous values + preferences
Digoxin containing plants
Oleander
milkweed
lily of the valley
fox glove
Dogbane
Anticholinergics containing plants
Deadly night shade (atropine)
jimson weed (scopolamine)
hyoscyamine
angels trumpet
mandrake
Indications for WBI vs gastric lavage
WBI - 2L PEG/hr until rectal effluent is clear
* Drug packers
* sustained / delayed release formulas
* potential bezoar (think ASA)
* Metals: iron, lithium
* high lethal: BB, CCB, TCA
Gastric Lavage - Intubate, LLD
GL w 200cc warm saline + suck until no fragments
* Within 1hr ingestion => CHAMP
* life threatening poison
* no antidote
* AC won’t work (not lithium)
Indications for GI decontamination
CHAMP
Camphor - neurotox, seizures
Halogenated HC
Aromatic HC - BM suppress + leukemia (toulene, benzene)
Metals - arsenic, Hg, Pb (neurotox)
Pesticides - cholinergic crosis, seizure, resp depression
Indications for methylene blue
MetHgB >30%
symptomatic
What is CAGE
Cut down?
Annoyed when ppl bring up bleeding
Guilt around actions with drinking
Eye opener - drink first in AM
0-1: low risk
2-3: high suspect of alcoholism
4: diagnostic
Components of CIWA
SONATA HHHH
Sweating
Orientation
N/V
Agitation
Tremor
Anxiety
Hallucinations: 1) auditory 2) visual 3) tactile
HA
>20 severe
<8 - no tx needed
Criteria for WERNIKE encephalopathy
2’ thiamine dependent enzyme deficiency => thiamine B1 deficient
2 signs:
- CB signs (wide based gait)
- oculomotor signs (nystagmus)
- known thiamine deficiency
- AMS/mild memory impairment
What is the COW scale
STOP TRYING Joints
Sweating
Tremor
O-mydriasis
Piloerection
Tachy
Rhinorrhea
Yawning
Irritation
Nausea/vomiting
Got to go (restless)
joint pain
>13= for suboxone start
(>12 per CAEP 2020 statement)
Indications for admission / discharge post hydrocarbon overdose
Admission
* Any CHAMP HCs
* SI attempt
* mild CNS depression
* tachypnea, hypoxia
* CXR - not improved in 6H
ICU admission
* Mod-severe CNS depression
* sig resp distress + hypoxia
* hypercapnia
* ++ resp support (PPV / intubation)
* hc of cardiac dysrhythmias
* HD instability
Discharge
* Observe for 6hrs
* asymptomatic
* no CXR findings post 6H
Stages of ETHYLENE GLYCOL
Indications for fomepizole / HD in toxic ETOH ingestion
Fomepizole
* Methanol: 6.6
* Ethylene glycol: 3.2
* Hx of ingestion + OG >10
* suspected ingestion PLUS (2):
pH <7.3
OG >10
bicarb <20
calcium oxalate crystals
HD
* Methanol: 16
* Ethylene glycol: 8
* pH <7.3
* anion gap >20
* evidence of EOD: seizure, coma, vision
* can’t eliminate parent / toxic compounds
* deteriorates despite aggressive tx
What is the dx criteria for SILENT syndrom
Neuro (CB) dysfunction 2’ lithium PLUS
* no prior neuro illness
* at least 2mos no lithium
symptoms: CB, EPS, brainstem dysfxn, hyperT = predictor of severity
List indications for dialysis
(lithium)
Acute >4mEq/L / Chronic >2.5mEq/L
CNS - seizures, decr LOC
Renal insuff - can’t excrete
unable to tolerate vol expansion
What meds are associated with serotonin syndrome
Antidepressants: SSRI, SNRI, TCA, lithium
Street drugs: MDMA, cocaine, LSD
opioids: dextromethorphan, methadone, tramadol, meperidine
St John’s wart
What is HUNTER’S CRITERIA
On serotonergic agent / washout
PLUS 1:
1) spontaneous clonus
2) inducible clonus + diaphoresis OR agitation
3) ocular clonus + diaphoresis OR agitation
4) inducible clonus + hyperTHERMIA + hyperTONIA
5) ocular clonus + hyperTHERMIA + hyperTONIA
6) hyperreflexia + tremor
treatment: stop drug, cool, benzos, crytohepatadine 12mg
List diagnostic criteria for NMS
HERACS
Hyperthermia (>38, oral)
Exposure <72hrs - dopamine antagonist (antipsych) OR withdrawal from dopamine agonist
Rigidity
AMS
CK elevation (x4 ULN)
Sympathetic NS lability (at least 2):
- BP >25% from baseline
- BP fluctuates DBP >20% or SBP >25% in 24H
- sweaty, pee yourself
- hypermetabolic - HR >25% / RR >50%
- negative w/o for other tox
Define acetaminophen overdose
TOXIC 150mg/kg
MASSIVE 1g/kg
(7.5mg - adult 4mg malnourished, ETOH, P450 inducer)
Define the stages of acetaminophen toxicity
Stage 1 - pre injury
0-12H (<1D)
* GI symptoms
* APAP level
Stage 2 - liver injury
8-72h (2D)
* RUQ pain
* AST up
Stage 3 - fulminant hepatic failure
2-4d (3D)
* Liver failure
* encephalopathy, DIC
* ARDS, MOF
Stage 4 - recovery
>4d (4D)
* Complete hepatic histologic recovery
* OR
* death
Indications to start NAC
ACUTE
* APAP 4H on / above nomogram line
* present >8H post ingestion
* time of ingest unknown => AST up / APAP detectable
* Toxic dose (150mg/kkg) + no APAP + <8hrs
CHRONIC
* Elevated AST >50 / X2N
* APAP higher than expected (66)
List the KING’S COLLAGE criteria
Cr >300 umol/L
Hepatic encephalopathy grade 3/4
INR >6.5
PH <7.3
(other strong predictors: lactate >3.5 / phosphate >3.75mg/dL)
Indications for dialysis in acetaminophen
(massive OD)
(think of KING’S criteria)
++APAP level (>1000mg/dL @4H)
Cr >300umol/L
Lactate >3.5
pH <7.3
encephalopathy
TOXIC DOSE of salicylates
200-300mg/kg
>500mg/kg (death)
level: >2.2mmol/L
List the stages of ASA toxicity
Early - 0-4H (4)
* Resp alkalosis
* met alklaosis
* Tinnitus
* tachypnea
Moderate - 2-12H (8)
* Resp alkalosis
* Met acidosis
* Hyperthermia
* low CNS glucose
Late - 10-24H (16)
* Resp acidosis
* met acidosis
* Acidemia
* organ failure
List risk factors for pulm edema in salicylate toxicity
Adults
* >40mg/dL
* Smoker
* neuro sx
* chronic ASA use
Kids
* >80mg/dL
* high anion gap
* low CO2
* low K
Indications for Urinary alkalnization in salicylate toxicity
SALICYLATE LEVEL >2.2
rapidly rising levels
sig acid -base disturbances
proven / suspected toxicity w symptoms of salicylate OD (tinnitus)
Indications for dialysis in salicylate toxicity
SALICYLATE LEVEL: ACUTE >7mmol/L / CHRONIC >2.9mmol/L
rapidly rising levels
deteriorating condition
CNS: AMS, coma, seizure
RS: pulm edema, intubated (can’t keep up w RR)
hepatic, renal failure
Other dialysis indications: severe acid /base
- unable to tolerate volume
Indications for HD in metformin OD
Lactate >20
severe acidosis <7.0
failure of supportive care + NaHCO3 within 2-4H of ingestion
List indications for DIGIFAB
HD unstable + bradyarrythmias (unresponsive to atropine)
HD unstable + cardiac ingestant
Dysrhythmias, ventricular
Dysrhythmias + plant ingestions
progressive rhythm disturbances
K >5
rising K level
Acute ingestion of >10mg + any of above
Level > 6ng/mL + any of above
CHILDREN
0.1mg/mL / >5ng/mL level PLUS
Symptoms
K>6
Co-ingestion of drugs (no need for unstable)
Co-ingestion of cardiac glycoside plant + dysrhythmia
Stages of inhalational injury
Immediate chem irritation + edema
necrotic lining + pseudomembrane casts forms
ciliary damage + decr mucous clearance
pulmonary edema + decr compliance (ARDS)
Indications for HBOT in CO toxicity
> 25% Co-HgB (adult) / >15% Co-HgB (preg)
any level PLUS
- neuro - syncope, coma, seizures, AMS (GCS <15)
- abnormal CB dysfunction
- prolonged CO exposure w minor clinical findings
Phases of caustic injury
- Necrosis: invasion of PMN + bacteria
- Vascular thrombosis
- Tissue slough => 1-5H post, tensile strength low = perforation risk high
- Granulation: 1wks - mos
- Strictures => contraction of scar tissue (wks -yrs)
Describe GRADES of caustic injury
Grade 1
* Edema
Grade 2
* White membrane exudate
* ulcers
* Friable tissue + hemorrhage
* non circ / nearly circ
Grade 3
* Full thickness
* deep tissue
* necrotic mucosa
* high risk for perforation
Indications for emergent sx with caustic ingestions
Free air / perforation on imaging
peritonitis / mediastinitis
incr / severe chest pain / abdo pain
persistent hypotension (source control)
Indications to intubate in caustic ingestions
Signs + symptoms
intentional OD
Indications to give 2PAM
ORGANOPHOSPHATE TOXICITY PLUS:
Resp depression / apnea
fasciculations
seizures
arrhythmias
CV instability
Using >4mg atropine
Indications to stop atropine
Resp secretions drying out
Breathing better
RR normal
Contraindications to physostigmine
TCA OD + CV instability (QRS)
widened QRS (>100msec)
bradycardia (AV block)
seizures
relative: reactive airway dz, intestinal obstruction
acute closed angle glaucoma (ACE inhibitor = ACH = muscarinic (miosis) + nicotinic (mydriasis) effect)
(could be okay for open angle glaucoma => miosis overall)
Indications for treatment anticholinergic (charcoal, physostigmine)
Charcoal
* Only for symptomatic pts
* high toxic quantity of anti-muscarinic plant
* seed ingested (<2H from ingestion)
Physostigmine
* Control symptoms of agitation / delirium
* no seizures
* normal QRS
Describe the stages of FE OD
Indication for treatment
in Fe OD
WBI indications - 2L /hr NG until effluent clear
* >20mg/kg ingestion
* see tabs on AXR
Deferoxamine = 100mg:10mg Fe (15mg/kg/hr (24H))
* Systemic illness
* level >90umol/L
* ingested >60mg/kg
Contraindications to WBI
Perforation
bowel obstruction, ileus
HD instability
What are the complications of deferoxamine
Anaphylactoid reaction
pink pee (vin rose)
hypotension
ototoxic
yersinia infection
ARDS
Visual toxicity
End points for deferoxamine
Patient stable
appears well
acidosis is gone
urine not pink
List the grades for HTN retinopathy
Gr 0 - normal
Gr 1 - arterial narrowing
Gr 2 - arterial narrowing + irregularity
Gr 3 - arterial narrowing + hemorrhage / exudate
Gr 4 - grade 3 + papilledema
List 2 types of classifications of AD
STANDFORD
* A - ascending (surgery +/- AV replacement)
* B - descending (med mgmt +/- TEVAR)
DEBAKEY
* 1 - ascending arch + distal aorta
* 2 - isolated ascending OR arch
* 3A - descending thoracic
* 3B - thoracic + abdominal
What is the WELL’S SCORE for DVT
C3P2OTR2D2
Calf swelling >3cm
Collateral veins present
Pitting edema
Prev DVT documented
Oedema of entire leg
Tenderness to calf
Recent paralysis / plaster / paresis of lower extremity
Recent surgery 12wks or immobilization 3days
Diff dx at least as likely (-2)
0-2: D dimer
>3 = D dimer + US
+dimer -US => rpt 1wk
What is the PERC score
HADCLOTS
Hormone use
age >50
DVT/PE hx
Coughing blood
Leg swelling
O2 <95%
Tachycardia >100
surgery / trauma <28days
PERC NEG <2% chance
What is the WELLS SCORE (PE)
LASTPCH
Leg swelling +3
Alternative dx unlikely +3
Surgery (4wks) / Immobilization (3d) 1.5+
Tachycardia >100 +1.5
Prev DVT / PE +1.5
Cancer (6mos) +1
Hemoptysis +1
0-4 unlikely - dimer alone
>5 - likely - CTPE
Explain the YEARs score
YEARS criteria
* Clinical signs of DVT
* Hemoptysis
* PE most likely
What are the PESI score components
80/90/100/110
age >80
SpO2 <90
SBP <100
HR <110
Hx of CA
Hx of cardiopulmonary dz
0 points - low risk = outpatient
>1 point - high risk, 9% risk for death
pulmonary embolism severity index
What is the modified HESTIA score
PACATSSRO
NO:
Pain >2dose IV narcotics
active bleed
co-morbidities (preg, severe liver dz, HIT)
anti-coagulation
Thrombolytics needed
Social reasons for admission
SBP <100
Renal - CrCl <30
O2 <94
What is the LIGHT’S CRITERIA
Protein pleural / serum >0.5
LDH pleural / serum >0.6
2/3 ULN of LDH
TRANSUDATIVE- low protein 2’ hydrostatic pressure
* CHF
* Cirrhosis
* nephrotic syndrome, GN
* hypoalbuminemia
* myxedema
* Peritoneal dialysis
* atelectasis
* CSF leak into pleural space
* VP shunt dysfunction
EXUDATIVE - high protein
* Bacterial pneumonia
* parapneumonic effusion
* lung abscess
* TB, viral
* primary lung Ca, mesothelioma, pulmonary / pleural mets
* carcinoma
* asbestosis, sarcoid
* uremia
* RA, SLE, Wegeners
* pancreatitis, hypothyroidism
* chylothorax
BERLIN definition
Acute <1wk
bilateral opacities
PF ratio
mild <300 (PEEP5)
mod <200 (PEEP5)
severe 100 w PEEP
What is the AERD: aspirin exacerbated resp disease triad
Asthma
nasal polyps
eosinophilic rhinitis
sensitivity to NSAIDs / aspirin
Tx- steroids
What is the VANCOUVER CP rule
STEP1 - (yes to any, no D/C // no to all - step 2)
prior ACS
abn ECG (STE/STD, q waves, LVHH, LBBB, paced)
Nitrate needs
+ trop @ 2hrs
STEP 2 (yes - DC home)
Pain on palpation
STEP 3 (yes to any - no DC)
>50
radiating to neck
low risk ACS screen
What is the HEART score
History (highly, mod, slightly suspicious)
ECG (STD, non specific repol, normal)
Age (65, 45-65, <45)
Risk factors (>3, 1-2, 0): DM, HTN, Obesity, + fm history, DLD, CAD
Troponin (3xN, 1-3Xn, <1)
0-3: D/C home
4-6: adm to hospital
>7: early invasive measures
Risk of MACE @ 6wks; (mace: AMI, PCI/CABG, death)
What is the KILLIP SCORE
CLASS 1: no signs of HF (3%)
CLASS 2: crackles, S3, incr JVP (10%)
CLASS 3: acute pulmonary edema (15%)
CLASS 4: cardiogenic shock (>30%)
30d mortality with acute MI
What is the HASBLED score
BLAMEKISS
Bleeding history
Liver disease
Age>65
