Lectures Flashcards
Pain control of choice for appendicitis
Morphine (.1mg/kg) and repeat as needed
-usually start giving 4mg (that’s underdosing)
Don’t give NSAIDs b/c increase bleeding
To r/o ACS how often do we recycle trops
After first trop, recycle in 6 hours
How to medically optimize an ACS patient who doesn’t go to cath lab
Aspirin, statin, BP control
Management for NSTEMI
Depends on CP and stability of pt
Stable NSTEMI w/o continuing CP = contraindicated to emergent cath!!! (will probs find no vessel disease), so medically optimize
Stable NSTEMI w/ ongoing CP => emergent cath
Unstable NSTEMI => emergent cath
Aortic dissection
(a) physical exam findings
(b) CXR
(c) US
Aortic dissection- tearing CP radiating towards the back
(a) Disparate pulses, muffled heart sounds
(b) CXR: widened mediastinum (not in all, just classically)
(c) US findings: dilated aortic root (over 4cm), potentially pericardial effusion
- if dissection involves the ascending aorta, it can back track into the pericardium
What is a Q-wave on EKG?
(a) When is it pathologic?
Q-wave is a the first downward reflection in ventricular depolarization before the R-wave
(a) Pathologic (indicative of old infarct) if height is greater than 1/4 height of the R-wave
Describe normal direction of T-wave
Physiologic T-waves go in the same direction as the QRS complex
-exception is LBBB when T waves are physiologically inverted (don’t indicate ischemia)
Describe pneumonic for reciprocal changes
PAILS
In a posterior MI you’d expect ST depressions in anterior leads => V2/V4 depressions make you concerned for posterior MI
What may ST elevations in aVR indicate?
ST elevation sin aVR can indicate proximal LAD occlusion or really extensive (3 vessel) disease
EKG findings indicative of critical LAD stenosis
Critical LAD stenosis can show on EKG by Wellens syndrome = deep T-wave inversions in V2/V3 (T-wave inversions in anterior leads)
Where would expect to see reciprocal changes in an anterior MI
LAD occlusion (anterior MI)- expect reciprocal ST depressions in inferior leads
When in ACS do you not give nitro?
Don’t give nitro if you’re worried about inferior MI b/c 40% of cases of inferior MI have right heart involvement
What is Sgarbosa’s criteria used to determine?
Determine if there is ST elevations on top of a LBBB
-hard to tell if it’s just a LBBB or if theres elevations
EKG findings of PE
Tachycardia
E/o right heart strain
- RBBB
- S1Q3T3: S wave in I, Q wave in III, and T-wave inversion in III
What are delta waves on EKG?
Delta waves seen in WPW = upslope btwn P and QRS complex b/c of the aberrant pathway btwn atria and ventricles that starts ventricular contraction earlier
What EKG finding may contraindicate zofran?
Prolonged QT- don’t give reglan or zofran
-if pt puking and can’t give either, can give ativan
Describe EKG appearance of supraventricular tachycardia
Narrow complex (from the atrium) tachy w/o P-waves
Management of supraventricular tachycardia
a) First line (before meds
(b) Pharma
SVT
(a) Start w/ vagal maneuvers: carotid massage, bear down
(b) If those don’t work (probs wont) start w/ 6mg of adenosine
Mgmt of Torsades
(a) Medically
(b) Second line
Torsades
(a) Give Mg2+
(b) Shock
What is MAT?
(a) EKG criteria
(b) First line tx
Multifocal atrial tachycardia- fast HR coming from the atria (P-waves present) but P-waves of dif morphology
(a) P-waves w/ 3 or more dif morphologies
(b) First line tx = treat the underlying pulm disease
- seen in COPD tx
- really refractory to cardiac tx, just have to try to treat the underlying pulm disease
Splinting vs. casting
Splinting- hard part w/ open/free side to accommodate swelling
So splint put on first (for about a weekish) then get more permanent cast
Clinical scenario that leads to
(a) scaphoid fracture
(b) fracture of 4th/5th metatarsal
(c) Distal radial fracture
(d) triquetrum fracture
Clinical scenario
(a,c) FOOSH (fall out outstretched hand) => scaphoid fracture and distal radial fracture
(b) Boxer’s fracture- punching something
(d) Triquetrum fracture from either hyperextension or hyperflexion of the wrist
Splint for
(a) scaphoid fracture
(b) fracture of 4th/5th metatarsal
(c) Distal radial fracture
(d) triquetrum fracture
Splint for
(a) Scaphoid fracture =
(b) Boxer’s fracture = ulnar gutter
(c) Distal radial fracture = sugar-tong split
(d) Triquetrium/chip fracture = volar slab
Step before splinting a fracture
Perform neurovascular exam!!!
-always before AND after reduction and immobilization
3 reasons to suture up a wound
- aid wound healing
- decreased risk of infection
- cosmesis
5 steps of suturing up a wound
- anesthetize
- irrigate
- sterile prep
- close wound
- dress wound
Why give lidocaine w/ epi?
Adrenaline causes local vasoconstriction to decrease bleeding, and to decrease systemic absorption to keep more locally => increases duration of action on local target
Where to never put lidocaine?
Place w/ end arterial supply: hand, penis, nose, pinna, toes
Max dose of
(a) 1% lidocaine w/o epi
(b) 1% lidocaine w/ epi
Max dose
a) 1% lidocaine w/o epi = 35cc (5mg/kg
(b) 1% lidcaine w/ epi = 50cc
Name the main absorbable vs. non-absorbable suture
Absorbable suture = Vicryl
Nonabsorbable suture = Nylon, silk
When to give tetanus vaccine to clean wounds
Give tetanus vaccine if pt has had less than 3 doses, last dose given more than 10 yrs ago, or unknown doses
When to give tetanus immunoglobulin in addition to tetanus vaccine for wounds?
Give tetanus immune globulin ONLY for contaminated wounds where pt has had fewer than 3 or unknown doses of tetanous vaccine
-never give immune globulin to clean/minor wound
Difference btwn dressing a wound closed by dermabond
Don’t put bacitracin over dermabond b/c it will inactivate it
Pharmacologic difference btwn morphine and codeine
The two natural opioids (morphine and codeine) are similar: but step by which codeine is metabolized into morphine involved enzyme CYP2D6
-about 10% of ppl are CYP2D6 deficient (therefore wouldn’t get any pain relief) and a lot of drugs (prozac, benadryl) can act as CYP2D6 inhibitors
When to use hydromorphine over morphine?
Morphine (natural opioid) releases causes bigger histamine release than hydromorphine (semisynthetic) => use hydromorphine when really large doses are required
Pain med for ppl w/ morphine allergy
- Make sure it’s a true allergy, don’t be confused by normal histamine-release caused physiologically by morphine
- fentanyl
- has shorter duration
Name 3 NSAIDs
Ibuprophen (advil), ketoralac (toradol), naproxen
When to use tylenol over advil
Acetaminophen (tylenol) isn’t an anti-inflammatory- use it as anti-pyretic and minimal pain
Advil (ibuprophen) is the better one <3
Starting morphine dose for adults
.1mg/kg
-often give 4g which is often underdose
Downside of opioids (name 3)
- Respiratory depression
- constipation
- risk of addiction