Meds - antiplatelets, NSAIDs
ETOH
Kidney disease
INR labile
SBP >160
Stroke history
0-2 = anticoag
>3 = high risk of bleed
risk of sig bleeding on anticoa
What is the CHADS2 rule
CHF
HTN
Age >75 (CHADS=65 >65)
DM
Stroke / tia
Annual stroke risk
0 = 0.8% risk for stroke
1-2 = 2.7
3-6 = 5.3
What is the CDN SYNCOPE RULE
FAINT RISK
Faint hx (-1)
Abnormal HEART (CHF, CAD, ICD) (+1)
Increased SBP (>180 / <90) (+2)
Non narrow QRS (<130) (+1)
Troponin >90th percentile (+2)
Rotated axis <30/>100 (+1)
Increased QTC >480 (+2)
Syncope hx - vasovagal (-2)
kardiac syncope (+2)
30d serious adverse risk
<0 - low risk (2hrs monitor)
1-3 - med risk
Inclusion / Exclusion Criteria for CDN Syncope Rule
INCLUSION
* ED patient
* >16 yrs
* present to ED within 24H of syncope
EXCLUSION
* Prolonged LOC (>5min)
* obvious witnessed seizure
* mental status - changes from baseline
* head trauma = LOC
* Major trauma
* unable to obtain hx (language barrier, ETOH, drug)
* underlying condition
What is the SAN FRANCISCO SYNCOPE RULE
CHESS
CHF
HCT <30%
ECG abnormal: changed, not sinus, new arrythmia
SOB
SBP <90
7D serious outcomes risk
if yes to any - not low risk
List CCS classification angina
1 - pain with strenuous activity
2- pain with moderate activity (>2 stairs)
3 - pain with mild activity (1-2 stairs ) => 60%
4 - pain at rest (95% stenosis)
List the DIAGNOSTIC CRITERIA for prinzmental angina
Nitrate responsive angina
transient ischemic - ECG changes
angiographic evidence of coronary artery spasm
What is SGARBBOSSA criteria
Concordant STE >1mm + QRS (any lead)
Concordant STD >1mm - QRS (V1-V3)
Discordance >25% STE / STD than main vector QRS
Diagnostic criteria for BER
No reciprocal changes
No isolated STE (inferior / limb leads)
max seen in V2-V5
Fish-hook => notching of terminal portion of QRS @ J point
J point elevation <3.5mm
STE <2mm in precordial leads / <0.5mm limb leads
temporal stability
NYHA classification of HF
1 - no symptoms with normal activity
2 - symptoms with normal activity
3 - symptoms with limitation of activity
4 - symptoms at rest
MAYO CRITERIA for Takotsubo
- Transient LV systolic function, regional
- No obstructive coronary disease /angiographic evidence of acute plaque rupture
- New ECG abnormalities (STE / TWI) or modest cardiac TNT elevation
- Absence of pheochromocytoma / myocarditis
extra:
ECHO - apical ballooning
ECG - transient anterior MI (q waves transient, STE)
Diagnostic criteria for pericarditis + myocarditis
PERICARDITIS
2 OF:
* typical chest pain
* ECG changes
* pericardial friction rub
* PCE (new / worsening)
MYOCARDITIS
@ least 1 of clinical:
* Pericarditis
* new SOB w/o HF
* unexplained Cardiogenic shock
* palpitations +/- arrythmia +/- syncope
1 diagnostic
* trop /CK +
* ECG - AVB, BBB, VF/VT
* ECHO/angio - evidence of LV depression
List stages of pericarditis
STAGE 1- Immediate (1wk)
* Diffuse STE, PR depression
* spodick sign - downslope TP
* reciprocal STD (AVR V1)
STAGE 2 - Days - 3wks (2wks
* Normalization ST/PR
* T wave flatten
STAGE 3 - 3wks
* TWI (deep)
STAGE 4 - >4wks
* Normalization of ECG
* Can have permanent TWI
Class 1 Indications for pacemaker
(AHA guidelines)
Sinus node dysfunction
* Symptomatic bradycardia
* Chronotropic incompetence
AV node dysfunction
* Complete 3rd deg
* High grade 2nd deg => >2 blocked Ps
* symptomatic 2nd deg, type 1/2
* 2nd deg, type 2 PLUS 1) wide QRS or 2) chronic bi-fasicular block
* exercise = 2nd/3rd deg block w/o ischemia
Indications for an ICD
(primary + secondary prevention)
Primary
MI + EF <30%
CM + EF <35% + NYHA 2/3
high risk for VT/VF:
Brugada
ARVC
Congenital long QTC
HOCM
Secondary
VT/VF arrest
unstable sustained VT + no underlying cause
sustained VT + heart dz
- CAD, dilated, channelopathy, valvular
Diagnostic Criteria for TORSADES
Ventricular rate >200
undulating baseline of QRS axis
paroxysms last <90seconds
Types of BRUGADA SYNDROME
What is the BRUGADA CRITERIA
Absence of RS complex
RS >100msec
evidence of AV dissociation *
VT LBBB / RBBB morphology (think of LAFB / LPFB) =>
LBBB V6 qR / V1 rS
RBBB V6 rS / V1 qR
What is GRIFFITH CRITERIA
LBBB /RBBB (in V1+V6)
neither present
= Look for AV dissociation
if not present = SVT
Components of NEWS2 score
RR
SpO2
Air vs O2
SBP
HR
LOC
Temp
What are the components of the FOUR SCORE
Eye response
Motor response
Brainstem reflexes
Respiration
List stages of hypothermia + ECG changes
Phases of ARS
WHO Pandemic phase classification
Phase 1: animal only
Phase 2: animal => human (isolated)
Phase 3: animal => human (sporadic)
Phase 4: human => human (local community)
Phase 5:human => human (x1 WHO region (6 total), x2 countries)
Phase 6: human => human (x2 WHO regions)
WHO Pandemic phase classification
Phase 1: animal only
Phase 2: animal => human (isolated)
Phase 3: animal => human (sporadic)
Phase 4: human => human (local community)
Phase 5:human => human (x1 WHO region (6 total), x2 countries)
Phase 6: human => human (x2 WHO regions)
Indications for transport to trauma center
PHYSIOLOGIC(3)
* GCS <13
* SBP <90
* RR >30 / <10
MECHANISM (4)
* Fall (A >20ft / C >10ft)
* MVC vs pedestrian
* motorcycle
* MVC high risk (intrusion, pt death, ejection)
AGE / CO-MORBIDITIES (5)
* Old >75 (>50)
* children
* pregnant
* NOAC
* burns
ANATOMY(6)
* Open / depressed skull #
* paralysis
* flail chest
* open pelvis
* penetrating injury 1) head 2) neck 3) torso 4) prox extremity
* crushed / mangled extremities
* >2 prox long bone #
Indications of OHIO pre-hospital geriatric trauma triage
> 70 PLUS any of the following:
- injury >2 body regions
- GCS <15 + known /suspect TBI
- SBP <100
- fracture >1 prox long bone 2’ MVC
- pedestrian vs MVC
- falls from height (including standing) + suspect TBI
Indication for surgeon presence at trauma resus
GCS <8
SBP <90 plus 1) GSW to prox extremities 2) neck 3) chest 4) abdo
2) intubated on scene
Penetrating GSW - neck, abdo, chest
resp compromise airway
Indications for transfer to burn center
Severity
* 3rd deg - any age
* partial thickness - >10% TBSA
Location
* Face
* hands
* genitalia, perineum
* major joints
Type
* Electrical
* chemical burns
* inhalational
PT characteristics
* BURN PLUS
- pre-existing med d/o
- co-comittant trauma
- peds in non peds hospital
- social / emotional / rehab intervention
What is the Gustillio classification
Hard / Soft Signs for penetrating neck
AB3CDS3-H / MN2OPQ-HD
HARD
* Airway compromise
* Bubbling air (wound)
* Bruit
* Blood ++
* Cerebral ischemia
* Decreased / absent radial pulse
* Stridor
* Subcut air ++
* Shock (no response to tx)
* Hemoptysis (massive)
SOFT
* Minor hemoptysis
* Neurologic findings
* Non expanding hematoma
* Oropharyngeal wound
* Proximity wound
* subQ air
* Hematemsis
* Dysphonia / dysphagia
Hard and Soft signs of LARYNGOTRACHEAL INJURY
AB2C-M
HARD - AB2C-M
* Airway obstruction
* Bubbling
* Bony crepitus / subcutaneous empysema
* Clothesline mechanism
* Massive subcut air
SOFT
* Pain w tongue mov’t
* dysphonia
* SOB
* stridor
* hematoma = loss of thyroid prominence
* visible neck wound
* palpable cartilage fracture
Complications: 1) tracheal stenosis 2) hoarseness 3) vocal cord paralysis 4) laryngeal nerve
Hard + Soft signs of popliteal injury
MARD
HARD
* Mottled / cool
* Arterial popliteal hemorrhage
* Rapid expanding popliteal hematoma
* Distal pulse deficit
SOFT
* Paresthesia
ROTTERDAM CRITERIA
BEIM
Basal cistern (normal, compressed, absent)
Epidural mass (present - 0, absent 1)
Intraventricular blood/SAH (absent 0, present 1)
Midline shift (<5mm 0 / >5mm 1)
pred 6mos mortality post TBI
What is the HUNT + HESS grading scale
0 – unruptured
1 – asymptomatic, minimal HA, no nuchal rigidity
2 – mod – severe HA, nuchal rigidity, no neuro deficits (excpt CN palsies)
3 – decr LOC, confusion, mild focal deficits
4 – stupor, mod-severe hemiparesis
5 – deep coma, decerebrate posturing
OTTAWA SAH RULE
ANTLEaF
Age 40
Neck pain / stiffness
Thunderclap
LOC
Exertion - onset
Flexion - pain with flexion
if no to all - R/O SAH
Inclusion/Exclusion Criteria for OTTAWA SAH rule
INCLUSION
* >16
* atraumatic
* pain peaks in 1hr
* presents within 2wks
* GCS 15
EXCLUSION
* Focal neuro deficits
* papilledema
* Known aneurysm, tumor, hydrocephalus
* prior SAH / SAH dx made
* recurrent similar headaches
* rpt visit
What is the ICH score
GI3A
GCS (3-4 +2 / 5-12 +1 / 13-15 0)
ICH vol >30mL
Intraventricular hemorrhage
Infratentorial hemorrhage
age >80
CT estimated mortality of ICH
ASIA IMPAIRMENT scale
A => complete, no sensation / motor, preserved in S4-S5
B => incomplete, sensation, no motor
C => incomplete, sensation, partial motor <3/5
D => incomplete, sensation partial, motor >3/5
E => normal, sensation, motor both intact
BCVI GRADING SCHEME
GRADE 1
* Intimal irregularity
* <25% narrowed
LMWH
rpt CT 7-10d => 3-6mos / endovascular stenting
GRADE 2
* Dissection / intramural hematoma
* >25% luminal narrowing, intraluminal clot
* visible intimal flap
Surgical accessible - operative repair
if not accessible - then grade 1
GRADE 3
* Pseudoaneurysm
* HD insignificant AV fistula
GRADE 4
Complete occlusion
GRADE 5
* Active extrav (hemorrhage)
* HD significant AV fistula
Operative repair
endovascular tx
List the DENVER CRITERIA
ABCDEF
* Arterial hemorrhage
* (nose, mouth, neck)
* Bruit (cervical, <50)
* Cervical expanding,hematoma
* Deficit =/= findings on CT
* E(I)maging = stroke on CT
* Focal deficits:
1) TIA
2) hemiparesis
3) horners
4) vertebrobasilar
RISK FACTORS
* High energy transfer mech
* near hanging + anoxic brain injury
FRACTURES (5)
* Le fort 2/3
* Mandibular #
* occipital condyle #
* complex skull / basilar
* c spine # - any level
OTHERS:
* TBI + GCS <6
* TBI + thoracic inj
* degloved scalp
* upper rib #
* blunt cardiac injury
* thoracic vascular injury
List the LEFORT CLASSIFICATION
LeFort 1
* Maxilla mobile
* transverse through maxilla - above roots of teeth
LeFort 2
* Maxilla + nasal complex
* maxilla => lacrimal bones, orbital floor + rim
LeFort 3
* Craniofacial disjunction
* maxilla => medial wall of orbit to include zygomatic arch
List the ELLIS CLASSIFICATION
Class 1
* Enamel
* minimal pain
Dentist out of hospital
Class 2
* Enamel, dentin
* pain
Dressing w aluminum foil, CaOH2
Dentist in clinic
Class 3
* Pulp exposed
* v painful
Dentist on call
What is the NEXUS CRITERIA
DART4
Distracting painful injury
Abnormal CXR
Rapid decel 1) fall >20ft 2) MVC >40ft
Tenderness 1) sternum 2) spine 3) scapula 4) chest wall
Indications for urgent thoracotomy
EAST
* >1500cc initial drainage
* >200cc/hr over 3hrs
ATLS
* >1500cc initial
* >200cc/hr / 3hrs
* persistent transfusion req’t
ROSENS
* Initial drainage >20cc/kg (peds 15)
* persistent bleeding >7cc/kg /hr (peds 2) (>200cc/hr) x3
* increasing HTX on CXR
* still hypotensive despite blood
* decompensation after initial resus
Indications for
ED thoracotomy
(penetrating)
ROSENS
Cardiac arrest + SOL in field
SBP <50 post fluid
severe shock + clinical tamponade
EAST
Pulseless, SOL
- penetrating thoracic trauma
- no SOL, penetrating
- SOL, penetrating, extraT
- no SOL, penetrating, extrT
WEST
<15min pre hospital CPR
<5min pre hospital CPR (neck extremity)
profound refractory shock
Indications for
ED thoracotomy
(blunt)
Cardiac arrest in ED
EAST
Pulseless:
- SOL, blunt
AGAINST: no SOL, blunt (no pulse)
WEST
<10min pre-hospital CPR
What is the PECARN ABDO RULE [PEDS]
(think HEAD-TOE) GT DAAVS
GCS 14 + blunt abdo trauma
Thoracic wall trauma
Decreased BREATH sounds
ABDO (4)
Abdo wall trauma
Abdominal tenderness
Vomiting
Seatbelt sign
other indications:
positive fast
hematuria
liver enzyme elevation
persistent hypotension NYD
high risk if yes to any = CT
inclusion/exclusion criteria for PECARN abdo rule (peds)
Inclusion
* <18yo
* blunt abdo trauma
* within 24H
Exclusion
* Penetrating
* pre-existing neuro
* pregnancy
* CT already done
What is the DOYLE CLASSIFICATION
Type 1
Tendon rupture
closed
+/- dorsal avulsion
Type 2
Tendon laceration
open
skin tissue loss
Type 3
Tendon injury
open
skin + tissue loss
Type 4
Mallet fracture
A - transepiphyseal plate #
B - # of 25-50% of articular surface
C - # fragment >50% of articular surface
MAYFIELD CLASSIFICATION
carpal instability
Scapholunate dissociation
* Terry Thomas sign => 2mm
* Signet ring sign (subluxed scaphoid)
Peri-lunate dislocation
* DORSAL d/c of capitate (radius - lunate intact)
* scaphoid, radial styloid, capitate #
Peri-lunate + Triquetrum d/c
* Capitate d/c, triquetrum d/c +/- #
* volar triquetral #
Lunate dislocation
* VOLAR d/c of lunate (Spilled Tea Cup sign)
* AP view: Piece of Pie sign (rotated lunate)
associated fractures with carpal instability
- scaphoid
- radial styloid
- capitate
- volar triquetral
What is the GARTLAND CLASSIFICATION
(supracondylar fractures)
What is the MAYO CLASSIFICATION
Type 1 no displacement
* Posterior splint, in flexion
Type 2 Displaced, stable
* <2mm - as above
* >2mm - ED ortho
Type 3 Displaced, unstable
* ED ortho
What is the MASON CLASSIFICATION
Type 1 no displacement
* Sling, early ROM
Type 2 <30% articular surface, >2mm displaced
* Sling, early ROM
Type 3 Comminuted
* Ortho +/- radial head excision
Type 4 Any of above PLUS elbow d/c
* Reduction
* Ortho
(radial head #)
What is the NEERS CLASSIFICATION
Fragment parts => anatomical neck, surgical neck, greater tuberosity, less tuberosity
part 1 => no frag meets displacement criteria
* (<45deg angle / <1cm separation)
2 part => 1 segment displaced (2 total parts)
3 part => 2 parts, placed
4 part => 3 segments displaced
(prox humerus #)
List NEERS CLASSIFICATION
Type 1 No/min displacement, lateral CC ligaments
* Conservative mgmt
Type 2
A - unstable - medial to CC ligament (medial portion d/p)
B - stable - fracture btwn CC ligaments (medial portion d/p)
* 2A= ORTHO
* 2B = conservative
Type 3 Intra-articular distal clavicle (AC joint)
* Conservative mgmt
Type 4 Peds only => SH1
Type 5 Comminuted, medial clavicle displaced, inferior frag attached to CC ligament
* ORTHO
(lateral clavicular #)
Indications with clavicle fractures
immediate ortho / delayed ortho / conservative mgmt
Immediate ortho
* Neurovascular compromise
* 100% displacement
* skin tenting
* open fracture
* soft tissue - Interpositioning
Delayed ortho (next day)
* Lateral: Type 2, type 5
* Middle: 100% displacement
* >2cm shortening
* severely comminuted
* Medial: >2cm overlap
* posterior displacement
Conservative mgmt
* Lateral: Type 1/3, stable
* Middle: non displaced
* Medial: non displaced
* peds - distal
What is ROCKWOOD CLASSIFICATION
123 PSI
Grade 1 Strain AC
* Sling
Grade 2 AC disrupted (widened AC)
* Sling
Grade 3 AC + CC disrupted (widened AC+CC)
* Sling
* ortho f/u
Grade 4 Posterior clavicular displacement
* Ortho
Grade 5 Superior clavicular displacement
* Ortho
Grade 6 Inferior clavicular displacement
* ortho
What is the ADA MILLER classification
Type 1
Acromion process
scapular spine
coracoid process
Type 2
Scapular neck
Type 3
Intra-articular # of glenoid fossa
Type 4
Scapular body (common)
OTTAWA RULES
foot/ankle/knee
FOOT
* Pain in midfoot AND
* 1) tender @ 5th MT base
* 2) tender @ navicular region
* 3) no wt bear (4 steps)
ANKLE
Pain in malleolar zone AND
1) pain post. 6cm lat mal
2) pain post. 6cm med mal
3) no wt bear (4 steps)
Exclusion
<18yrs (now valid >2)
pregnancy
2nd presentation
isolated skin / soft tissue
10d post injury
not traumatic
sent from outside hospital w XR
intoxicated / unreliable
KNEE
If only 1:
>55yrs
can’t wt bear (4steps)
can’t flex knee (90deg)
isolated patellar pain
pain to fibular head
Exclusion
<18yrs (now valid >2)
pregnancy
2nd presentation
isolated skin / soft tissue
7d post injury
poly trauma / distracting
GRADES of ANKLE SPRAIN
Grade 1 Ligamentous stretching
No joint instability
Grade 2 Partial ligamentous tear
Mod joint instability
Grade 3 Complete tear
Marked joint instability
What is the SIMMONS TRIAD
Palpable gap
angle of declination
+ thompson test (squeeze = no plantar flexion)
incomplete - plantar flexion weakness
(Achilles rupture)
What is the HAWKINS CLASSIFICATION
Type 1 Non displaced #
Type 2 # and subtalar subluxation
Type 3 As above + tibiotalar subluxation
Type 4 As above AND talonavicular
(talar fracture)
List the WEBER CLASSIFICATION
A Below tibio-talar joint
deltoid ligament disruption
B @ level of tibiotalar joint
50% disruption syndesmosis
C Above/prox to tibiotalar joint
disruption syndesmosis
(fibular #)
Describe the SCHATZKER CLASSIFICATION
Type 1 Lateral tibial plateau
Type 2 Type 1 + depressed component
Type 3 Pure depression of lat tibial plateau
Type 4 Medial tibial plateau +/- depression
Type 5 Bicondylar fracture
Type 6 Dissociation of tibial metaphysis + diaphysis
(tibial plateau#)
Describe the WATSON JONES CLASSIFICATION
Type 1 => incomplete avulsion (cast in extension)
Type 2 => complete avulsion (extra-articular)
Type 3 => complete avulsion (intra-articular)
(tibial tuberosity #)
What is the TILE CLASSIFICATION
TYPE A Intact posterior arch
* Stable Avulsion
* iliac spine#
* ischial tuberosity
TYPE B Incomplete disruption of posterior arch
rotation instability / vertical intact
* Lateral compression
* open book
TYPE C Complete disruption of posterior arch
unstable (rot + vertical instability)
* Iliac, sacroiliac + vertical sacral injury
List types of avulsion fractures on pelvis + associated muscle
Sartorius - Anterior superior iliac spine
Rectus femoris - Anterior inferior iliac spine
Iliopsoas -Lesser trochanter
Adductors - Inferior pubic rami
Hamstrings - Ischial tuberosity
Abdo muscles - Iliac crest
What is the YOUNG BURGESS CLASSIFICATION
RABT SCORE
Penetrating injury
positive FAST
Shock index >1.0 (SBP/HR)
Pelvic fracture
>2 = MTP
Indications for angiography (pelvic trauma)
EAST GUIDELINES
Persistent hypovol in major pelvic # (despite hemorrhage control)
patient w evidence of arterial contrast extrav in pelvis by CT
angiography +/- embolization w ongoing bleeding after non pelvic sources of blood loss is r/o’d
>60 w major pelvic fracture (open book, butterfly, vertical)
What are the DANNENBERG STAGES
TB
Bacterial invasion - Primary
* Alveoli macrophages eat bacilli
* 1) infection stops (host wins)
* 2) infection continues (bacilli beats host immune system)
Tubercle formation - Primary
* Bacilli replicate and lyse macrophage, releases TB
* Tubercle formation
* lymphatic + hematologic spread => LD, kidneys, bones, VBs, lung
Granuloma - 2-3wks
(1) latent (2) progressive primary
* T cell mediated
* caseating necrotic granulomas
* 1) host response sufficient => latent TB
* 2) host response insufficient => progressive primary
Reactivation / Liquefaction - mos
Dormant foci reactivated =>
* 1) liquefication of tubercle + cavitation
* OR 2) re-infection
CDC / WHO definition of HIV stages
Diagnostic criteria for sinusitis / rhinosinusitis
@ least 10days
persistent + not improving
Plus 1/3:
3-4D severe symptoms (T >39)
nasal discharge, facial pain => no improvement
onset of progressive symptoms with worsening symptoms after initial improvement
What is the CENTOR Criteria
PENF
Painful anterior lymphadenopathy
Exudative tonsils
No cough
Fever
(all worth 1 point)
age 3-15 (+1) / age 15-45 (0) / age >45 (-1)
What is the JONES criteria
JONES CAFEP
Joints - migratory polyarthritis
Carditis
Nodules, subcutaneous
Erythema marginatum
Sydenham chorea
CRP +
Arthralgias
Fever
ESR +
Prolonged PR
What is clinical criteria for scarlet fever
Soaring fever
Sore throat
Sandpaper rash (12-48H post fever)
Strawberry tongue
Streptococcal - Group A
Small <10
Pastia lines => in skin creases - then desquamates once rash is gone
Forcheimer spots - spots on palate
SIX S’S
What is the CURB-65 score
Confusion
Urea >7
RR >30
BP <90
Age >65
0- 1 = outpatient
2 = admission / hospitalize
3-5 = ICU
What is the SMART COP score
Systolic BP low (2)
Multilobar (1)
Albumin (1)
RR high (1)
Tachycardia (1)
Confusion (1)
O2 poor (2)
PH acidotic (2)
>3pts = need for invasive resp + vasopressor requirements in >50
List components of the PSI score
Age, sex
Vitals: RR, SBP, HR, Temp
bloodwork: BUN, Na, Glc, HCT
pAO2 <60 / pH <7.35
Pleural effusion on XR
Nursing home resident
altered
Comorbid - neoplastic dz, CHF, liver / renal dz
estimates mortality for adult patients w CAP
Class 4 / 5 = admit
What is the DUKE CRITERIA
BE FEVIR
Blood culture + (typical bacteria)
ECHO findings: 1) paravalvular abscess 2) new regurgitation 3) new dehesicance of valve 4) vegetation on valve
Fever
Vascular findings:
Immunologic findings:
Evidence - single positive C+S
Risk factors (see above)
x2 major / x1 major - 3min / 5maj
Indications for surgical mgmt in infective endocarditis
Vegetarians
Hate
BEF
Vegetation OR peri-annular extension
Heart failure
Bacteremia (persistent)
Emboli, recurrent
Fungal
What is the ROCHESTER CRITERIA
MUST FULFILL ALL:
<60D
Appears well
no evidence focal infection
No prior illness
* Term >37wks
* no perinatal abx
* no unexplained hyperbilirubinemia
* no prev hospitalizations
* no chronic / underlying illness
* not hospitalized longer than mother after delivery
Lab values
* WBC 5-15
* Band neutrophils <1.5
* urine WBC <5WBC/hpf
* CRP <20
* no diarrhea - if present (fecal leuks <5WBC/hpf)
febrile infants at low risk for SBI
Clinical criteria of KAWASAKI DZ
CRASH + BURN
4/5 CRASH + 5days of fever
Conjunctivitis => non exudative, bilateral
Rash => generalized (trunk => face + extremities)
Adenopathy, 1.5cm
Strawberry tongue / mouth change (cracked lips, pharyngeal erythema)
Hands/feet erythema - peeling => swelling of hands / feet
Cardiac findings => Prolonged PR, non specific ST/T wave changes
Clinical criteria of incomplete KAWASAKI
<6mos
2/5 CRASH + 5days of fever
CRP >30 / ESR >40
3 of PAAAWS
PLT >450
Anemia
Albumin <30
ALT elevated
WBC >15
Sterile urine >10WBC/hpf
Criteria of MIS-C
24h of fever
<21
multisystem
Inflammatory markers [CRP >50, ferritin, procalcitonin, albumin, WBC (neutrophils, lymphocytes), PLT]
Sever symptoms => needing hospitalization
COVID +
What is the LRINEC SCORE
Leukocytosis
Renal failure / AKI
I - hyperglycemia (>10)
Na - sodium low
Erythocyte (HgB <11)
CRP >150
>8 - high risk
<3 - low risk
Describe the diff btwn staph / strep TSS + SSSS
STAGES of rabies
- Incubation -1-3mos
- Prodrome - Days - wks
* ILI, non specific
* paresthesia around the wound - Acute Neuro 2 types
* FURIOUS/encephalopathic (80%)
* DUMB/paralysis (20%) - Coma
- Death
What are ENVENOMATION GRADES
GRADE 0 Minimal
* <1inch surrounding erythema + edeama
* no systemic symptoms >12H
GRADE 1 Minimal
* 1-5inches, erythema + edema
* pain + throbbing
* no systemic symptoms >12H
GRADE 2 Moderate
* Edema towards trunk
* petechiae + bruising to area of edema
* temp elevated, NV
GRADE 3 Severe
* <12h - edema to extrem + trunk
* petechiae, gen bruising
* HR, hypoptensive
* labs: elevated CK, AKI, decr PLT, fibrinogen
* elevated d dimer, PTT, WBC
GRADE 4 Very severe
* Ecchymosis, bleb formation, necrosis
* incontinence, seizures / coma
* cardiopulm arrest
What is WALDVOGEL’S classification
Hematogenous (RF: extremes of age, vertebral OM, metaphysis OM, synovial involvement)
Contiguous - vascular source
Chronic (>6wks)
(OM)
Stages + Grading of OM
STAGES
A - non infected
B - infected
C- ischemic
D - infected + ischemic
TEXAS GRADING
0 - pre ulcer
1 - FULL thickness ulcer
2 - tendon involved
3 - bone involved
What is KOCHER’S criteria
NEWT
What is KOCHER’S criteria
NEWT
>2 = 40% chance of septic hip
>3 = 93%
Non weight bear
ESR >40
WBC >12
Temp >38.5
*helps identify if effusion in peds is septic arthritis vs transient synovitis (US- b/l effusion)
>3 = 93% for septic arthritis
List DIAGNOSTIC CRITERIA for trigeminal neuralgia
Recurrent episodes of UNILATERAL FACIAL PAIN => V2/V3 distribution
PLUS
Pain: 1) 1sec - 2min 2) severe 3) sharp electric, shooting
precipitated by innocuous stimuli (trigeminal distribution)
not explained by alternative dx
[other symptoms: Facial muscle spasms – tick douloureux, autonomic symptoms: lacrimation, conjunctival injection, rhinorrhea]
What is the HOUSE BRACKMAN score CN7 palsy
Grade 1: normal
Grade 2: mild - complete eye closure, normal symmetry @ rest
Grade 3: moderate - complete eye closure + noticeable asymmetry @ rest
Grade 4: mod-severe - incomplete eye closure + obvious asymmetry
Grade 5: severe - incomplete eye closure + muscle twitch
Grade 6: total paralysis
What is the diagnostic criteria for ACUTE VESTIBULAR syndrome
> 24H
Acute onset
persistent vertigo / dizziness
PLUS 1) nystagmus
2) N/V
3) head motion intolerance
4) gait unsteady
BP stroke targets
XR findings of LISFRANC INJURY
AP
* Fleck sign (# of metatarsal base)
* widening of MT 1+2 >2mm
* medial edge 2nd MT + medial cuneiform
OBLIQUE
* Medial edge 4th MT + medial cuboid
* base of 5th MT subluxed >3mm lateral edge of cuboid
LATERAL
* Dorsal alignment metatarsal + tarsals
* line btwn plantar aspect of 5th MT + medial coneiform
What is the TOAST classification
- Large artery atherosclerosis (embolus / thrombosis)
- Cardio-embolism
- Small vessel occlusion
- Stroke of other determined etiology
Stroke of undetermined etiology
Classification of ischemic strokes
What is the ABCD2 rule?
Age >60
Blood pressure: >140/ >90
Clinical: a) unilateral weakness (2) b) speech only (1)
Duration of symptoms: a) >60min (2) b) 10-59min (1)
Diabetes
Predicts 7 day risk of stroke in patients w TIA
0-3 low risk
>4: high risk (mod 4-5 / severe >6)
- consider DAPT [ASA 325LD => 100mg daily / CLOPIDOGREL 300-600mg LD => 75mg daily] x3wks
- consider admission, neuro consult, MRI
What is the CDN TIA score
Clinical
* 1st TIA
* >10min
* Initial DBP >110
* on an anticoagulant
hx:
weakness
gait disturbance
dysarthria / dysphagia
vertigo (-3)
Labs
* EKG - AFIB
* CT - old / new infarct
* glc >15
* plt >400
-3 to 3: low risk => non infused CT, outpatient follow up
4-8: moderate risk => non infused CT/CTA, emergent follow up
>9: high risk, non infused CT / CTA + neuro in ED
What is the VAN score
WEAKNESS (pronator driftt) PLUS
Vision
Aphasia
Neglect
identifies large vessel occlusion
Parts of the NIHSS score
a) aLOC
b) questions
c) follow commands
Best language
Dysarthria
Eyes:
Best gaze
Visual fields
Extinction of neglect
Sensory
Facial palsy
Motor (arms)
Motor (legs)
Limb ataxia
quantifies stroke severity
0-4 = minor ischemic stroke
Components of modified Rankin score
0 – no symptoms
1 – symptoms, no disability
2 – mild disability, independent of all ALDs
3 – mod disability, independent of walking
4 – mod – severe disability, walk w assistance
5 – bedridden
6 – death
Quantifies degree of disability on daily life post stroke
DIAGNOSTIC CRITERIA for migraine w/o aura
Without aura (5 4-3 2 1)
>5 attacks
4h-3d
2 of (DUMP - disabling, unilateral, mod-severe pain, pulsatile)
+ 1 of (N/V or photophobia / photophobia)
DIAGNOSTIC CRITERIA for migraine w aura
With aura
>2 attacks
>1 aura (retinal, visual, sensory, speech, motor, brainstem)
+ >3 of following
>2 succession,
w or within 6hrs of HA
unilateral
5-60min
positive sx (scintillating scotomas, photopsia, blurred vision, teichopsia, fortification spectrum)
DIAGNOSTIC criteria for cluster HA
> 5 attacks:
Unilateral
orbital / temporal pain
1.5-3 hr (lots in 24H)
either / both:
1) restlessness / agitation
2) at least 1:
conjunctival injection
nasal congestion
eyelid edema
miosis/ptosis
face sweating
DIAGNOSTIC criteria for cluster HA
> 5 attacks:
Unilateral
orbital / temporal pain
1.5-3 hr (lots in 24H)
either / both: 1) restlessness / agitation
2) at least 1: conjunctival injection, nasal congestion, eyelid edema, miosis/ptosis, face sweating
DIAGNOSTIC criteria FOR IDIOPATHIC intracranial HTN
HI LOC
HA better with LP
Increased ICP signs: papilledema / vomiting
LP negative
Opening pressure >280 (peds) / >250 (adults)
CT normal
*VISUAL SYMPTOMS => transient photopsia, diplopia, pulsatile tinnitus
ROME CRITERIA
List PID diagnostic criteria
minimum
1) Lower abdomen pain OR
2) adnexal pain OR
3) CMT
Additional criteria
1) Fever >38.3
2) ESR/CRP
3) WBC on wet mount
4) G+C positive
5) cervix is friable / mucopurulent vag d/c
Definitive Dx Criteria
1) Endometrial bx w histopathologic evidence of endometritis
2) TV US - thickened fluid filled tubules +/- free pelvic fluid
3) gold standard- laparoscopy => abnormalities consistent w PID
What is the AMSEL CRITERIA
Need 3/4
1. thin, white, homogenous discharge - coats vaginal walls
2. clue cells on microscopy
3. vaginal fluid ph >4.5
4. fishy odor to discharge pre/post addition of 10% KOH
(bacterial vaginosis)
What is the WESSEL CRITERIA
crying no reason
>3hrs a day
>3d /week
in an infant <3mos old
different from normal: episodes of hypertonia, louder / higher / more variable, paroxysmal, non consolable
(infantile colic)
What’s the definition of BRUE
<1yr)
Brief (<1min)
Resolved (normal vitals / physical exam)
Unexplained
Event >1 of ABCT: aLOC / breathing - irregular, apnea / cyanosis, pallor / tone (hyper-hypotonia)
What is the Westley Croup SCORE
RASCL’s can get croup
Retractions (0-3)
Air entry (0-2)
Stridor (0-2)
Cyanosis (0/4 w agitation / 5 at rest)
LOC (0 normal / 5 altered)
Mild 0-2 / Mod 3-5 / Severe 6-11 / failure >12
What is the PRAM asthma score?
SSOWA
Suprasternal indrawing: 0 (absent) 2 (present)
Scalene retractions: 0 (absent) 2 (present)
O2 on RA: 0 (>93%) / 1 (90-93%)/ 2 <90%
Wheezing0(absent)/1(exp only)/2(exp+insp)/3(silent chest)
Air entry0(normal)/1(decr @base)/2(+decr)/3(minimal)
MILD0-3 / MOD4-7 / SEVERE8-12
components of Gorelick scale
General appearance
Eyes (sunken)
Tears
Mucous membranes
Breathing (i.e. kusmall)
Quality of pulses
Skin turgor
HR
Urine output
Cap refill
CATCH RULE
SIGH BBD
- Suspect open / depr’d skull #
- Irritable on exam
- GCS <15 @ 2H post
- History of worsening HA
- Basilar skull # signs
- Boggy hematoma large
- Dangerous mechanism
(vomit x4 => CATCH2)
Mechanisms
* fall >3ft / 5 stairs
* MVC
* Bike + no helmet
YES TO ANY - CT
inclusion / exclusion for CATCH
INCLUSION
* within 24h
* GCS 13-15
* <16yrs
* (Minor head injury):
* confused
* amnesia
* LOC - witnessed
* emesis >1 episode
* persistent irritability
EXCLUSION
* penetrating
* depressed skull #
* focal neuro
* developmental delay
* child abuse
* re-evaluate
* pregnancy
PECARN HEAD RULE
GAS / HALM
HIGH RISK vs CT
* GCS <15
* Altered LOC
* Skull # <2: palpable depressed / >2: basilar skull #
MEDIUM RISK - OBS vs CT
* H: <2 hematoma />2 HA
* Acting: <2 weird />2 emesis
* LOC: <2 >5seconds />2 any LOC
* Mechanism*
Mechanisms
* pedestrian
* ejection
* MVC death
* rollover
* fall >3ft (<2y) / >5ft (>2y)
* axial load
inclusion / exculsion criteria for PECARN
INCLUSION
* within 24H
* GCS 14
* <18yrs
EXCLUSION
* penetrating
* pre-existing neuro
* pre-hospital imaging
* no signs of trauma
* trivial injury
=> ground level fall
=> ran into things
CT HEAD RULE
65-2-2-2 / AD
HIGH RISK
* >65
* 2 fractures - basilar skull
* - open /dep
* 2 emesis
* 2HRS post injury; GCS <15
MEDIUM RISK
* Amnesia pre impact
* Dangerous mech
Mechanisms
* Pedestrian
* ejection
* fall >3ft / 5 stairs
inclusion / exclusion CT head rule
INCLUSION
* within 24H
* GCS 13-15
* (Minor TBI):
* BLUNT +
* confused
* amnesia
* LOC - witnessed
EXCLUSION
* pregnancy
* Penetrating
* pediatrics >16
* presenting twice
* prolonged >24H
* anticoagulated
* neuro def focal
* trauma unstable
* seizure pre ED
CT CSPINE RULE
HIGH RISK: DAP
* Dangerous mech
* Age >65
* Paresthesia
Low risk (5)
* simple rear ended
* sitting in ED
* ambulatory
* no midline neck pain
* delayed onset of neck pain
Mechanisms
* fall >3ft
* axial load
* ATV
* MVC high speed
* ejection
* roll over
* bike struck
INCLUSION / EXCLUSION FOR CDN C SPINE RULE
INCLUSION
* <48H + neck pain OR
* dangerous mech
* not ambulatory
* Injury > clavicle
* GCS 15
* >16
* blunt
EXCLUSION
* pregnancy
* penetrating
* pediatric <16
* presenting twice
* previous VB injury / pathology
* pev spin surgery
* paralysis
* no trauma
* unstable
NEXUS C SPINE RULE
NSAID
Neurologic deficit
Spinal tenderness (midline)
Altered LOC
Intoxication
Distracting injury
EPINEPHRINE DOSING
0.01mg/kg
allergy: 1mg/mL
cardiac: 0.1mg/mL
Infusion: 0.1-1mcg/kg/min
THROMBOLYTIC DOSING
PE (TPA)
cardiac arrest (50mg)
non arrest (10mg LD => 90mg / 2hrs => total 100mg Q24H)
STROKE
0.9mg/kg (max 90mg)
1.10% of dose (bolus), 90% of remainder of dose /1hr
STEMI
NON ARREST: 15mg / 2min then 0.75mg/kg (max 50mg) over 30min THEN 0.5mg/kg (max 35mg) over 60min
CARDIAC ARREST: 50mg IV
TPA CONTRAINDICATIONS (STROKE)
Absolute + relative
absolute
* ICH imaging
* active bleeding
relative:
* Any ICH
* CVA <3mos >4.5H
* ICH malignancy
* known intracranial AVM
* face/head trauma <3mos
* aortic dissection
* intra-cranial/spinal surgery <2mos
* HTN unresponsive to treatment (SBP >185 / DBP >110)
- Hx of ischemic CVA >3mos
- pregnancy
- recent internal bleeding 2-4wks
- major surgery <3wks
- active PUD
- sig HTN on presentation
stroke specific:
* SAH specific sx + normal CT
* PLT <100
* currently anticoagulated
* hypo/hyperglycemia
* minor symptoms / improving
* GI hemorrhage <21d
* GI malignancy
TPA CONTRAINDICATIONS (PE/MI)
ABSOLUTE / RELATIVE
Absolute:
* Any ICH
* Active bleeding
*
* CVA 3mos 4.5H
* ICH malignancy
* known intracranial AVM
* face/head trauma 3mos
* aortic dissection
* intra-cranial/spinal surgery 2mos
* HTN unresponsive to treatment
* (SBP >185 / DBP >110)
relative
* Hx of ischemic CVA >3mos
* pregnancy
* recent internal bleeding 2-4wks
* major surgery <3wks
* active PUD
* sig HTN on presentation
Cardiac arrest / PE specific:
* Traumatic (PTX, flail, pulm contusion, hemorrhage) or prolonged CPR >10min
* dementia
Drugs that cause SIADH
SIADH
SSRI
Ibuprofen, opiates
Anti-epileptic drugs; carbamazepine, VPA, SSRIs (i.e. sertraline), barbiturates
Diuretics - thiazide
Haldol
OTHERS:
Cancer drugs - anti-neoplastics, vincristine
Antipsychotics- haldol, thioridazine, amitriptyline, MOIs, SSRIs
Pain; opiates, NSAIDs
Exogenous hormone administration; vasopressin, desmopressin (dDAVP) or oxytocin
Thiazide diuretics
Cyclophosphamide
Drugs that cause SJS / TENS
O’SATTAN
OCPs
Sulfa drugs (septra, dapsone)
Allopurinol
Tetracycline - doxycycline. Other abx: levo, cipro, amoxicillin, ampicillin
Tb - rifampin (associated)
Antiseizure(PD-LC): phenobarb, dilantin, lamotrigine, carbamazepine
NSAIDs
viruses: mycoplasma, HSV
Drugs that cause DRESS
(also TENS/SJS): ASA
Antiseizures (PD-LC)- Phenobarb, dilantin, lamotrigine, carbamazepine
Sulfa - dapsone, septra
Allopurinol
DRESS specific:
Vanco
All of RIPE
Drugs that cause erythema nodosum
YESDOSUM (for all causes)
SITOP
Sulfonamides
Iodides
TNF alpha inhibitors
OCPs
Penicillins
Drugs that cause SLE
CHIMP
Chloropromazine
Hydralazine
INH
Methyldopa
Procainamide
Drugs that cause pancreatitis
PANCREAS
Propofol
Acetaminophen
NSAIDs/nitrofurantoin
Cannabis
Rifampin
Estrogen
ASA
Steroids / sulfa
List drug causes thrombocytopenia
CC I HATE PLTS
Cocaine
Chemo - cisplatin, cycospirin
Ibuprofen, IVIG
Heparin, LMWH, clopidogrel
Antiepileptics - phenytoin, VPA
Tylenol
Ethambutol
Penicillin
Lasix
TMP/SMX
Statins / Salicylates
DDX of increased QTC
Antipsychotic - haldol, olanzapine
anti-depressants - TCA, citalopram, lithium
anti-arrhythmic - procainamide, amiodarone
antibiotics - azithromycin, macrolides
anti-emetics - ondansetron, gravol
anti-malarial - quinine
Anti-histamine - benadryl
Increased ICP
hypothermia
hypoK/Ca/Mg
Hydrofluoric acid, ethylene glycol (2’ oxalate byproduct)
methadone
congenital - MVP, Romano-ward, Jarvell-Lange-Neilson
Drugs that cause TTP
ADA QI
Antipsychotic - Quetiapine
Drugs of abuse: cocaine, oxycodone ER
Antibiotics - septra, flagyl, penicillin
Quinine
Immunosuppressive - cyclosporin, IVIG, interferon alpha/beta
CYP450 INHIBITORS
Acute ETOH
antifungals (ketoconazole, fluconazole)
antiarrythmics (amiodarone, verapamil)
antidepressants (SSRI’s)
antiviral HAART
antibiotics - Sulfa, macrolides, fluoroquinolones, flagyl, erythromycin, clarithromycin
INH
PPI’s
NSAIDS, ASA
Tylenol, tramadol
INCR INR
CYP450 INDUCERS
CRAPS
Chronic ETOH
CRAPS
Carbamazepine
rifampin
alcohol (chronic)
Phenobarbital, phenytoin
sulfonylureas, St johns wart
dexamethasone
MISCARRIAGE RISK FACTORS
Age
parity
tobacco, ETOH, drugs
infection
trauma
fibroids
Hx of miscarriage
ECTOPIC RF
smoking, advanced age
PID
IUD
Tubal surgery (for tubal sterilization
hx: prior spontaneous abortion, medically induced abortion
Hx of ectopic
hx of infertility
Indications / contraindications for methotrexate
Indications
* Stable (hemodynamic)
* reliable
* BHCG <5000
* US:
- tubal mass <3.5cm
- no cardiac activity
- no evidence of rupture
Contraindications
* Bone marrow d/o: leukopenia, thrombocytopenia
* Hepatic disease
* renal disease
* heterotopic preg
* breastfeeding
MOLAR PREGNANCY RF
Previous
extremes of age (mostly >35)
spontaneous abortion
infertility
PREG INDUCED HTN RF
Extremes of age (<20 / >40)
Obesity, smoker, black
Parity: primigravida, nulliparity
twin / molar pregnancy
HTN hx: 1) chronic HTN
2) renal dz
3) Hx of pre-eclampsia
4) gestational HTN
5) vascular disease
Autoimmune: SLE, antiphospholipid, hyperthyroid
sleep disordered breathing
Invitro fertilization
Definition of PIH/gestational HTN
> 20wks
140/90
no proteinuria
no EOD
Definition of pre-eclampsia
<20wks PLUS
>140/90 (x2) or >160/110 (x1)
PLUS
proteinuria - dip / >0.3mg/dL
OR
EOD: CEELLP
Cr >1.5
Eyes - disturbances
Encephalopathy
LFTs x2ULN
Lung edema
Plt <100
DIAGNOSTIC criteria for HELLP
Hemolysis: @ least 2
- peripheral smear (schistocytes + burr cells)
- LDH x2 ULN OR haptoglobin down
- bili up
Elevated Liver enzymes: AST/ALT x2 ULN
Plts <100
CT findings of eclampsia
MEHH
microinfarcts
edema
hemorrhage - punctate
hemorrhage- cerebral
PLACENTAL ABRUPTION RF
Trauma
HTN
Twins
Tobacco
thrombophilia
age
parity
prev abruption
cocaine use
pre-eclampsia
What is the PALM COIN classification system
Polyps
Adenomyosis
Leimyoma
Malignancy
Coagulopathy => vWF, hemophilia, low plts, ITP
Ovulatory dysfxn
Endometrial
Iatrogenic
Not yet classified
Endocrine: weight related (anorexia/obesity, pregnancy, exercise, PCOS), hyperprolactinemia, Cushing’s, adrenal hyperplasia, hypothyroidism
ENDOMETRIAL CANCER RF
Obesity
later menopause
nulliparity
estrogen - 1) exogenous (tamoxifen) 2) unopposed (PCOS)
>35
DM
Contraindications for OCP
VTE risk
smoker
<35
pregnancy
HTN >160/100
IHD
CVA, migraines
breast CA
Liver cirrhosis
DM
OVARIAN TORSION RF
masses
Tumors
cysts >5cm - increases risk significantly
PCOS
IVF, hyperstimulation
pregnancy, reproductive age
hx of tubal ligation
List common CT / US findings of ovarian torsion
General
* Enlarged ovary
* Ovarian mass
* Ovarian edema
* Pelvic free fluid
US
* No venous flow
* No arterial flow
* loss of enhancement
* whirpool sign
CT
* FT thick
* hemorrhage
* uterus deviated to affected side
Anatomical differences btwn peds / adults C spine
Higher fulcrum (C2-C3: 2y => C5-C6: 8y)
pseudo-subluxation (C2-C3 in children <8-12y)
large head => greater flex / ex injuries
large occiput => head in flexion
Ligamentous injury > fractures
incomplete ossification = hard to read XR
spinal processes epiphysis = fractures
SCIWORA
pre-vertebral space (changes w inspiration)
General anatomical differences in peds
List 5 differences to ped metabolism / pharmacokinetics
List an inborn of metabolism ddx
High ammonia + acidosis
- fatty acid defect
- carb storage defect
- organic acidemia
High ammonia only
- urea cycle
No acidosis / No ammonia
- amino acid (= NO AA)
List components of the APGAR score
Activity
Pulse
Grimace
Appearance
Respiration
What are the low risk features of BRUE
> 60days
premature: >32wks, post conception age >45wks
only one BRUE (no hx of previous)
duration <1min
no CPR needed by trained medical provider
no concerning history
- including risk for child abuse
- resp illness
- recent injury
- symptoms in days preceding event
- medication
- vomiting / lethargy
- developmental dealy
- hx of sudden unexplained death in a sibling
normal physical exam / normal vitals
DDX for Stridor
XR findings of bacterial tracheitis
Narrowed subglottic space
ragged edge of usually smooth tracheal air column
hazy density within tracheal lumen
ddx for wheeze
Bronchiolitis
Croup
Pneumonia
TB
Bronchiolitis obliterans
GERD
Cystic fibrosis
CHF
Tracheo-esophageal fistula
Mediastinal mass
Vascular ring
Foreign body aspiration
Anaphylaxis
XR findings in bronchiolitis
atelectasis
diaphragmatic flattening
bronchial wall thickening
peri-bronchial cuffing
List cyanotic / acyanotic CHD lesions
List various CXR findings + their CHD
Common lead points causing intussusception
Peyer’s patches (inflamed lymphoid tissue)
HSP vasculitis
Meckel’s diverticulum
Lymphoma
Polyps
post surgical scars
celiac disease
cystic fibrosis
XR findings of intussusception
Target sign
crescent sign
meniscus sign
free air (if perf)
dilated small bowel
lack of air in cecum / large bowel
List etiology of maternal cardiac arrest
Anesthetic complications
Bleeding
Cardiovascular - takutsubos, PPMS
Drugs
Embolic (PE, amniotic)
Fever
General non obstetric causes of CA (H+Ts)
HTN (eclampsia)
Mechanism of hypercalcemia in cancer
- Hormone causes Ca release (PTHrP, prostaglandin, peptides)
- Metastatic disease (osteoclasts = release Ca / PO4)
- Lymphomas (secrete 1,25 OH)
- Ectopic hyperparathyroidism
What is the CIARO BISHOP score
LAB DX: 2 BW (25% incr / decr)
3d before / 7 d post chemo
* Uric acid (high)
* K >6
* phosphate (high)
* Calcium (low)
CLINICAL DX: Lab TLS+ 1 clinical
* AKI 1.5 xULN
* cardiac - arrythmia, sudden death
* neuro - seizures
Multiple myeloma findings
CRAB
Calcium up
Renal dysfunction
Anemia
Bone disease
Diagnostic criteria for polycythemia vera
HgB >185 (M) >165 (F)
Not hypoxic (O2 >92%)
splenomegaly
Polycythemia vera classification
- Apparent - dehydration
- Primary - myelodysplasia (myeloproliferative D/O)
- Secondary - CHF + shunt, COPD, sleep apnea, high altitude, COHgB
What is the MASCC risk score
5BB4CC3FF <60(2+)
Blood pressure (>90 = +5 / <90 = 0)
Burden of disease (5+ / 3+ / Severe = 0)
COPD (4+ not active / active = 0)
Cancer type (solid, hematologic, no prior fungal 4+ / prior fungal infxn + heme = 0)
Fluid (no dehydration = 3 / need fluids = 0)
Fever (temp outpatient =3 / temp in hospital = 0)
<21 = high risk
List low risk febrile neutropenia patients
no comorbid
no source of infection (PNA, line)
no acute leukemia
hemodynamically stable
MASCC >21
Obs 4hrs
onc doc agrees
compliant patient
access to phone / transport back to hospital
cipro 750mg PO BID + amox/clav
List high risk febrile neutropenia patients
comorbid
evidence of infection => PNA, SSTI, line, AMS, end organ damage
acute leukemia
HD unstable, organ failure
MASCC <21
uncontrolled cancer
expected neutropenia >10d
Piptaz/vanco +/- gentamicin if sick
peds - cefepime/ piptaz/ meropenem
blood products components
FFP: 4U (10cc/kg)
* F8
* fibrinogen
* clotting factors
CRYOPRECIPITATE: 10U = 4g fibrinogen (1U/10kg)
* F8
* F13, vWF
* fibrinogen (150mg/unit)
PCC: 30U/kg (max 3000)
* F2,7,9,10
* Protein C+S
* heparin
Adjuncts
* TXA 1g
* Vit K 10mg
* DDAVP 20mcg (incr F8, vWF release)
Meds to avoid in G6PD
BARF’N MEDS
BAL (dimercaprol)
Amyl nitrite, all nitrites
Rasburicase - can cause metHb
Fluroquinolone - ciprofloxacin, moxifloxacin
Nitrofurantoin, nitroprusside
Methylene blue
EMLA (prilocaine)
Dapsone
Sulfonylureas - glipizide, glyburide
List:
Extrinsic pathway factors
Intrinsic pathway factors
Common pathway factors
Vitamin K dependent factors
extrinsic: 7
intrinsic: 8, 9, 11, 12
common pathways: 10, 5, 2 (prothrombin), 1
vitamin K dependent factors: 2, 7, 9, 10
list anticoagulation + reversals
Heparin (Protamine 1mg / 100U UFH)
Thrombin (2a)
* aPTT
LMWH (Protamine 1mg /1mg LMWH)
Xa
* Anti-Xa
Warfarin (Vit K, PCC(octaplex) / FPP)
Vit K antagonist
* INR
Dabigatran (Praxbind 5mg)
Thrombin (2a)
* TT
Apixaban/Rivaroxaban (Andexanet alfa, octaplex )
F10a
* anti Xa
Definition of DKA vs HHS
DKA
* Glc >11.1
* AG >12
* Bicarb <15
* pH <7.3
* BUN 25-50
* + ketones
HHS
* Glc >33 mmol/L
* AG variable
* Bicarb >15
* pH >7.3
* BUN >50
* no ketones
* osmoles >330 mOsm/L
What is the Burch Wartofsky Score
Thyroid Problems Make Fattys Go Crazy
Tachycardia
Precipitating event (ACS, MI, PE)
Mental status
Fever
GI/hepatic symptoms
CHF
> 45: thyroid storm / 25-44: impending storm / <25: unlikely
Common causes:
thyroid storm
(can use similar for myxedema coma)
PTSSSD I3
Pregnancy
Trauma - penetrating / blunt to gland, burns
Sugar - DKA, HSS, hypoglycemia
Surgery
Stress
Drugs - thyroid hormone, lithium
Infection, sepsis
Ischemia - MI, PE, CVA
Iodine - amiodarone, contrast
What doses of prednisone causes an incr infection rate
> 20mg/day
700mg total
30days duration
List 4 types of immune rxns + examples
ACID
Allergic
i. IgE mediated
ii. Mast cell mediated
* Anaphylaxis
Cytotoxic (Antibody / IgG/IgM)
* Blood transfusion (ABO incompatibility)
* RH reaction
Immune (Immune complexes)
* Serum sickness
* reactive arthritis
Delayed hypersensitivity (T cell)
* Contact dermatitis
* DRESS /erythema multiforme, SJS/TENS
What is the diagnostic criteria for anaphylaxis
- Known exposure PLUS hypotension
- Likely exposure PLUS (2 of):
- Mucosal / skin involvement (hives)
- Resp involvement (wheezes, SOB etc)
- GI involvement - N/V
- Hypotension
- Unknown exposure/allergy PLUS skin/mucosal involvement AND (1 of)
- Resp involvement
- Hypotension
List 4 types of angioedema (besides allergic) + mechanism
Allergy - histamine mediated
Hereditary - bradykinin (C1 inhibitor deficiency)
Acquired - bradykinin (C1 inhibitor deficiency)
ACEi induced - aCEi induced (ACE activates bradykinin)
Idiopathic - bradykinin (unknown)
What is the diagnostic criteria for SLE
SOAP BRAIN MD
Serositis [pleuritis, effusion, pericardial effusion / pericarditis]
Oral ulcers [palate, buccal, nasal, tongue]
Arthritis [>2 joint, >30min AM]
Photosensitivity
Blood d/o => pancytopenia
Renal d/o [++protein, red blood casts]
ANA
Immuno criteria
Neuro d/o [seizures, psychosis, CN neuropathies, confusion state]
Malar rash
Discoid rash
DDX for large / medium / small vessel disease
Large
* GCA
* Takayasu’s
Medium
* Pan Nodosa Arthritis
* Buerger’s disease
* Kawasaki’s disease
Small
* Bechet’s disease
* Goodpasture’s disease
* Wegner’s granulomatosis
* Microscopic polyangiitis
* Churg-Strauss dz
* HSP
* ANCA associated
Diagnostic criteria for Bechet’s disease
> 3 oral aphthous ulcers / year PLUS 2 or more:
* recurrent genital lesions
* recurrent eye lesions (uveitis cells, retinal vasculitis)
* recurrent skin lesions (erythema nodosum)
* pathergy test (non specific hypersensitivity test)
DDX for arthritis
Monoarticular
* Osteoarthritis
* Septic arthritis
* Gout / pseudogout
* Trauma
Polyarticular - Symmetric (PAPER)
* Polymyalgia rheumatica
* Ankylosing spondylitis
* Psoriatic arthritis
* Enteric arthritis
* RA
Polyarticular - Asymmetric
* Disseminated gonococcal
* ARF - post GAS
* Lyme
* Reactive
* Viral - dengue, chikungunya
* rat bite fever
XR findings of septic joint
Subchondral bone destruction
periosteal new bone
joint space narrowed / lost
osteoporosis
joint effusion
XR findings of degenerative changes
Asymmetrical joint space narrowing
sclerosis of juxta-articular bone
bone spurs (subchondral)
subchondral cysts
sclerosis
no osteoarthritis
Common causes for reactive arthritis
YESS-CV
Yersinia
E coli
Shigella
Salmonella
Campylobacter
Vibrio
Gonorrhea, chlamydia
XR findings of RA
Osteoporosis (peri-articular bone)
symmetrical joint space narrowing
marginal erosions
little reactive bone formation
Diagnostic criteria of PMR
50/40/30
Age >50
ESR >40
Bilateral hip/shoulder pain x 30 days
Drugs that cause SIADH
SIADH POC
SSRIs
Ibuprofen
Anti-epileptics: carbamazepine, VPA, phenobarb
Diuretics - thiazide
Haldol
Pain meds: opiates, NSAIDs
Oxytocin
Cyclophosphamide
DDX for osmol gap
ALCOHOL
* Methanol
* ethylene glycol
* propylene glycol
* isopropanol (no AG)
* ethanol
* Acetone
SUGAR
* Mannitol
* sorbitol
FAT
* Hyperlipidemia
PROTEIN
* MM
* gamma globulins
DDX for double gap
RAMMED
Renal failure
alcohol ketoacidosis
Methanol
multiorgan dysfunction
Ethylene glycol
DKA
DDX for AGMA
MUDPILES
Methanol
urea
DKA
Paraldehyde / APAP
Iron / isoniazid
Lactic acidosis
Ethanol
Salicylate / ASA /aspirin
DDX for non-AGMA
HHAARD UP
HyperCl
HyperPTH
Addisons
Acetazolamide
RTA
Diarrhea
Uretero-enteric fistula
Pancreato-enteric fistula
DDX for metabolic alkalosis
CLEVER
Contraction alkalosis (diuretics)
Licorice
Endo - Conn’s, Cushings
Vomit
Excess alkali (bicarb)
Refeeding
Common causes for pill esophagitis
PILLS
phenytoin, penicillin
Iron, Ibuprofen
L-arginine
Lincomycin
Steroids
Diagnostic criteria for non ulcerative dyspepsia
Recurrent abdo pain
>1mo
Pain present >25%
no organic disease
Management of H pylori
14d PO
Bismuth therapy (PF - TB)
* PPI
* Flagyl
* Tetracycline
* Bismuth
Non Bismuth therapy (PF - AC)
* PPI
* Flagyl
* Amoxicillin
* Clarithromycin
List causes (10) of acute liver failure
ABCDEFGHI
A - acetaminophen, Hep A, amanita phalloides
B - Budd Chiari, Hep B
C - Hep C, cancer
D - drugs, toxins
E - ETOH, EBV
F - fatty liver
G - genetic => Wilson’s
H - HSV, HELLP
I - Ischemia, sepsis, shock
How to diagnose:
primary
secondary
PD peritonitis
PRIMARY
* >250mm PMNs
* + ascites fluid culture
SECONDARY: RUYON’S CRITERIA (need 2):
* glc <2.8mmol/L
* protein >10g/L
* LDH > upper limit of normal
PD
+ dialysate fluid culture
OR >2 of:
* dialysate PMN >100
* +effluent fluid
* cloudy fluid/abdo pain
What is the diagnostic criteria for HRS
Chronic / acute hepatic disease with advanced hepatic failure + portal HTN
AKI (Cr >150)
* absence of other apparent cause of AKI
* no parenchymal disease: protein >500mg/day, microhematuria >50cells/hpf
* Failure to improve despite fluid replacement, stopping diuretics, albumin
List false positives / negatives of hemoccult blood
False positive
* Bismuth
* iron
* red meat
* NSAIDs
False negative
* Pepto bismol
* Beets
* Magnesium.
* Spinach
What are the components of the BLATCHFORD score
Lab
1. BUN
2. HgB
3. SBP <110
4. HR >100
Clinical
1. Melena
2. Syncope
3. CHF
4. Hepatic disease
0 = low risk / >0 = high risk
Assesses need for intervention in UGIB
What are the components of the ROCKALL score
ABCDE
Age <60
BP / HR - evidnece of shock
Comorbidities (liver dz, CHF)
Diagnosis (mallory weiss = no lesion = 0)
Endoscopic findings of recent bleed
<3 = low risk / >8 = high risk
Assesses risk for bad outcomes (recurrent bleeds/death)
High risk patients for neurotoxicity
PHATLAAS
Preterm
Hemolysis - G6PD, hereditary spherocytosis
Acidosis
Temperature instability
Lethargy
Albumin - low
Asphyxia
Sepsis
List causes (10) of pancreatitis
II GETT V SMASHED
Idiopathic
Ischemia
Gallstones
ETOH
Tumors - ampullary tumor, pancreatic carcinoma, neuroendocrine tumor
Trauma - penetrating, blunt
Vascular - hypoperfusion, embolism, ischemia, hypercoagulopathy, vasculitis
Steroids
Mumps - viral: coxsackie, HIV, CMV, EBV, varicella, bacteria: TB
Autoimmune
Scorpion bites
Hyperlipidemia, hypercalcemia, hyperuremia, hereditary
ERCP - post
Drugs**
List drugs (5) that cause pancreatitis
PANCREAS
Propofol
Acetaminophen
NSAIDs
Cannabis, cancer meds: cisplatin, cyclosporine
ETOH
ASA
Sulpha drugs, steroids
What is the ATLANTA classification
- No organ failure, no systemic complications
- No organ failure <48H, some systemic complications
- Organ failure >48H
DDX for elevated lipase
Pancreatitis
Pancreatic tumor
Pancreatic stone
T2DM
DKA
PUD
peritonitis
bowel obstruction / infarction
Celiac disease
IBD
post ERCP
cholecystitis
renal failure
Ectopic pregnancy
List 4 scoring systems to predict severe pancreatitis
Ranson’s
APACHE II
BISIP
CTSI score
What are the components of the RANSON criteria @ admission + 48H
@ admission
* Glc >11.1
* Age >55
* LDH >350
* AST >250
* WBC >16
@48H
* Ca < 2mmol/L
* Hct 10% drop
* paO2 <60
* BUN <2 (1.8mmol/L)
* Base deficit 4
* Sequestration of fluid >6L
What is the ALVARADO score + what does it mean
SIGNS
* RLQ +
* Fever
* rebound tenderness
SYMPTOMS
* Migration of pain to RLQ
* nausea
* anorexia
LABS
* WBC >10
* leuk L shift
<4 = low risk
>6 = high risk
List extra-intestinal manifestations of IBD
A PIE SACK
Apthous ulcers, anemia of chronic disease
Pyoderma gangrenosum, psoriasis
Iritis, uveitis, scleritis, episcleritis
Erythema nodosum
Sacrolitis, sclerosing cholangitis (GI?)
Arthritis (crohns), ankylosing spondylitis
Clubbing of fingers
Kidney stones
Causes / risk factors for low flow priapism
STILL HARD
Spinal cord injury, CVA, seizure d/o
Toxic – black widow spiders
Illicit drugs – ETOH, cocaine, marijuana
Leukocytosis – leukemia, MM, SCD
Hypertensives – labetalol, hydralazine, prazosin
Anticoagulation – warfarin / heparin stopped
Ritalin
Depression – SSRI, trazadone, antipsych (risperidone)
other: cancers - bladder, prostate Ca, RCC mets
Drugs that cause priapism
LIMP DD
Labetalol, hydralazine, prazosin
IV heparin, stop warfarin
Methylphenidate
PDE-5 inhibitor
Drugs of abuse: ETOH, cocaine, marijuana
Depression: trazodone, risperidone
DDX for urinary retention
DOON
Drugs
* Antihistamines
* Anticholinergics
* Antidepressants
* Antispasmodics
* Amphetamines
Obstructive
* BPH, Prostatitis
* Tumor
* Phimosis meatal stenosis
* Foreign body
* Stricture
Other
* Trauma - rupture
* UTI
* prostatitis
* urethritis
* Lazy bladder syndrome
Neurologic
* Spinal shock
* spinal cord injury
* MS
* Herpes zoster
* DM
Renal DDX for pain associated w urolithiasis
Renal infarct, hemorrhage
renal tumor, urothelial tumors, metastatic tumors (of upper + lower urinary tract, ureter)
pyelonephritis
previous surgery (stricture)
urinary retention
papillary necrosis
DDX for:
hyaline casts
RBC casts
WBC casts
Granular / muddy brown casts
Eosinophilic casts
hyaline casts => dehydration, exercise, glomerular proteinuria
RBC => GN, vasculitis
WBC => pyelonephritis, papillary necrosis, renal parenchymal inflammatino
Muddy => ATN
Eosinophilic => AIN
What diagnostic criteria for nephrotic syndrome
HYPOproteinemia (serum albumin low)
Proteinuria
A) >3g/day OR
B) single spot urine collection
PR/CR >3mg/dL
Edema
HYPERlipidemia
Diagnostic criteria for contrast induced nephropathy
Rise of Cr >25% from baseline
24-48H within exposure
AND
1. non oliguria
2. usually ATN
3. absence of other causes
Drugs that cause rhabdo
MASSSS
MAOi
Anti-psychotics (NMS)
Statins
Steroids
Sympathomimetics
SSRIs (Serotonin syndrome)
Volatile anesthetics, SCh (MH)
DDX for desquamating rash
SJS / TENS
Strep TSS
Staph TSS
Staph SSS
erythroderma
burns (thermal, radiation)
pemphigus vulgaris
bullous pemphigus
kawasaki
Drugs that cause erythema nodosum
SITOP
Penicillins
OCPs
Sulfonamides
Iodides
TNF alpha inhibitors
Causes for erythema nodosum
YESDOSUM
Yersinia, salmonella, campy
EBV (mono) + other viruses: HSV, HIV, HEP
Strep (GAS MCC)
Drugs
OCP + preg
Sarcoidosis, SLE, Bechet’s
Ulcerative colitis, crohn’s disease
Malignancy
Anti-epileptics that cause SJS/TENS/DRESS
PD LC
Phenobarb
Dilantin
Lamotrigine
Carbamazepine
Diagnostic criteria for atopic dermatitis
Itchy skin PLUS (3 or more)
1. hx of skin crease involvement
2. generalized dry skin
3. hx of hay fever / asthma
4. rash onset <2yrs flexural surfaces involved
What is Mackler’s triad
Indicates spontaneous esophageal rupture
1. subcutaneous emphysema
2. chest pain
3. vomiting
List ROPER HALL classification
Grade 1
* corneal epithelial damage
* no limbal ischemia (good prog)
Grade 2
* corneal haze, iris details visible
* <1/3 limbal ischemia (good prog)
Grade 3
* total epithelial loss, stromal haze, iris details visible
* 1/3-1/2 limbal ischemia (guarded prognosis)
Grade 4
* cornea opaque, iris + pupil obscured
* >1/2 limbal ischemia (poor px)
List the DUA classification
Grade 1
* 0 o’clock limbus involvement
* 0% conjunctival involvement
Grade 2
* <3 o’clock
* <30%
Grade 3
* 3-6 o’clock
* <30-50%
Grade 4
* 6-9 o’clock
* 50-75%
Grade 5
* 9-12 o’clock
* 75-100%
Grade 6
* whole limbus
* 100% conjunctival involvement
List the GRADES of hyphema
Gr. 1: up to 1/3
Gr. 2: up to ½
Gr. 3: >1/2 but not full
Gr. 4: full
ABX for MRSA
PO clindamycin, septra, doxycycline (>8yr), rifampin
IV: linezolid, vanco, daptomycin
Mupirocin
ABX for pseudomonas
Piptaz
gentamycin, tobramycin
ceftazidime, cefepime, ciprofloxacin
imipenem, meropenem
Indications for prophylactic ABX
Dental procedure plus
* hx of endocarditis
* prosthetic valve
* cardiac valvopathy (transplanted heart)
* unrepaired cyanotic CHD
* repaired CHD => 1) w prosthesis: 6mos 2) residual defect
BHCG discriminatory zones
TAUS: HCG 6000
TVUS : HCG 1500 - 3000 (upper)
gestational sac 1000
yolk sac 2500
fetal pole 5000
FHR 7000
US criteria for abnormal pregnancy
No FHR + 1) 10wks OR 2) 5mm CRL
BHCG >3000 + no gestational sac
Gestational sac >25mm + no fetus
Gestational sac >13mm + no yolk sac
List a ddx for metHgB
Naphthalene
Methylene blue
nitRITES
* amyl nitrite
* Na nitrite
* nitroprusside
* nitric oxide
nitRATES
* well water
anti-biotics
* sulfa
* dapsone
anti-malarial
* quinones
* chloroquine
anti-neoplastic
* cyclophosphamide
topical anesthesia
* benzocaine
* lidocaine
* prilocaine
congenital causes:
* NADH metHb reductase (can’t reduce Fe=> Fe2+)
* G6PD deficiency (can’t make NADH)
NNAAAT
Differentiate btwn organic + functional cause of psychosis
Organic
* Acute onset
* any age
* fluctuating LOC
* Disorientated
* attention disturbances
* poor recent hx
* hallucinations
* cognitive changes
* abnormal vital signs
* nystagmus
* focal neuro signs
* signs of trauma
Functional (PSYCH)
* Onset over wks - months
* age onset 12-40yrs
* alert
* orientated
* agitated, anxious
* poor immediate memory
* hallucinations (auditory)
* delusions, illusions
* normal vitals
* no nystagmus
* purposeful movement
* no trauma
Indications for surgical mgmt
Vegetarians
Hate
BEF
Vegetation OR peri-annular extension
Heart failure
Bacteremia (persistent)
Emboli, recurrent
Fungal
BP stroke targets
Ischemic (no TPA) <220 /120
20% reduction /24H
Ischemic (TPA) <185/110
Post TPA / during <180/105
ICH <140-160 / MAP <130
* CSBP + UTD
SAH <140-160 / MAP <130
meds that cause a myasthenic crisis
BB – labetalol, metoprolol, propranolol
class 1 anti-arrythmics - procainamide, quinidine
NMB
Bolulinum toxin (don’t get botox)
Mg
Antibiotics:
- Aminoglycosides – gentamicin, tobramycin
- Fluoroquinolones – ciprofloxacin, levofloxacin
- Macrolides – azithro, clarithro
Lithium
Steroids
Phenytoin, phenobarb, carbamazepine
meds that cause bradycardia
PACED
P - propranolol (b-blockers), poppies (opioids), physostigmine
A - anticholinesterase drugs, anti-arrythmias
C - clonidine, CCB
E - ethanol / other alcohols
D - digoxin, digitalis
(others - organophosphates, barbiturates)
List a differential for hemoptysis
Non infectious
* Bronchitis
* Congenital - cystic fibrosis
* trauma
* foreign body
* Vasculitis - SLE, goodpastures, Wegners
* PE
* pulm HTN
* AVM
* cancer
Infectious
* TB
* fungal - aspergilliousis, blasto, cocciodio
* bacteria - S aures, legionella, klebsiella
* Ebola
* Hanta
* parasites
Bioterrorism
* Anthrax
* tularemia
* plague
* hemorrhagic fevers (Dengue, malaria, chikugunga)
* mustard gas
P4 yellow
Early / Late complications of tracheostomy
Early
- Bleed
- infection
- pneumothorax
- Pneumomediastinum
- air embolism
- accidental decannulation
- Obstruction
Late
- Stenosis - trachea, stoma, tracheomalacia
- fistula - tracheo-arterial, tracheo-esophageal
- trach tube dislodged
- Dysphonia
- Dysphagia
- obstruction
- aspiration
- Nosocomial PNA
Causes for respiratory failure
hypoxic
normal A-a gradient
1. hypoventilation
* central (opioids, sedatives)
* chest wall
* NM: GBS, MG, botulism, ALS
* lung disease
- low inspired O2
Decreased A-a gradient
1. Improves w O2
* pneumonia, PE, COPDE
* interstitial lung dz
2. does not improve w O2 (SHUNT)
* cardiac shunt
* severe pneumonia / edema
Causes for non cardio pulm edema
(ARDS)
HAPE
ARDS
TRALI
Inhalational injury
Aspiration - gastric contents
Submersion / drowning
near hanging / strangulation
Re-expansion pulmonary edema
ICH / bleed
Ovarian hyperstimulation syndrome
Envenomation
Drugs: ASA, Narcotics, cholinergics, TCA, bleomycin, amiodarone, barbiturates, fentanyl
vent setting:
FiO2 88-95%
RR20
VT6cc/kg
PEEP 5-10cmH20
Pplat <30 cmH20
pH 7.3-7.45
Asthma pathophysiology
ABER
Airway inflammation
Bronchial hyperreactivity
Edema, mucous, hypertrophy of airway
Remodeling
Most common causes COPDE
(Bacteria/Viral/non infectious)
VIRUS
* Rhinovirus
* RSV
* Influenza
* coronavirus
BACTERIA
* S pneumo
* H flu
* Moraxella catarrhalis (classic)
* pseudomonas
NON INFECTIOUS
* med non compliance
* CHF
* PTX
* Allergies
* MI
* PE
List indications for NIPPV in COPDE
BLOODGAS:
* PH <7.35
* CO2 >45
RESP DISTRESS:
* RR>25
* Mod - severe dyspnea
* accessory muscle use
* paradoxical breathing
DDX FOR ECG changes
STE / STD , peaked T, TWI
DDX For osborne J waves
Hypothermia
ICH /SAH
sepsis
HyperCa
ddx for PVCs
Hypoxia, acidosis
hypoK, hypoMg
Digoxin
ETOH
Na channel blockade
MI, blunt cardiac injury
ddx for U waves
hypoK/hypoMg
barium
beta agonists
caffeine
sepsis
Electrolytes + ECG findings
What is the KILLIP SCORE
30d mortality with acute MI
CLASS 1: no signs of HF (3%)
CLASS 2: crackles, S3, incr JVP (10%)
CLASS 3: acute pulmonary edema (15%)
CLASS 4: cardiogenic shock (>30%)
DDX for false positive troponin
Myopathies
hemolysis
Fibrin
ALP elevated
lab error
heterophile antibodies
Describe pathophys of ACS event
Plaque ruptures (endothelium damaged)
Plts aggregate
Thrombosis forms
Coronary vasoconstriction
Reperfusion injury
Emergent indications for cath referral
Refractory NSTEMI pain
Ischemia causing:
- flash pulm edema
- cardiogenic shock
- refractory arrythmia
STEMI
- deWinter T wave
- Wellens
failure of lytics or re-stenosis
Indications for lytics if door to needle >120min
no contraindications to lytics
ischemic symptoms <12H
ongoing ischemia (12-24H) after symptom onset
long delays more than 120min
ECG findings of AIVR
accelerated idioventricular rhythm
WCT >100msec
no p waves
rate 50-110
Indications for a 15lead EKG
All inferior STEMI
STE or STD in V1-V3
Equivocal STE in inferior or lateral leads
Hypotension + ACS
What is WELLEN’S SYNDROME / DE WINTER T WAVE criteria
Diagnostic criteria of Q WAVES
> 1mm wide
2mm deep
25% of QRS
List the DIAGNOSTIC CRITERIA for prinzmental angina
Nitro responsive
ECG - transient ischemic changes
Angio - shows coronary artery spasm
List risk factors for SCAD
(spontaneous coronary artery dissection)
Post partum, multiparity
Hormone therapy
F>M
Fibromuscular dysplasia
Connective tissue disorder
Systemic inflammatory conditions
Diagnostic criteria for BER
No reciprocal changes
No isolated STE (inferior / limb leads)
J point elevation <3.5mm, max seen in V2-V5
STE <2mm in precordial leads / <0.5mm limb leads
Fish-hook => notching of terminal portion of QRS @ J point
[mech] HIGH OUTPUT failure
Heart function is fine => can’t keep up with increased demand
- increased CO
- low SVR (peripheral vasodilation / AV shunt)
- low arterial - venous O2 content diff
Causes of HIGH output failure
AV fistula
Pregnancy
severe anemia
thyrotoxicosis
morbid obesity
liver failure / cirrhosis
carcinoid syndrome
sepsis
Genetic types of cardiomyopathy
Ddx for epsilon waves
ARVC
RV infarction
sarcoid
infiltrative disease
Risk factors for peripartum CM
Known myocarditis
use of tocolytics
cocaine use
Pre-eclampsia
genetic pre-disposition
advanced age
twins, multipariety
obesity
Restrictive causes of CM
Amyloidosis
sarcoidosis
Gaucher’s disease
neoplastic infiltrative
hemochromatosis
Fabry’s disease
summary of valvular dz
Causes of constrictive pericarditis
Idiopathic
post-infectious
viral
trauma
Cancer
Post radiation therapy
Drug induced
post cardiac surgery
systemic rheumatic dz
asbestosis
sarcoidosis
Uremic pericarditis
List causes of myocarditis
Differential for pericardial effusion
List POCUS findings with tamponade
Pericardial effusion
RV collapse during diastole (most specific)
RA collapse during systole
Ventricular interdependence (RV collapse + LV fills)
IVC distension
Causes of pneumopericardium
idiopathic, valsalva
iatrogenic - endoscope, ETT, thoracentesis
asthma
Infection w gas forming organisms
trauma / barotrauma - PEEP
labor
cocaine inhalation
Risk factors for short term poor outcome in syncope
Cardiac syncope:
* No prodrome / palpitations
* long duration
* exertional onset
* seated at onset
others:
* +SF
* >65
* Male
* HX of 1) fam sudden death 2) structural heart dz 3) arrythmia
List causes of MOBITZ 2
Describe pacemaker codes
Paced: Atria / Ventricle / Dual / O - none
Sensed: Atria / Ventricle / Dual / O - none
Response: Triggered / Inhibited / Dual / O - none
Programmability: P - simple / M - multiprogrammable / R - rate adaptive / C-communicating / O- none
Anti-tachycardia function: pacing / Shock / Dual
Initial temp PM settings
Rate 80
Output 5mA
Sensitivity 3mV
Complications of PM insertion
Explain diff pacemaker syndromes
Causes of pacemaker malfunction
Indications for an ICD
(primary + secondary prevention)
Primary
* MI + EF <30%
* CM + EF <35% + nyha 2/3
* high risk for VT/VF:
- brugada
- congenital long QTC
- ARVC
- HOCM
Secondary
VF/VT (arrest, unstable) with no reversible cause
Sustained VT + underlying disease
* dilated CM
* CAD
* channelopathy
* valvular
Causes of ICD malfunction
Change in shock freq
* Oversensing
* lead displacement
* incr in VT/VF
* trying to shock SVT
Syncope / lightheaded
* Not pacing brady
* low battery = trying to shock VT
* SVT w HD compromise
Cardiac arrest
* Missed defibrillation
List 3 Interactions with warfarin
INCR INR = CYP450 INHIBITORS
acute ETOH intoxication
ALSO: garlic, ginko, mango, papya
Other options for rhythm control
AF PIS
amiodarone
flecainide
propafenone
Ibutilide
Sotalol
Causes of WPW
Idiopathic
Ebsteins anomaly
HOCM
Transposition of the great vessels
endocardial fibroelastosis
MVP
Tricuspid atresia
ECG findings of MAT
3 diff P waves
varying PR, RR
Irregular
HR >100
mgmt: CCB, BB, electrolytes, TV pacing, ablation
Effects of amiodarone
ACUTE
* Hypotension
* hyperthyroidism
* prolonged QRS/QTC
* DECR contractility
CHRONIC
* Pulmonary toxicity => fibrosis
* hypothyroidism
* skin photosensitivity
* corneal deposits
* GI tolerance
* Drug toxicity => warfarin, dig, pheny
Diagnostic Criteria for TORSADES
Ventricular rate >200
undulating baseline of QRS axis
paroxysms last <90seconds
Two types of Torsades
Types of BRUGADA SYNDROME
What are vagal maneuvers
includ to perform on a baby
Bearing down (Valsalva maneuver)
blow into 10cc syringe sitting => supine with legs up
children
* blow into a occluded straw
* baby:
* assuming head down position (15-20sec)
* Bag containing a slurry crushed ice + water to face
* rectal stimulation using a thermometer
Methods to differentiate VT vs SVT
Griffith
Brugada
Verecki
Wellens
What is GRIFFITH CRITERIA
No RBBB/LBBB (V1/V6)
no AV dissociation
= SVT
Causes of electrical storm (10)
Increased QTC syndrome, WPW, HOCM
Torsades
ischemia
CHF
electrolyte - hypoK, hypomg, hypoCa
drugs - hydrocarbons, epinephrine, cocaine
How does drowning effect pulm surfactant / mechanisms for hypoxia
- Surfactant washout
* Alveolar collapse = bronchospasm / laryngospasm
* Atelectasis - VQ mismatch (aspiration during drown)
- Intrapulmonary shunting
aspirated ~1cc/kg = surfactant wash out
intravascular abnormalities 10cc/kg
Effects of SUBMERSION injury
CNS: Hypoxemic ischemic result
RS: incr infxn risk, aspiration of gastric contents, non cardiac ARDS
Temp/hypoxemia/acidosis causes:
- dysrhythmias
- rhabdo
- DIC
Protective factors against submersion injury
Increasing age
warm water
duration / degree of hypothermia
Diving reflex (blood shunts to CVS/CNS)
how hard they tried to resuscitate
What is IMMERSION syndrome
Syncope when you’re in water >5deg colder than body temp
triggers a cardiac arrythmia via
1) vagal stimulation (aystole)
2) sympathetic response (VF 2’ QT prolongation)
Indications for intubation in drowning
SpO2 <90%
PaCO2 >50
respiratory distress
loss of airway reflexes
significant head or chest associated trauma (anticipated course)
mechanism of AE vs AV formation
Complications of intact vs repair AAA
Intact
* Rupture
* Thrombosis
* paralysis
* AE + AV fistula
Repair
* Endoleak
* ischemia (limb, renal, pelvis)
* paralysis
* AE fistula
* device migration
* infection of graft
* bleeding
* pseudoaneurysm
List ddx for widened mediastinum
Thyroid gland
thymoma
lymphoma
cardiac tamponade
positioning
aortic dissection / aneurysm
venous bleeding (from clavicle / rib #)
mediastinal lymphadenopathy
esophageal rupture
What meds are bad (AD)
Hydralazine
Nifedipine
Nitroprusside (if you give before BB)
due to reflex tachy => minimal chronotropic / inotropic effects
List complications from AD
Difference btwn vascular + neurogenic claudication
diagnostic criteria for Rayneuds
Criteria:
triphasic attacks - white / blue /red
1. cold / emotion
2. last 2yrs
3. no other cause (scleroderma, RA, SLE)
4. minimal evidence of ischemia
5. bilateral
Criteria for Buergers
Criteria
- hx of smoking
- no other atherosclerotic RF
- >50YRS
- upper limb OR phlebitis migrans
- infra-popliteal artery occlusion
- exclusion of autoimmune dz, thrombophilia, DM and prox embolic source
small-med sized vasculitis
List indications for angiography in vascular disease
Positive EAST [3min, symptoms]
20mmHg BP difference (btwn arms)
Bruit
evidence of distal emboli
Complications of AV fistulas
- bleeding
- thrombosis
- infection
- aneurysm / pseudoaneurysm
- dialysis access steal syndrome (hand ischemia)
- neuropathy
- high output heart failure
Ddx for DIMER (summary)
+ and false negative
(+) DDIMER
Trauma
Burn
crush
rhabdo
preg
inflammation
cancer
DIC
infection
ischemia
age
False negative
* Early clot
* old clot
* small clot burden
* warfarin (d dimer reduc)
* deficient fibrinolysis
List a ddx for DVT
Chronic venous insufficiency / venous stasis
baker’s cyst
trauma
fracture
compartment syndrome
cellulitis
muscle strain / hematoma
CHF
Vasculitis
superficial thrombophlebitis
claudication / ischemia
intra-abdominal compression (venous)
Who specifically needs warfarin (DVT /PE)
Antiphospholipid antibody
renal impairment
drug interactions
extremes of weight
conditions that impair oral absorption
Contraindications to anticoagulation (DVT)
Use of IVC filter
acute bleed
ICH
Bleeding diathesis
major trauma
List indications for anticoagulation for isolated DVT
Pregnancy
severe symptoms
risk of extension
unable or unwilling to return for serial studies
progression of DVT on rpt US
List risk factors for isolated DVT extension
> 5cm
close to popliteal vein
multiple deep veins
no reversible risk factors
hx of VTE
In patient
active cancer
positive D dimer
**pregnancy
What is the management for DVT
List complications of DVT
PE
Pulm HTN
Recurrent DVT
post thrombotic syndrome - chronic venous insufficiency
- Varicose veins
- Chronic pain, edema
- Infection risk
- Skin changes
Non healing ulcers
List predictors of mortality in PE
(high risk features)
Hypotension SBP <90
RV failure
RV dilation (ECHO)
BNP + / troponin +
Indications for TPA in PE
Cardiogenic shock
persistent hypotension (SBP <90)
Circulatory collapse - syncope +/- CPR
Consider: RV strain, persistent hypoxemia, extensive embolic burden
- free floating thrombus (RA/RV)
SUBMASSIVE VS MASSIVE pe
List types of ovarian
follicular (pathologic when >3cm)
Corpus luteal (>3cm)
Endometrioma (chocolate)
Malignant neoplasms
Non neoplastic
a. Fibroma
b. Cystadenoma
c. teratoma (dermoid cyst)
Menstrual cycle review
FOLM (avg 28d)
follicular => day 1 (low estrogen + progesterone)
- Estrogen rise
- Endometrium thickens
- Follicle releases ovum
Ovulation - end of follicular phase (day 14)
- LH surge
Luteal
- Progesterone (by corpus luteum) - matures uterine lining
- No implantation - corpus luteum dies
- Death = drop in estrogen + progesterone
Menses
Differences w MALE vs FEMALE SA victims
Males tend to be of similar age (20-30yr)
known their assailants less often
multiple assailants
more forcible penetration (anal 52%, 15% oral, 33% both)
more anal trauma
more object + digital penetration
more weapons used
Risk factors for death (IPV)
Indications for comprehensive tox screen following SA (5)
LOC
no motor control
confused / amnesia
believe they were drugged
<72-96H since assault
Sex + age of consent
Age of consent 16
12-13 => <2
14-15 = <5
Clues someone is being trafficked
Unconsistent hx
markings / tattos of ownership
delay presentation
no documents/identification
companion won’t leave, answers all questions
AMNIOTIC FLUID EMBOLISM RF
Uterine rupture
abruption
previa
C section
eclampsia
Amniocentesis
Indications for pelvic US + BHCG
Vaginal bleeding PLUS
1. No US showing IUP +/- pelvic pain
2. Near term preg
3. Active labor
Reasons for BHCG false + / false -
False +
* Molar pregnancy
* blighted ovum
* ectopic preg
* Post abortion
* post menopause
* IVF
* tumors = choriocarcinoma
* placenta trophoblastic tumor
False -
* Too early <10days
* diluted urine
* lab error
Diagnostic criteria for hyperemesis gravidarum
Vomit
weight loss (>5% pre preg)
ketones (urine)
[mech]: rapid incr in BHCG occurring in 6-20wks
Expected BHCG levels
Peak at 8-10weeks (doubles Q48H)
methotrexate d4=>7 (15% drop)
Indications MTX has failed
Bleeding
HD unstable
pelvic fluid ++
(evidence of rupture)
indications for laparotomy in ectopic pregnancy
HD unstable
size >3.5cm
pelvic adhesions ++
Clinical features of a MOLAR pregnancy
Persistent vomit
intermittent bleed
pelvic pressure / pain
enlarged uterus
US: no FHR
Large size for dates
mgmt of eclampsia
Supportive - IVF
MgSO4 2-4g IV
lower BP: labetolol, hydralazine, nicardipine, nitroglycerin
- GOAL <160/105 post seizure
+/- CT head
Delivery
When to stop Mg
Decreased:
- Reflexes
- Ventilation
UO (<2cc/hr)
Contraindications to MgSO4
* Hypocalcemia
* myasthenia gravis (block on ACH receptor)
* renal failure
How to diagnose placental abruption
FHR (most sensitive)
ultrasound (not sensitive for placental abruption)
APT test (pink = fetal blood = abruption)
Causes of RH sensitization
Threatened miscarriage / spontaneous miscarriage
uterine manipulation
amniocentesis
placental abruption
ectopic surgery
trauma
Two tests used to determine maternal - fetal mixing
APT test: => alkali denaturation test (differentiates fetal vs maternal blood)
vag blood + NaOH = 1) pink = fetus 2) brown = mom
Kleihauer Betke test => can detect 5cc of mixing
Compare AFLP / intrahepatic cholestasis / HELLP
What is the fetal anticonvulsant syndrome tetrad
Neural tube defects
microcephaly
mental deficiency
cardiac abnormalities
PRETERM RF
<37wks
Extremes of age, low SES
smoking/cocaine
prolonged standing / stress
Infection: UTI/STI
GYNE:
hx preterm
multiple gestations
cervical incompetence
low preg weight gain
first trimester bleed
placental abruption / previa
prior repro organ sx
33wk gestation w abdo pain
+PV bleed: ddx?
- placental abruption (painful)
- placenta previa (painless)
- vasa previa
- premature ROM / labour (bloody show)
PROM RF
extremes of age
bad things: smoking, cocaine
Multiple gestations
Infections: UTI, bacterial vaginosis
amniocentesis (not in box)
chorioamniotis (not in box)
- pre-eclampsia (not in box)
- placental abruption
- cervical incompetence
- psychosocial stressors
- prolonged standing
Methods to detect PROM
Nitrazine – (amniotic fluid pH >6.5 = paper blue / normal yellow)
Ferning – amniotic fluid crystallizes
Smear combustion – amniotic fluid will turn white + crystalize when you light it on fire
Pooling of fluid in posterior fornix
fluid out of cervix w valsalva
Stages of Labor
Stage 1: cervical => onset to full dilation / effacement
Stage 2: fetus => full dilation to fetal delivery
Stage 3: placenta => fetal delivery to placental delivery
Stage 4: uterine => first hour post partum
Indications for a 3rd trimester US
Bleeding
r/o previa, abruption
r/o cord prolapse
measure amniotic fluid
gestational age
fetal heart motion / fetal position
multiples
anatomy
List examples of tocolytics
MINT
MgSO4 4-6g IV
Indomethacin
Nifedipine
Terbutaline 5-10mg PO (0.25mg SC)
meds to delay labor to allow steroid administration
Contraindications to tocolytics
Vaginal bleeding
Fetus: anomality, distress
HTN: pre-eclampsia, eclampsia
infection: chorioamnionitis, sepsis
DIC
Relative: cervix >5cm, CVS dz, abruption, stable previa
How to manage a shoulder dystocia
HELPERR B
Help - call for help
Episiotomy (indications: shoulder dystocia + breech)
Leg’s up: McRobert’s
Pressure - suprapubic
Enter: 1) Wood’s corkscrew 2) Rubin
Roll onto all 4s
Remove posterior arm
Break clavicle
Complications of a shoulder dystocia delivery
Nerve damage
clavicular fracture
humerus fracture
damage to brachial plexus
death
asphyxia
PPH specific drugs
TOCE -M
>500cc / >1L if C section
What are causes of tachy/brady syndrome
Ischemia
fibrosis
CM
CTD
Drugs: BB, CCB, digitalis, quinine
HARD / SOFT SIGNS OF PERIPHERAL VASCULAR INJURY
HAAA
HARD
* Hematoma
* Absent distal pulse
* Arterial hemorrhage (pulsatile)
* Audible bruit (palpable thrill)
SOFT
* non expanding hematoma
* decreased distal pulses / decr ABI
* ++ hemorrhage
* peripheral nerve injury
* bone / penetrating prox wound
List ROPER HALL classification
List the DUA classification
List drugs that are radio-opaque
CHIPES
Chloral hydrate, calcium salts
Heavy metals - Pb, Mg
Iron
Packers
Enteric coated, sustained release salicylates
Solvents - halogenated HC
Drugs that activated charcoal doesn’t work on
PHAILS
Pesticides
heavy metals
Acids / alkalis
Iron
Lithium
Solvents
List meds to use MDAC on
ABCDQ
Anticonvulsants (VPA, phenytoin), amanita phalloides
Barbiturates
Carbamazepine, concretion forming (ASA)
Dapsone, dilantin
Quinine
Indications for GI decontamination
CHAMP
Camphor - neurotox, seizures
Halogenated HC
Aromatic HC - BM suppress + leukemia (toulene, benzene)
Metals - arsenic, Hg, Pb (neurotox)
Pesticides - cholinergic crosis, seizure, resp depression
List a ddx for metHgB
NNAAAT
nitRITES - amyl nitrite, Na nitrite, nitroprusside, nitric oxide
nitRATES - well water
anti-biotics - sulfa, dapsone
anti-malarial - quinones, chloroquine
anti-neoplastic - cyclophosphamide
topical anesthesia - benzocaine, lidocaine, prilocaine
Naphthalene
Methylene blue
NADH metHb reductase (can’t reduce Fe=> Fe2+)
G6PD deficiency (can’t make NADH)
sources of methanol, ethylene glycol + isopropyl ETOH
METHANOL
* antifreeze
* windshield fluid
* carburator fluid
* glass cleaner
* emblaming fluid
ETHYLENE GLYCOL
* antifreeze
* Brake fluid
* coolant
* de-icing fluid
ISOPROPYL ALCOHOL
* rubbing ETOH
* disinfectants
* hand sani
